Strategic Health Technology Incorporation
description
Transcript of Strategic Health Technology Incorporation
Strategic Health TechnologyIncorporation
Binseng Wang, ScD, CCE, fAIMBE, fACCENovember 8, 2012
2
¡Gracias por tu invitación!
• It is an honor for me to be here to exchange ideas and experience with you.
• It would be presumptuous of me to teach you anything about technology incorporation because I know you have being doing it for almost a decade (and confirmed by the Discussion Panel on Tuesday).
• I hope to incorporate your experience in the next revision of my book on this subject.
• I also want to apologize for my inability to speak Spanish correctly.
3
MOTIVATION
• According to the World Health Organization - WHO*Up to three quarters of these [medical] devices do not function in their new settings and remain unused. Factors contributing to this are: lack of needs assessment, appropriate design, robust infrastructure, spare parts when devices break down, consumables, and a lack of information for procurement and maintenance, as well as trained health-care staff.
*WHO, Medical devices: managing the Mismatch, Geneva 2010THE = total healthcare expenditureMTE = medical technology expenditure
COUNTRY THE/Capita (€) MTE/Capita (€) MTE/THE (%) MTE (€ billion)Europe 2,173 145 6.66% 72.57USA 5,098 330 6.48% 97.96Mexico (estimated) 1,300 117 9.00% 13.45
Now that Mexico is providing universal health coverage for all (Seguro Popular), how will it manage technology in a safe, cost effective manner?
4
CONTENTS
• INTRODUCTION• CONCEPTUAL FRAMEWORK• STRATEGIC INCORPORATION PROCESS
– Strategic Planning– Strategic Acquisition
• OUTCOME EVALUATION• DISCUSSION
– Misconceptions– Challenges
• CONCLUSIONS
5
Reference
• Binseng WangStrategic Health Technology Incorporation,Morgan and Claypool Publishers, 2009
• Binseng WangMedical Equipment Maintenance: Management and Oversight, Morgan and Claypool Publishers, 2012
NEW
Other Publications
• Wang B, Fedele J, Pridgen B, Rui T, Barnett L, Granade C, Helfrich R, Stephenson B, Lesueur D, Huffman T, Wakefield JR, Hertzler LW & Poplin B. Evidence-Based Maintenance: I - Measuring maintenance effectiveness with failure codes, J Clin Eng, July-Sept 2010, 35:132-144.
• Wang et al. Evidence-Based Maintenance: II - Comparing maintenance strategies using failure codes, J. Clin. Eng., Oct-Dec 2010, 35:223-230
• Wang et al. Evidence-Based Maintenance: III - Enhancing patient safety using failure code analysis, J. Clin. Eng., Apr-June 2011, 36:72-84
• Wang et al. Evidence-Based Maintenance: IV – Comparing maintenance procedures using failure codes, in preparation
6
PatientsDoctors
Political Leaders
Health LeadersVendors
Regulat
ors
Competitors
Nurses
Payers
INTRODUCTION
7
8
Health Technology Costs
• Equipment costs (depreciation, maintenance, etc.) is actually the lowest of all health technologies
0%
5%
10%
15%
Drugs Implants Other Supplies Clin Eng
Mea
n Pe
r Dis
char
ge C
ost
(%To
tal H
osp
per D
isch
arge
Cos
t)
• Wang et al., Financial Impact of Medical Technology, IEEE Eng Med Biol magazine, 27(4):80-85, Jul/Aug 2008.
• Maeda et al., What Hospital Inpatient Services Contributed the Most to the 2001-2006 Growth in the Cost per Case? Health Serv Res, 47:1814–1835, 2012
Strategic Health Technology
Incorporation Process
Technology Incorporation
Plan
Patients’ Needs
Doctors &
Nurses’
PreferencesGlobal Mission& Goals
MarketPressure
Financial
ConstraintsRegu
lations
& Standards
Technology
Evolution
Strategic Health Technology Incorporation
9
Needs +Benefits• clinical• operational• financial
Impacts• patients• users• infrastructure• costs
Health Technology
CONCEPTUAL FRAMEWORK
• Health technology is nothing but a tool. It has little intrinsic value but can be invaluable in providing high-quality care in a cost-effective way if used by the right person(s) at the right time and in the right manner.
10
R&D Marketing & Distributioninvestment high profit medium profit low profit
prod
ucts
pro
duce
d
time (years)
PRODUCER’S PERSPECTIVE
Reg
ulat
ory
appr
oval
clinical trials early adoption mass adoption obsolescencepossible loss high revenue low revenue
USER’S PERSPECTIVE
Technology Lifecycle from Different Perspectives
11
Health Policy Cycle
ETHICSPOLITICS Problem Definition
Diagnosis
Policy DevelopmentPolitical Decision
Implementation
Evaluation
Adapted from Hsiao et al., Getting Health Reform Right, Harvard Univ./World Bank Inst., 2000
12
feedback
Health Policy(Mission & Vision)
StrategicPlanning
Acquisition
Maintenance &Management
Installation/Acceptance
Clinical Use
Retirement
Quality Improvement & Risk Management
Utilization Standards
Technology AssessmentRegulations & Standards
Market CompetitionFinancial Constraints
Epidemiological Data
Service Suppliers
Manufacturers& Distributors
Facilities Management
Information Technology
Material Management
Architects
Technology Management Lifecycle
13
Initial Investment- Equipment price - Accessories- Shipping, insurance
& customs- Installation< 20% of Total Cost of
Ownership (TCO)
Invisible Costs- Operations- Maintenance- Administrative- User learning> 80% of TCO
Total Cost of Ownership (TCO)
14
15
CONTENTS
• INTRODUCTION• CONCEPTUAL FRAMEWORK• STRATEGIC INCORPORATION PROCESS
– Strategic Planning– Strategic Acquisition
• OUTCOME EVALUATION• DISCUSSION
– Misconceptions– Challenges
• CONCLUSIONS
Technology PlanningTechnology Audit
Technology Evaluation
Evaluation Consolidation
Technology Plan
InstallationAcceptance
Technology ManagementTechnology Acquisition
ProductSelection
Procurement
Alternatives to Purchasing
STRATEGIC INCORPORATION PROCESS
16
Other Suppliers
Manufacturers
Architects
Facilities Mgmt
Information Technology
Material Mgmt
ClinicalEngineering
Technology AssessmentRegulations & Standards
Market CompetitionFinancial Constraints
Epidemiological Data
Information SourcesTechnology
Incorporation Committee
Task Force 1
Task Force 2
Task Force 3
Health Policy(mission, vision, strategies, etc.
Admin Support
Technical Support
Organization Board or CEO
Chief Medical Officer
Chief Nursing Officer
Chief Operations
Officer
Chief Finance Officer
Resources for Technology Incorporation
17
18
Technology Planning
• Technology Audit – Inventory– Condition– Distribution
• Technology Evaluation– Need assessment– Impact assessment– Costs assessment– Benefits assessment
• Evaluation Consolidation• Technology Plan
Technology PlanningTechnology Audit
Technology Evaluation
Evaluation Consolidation
Technology Plan
19
Strategic Considerations
• Included in the Benefits Assessment as “indirect” benefits
• Examples:– Maternal-child care emphasis => OBGY & neonatal
technologies– Disease prevention => cold chain for vaccine storage &
distribution– Surgical revenue => improvement in diagnostic technologies– Market competitiveness => surgical robots
• In other words, “strategic” means to look beyond immediate needs and consider broader and longer vision
20
Sample Evaluation Summary
Infr
astr
uctu
re
Use
rs
Mai
nten
ance
Inve
stm
ent
Rec
urre
nt
Use
rs
Clin
ical
Fina
ncia
l
Indi
rect
1 Video-endoscopy for lower GI 3.5 0.0 -1.5 -2.0 -1.0 -1.0 -2.0 3.0 5.0 3.0 1.7 $20,000 $20,0002 YAG surgical laser 3.0 0.0 2.0 -1.5 -2.5 -2.0 -2.0 2.0 4.0 3.0 1.4 $65,000 $85,0003 Cardiac ultrasound system 3.0 0.0 -3.0 -1.5 -3.0 -1.5 -2.0 3.0 2.0 4.0 1.1 $60,000 $145,0004 Endoscope washer and disinfection 4.5 -0.5 -1.0 -1.0 -1.0 -2.0 -2.0 2.0 2.0 1.0 1.1 $12,000 $157,0005 Automated chemistry analyzer 2.5 -2.0 -1.5 -3.0 -3.0 -3.0 -2.0 5.0 3.0 2.0 0.9 $250,000 $407,0006 Surgical light 2.5 -1.0 1.0 -1.0 -2.0 0.0 0.0 2.0 1.0 0.0 0.7 $25,000 $432,0007 intra-aortic balloon pump 3.0 -1.0 -1.0 -2.5 -2.0 -2.0 -1.0 3.0 1.5 1.0 0.7 $50,000 $482,0008 250 general purpose infusion pumps 2.5 0.0 2.0 -1.0 -3.5 -2.0 -2.0 3.0 1.0 0.0 0.6 $750,000 $1,232,0009 Video-endoscopy for upper GI 1.5 0.0 -1.0 -1.5 -1.0 -1.0 -2.0 1.0 1.0 2.0 0.4 $20,000 $1,252,000
10 Second CT scanner (64 slice) 2.0 -4.0 -3.0 -4.0 -5.0 -3.5 -3.0 4.0 2.0 5.0 0.4 $1,000,000 $2,252,00011 Phaco-emulsifier for eye surgery -2.0 0.0 -2.0 -2.0 -1.0 -1.0 -3.0 2.0 2.0 3.0 -0.1 $55,000 $2,307,00012 Surgical table -1.0 -1.0 0.0 0.0 -2.0 0.0 0.0 1.0 1.0 0.0 -0.1 $35,000 $2,342,000
TOTAL SCORE
INVESTMENT COST (US$)
CUMULATIVE COST (US$)
ITEM EQUIPMENT BEING EVALUATED NEED EVALUA
TION
IMPACT EVALUATION COSTS EVAUATION BENEFITS EVALUATION
The 2nd CT could be a strategic initiative but also could be something that will not
provide good return on investment (ROI)
21
STRATEGIC TECHNOLOGY ACQUISITION
• Product Selection– Technical considerations– Regulatory considerations– Financial considerations– Supplier considerations
• Procurement– Isolated Purchasing– Group Purchasing
• Alternatives to Purchasing– Lease– Rental (short term lease)– Consumable-purchase agreement– Revenue-sharing agreement– Donation
Technology Acquisition
ProductSelection
Procurement
Alternatives to Purchasing
prod
ucts
pro
duce
dtime (years)
Product A
Product B
Reg
ulat
ory
appr
oval
clinical trials early adoption mass adoption obsolescence
possible loss high revenue low revenue
USER’S PERSPECTIVE
22
CONTENTS
• INTRODUCTION• CONCEPTUAL FRAMEWORK• STRATEGIC INCORPORATION PROCESS
– Strategic Planning– Strategic Acquisition
• OUTCOME EVALUATION• DISCUSSION
– Misconceptions– Challenges
• CONCLUSIONS
23
OUTCOME EVALUATION
• For health policy– Population health status– Population satisfaction– Financial risk protection
FINANCING PROVIDER PAYMENT
MECHANISMS
ORGANIZATION REGULATION CHANGING INDIVIDUAL BEHAVIOR
INTERMEDIATE OUTCOMES• Access• Quality• Equity• Efficiency
FINAL OUTCOMES• Health Status• Satisfaction• Financial Risk Protection
Adapted from Hsiao et al., Getting Health Reform Right, Harvard Univ./World Bank Inst., 2000
24
OUTCOME EVALUATION (Evidence-Based Technology Incorporation)
• For health technology– Technology “health status”
• % of technology in use• Global failure rate for equipment• Uptime for mission critical equipment
– Technology impact• Mortality & morbidity reductions• Length of stay reductions• Patient incident reductions
– Clinical user satisfaction– Financial impact
• Reduction of unnecessary replacements & new capital investments• Reduction of maintenance costs
• For health policy– Population health status– Population satisfaction– Financial risk protection
25
Medical Equipment Maintenance & Mgmt in USA
• Maintenance Costs (efficiency)
• Reliability (effectiveness)
100
1,000
10,000
100,000
100 1,000 10,000 100,000
Tota
l # re
pair
WO
s
#Capital devices maintained
r = .80p < .0001
Major teaching
Minor teaching
Non-teaching
Unknown
Questionable
0.75 line
$10
$100
$1,000
$10,000
$100,000
$10 $100 $1,000 $10,000To
tal C
E ex
pens
e ($
k)
Total operating expenses ($M)
r = .85p < .0000001
Major teaching
Minor teaching
Non-teaching
Unknown
Questionable
1% line
25
man
agem
ent Clinical Use
Health Policy(Mission & Vision)
StrategicPlanning
Acquisition
Maintenance &Management
Installation/Acceptance
Retirement
Quality Improvement & Risk Management
Utilization Standards
Technology AssessmentRegulations & Standards
Market CompetitionFinancial Constraints
Epidemiological Data
Service Suppliers
Manufacturers& Distributors
Facilities Management
Information Technology
Material Management
Architects
Technology Must Be Well Managed After Incorporation
26
feedback
Evidence-Based Maintenance - EBM
A continual improvement process that analyzes the effectiveness of maintenance resources deployed in comparison to outcomes achieved previously or elsewhere and makes necessary adjustments to maintenance planning and implementation.
27
Fishing = Process Catching = Outcome
EBM Strategy & Frequency Comparison
0%
20%
40%
60%
80%
100%
No Fail UPF ACC BATT USE EF NET SIF HF PF PPF
Estim
ated
Ann
ual F
ailu
re P
roba
bilit
y (A
FP) Pulse Oximeter
(#units: F12 = 522 ,R/R = 351, Samp = 251) F12R/RSamp
0%
5%
10%
SIF HF PF PPF
28
F12 = annual inspectionR/R = repair or replaceSamp = statistical sampling
29
EBM Procedure Comparison
0%
20%
40%
60%
80%
100%
No Fail UPF ACC BATT USE EF NET SIF HF PF PPF
Estim
ated
Ann
ual F
ailu
re P
roba
bilit
y (AF
P)
Multi-parameter Patient Monitor(#units: OEM = 338, Hospital = 920)
OEM
Hospital
OEM = manufacturer recommended procedureHospital = hospital developed procedure
EBM Cause-Code Grouping Analyses Results
No Failure61%Future
9%
Indirect28%
Direct2%
Battery-Powered Mon/Pace/Defibrillator
No Failure35%
Future16%
Indirect47%
Direct2%
Vital Signs Monitors
No Failure71%
Future6%
Indirect22%
Direct1%
Pulse Oximeters
No Failure17%
Future24%
Indirect56%
Direct3%
Single-Channel Infusion Pumps
30
No failure = no problem found in SM or repairFuture = unpreventable failureIndirect = use, peripheral, evident failureDirect = hidden, preventable, predictable, service-induced
31
DISCUSSION: Misconceptions1
• Equipment life expectancy (aka “lifetime” or “usable life”)– Replace equipment before “end of life expectancy?”– How is reliability affected by life expectancy?– Besides the average life expectancy, shouldn’t you look at
the standard deviations and individual cases?
0%
20%
40%
60%
80%
100%
0 5 10 15
Estim
ated
Rel
iabi
lity
years after installation
binary
linear
exponential
32
DISCUSSION: Misconceptions2
• “End of Life” notices from manufacturers– Should stop using equipment?– Replace equipment as soon as possible?– Ignore the notice?– Evaluate “return on investment” for continual support and, if
justified, include in the Strategic Equipment Planning?
R&D Marketing & Distributioninvestment high profit medium profit low profit
prod
ucts
pro
duce
d
time (years)
PRODUCER’S PERSPECTIVE
Reg
ulat
ory
appr
oval
END OF LIFE
See, e.g., M.N. Skoufalos, Numbered Days-Examining the true meaning of medical equipment ‘End of Life,’ Medical Dealer, Oct 2012, pp. 57-60.
33
DISCUSSION: Misconceptions3
• “Maintenance Expenditure Limit” (MEL)US Army Tech Bulletin Med 7 states repairs shall NOT be conducted if the cost of repair exceeds the replacement cost multiplied by the percent of useful life remaining (limited between 10% and 65% for equipment that exceeded its life expectancy and has not exceeded 80%, respectively).
0
10
20
30
40
50
60
70
0% 20% 40% 60% 80% 100%
MEL
(% o
f Rep
lace
men
t Cos
t)
% Useful Like Remaining
While repairs should NOT be conducted at any cost, it should also NOT be constrained rigidly to replacement cost, as capital budget is often separate from operating budget.
34
DISCUSSION: Misconceptions4
• Appropriate Technology (Equipment) was characterized by the Office of Technology Assessment (OTA) as:– A technology may be considered appropriate when its development and use:
1) are in reaction to or in anticipation of defined goals relating to problems or opportunities in the disability area,
2) are compatible with resource constraints and occur in an efficient manner, and 3) result in desirable outcomes with acceptable negative consequences or risks to
parties at interest.– “Appropriate technology” or “appropriate application of technology” does not
require that a technology be simple or that it be inexpensive, only that it be suitable for the intended effects and that it take into account any constraints, such as the resources available.
– The most appropriate technology in a given situation is one that provides the greatest ratio of desirable outcomes to negative effects and resources consumed, providing that outcomes and consequences have been defined and are of sufficient value as judged by appropriate parties at interest.
OTA, Technology and Handicapped People, May 1982
35
DISCUSSION: Misconceptions5
• Examples of Appropriate Technology that can be considered strategic in incorporation:– Solar-powered refrigerators for vaccination campaigns– Cellular telephones for rural healthcare– Telemedicine for remote areas and prisons– Water treatment systems for disaster relief (Mexico)
• Better even than appropriate technology is technology (knowledge) transfer
Give a man a fish and you feed him for a day.
Teach him to fish and you feed him for life.
DISCUSSION: Challenges
• Many challenges (opportunities)– Lack of accurate, reliable information (comparative performance,
reliability, support costs, purchase costs, etc.)– Lack of trained purchasing and technical personnel– Many rules, regulations, and restrictions – Inflexible finance restrictions (can only buy equipment but not
parts, only products made in certain countries, etc.)– Many others…
• However, all these are fairly easy to resolve...
36
DISCUSSION: Challenges2
• The real challenges (i.e., the root causes) are more difficult– Lack of awareness among decision makers– Emotional involvement:
• Power struggle• Status symbol
– Greed and short-sightedness of some lenders, donation organizations, manufacturers and suppliers
• Hope you have other solutions to share with me
37
CONCLUSIONS
• Incorporation is not difficult:– Analyze carefully the need, impacts, costs, risks and benefits of
each technology incorporation– Assess alternative technologies – Compare competitive products available on the market in terms
of quality, specifications, and total cost of ownership– Use a multidisciplinary team to manage the procurement
process to ensure all aspects are covered, as well as transparency
– Analyze possible alternatives to acquisition• But you need to be willing and able to address the challenges
38
39
CONCLUSIONS2
• Technology is evolving extremely fast:– Electronic health records– Telemedicine– Telehomecare– Mobile health– Tissue engineering, nanotechnology,
biomaterials, etc.– Synthetic biology– Organ re-growth and replacement
• The sooner you start managing technology, the easier will be to face the on slaughter of new technologies
Hardware & software
Wetware
But the good news is that you may have >100 years of work time as your life expectancy will be >150 years soon…
THANK YOU! ¡GRACIAS!
• Please contact me if you have any questions or suggestions
– Binseng Wang, ScD, CCE, fAIMBE, fACCE• Vice President, Quality & Regulatory Compliance• ARAMARK Healthcare Technologies (
www.aramarkheatlhcaretechnologies.com)• Telephone: 704-948-5729• Email: [email protected]
– Member of ACCE’s InternationalCommittee
40