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Implantable cardioverter defibrillators – driven by MR compatibility, subcutaneous devices
In spite of a relatively short history, the use of implantable cardioverter defibrillators (ICDs) has been growing by leaps and bounds. For clinicians, an ICD offers a direct means to avoid sudden cardiac death. Other reasons for the popularity of ICDs include advances in technology, above all miniaturization. More recently, new implantation methodologies such as subcutaneous ICD promise a further boost to their use. The working of ICDs are also easy to explain to patients. There is, nevertheless, one major challenge which ICDs have to still address: limitations to battery life.
Primary and secondary prevention
The principle behind an ICD is relatively straightforward, and covers two broad types of prevention: primary and secondary.
Primary prevention, which accounts for the bulk of ICD implants, refers to patients who have not yet suffered life-threatening arrhythmia.
Secondary prevention concerns survivors of cardiac arrest secondary to ventricular fibrillation or sustained tachycardia (together known as a tachyarrhythmia). Although the user group is smaller, secondary prevention makes the strongest case for an ICD.
Differentiating ventricular tachycardia and ventricular fibrillation
After implantation, the ICD continuously monitors cardiac rhythm and detects abnormalities. ICDs are programmed to recognize and differentiate between ventricular tachycardia (VT) and ventricular fibrillation (VF), after which they deliver therapy in the form of a low- or high-energy electric shock or programmable overdrive pacing to restore sinus rhythm – in the case of ventricular tachycardia, to break the tachycardia before it progresses to fibrillation. Overdrive or anti-tachycardia pacing (ATP) is effective only against VT, not ventricular fibrillation.
Defibrillation now almost 70 years old
The first defibrillation of a human heart dates to 1947, when Claude Beck, an American surgeon at Western University in Ohio, sought to revive a 14-year-old boy whose pulse had stopped during wound closure, following cardiothoracic surgery. Cardiac massage was attempted for 45 minutes, but failed to restart the heart. Ventricular fibrillation was confirmed by ECG. Beck saw no other choice but to deliver a single electric shock. This did not work. However, along with intracardiac administration of procaine hydrochloride, a second shock restored sinus rhythm. Beck’s success led to worldwide acceptance of defibrillation. However, his alternating current (AC) device (subsequently commercialised by RAND Development Corporation) was capable of defibrillating only exposed hearts.
Merging defibrillation and cardioversion
On its part, the pioneering of cardioversion (and the coining of this term) is credited to Bernard Lown, a physician at the Peter Bent Brigham Hospital in Boston. Lown merged defibrillation and cardioversion, and coupled these to portability. In 1959, he successfully applied transthoracic AC shock via a defibrillator to a patient with recurrent bouts of ventricular tachycardia (VT), who had failed to respond to intravenous procainamide. This was the first termination of an arrhythmia other than VF.
Two years later, Lown joined a young electrical engineer called Barouh Berkovitz, who had been researching a relatively safer direct current (DC) defibrillator – based on earlier work in the Soviet Union and Czechoslovakia.
Together, Lown and Berkovits pioneered the concept of synchronizing delivery of an electric shock with the QRS complex sensed by ECG, and a monophasic waveform for shock delivery during a rhythm other than VF. Their work led to launch of the first DC cardioverter-defibrillator in patients.
The implantable ICD device: parallel pathways
The Lown-Berkovits effort was confined to external devices. The concept of an implantable, automated cardiac defibrillator dates to work by Michel Mirowski at Israel’s Tel Hashomer Hospital in the mid-1960s. Mirowski moved to the US in 1968, where he joined forces with Morton Mower, a cardiologist at Sinai Hospital in Baltimore. The two tested a prototype automated defibrillator on dogs.
As often happens in science, another researcher had also been approaching the challenge on a parallel path. In 1970, Dr. John Schuder from the University of Missouri successfully tested an implanted cardiac defibrillator, again in a dog. Schuder also developed the low-energy, high voltage, biphasic waveforms which paved the way for current ICD therapy.
The first human ICD, however, was credited to Mirowski and Mower, along with Dr. Stephen Heiman, owner of a medical technology business called Medrac. In 1980, a defibrillator based on their design was implanted in a patient at Johns Hopkins University, followed shortly afterwards by a model incorporating a cardioverter. The ICD obtained approval from the US Food and Drug Administration (FDA) in 1985.
From thoracotomy to transvenous implantation
The first generation of ICDs were implanted via a thoracotomy, using defibrillator patches applied to the pericardium or epicardium, and connected by transvenous and subcutaneous leads to the device, which was contained in a pocket in the abdominal wall.
ICDs have since become smaller and lighter (thicknesses below 13 mm and weights of 70-75 grams). They are typically implanted transvenously with the device placed, like a pacemaker, in the left pectoral region. Defibrillation is achieved via intravascular coil or spring electrodes.
ICDs versus pharmacotherapy
Over the past two decades, clinical trials have demonstrated the benefits of ICDs compared to antiarrhythmic drugs (AADs). Three randomized trials, known as AVID (Antiarrhythmic versus Implantable Devices), the Canadian Implantable Defibrillator (CIDS) study, and Cardiac Arrest Study Hamburg (CASH), were initiated between the late 1980s and early 1990s in the US, Canada and Europe, respectively.
In 2000, a meta-analysis of the three studies was published in European Heart Journal.’ This found that ICDs reduced the relative risk of recurrent sudden cardiac death by 50% and death from any cause by 28%.
Use after myocardial infarction, quality of life issues
Follow-on initiatives looked at other issues. The Multicenter Automatic Defibrillator Implantation Trial (MADDIT) found that ICD benefited patients with reduced left ventricular function after myocardial infarction (MI). In 2005, the Sudden Cardiac Death in Heart Failure trial (SCD-HeFT) established that ICD reduced all-cause death risk in heart failure patients by 23% as compared to a placebo and absolute mortality by 7.2% after five years.
Quality-of-life (QoL) issues have also assisted acceptance of ICDs. In 2009, psychologists and cardiologists at universities in North Carolina and Florida concluded that QoL in ICD patients was at least equal to, or better than, that of AAD users.
Guidelines on ICD use – differences between US and Europe
Professional bodies have established guidelines on the use of ICDs and routinely provide updates. In the US, these originate from the American College of Cardiology, American Heart Association and the Heart Failure Society of America, and in Europe from the European Society of Cardiology.
Although there are many areas of agreement, some differences exist between the US guideline and the European Society of Cardiology. One difference is that in the US guideline, cardiac resynchronization therapy (CRT) is recommended in New York Heart Association (NYHA) class I patients who have LVEF ≤30%, have ischemic heart disease, are in sinus rhythm, and have a left bundle branch block (LBBB) with a QRS duration ≥150 ms. There is no similar recommendation in the European Society of Cardiology document.
The European Society of Cardiology recommendations include patients with QRS duration <120 ms. The US does not recommend CRT for any functional class or ejection fraction with QRS durations <120 ms.
ICD and magnetic resonance
The biggest driver of ICD use in recent years, however, may consist of compatibility with magnetic resonance (MR) imaging. Like other metallic objects, ICDs have been contraindicated for MR. This is however set to change, after the first MR-compatible ICD (Medtronic’s Evera SureScan) received FDA approval in September 2016.
The relevance of MR was researched in significant depth by a team at Pittsburgh’s Allegheny General Hospital, led by Dr. Robert Biederman, medical director of its Cardiovascular MRI Center. The study covered patients in three implantable cardiac device case groups, namely cardiovascular, musculoskeletal and neurology.
The findings were conclusive. In 92-100% of cardiac and musculoskeletal, and 88% of neurology cases, MR exam provided value for the final diagnosis. In 18% of neurology cases, the MR exam altered the diagnosis entirely. In the bulk of cases, said Dr. Biederman, the information could not be obtained with cardiac catheterization, echo or nuclear. In addition, patients were saved from a biopsy of the heart muscle, with all its attendant risks.
The launch of leadless, subcutaneous ICDs
Meanwhile, other factors too are driving development of ICDs. One of the biggest shortcomings of ICDs is the need to run an electric lead through blood vessels. These are susceptible to breakages.
In 2012, Boston Scientific received FDA approval for the world’s first leadless, subcutaneous ICD (S-ICD). Rather than leads, the device uses a pulse generator and electrode beneath the skin with a shocking coil implanted under the left arm. A second-generation S-ICD system, branded Emblem, was approved in 2015.
Nevertheless, S-ICDs have drawbacks. Lacking a lead in sufficient contact with the heart, they cannot pace patients out of bad heart rhythms. S-ICDs are also not MR compatible.
The challenge of battery life
Many experts believe that the principal challenge facing ICDs is battery life. According to the Mayo Clinic, batteries in an ICD ‘can last up to seven years.’ It recommends monitoring battery status every 3-6 months during routine checkups, and states when the battery is ‘nearly out of power,’ the old shock generator needs to be ‘replaced with a new one during a minor outpatient procedure.’
Nevertheless, there has recently been some attention about the risk of the latter. In 2014, a research team led by Daniel B. Kramer of Harvard Medical School studied 111,826 patients in the US National Cardiovascular Data Registry (NCDR) who had end-of-battery life ICD generator replacements. They found more than 40% of patients died within five years of ICD generator replacement, and almost 10% within a year. The authors, however, emphasized that atrial fibrillation, heart failure, and left ventricular ejection fraction were independently associated with poorer survival as were noncardiac co-morbidities (chronic lung disease, cerebrovascular disease, diabetes and kidney conditions). What was needed, they concluded, would be a non-ICD control group.
A recent article in the British Medical Journal’ (BMJ) suggests that battery life needs to be extended to 25 years or more to avoid the risks associated with replacement. The author, Dr. John Dean, a cardiologist at Royal Devon and Exeter Hospital in the UK, points out that 1-5% of battery replacements also carry infection risk for patients.
The future: patient needs and superior waveforms
Ultimately, it is patient needs which will drive the next wave in ICD development. While the medical devices industry has focused on device miniaturization, longer battery life is also clearly a priority. Indeed, a 2004 study in Pacing and Clinical Electrophysiology’ found 90% of ICD patients saying they would trade off smaller ICDs for longer-lasting models.
ICD manufacturers are also looking at developing more sophisticated cardioversion/defibrillation waveforms in order to reduce the threshold of defibrillation, and thereby reduce pain and discomfort.
The tele-ICU and robotics – solution for high ICU telemedicine cost ?
Healthcare, like other services, requires getting appropriate expertise to the place where it is needed at the right time. Requirements like these become critical when a patient faces a sudden and unpredictable life-threatening condition. The latter is a near-routine occurrence in a hospital’s intensive care unit (ICU). Still, a host of factors make it impossible for clinicians to be present at every point in the ICU, all the time.
Early acceptance of robotic telepresence
Such shortcomings are sought to be addressed by ICU robots, one of the latest applications in the emerging field of ‘robotic telepresence’. The use of ICU robots, also referred to as teleoperated medical devices, is growing rapidly as a supplement for patient care in the ICU. In its early stages, healthcare providers were overwhelmingly convinced of their potential. In September 2012, for example, a survey of over 10,000 ICU robotic interventions in the journal ‘Telemedicine journal and e-health’ found 100 percent of practitioners considered the robot to improve both patient care and patient satisfaction.
Autonomous, optimised for ICU, hospital environment
ICU robots essentially provide access for physicians and other specialists to implement a variety of medical procedures round-the-clock, while reducing delays for difficult admissions or procedures.
The robots can be pre-programmed to drive on their own around an ICU, or this mode can be overridden and controlled by an individual, located on the premises, at a facility near by or thousands of kilometres away, via a keyboard or joystick.
The robotic sensors are optimized to perform in a hospital environment, enabling the robot to identify and avoid things like IV lines, cables and glass doors.
Plug-and-play for medical devices
The robot itself contains combinations of display types, microphones, speakers and cameras; these have pan-tilt and zoom capabilities, and are powerful and manoeuvrable enough to permit physicians to view fine details and listen to the smallest sounds.
Typical accessories in an ICU robot include an integrated electronic stethoscope to allow physicians to listen remotely to heart and lung sounds using earbuds. However, most Class II medical devices can be plugged into the robot, which streams data back in real time. On the other side, robots can also access digitized medical records of patients.
Recent innovations include a smartphone application, enabling physicians to access the robot’s camera. Another is ‘point and click’ navigation, by virtue of which a user can simply click somewhere on a map of the hospital and the robot gets itself there.
UCLA pioneers ICU robot
The history of ICU robotics dates to 2005, when the University of California at Los Angeles (UCLA) Medical Center became the world’s first hospital to introduce a robot in its neurosurgery intensive care unit under a US military-funded pilot project. The UCLA pilot saw intensivists (clinicians specialized in the care of critically ill patients) monitoring patients from their homes and offices.
The robot was RP-6, developed by California-based InTouch, a company known for its ‘auto-drive’ robotics technology used in defence and public safety. Controlled by a webcam and joystick over a broadband connection, the 65 inch (166 cm) wheeled robot boasted 8-hour runtime from a single charge. Onwards from 2006, InTouch offered hospitals an option to rent the RP-6 for USD 4,000 a month, or buy it outright for USD 120,000. Its earliest customers included Detroit Medical Center and Baltimore’s Sinai Hospital.
The iRobot-InTouch Health Alliance
Meanwhile, another US company iRobot (vendor of the robotic household vacuum, Roomba) set up a Healthcare Robotics division in 2009.
In 2011, iRobot and InTouch Health announced an alliance targeting healthcare. The next year they unveiled the RP-VITA (Remote Presence Virtual + Independent Telemedicine Assistant), a robot which went beyond simply providing remote interactive capability between a clinician and patients to a hugely-enhanced navigation capability, based on sophisticated mapping and obstacle detection and avoidance technologies tailored to a hospital environment. Its aim was to free the clinician for clinical tasks.
FDA clearance
The most revolutionary capability of RP-VITA was autonomous navigation, which was submitted to the the US Food and Drug Administration (FDA) for 510(k) approval. In January 2013, the FDA cleared RP-VITA, making it the first autonomously navigating telepresence robot in healthcare, with clearance for use before, during and after surgery and for cardiovascular, neurological, prenatal and psychological as well as critical care.
Demand driven by range of factors
The key drivers of demand for ICU robots today include time factors (urgency in ICU cases) and access (unavailability of ICU expertise) in remote areas. Both these are compounded by staff shortages.
There are fewer than 6,000 practising intensivists in the United States today and more than 5 million patients admitted to ICUs annually. A few years ago, Teresa Rincon, chair of the Tele-ICU Committee of the Society of Critical Care Medicine (SCCM) noted that the number of intensivists in the US was “not enough for each hospital to have one.” Indeed, it is estimated that only about 37 percent of ICU patients in the US receive intensivist care, although trained intensivists in the ICU correlates to better outcomes and decreased length of stay – both in the ICU and hospital.
The challenge of coma
In terms of urgency, the SCCM notes that up to 58% of emergency department admissions in the US result in an ICU admission.
Following admission, one of the major drivers of demand for ICU robots is coma. The reliable assessment of comatose patients is always critical. A hospital needs to quickly identify clinical status changes in order to determine and implement appropriate interventions.
In January 2017, the prestigious Mayo Clinic published results from a 15-month study of 100 patients, which is reported as the first to look specifically at telemedicine in assessing patients in coma. The results suggest that patients with depressed levels of consciousness can be assessed reliably through telemedicine.
Another urgent complication is delirium. Delirium incidence has been estimated at over 80% in critically ill patients. This is accompanied by a threefold increase in mortality risk, according to an oft-cited study in an April 2004 issue of the ‘Journal of the American Medical Association’.
Clinician availability
Medical emergencies like coma and delirium require the presence of highly qualified clinicians, but as discussed previously, real-life constraints limit their availability round-the-clock.
Access is another crucial consideration. Most hospitals simply lack the patient volume to employ full-time intensivists in fields like neonatology, while their availability is limited for the same reason in remote rural locations.
The tele-ICU
The first attempts to address such challenges were centred on telemedicine or Tele-ICU care, involving continuous surveillance and interactive care by offsite clinicians. This was achieved by video observation of the patient and interrogation of equipment, along with instructions conveyed to other ICU staff.
Although more studies are needed, there is evidence of an association of the Tele-ICU with lower mortality and shorter length of stay in both the ICU as well as the hospital. Another benefit is that a Tele-ICU enables stricter adherence to guidelines.
US leads the way
Europe was a relative latecomer to ICU telemedicine, with a near-total focus on teleconsultation and almost-total reliance on the US experience.
For example, Britain’s NHS refers extensively to US studies on ICU telemedicine in its own Technology Enabled Care Services (TECS) Evidence Database, while the University of Pittsburgh Medical Center has opened a Tele-ICU centre in Italy, which allows US physicians to perform remote consults for Italian ICU patients.
From telemedicine to robotics: business model turned around
In many senses, ICU robotics have been a natural successor to the Tele-ICU, albeit with a significant reversal in its operating model.
The Tele-ICU functions centrally. Rooms are hard-wired with high-resolution cameras and transmit data to a remote command centre staffed by an intensivist (tele-intensivist). The intensivist, who typically covers multiple ICUs, has access to the same clinical information (e.g. vital signs, lab values, notes, physician orders etc.) as the ICU bedside team consisting of nurses, respiratory therapists, non-ICU physician and transfers instructions to them via a two-way communication link. Robotics, driven by advances in technology and mobility, have made it possible for the Tele-ICU care model to become decentralized. The ICU robot is controlled wirelessly by the tele-intensivist, who is freed from a dedicated command centre, and can indeed be just about anywhere. The robot moves from room to room, examining patients based on instructions from the intensivist and interacting as required with staff. The latter interaction is now seen to be far more efficient, since it occurs only after the intensivist has given instructions on the procedures which need to be performed on a patient.
The cost factor
ICU robots seem to also address another major limitation of Tele-ICU, namely cost. Most studies on Tele-ICU have found that though the technologies deployed have been adequate, they have also been much too expensive.
In the US, some hospitals collided with reality, quickly and harshly, “removing tele-ICUs after outcomes failed to justify the costs.” A study in December 2009, in the prestigious ‘Journal of the American Medical Association’ also questioned a key maxim of the Tele-ICU, pointing to evidence that remote monitoring of patients in ICUs was not associated with an overall improvement in the risk of death or length of stay in the ICU or hospital.
Perspectives have been similar in Europe. For example, a Dutch study published in 2011 in the ‘Netherlands Journal of Critical Care’ concluded that hospitals were unlikely to see the “enormous” investment entailed by a tele-ICU as being cost-effective. Concerns about Tele-ICUs were also echoed the same year in Canada, where critical care clinicians, writing in the ‘Journal of Critical Care’ expressed scepticism regarding the ability of a Tele-ICU to address challenges of human resource limitation or even deliver quality care.
The personal touch
While a conclusive answer to the question of cost-effectiveness of OCU robots will require a larger user base, one powerful advantage seems to be the ability to target the eventual subject of the healthcare process, the patient. According to Paul Vespa, a neurosurgeon at UCLA’s David Geffen School of Medicine patients “interact with the robot as if it is a person.”
Steps to realize full potential
Before there is growth in numbers of ICU robots, some of the factors which will need to be addressed have been identified in a ‘Journal of Critical Care’ article in December 2013 by the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City, US.
These consist of formal training and orientation, identification of roles, responsibilities, and expectations, needs assessment, and administrative support and organization. Failure to adopt these, say the authors, will mean ICU robots may not see their full potential realized.
21st Century hospitals – pressures for transformation
New service and business models are challenging the traditional role of a hospital – as a place where sick people are taken to get better. Instead, a growing body of evidence suggests that the key mission of future hospitals will be to help people to avoid falling ill, and to manage those that do in fundamentally different ways than at present. Such processes are principally driven by economic pressures and the promise of new technologies. However, patients are also playing a major role.
Patients more proactive
It has indeed been apparent for some time that patients are far less passive than they were in the past. In Britain, a study by the King’s Fund think-tank found patients wished to be far more involved in healthcare decisions. In addition, the study reported that patient satisfaction depended not just on medical outcomes, but also on being treated with dignity and respect.
Emerging technologies are seen as one way to enhance the patient experience, and several popular apps show how rapidly patients have moved to centre-stage. In the US, Heal, a smartphone app, lets patients search for physicians in a manner similar to Uber’s connecting passengers to drivers. Zocdoc, another tool for finding doctors, has added an artificial intelligence-powered Insurance Checker feature which lets patients select and verify insurance information as they are booking appointments. An app called Welloh goes beyond doctors to give users information about hospitals, pharmacies, care centres and other facilities. Clinical trials are also opening up to volunteers, thanks to an app called TrialReach, which helps patients find open clinical trials for specific medical conditions.
These new health access paradigms resonate strongly with younger patients. According to a report from Salesforce, over 70 percent want their physicians to adopt mobile health applications.
Apple integrating health apps
Evidence of the opportunities arising from enhanced patient participation comes from Apple, which plans to bring the current clutter of healthcare apps under one roof. Its new Health Records feature will allow users to see their records of allergies, immunizations, lab results, medications and other conditions in a single window and send notifications when any data is updated.
Big Data
One of the most promising and best known tools in the emerging technology arsenal is computing giant IBM’s Watson, which deploys artificial intelligence (AI) to collect and interpret vast amounts of data from medical literature in order to advise on best treatment options. Scores of other tools provide personalized treatment plans for cancer patients using the genetic background of their tumours, accompanied by analysis from tens of thousands of other, similar cases.
These kinds of innovations count on assimilating and interpreting what has come to be known as Big Data. The sources for this data, whose volume continues to grow by leaps and bounds, are many. They include clinical studies, prescriptions, radiological images and a host of other healthcare information.
The Internet of Things
One new source of data is from the Internet of Things. Connected medical devices such as insulin pumps and pacemakers pick up signals and automatically transmit information to networked computers, which allow physicians (and patients) to perform real-time monitoring.
An array of wearable devices to track vital signs are another fast-growing source of medical data. On an individual basis, this may not amount to much. However, when the data is provided by millions of users, its size becomes staggering, as does its potential for providing insights.
Cloud computing
Such a burgeoning mass of data is being generated asynchronously, processed and stored by different machines on multiple platforms. Making it usable is hardly simple.
One promising answer to such a challenge lies in cloud computing technology, which has dramatically reduced the cost of data storage, as well as the time required to process and transfer the data to multiple users at different locations. For patients needing to visit a lot of specialists, the accessibility of their data from a variety of locations can be indispensable.
The Electronic Health Record
One of cloud computing’s biggest areas of impact may be the electronic health record (EHR), one of whose goals was in fact to address the above challenge – patient data access in real time by different specialists.
The EHR has generally failed to meet expectations (and over-expectations). In both Europe and the US, the EHR’s key technical/operational limitation was that clinical and financial data could not be easily shared and exchanged among providers – as many had assumed or otherwise hoped for. In the US, EHRs have generally also failed to meet levels of reporting that support the ‘meaningful use’ requirements of pay-for-performance programmes.
Cloud computing seems likely to give a new lease of life to the EHR. Server-based EHRs always run the risk of system failure, which would prevent access to critical patient data until the server has been restored. Such a scenario does not concern cloud-based EHRs. In addition, cloud services are encrypted and provide security. Cloud-based EHRs also reduce entry barriers to adoption by transferring responsibility for confidential patient information to specialized vendors.
Design and hospital re-purposing
The impact of such developments are reaching into the very design of a hospital. Christopher Shaw, Chair of a professional organization called Architects for Health and founder of the design firm Medical Architecture, believes there is a growing mismatch between the physical infrastructure of a hospital and the nature of activities expected to be required over the coming decades.
One key question here is the future of hospital buildings – whether to renovate and incrementally redesign structures or start afresh. Indeed, even as popular imagination associates future hospitals with robotic doctors, another equally beguiling scenario consists of individualized medicine, extending to some forms of surgery, carried out at home.
Hub-and-spoke models
The reality may lie in between, at least in the foreseeable future. One of the most likely scenarios might be a hub-and-spoke hospital model. Its inside tier would consist of academic medical centres serving larger populations and focused on acute care. The middle tier would be an intermediate-care hospital, located in smaller cities or larger towns and providing longer-term rehabilitation and nursing support. The outer tier would be comprised of polyclinics for outpatient diagnostics and elective care, referred from primary care physicians. At the periphery would be the patient’s home, with telemedicine treatment, and possibly some form of tele-surgery assisted by paramedical professionals on the scene. Some of the latter may well be robots.
Telehealth
After many false starts, telehealth technology is now on the edge of take-off – helping allocate care to patients more efficiently, by eliminating the need to visit hospitals, when they do not have a need to access concentrated multi-disciplinary expertise.
Telehealth is also seen as a means to bring patients back more quickly to their homes. Indeed, there is a considerable body of evidence which suggests that the sooner patients begin recovery at home, the more quickly they heal.
Telehealth is not only being pushed by technology but also pulled by economics. In the US, for example, healthcare providers of diabetic patient care have to contend with value-based measures. As a result, they are becoming increasingly dependent on real-time data from remote glucose monitors. Telehealth allows patients to be more engaged, and participate with physicians in ensuring better outcomes, by adhering to insulin or other medications.
Emerging models – examples
The challenge facing the emerging healthcare model lies in the best way to integrate resources, delivery and support mechanisms, and the need to avoid duplication. However, there are encouraging signs from several parts of the world.
In the US, Westchester Medical Center Health Network (WMC Health), is an example of the emerging hub-and-spoke hospital model. The core of the system consists of a 1,500-bed facility headquartered in Valhalla, New York, which is the only facility for complex interventions and procedures. Buttressing this are six (intermediate) hospitals, as well as several polyclinics and medical campuses. The system covers a population of more than 3 million people spread over 15,000 square kilometres.
In Europe, there are several efforts to redefine hospital design. In a variation of hub and spoke, Guy’s Hospital at London has developed its cancer centre as a stack of ‘villages’, one atop another, with each providing a different service (radiotherapy, chemotherapy, etc.).
Certain hospitals have sought to move in the opposite direction, bringing a full range of services to patients in one room or area. In Veldhoven, the Netherlands, a new Woman-Mother-Child Center at Maxima Hospital provides prenatal, delivery, postnatal and breastfeeding support services from one room.
UMC+ in Maastricht, NL
Some of the most radical efforts to address the redefinition of the hospital are being explored in the Netherlands, at Medical University Centre+ (UMC+) in Maastricht.
In late 2009, the departments of Dermatology and Orthopedics at UMC+ started out on separate tracks of what is called ‘design thinking’. Each department independently developed and implemented new care and financing systems, closely adapted to what they saw as the real needs of their patients, and combining specialities, which had been traditionally separated.
The key mission at UMC+ is to avoid pushing strategy down individual departments, which have highly specific patient groups, processes and technologies, and instead build strategy bottom up, involving inputs from across the staffing chain.
Nevertheless, the aim of design thinking is to also generate organizational change. Over time, several other departments began applying the methodologies pioneered by Dermatology and Orthopedics, creating a new hospital healthcare model.
Over time, the UMC+ model is transforming healthcare focused on rehabilitation, to preventive public health and development. The shift has also changed the role of the Board. Directors no longer set out strategies, but make communication possible between different departments. The Board aims to ensure that different departments do not seek to reinvent the wheel, and instead continuously develop and implement internal best practices.
The challenge of demographics
Nevertheless, many challenges still lie ahead. While Internet- and smartphone-friendly millennials are clearly going to benefit from new hospital care models, the bulk of hospital and healthcare needs for the next decade or two lie in the elderly. According to a Partners HealthCare study in 2016, few seniors obtain information or accomplish healthcare-related tasks online. Only 16 percent of seniors said they used the Internet to obtain health information, while just 7 percent contacted physicians online.