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The Effect of Internet of Things on Healthcare Technology

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Introduction

The Internet of Things (IoT) describes a phenomenon[i] through which the operational aspects of the physical world become increasingly integrated with digital platforms, enabling information to move seamlessly toward the computational resources that are able to make sense of it. Its functionality derives from the interactions between three architectural layers: sensors tasked with data collection, communication networks between sensors that orchestrate data flow, and the analytical computational platforms that interpret these data and convey meaningful representations to users. Alongside the big data revolution, IoT is at the center of a substantial increase in the mobility and diversity of data which have helped usher in a new age of open information across a plethora of fields.

Unprecedented expansion in the capacity for data transfer at each of these levels has facilitated a big push in the healthcare sector to identify a more encompassing set of performance indicators, and attempt to record, track and analyze these exhaustively. By expanding the ambit of medical monitoring applications with the aid of portable devices, the Internet of Things has tremendous untapped promise in radically improving health outcomes, particularly with regard to the treatment of chronic diseases which expends an inordinate amount of human and economic resources.[ii] We thus examine some of the key enabling mechanisms which have contributed to the influence wielded by the Internet of Things on the developmental frontiers of healthcare technology.

Drivers

Big Data Infrastructure: The latent demand for healthcare insight has fuelled the development of data warehouses and algorithms which provide back-end support for processing information collected by the network of sensors in a big data ecosystem. This can be attributed to the increasing subscription to evidence based approaches that require individual data sets to be aggregated to constitute sufficiently sized populations, which can then be mined for statistically rigorous conclusions on treatment efficacy. This has redirected efforts downstream toward data collection and tracking through building up the network of data collection devices.

Widening Sensor Application: The deployment of cost efficient sensors at an increasing rate has permitted the IoT movement to gain traction in its progress toward a comprehensive network. Gartner forecasts there will be almost five billion connected devices by the end of this year and 25 billion in 2020[iii]. Sensors are now capable of being embedded in a wider spectrum of physical objects that span the healthcare sector and are connected to monitors real-time through the same internet protocol supporting the Internet. They assume a burgeoning array of functions including accelerometry, compass direction, positional tracking and environmental indicator logging, all of which generate usable information that can be interpreted by applications to form a more holistic picture of patient health status or mined for predictive insight.

Interoperability: With Internet of Things infrastructure unfolding in a bottom-up manner, policy actions to encourage interoperability across disparate information systems has helped unlock tremendous potential economic utility[iv] and broadened the set of interdisciplinary use cases of healthcare devices. As an increasing number of services gravitate toward benchmarks such as the Open Platform Communications (OPC) standard, healthcare applications relying on IoT become more adept at eliminating barriers to usage. The OPC standard was initially conceptualized in 1996 as a means of creating commonalities across various forms of industrial telecommunication, and continues to serve as a benchmark that various data transportation technologies rely upon to facilitate data access and interoperability. The convergence of these trends permits drawing on information from a patient’s demographic profile or consumption habits that might exist outside of his electronic medical records to make more accurate diagnoses and recommendations, and could also introduce one-stop-shop solutions that provide payment history or drive reimbursements alongside treatment recommendations. We learn that complex system design challenges depend on interoperability to acquire full employability across a variety of settings, from home health monitors to health informatics systems that mandate coordination over multiple levels.

Privacy/Security: As information of a sensitive nature is often contained within a healthcare information system, security rapidly emerges as an imperative. Safeguards restricting the flow of data in the spirit of HIPAA have sprung up in a prevalent manner, providing control in the form of virtual private networks demanding device authentication, secure booting, access management, firewalling and operational systems that receive periodic updates and patches to better acclimate to nascent cyberspace threats[v]. While imperfect, these set in motion a virtuous cycle that instills consumer confidence in committing sensitive financial and health-related information to these systems, which can be employed for greater benefit accruing to users, thereby coalescing into a precedent for continued investment into countermeasures that protect health information security.

Developmental Direction

The Internet of Things foray into healthcare is estimated to rise in total economic impact from $170B to $1.6T [vi]by the year 2025. Most of the benefits derived from this revolve around productivity enhancements, time savings, improved asset utilization, as well as complex real time monitoring and coordination. The successful manifestation of IoT can be observed in the use of multiple devices that have proliferated in the digital ecosystem that we have detailed in this article.

Complex Coordination: The interaction of infusion pumps for anesthetic drug delivery to a patient’s heart takes place at the foreground of a series of other exchanges between monitors, ventilators and healthcare professionals. A trained anesthesiologist works as a single nexus of control between numerous independently operating devices, and is required to oversee the delivery and keep track of patient status during the surgical procedure. This presents a challenge of combining information across various interfaces, preventing the false alarms that individual devices trigger from getting in the way of addressing actual healthcare threats, and most crucially, eliminating the risk of human error in causing further complications.

Systems such as the Integrated Clinical Environment (ICE)[vii]  consolidate supervisory, control and data logging capabilities within a connected, intelligent substrate, leveraging a Data Distribution System that can parse through real time data streams quickly to discern which of these genuinely require human intervention. ICE could coordinate drug combination infusions to the patient with inputs from the electronical medical records and calibrate quantities through the device directly, thus reducing the avenues through which human error could undermine care quality. By centralizing a locus of control that is able to obtain an encompassing perspective of all indicators, ICE avoids misguidedly reallocating resources in response to false alarms that might result from low oximeter readings, instead undertaking corrective action only when both oxygen and carbon dioxide levels signal a lowered respiratory rate.

Facilitating Appropriate Intervention: Treatment procedures that are self-administered frequently report reduced effectiveness relative to regimes that fall under the supervision of nurse practitioners, partly due to the heightened susceptibility to family member interference, unexpected patient conditions, or a lack of discipline to follow through with tedious, repetitive procedures[viii]. Ginger.io provides a mobile application that allows diabetic patients to submit to tracking by their mobile phones, and receive strategic healthcare interventions while going about a regime that is largely enforced on a personal level. With the aid of mobile phones that have been retrofitted with the requisite sensors, the location, contact details and movement of these individuals are tracked directly. These are then interfaced with public health research insights developed by the NIH in comparison with other sources of behavioral health information. The insights extracted from the real time data streams arriving from the application can suggest patterns of behavior that might be consistent with illness or patient comorbidity. For instance, failure to move about in accordance with daily routines could indicate a lack of well-being, prompting healthcare professionals to take a closer look at other indicators or engage the patient directly.

Situational Awareness: The large amount of sensors deployed across all geographic locales and collecting various different types of data provide a fertile ground for collaboration with healthcare specific applications[ix]. These provide the concerned entities with a grasp of all the possible variables that might affect their well-being, which can prove critical in the case of ailments that are extremely sensitive to external environmental variations. Asthmapolis offers a GPS enabled tracker that measures inhaler usage by asthmatics, taken against a backdrop of externally oriented asthma catalysts. Usage levels are collated by a central database and inspected against environmental conditions that contribute to inhaler usage, such as particulate concentration in air, presence of pollen or volcanic fog. When such information is subsumed under a spatial map, asthmatics are able to acquire a transcendent awareness on areas to avoid in order to mitigate their symptoms.

Implications

Experts concur that there persists immense untapped potential for the application of Internet of Things in a healthcare setting. To ease into an environment where the merits of such integration outweigh the embryonic hazards, various stakeholders need to systematically address some key concerns that have surfaced through recent application[x]. Consumers, for instance, will have to strike an equitable balance between granting agencies permission to access private data and discerning which sets of information are of material significance in a field characterized by informational overload. Technology suppliers have to wrestle with the challenges of making sensors and network solutions increasingly affordable, such that the benefits can accrue to even the most underprivileged in society. Public policy regulators, have to actively set precedent in promoting market conditions for the drivers that have made IoT an abiding pillar in healthcare technology.

[i] http://www.wired.com/insights/2014/11/the-internet-of-things-bigger/

[ii] http://www.forbes.com/sites/tjmccue/2015/04/22/117-billion-market-for-internet-of-things-in-healthcare-by-2020/

[iii] http://www.gartner.com/newsroom/id/2905717

[iv] http://www.mckinsey.com/insights/business_technology/the_internet_of_things_the_value_of_digitizing_the_physical_world

[v] http://dupress.com/articles/internet-of-things-iot-in-medical-devices-industry/

[vi] https://www.mckinsey.com/~/media/mckinsey/dotcom/client_service/Healthcare%20Systems%20and%20Services/PDFs/The_big_data_revolution_in_healthcare.ashx

[vii] http://electronicdesign.com/communications/internet-things-can-save-50000-lives-year

[viii] http://www.forbes.com/sites/85broads/2014/03/26/4-ways-the-internet-of-things-is-transforming-healthcare/

[ix] http://www.mckinsey.com/insights/high_tech_telecoms_internet/the_internet_of_things

[x] http://www.philips.com/a-w/innovationmatters/blog/how-the-internet-of-things-is-revolutionizing-healthcare.html

Impact of The Affordable Care Act on Physician Reimbursements

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The Patient Protection and Affordable Care Act (PPCA or commonly called ACA), passed by the Obama Administration in 2010, creates several key changes within the American health care system that addresses health care affordability and availability in order to include national coverage. The Affordable Care Act includes “guaranteed issue” and “community rating” requirements, and individual mandates. These reforms compel insurers to provide coverage to any person regardless of their current and pre-disposing medical health conditions, and prohibit insurers from charging patients different coverage premiums for similar conditions.  The individual mandate, which requires individuals to have health insurance coverage or else incur an IRS fee, ensures that more individuals, both young and old, are obliged to obtain some form of coverage. States may set up health insurance exchanges under the Affordable Care Act allowing Americans within their state insurance exchange to obtain ideal coverage plans from competing private health care providers. Americans in states that have chosen not to elect a state exchange may sign up under the federal exchange to acquire coverage. While the new legislation most immediately and obviously impacts patients, the change it creates in the overall American health care system affects another key player in health care- the physicians.

As a result of the passing of the Affordable Care Act, physicians can expect to see a boom in the number of patients they care for. Especially with the recent Supreme Court ruling in King v. Burwell allowing for tax credits on both state and federal exchanges, more individuals have access to coverage and health services. The exchanges remove a major obstacle in acquiring insurance coverage for patients and allow for more patients to seek out primary care physicians. Additionally, a new Affordable Care Act revision, effective January 1, 2014, required insurers to cover ten specific services, referred to as “essential health benefits”, and sixty-three different preventive services. These newly-covered services include maternity care, mental health services, medications, rehabilitation services, chronic disease management, blood pressure and mammography screenings, a variety of immunizations, childhood behavioral and autism screenings, and access to contraception [1].As a result of such widespread coverage, physicians do not have to collect out-of-pocket payments directly from patients and will instead receive them as reimbursements from health plans.  Due to the ACA’s individual mandate and expansion of covered services, physicians can expect to see a rise in their reimbursements due to a greater influx of patients, especially those of the younger generation, seeking them out for their services.

Along with an increase in the number of reimbursements, physicians also saw a rise in reimbursement rates from the ACA during 2013 and 2014. To entice physicians to accept patients who have insurance under Obamacare’s new exchanges, legislators added a provision to raise reimbursement rates. With the ACA promoting primary care as one of its main goals, primary care physicians’ Medicaid reimbursement rates in 2013 and 2014 were raised to match Medicare rates [5]. Furthermore, primary care doctors and general surgeons received a 10% percent bonus for opening or continuing to practice in medically underserved communities. Furthermore, Medicare primary care physicians received a 10% bonus for primary services from 2011 through 2015 [4]. For reference, Medicare, the federal health coverage provided for seniors, offers physicians a reimbursement rate of approximately 80% of what private health insurance pays. Medicaid, which provides coverage for low-socioeconomic individuals who qualify, reimburses physicians a much lower rate of about 56% [3]. The Affordable Care Act focused on providing greater availability to primary care. Physicians who supported the ACA saw a large increase in their reimbursement rates, leading to an overall higher revenue.

However, this “two-year bribe” to enlist the support of physicians for the new Medicaid insurance plans had expired on January 1, 2015 [3]. As a result, the Medicaid reimbursement rates for physicians have decreased in 2015. An Urban Institute report has estimated a 42.8% reduction in Medicaid reimbursement rates for physicians as a result of the readjustments to pre-2013. The magnitude of the reduction depends on whether or not states have decided to extend the Medicaid primary fee bump using their own state funds.  Due to ongoing budgetary concerns, many states were unable to use their own funds to extend the fee increase policy [3]. This has resulted in a variation of reimbursement rates across states. Alabama, Colorado, Iowa, Maryland, Mississippi, and New Mexico have elected to continue paying primary care services at the Medicare level. Conversely, Alaska, Connecticut, Delaware, Hawaii, Maine, Michigan, Nebraska, Nevada, and South Carolina are paying Medicaid fees at higher rates, but are not necessarily at the same level of Medicare rates. At least 24 states have chosen to revert back to their lower pre-2013 rates [2]. Ultimately, the foreseeable problem from the fee cuts is that doctors will be reluctant to accept patients under Medicaid due to the lower rates, potentially resulting in accessibility problems for patients.

With the differences in high and low reimbursement rates between states, there is an opportunity here for legislators to evaluate the effect of increased primary care rates. By comparing the data from states that have continued to increase rates versus data from states that have reverted to their pre-2013 rates, we can learn how changes in physician reimbursement affect accessibility to patient health care. Looking forward, legislators can utilize the examination of the different rates to provide information on the effects of the proposed fee bump policy, ultimately using previous precedents to determine whether or not the fee bump should be continued, standardized, or eliminated across all states. We need to consider and address the role policy plays in physician’s decision to support the ACA, while keeping in mind the Affordable Care Act’s ultimate goals to provide easier access and more availability to primary care services.

 

Sources:

[1] Bendix, Jeffrey. “Affordable Care Act Affects Reimbursements.” Medical Economics: Health Law & Policy. Medical Economics. 25 July 2012. Web. 22 Oct. 2015.

[2] “An Update on the Medicaid Primary Care Payment Increase.” MacPac: Publications. MacPac. Mar. 2015. Web. 18 Oct. 2015.

[3] Matthews, Marrill. “Doctors Face A Huge Medicare And Medicaid Pay Cut In 2015.” Forbes: Healthcare, Fiscal, and Tax. Forbes. 5 Jan. 2015. Web. 22 Oct. 2015.

[4] “Obamacare and Doctors.” Obamacare Facts. Obamacare Facts. n.d. Web. 21 Oct. 2015

[5] Page, Leigh. “8 Ways That the ACA Is Affecting Doctors’ Incomes.” Recruiting Physicians Today 21.5 (2013). New England Journal of Medicine. Web. 18 Oct. 2015.

[6] Zuckerman, Stephen., Skopec, Laura., McCormack, Kristen. “Reversing the Medicaid Fee Bump: How Much Could Medicaid Physician Fee for Primary Care Fall in 2015?” Urban Institute Research. Urban Institute. 10 Dec. 2014. Web. 20 Oct. 2015.

Healthcare Information Technology and Its Impact on the Health Insurance Portability and Accountability Act

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Healthcare Information Technology: A Primer

HIT is a far reaching phenomenon responsible for integrating the flow of health information across consumers, service providers and regulatory entities, improving the coordination of safe and efficient outcomes within the healthcare delivery system[1].The physical implementations of these include computerized systems that perform acquisition, storage and retrieval of healthcare information for decision making.[2]

While the successful adoption of healthcare information technology culminates in benefits on the patient care front such as improved healthcare quality and promises public benefits to the extent of early detection of pandemics, it has resulted in concomitant threats to patient privacy. The ease of accessing electronic health information for studies has compromised information privacy through information exchanges[3].

HIPAA

HIPAA was enacted August 21, 1996 [4]as part of a wider body of legislature with the express mandate of extending healthcare insurance coverage to workers in the midst of structural or cyclical unemployment and establishing operating guidelines and standardized health plan identifiers for electronic healthcare transactions between service providers, healthcare plans and employers[5].

The legislative spirit of Title II in HIPAA lends itself to the morass of complications introduced by HIT. It fosters a conducive environment for the enforcement of legislation maintaining the privacy of health information that can be tied to specific individuals through the timely institution of punitive measures that accompany violations. Five core rules incorporated within Title II are germane to the topic of our consideration – the Privacy Rule, the Transactions and Code Sets Rule, the Security Rule, the Unique Identifiers Rule, and the Enforcement Rule. These promote greater administrative efficacy through holding the applications of HIT to certain universal standards of quality.

HIPAA Privacy Rule

The Privacy Rule mounts a direct response to the manifold opportunities for compromising privacy that emerge from the incremental prevalence of HIT[6].  As the central pillar of the privacy security framework that HIPAA relies upon to manage HIT, the Privacy Rule negotiates between the competing priorities of safeguarding health information privacy for patients and the necessity of providing key health information required for the smooth execution of prediction, treatment and payment consolidation purposes within an integrated healthcare system.

Key Stakeholders

The Privacy Rule maintains jurisdiction over health plans, clearinghouses and healthcare providers which facilitate electronically certain financial and administrative transactions subject to standards adopted by HHS[7]. By extension, the Department of Health and Human Services is also expanding coverage to include independent contractors of the covered entities who adhere to the definition of business associates, which perform functions on behalf of the aforementioned covered entities that utilize PHI. While impossible to exhaustively discuss all the applications of the Privacy Rule in governing HIT, we attempt to categorize applications under the umbrella of a number guiding principles that have shaped the legislation.

Principal Tenet: Right to Access

In principle, the Privacy Rule identifies information that falls under the category of Protected Health Information (PHI) and controls the circumstances in which this can be used or disclosed. PHI is defined as information held by covered entities[8] that concern health status, provision of health care, or payment for health care that can be linked to an individual, often encompassing components of the patient’s medical records and history. In regulation, the privacy rule requires covered entities to eschew disclosure of PHI unless specifically requested to do so by the concerned individual or a personal representative through a written authorization, or when the HHS embarks on a compliance investigation, review or enforcement action[9].

The imposition of time limits on responding to health information requests underscores the need to provide data accurately and minimize turnaround time, marshalling adequate resources and incentives toward electronic system developments that permit a more streamlined request response. In addition, the integration of HIT provides a viable platform of electronic channels that allow requests from users to be funnelled to the relevant service providers at minimal cost. On the front of providing information, HIT and electronic access converge on a more convenient mode of distribution. Vast amounts of PHI can be converted to storage devices such as thumb drives in readily producible format for more data rich reports.

A caveat persists in that an extensive network does not guarantee provision of immediate access; response time frames will ultimately depend on the interaction between system bandwidth and incoming load. In the same vein, HIT also introduces multiple possible vulnerabilities that are ripe for exploitation. In an electronic exchange environment, forms of oral or written verification can be duplicated or bypassed easily. Furthermore, the appointment of personal representatives in these circumstances generates additional uncertainty in the identification process. Covered entities have to ensure that they have the capacity to authenticate and verify the identities of users with reasonable confidence. We look to the other core tenets of the Privacy Rule as a means for navigating between the diametrically opposed demands of accurate identification and privacy protection.

Core Tenet: Correction

An inherent necessity of an information system that relies on self-declaration of important data fields pertinent to the user’s personal particulars often introduces the real possibility of human error. The desire to rectify erroneous information which could prove critical in an emergency is hence a perfectly legitimate rationale for providing users with access and modification rights to their own healthcare information. The Privacy Rule acknowledges the need for participation of users in accessing such data, and is bound to act within 60 days to either correct the record or notify the individual that the request has been denied on the grounds that existing entries are more accurate or already complete.

Core Tenet: Openness and Transparency

The principal thrust of the Privacy Rule is to inculcate a relationship between entities and users that operates on mutual faith – users give up critical information in the hope that their quality of care will be enhanced. The surest way to forge this is through cultivating greater openness and transparency in regard to policies and procedures orchestrating HIT. The Privacy Rule thus includes provisions for notice of privacy practices (NPPs) when a provider first engages targeted individuals electronically. This provides targeted individuals with notices detailing how a covered entity may use and disclose their PHI, their rights with respect to that information, as well as the covered entity’s obligations to protect the information.

Core Tenet: Safeguards & Accountability

Furthering the notion of fostering greater trust, the safeguards principle advocates the origination of a holistic system of administrative, physical and technical checks and balances to guard against breaches in PHI dissemination[10]. These include practices as securing locations and equipment, password security and executive training. While no specific measures have been identified, the breadth of the legislation’s scope encourages the extension of security to participants who fall beyond the jurisdiction of covered entities.

The yardstick in evaluating the efficacy of safeguards lies within their implementation – safeguards should be enacted through contractual devices which involve penalties for violations. Hence, enforcing adherence through control measures such as monitoring and reporting occupies a role of paramount importance. The toolbox of punitive measures dictates that liabilities for civil money penalties are ascribed to covered entities, thus placing the onus on them to keep their employees and business associates in line.

 

Core Tenet: Individual Choice

As a statute designed to shield users from the adverse impacts of privacy abrogation, the Privacy Rule conversely confers upon users the right to become more engaged in manipulating their personal records. These are granted on the basis of optional consent, where covered entities can exercise their judgment in how they go about soliciting user consent to use or disclose PHI, as well as in implementing more rigorous policies in requesting for consent prior to any information disclosure. Equivalently, the Rule also endows individuals with the right to submit additional requests for covered entities to curtail the usage and disclosure of healthcare information for treatment, payment, or health care operations purposes[11]. Electronic platforms can calibrate the granularity of options allowing entry and exit from information disclosure schemes,[12] according to the scale and magnitude of the requests initiated by certain users.

Core Tenet: Collection, Use and Disclosure

In the usage and aggregation of health information, processes must be directed toward a pre-defined, specific objective,[13] with boundaries present to preclude usage for discriminatory purposes. These are articulated succinctly in the minimum necessary standard, which stipulates that covered entities restrict requests for PHI to the minimum necessary from other covered entities. Entities are obliged to conceive of unequivocally precise procedures for recurring transactions and a reasonable set of criteria for non-routine requests.[14] These should be consistent across all partner agencies in the network, exist in alignment with state legislature, and support the core healthcare functions of operations, treatment or payment.

[1] Chaudhry, B. Wang, J., & Wu, S. et al., (2006). Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care, Annals of Internal Medicine, 144(10), 742–752.

[2] 42 U.S. Code § 1320a–7c – Fraud and abuse control program. (n.d.). Cornell Legal Information Institute, 42(7).

[3]  Perera, Gihan; Holbrook, Anne; Thabane,Lehana; Foster, Gary; Willison, Donald J. (February 2011). “Views on health information sharing and privacy from primary care practices using electronic medical records”. Internal Journal of Medical Information 80 (2): 94–101.

[4]  Atchinson, Brian K.; Fox, Daniel M. (May–June 1997). “The Politics Of The Health Insurance Portability And Accountability Act” (PDF). Health Affairs 16 (3): 146–150.

[5] Centers for Medicare & Medicaid Services, Http://www.cms.gov/HIPAAGenInfo/. (n.d.). Retrieved October 1, 2015.

[6] Summary of the HIPAA Privacy Rule. (n.d.). http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html Retrieved October 1, 2015.

[7] HHS Adminstrative Standards (n.d.). http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1299/page/1.htm Retrieved October 1, 2015

[8] Title 45 – Public Welfare. (n.d.). Code of Federal Regulations.

[9] Enforcement Highlights”. OCR Home, Health Information Privacy, Enforcement Activities & Results, Enforcement Highlights. U.S. Department of Health & Human Services. Retrieved 3 March 2014.

[10] “Breaches Affecting 500 or more Individuals”. OCR Home, Health Information Privacy, HIPAA Administrative Simplification Statute and Rules, Breach Notification Rule. U.S. Department of Health & Human Services. Retrieved 3 March 2014.

[11] Wolf M, Bennett C (2006). “Local perspective of the impact of the HIPAA privacy rule on research”. Cancer 106 (2): 474–9.

[12] “How the Lack of Prescriptive Technical Granularity in HIPAA Has Compromised Patient Privacy”. Northern Illinois University Law Review, Volume 30, Number 3, Summer 2010.

[13] “Encouraging the Use of, and Rethinking Protections for De-Identified (and “Anonymized”) Health Data” (PDF). Center for Democracy and Technology. June 2009. Retrieved June 12, 2014.

[14] “HIPAA: What? De-identification of Protected Health Information (PHI)”. HIPAA Research Guide. University of Wisconsin-Madison. August 26, 2003. Retrieved June 12, 2014.

Perioperative Surgical Home

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In June 2015, the Department of Health and Human Services honored the Peri-Operative Surgical Home at Phoenix Indian Medical Center with the HHS Innovates Award for its prominent contribution to perioperative care. The award recognized the “Assessment and Planning (A&P)” process [1], which addresses the lack of coordination in perioperative care before, during and after surgical operations.

Perioperative surgical home (PSH) has been proposed as a solution to the underperforming, fragmented, costly perioperative care system. The American Society of Anesthesiologists defines PSH as “a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience” [2]. It serves the needs of the older patient population in industrialized countries, who often  require extensive perioperative care. [3]

The PSH model aims to improve patient health and experience, and raise cost-effectiveness. The model stresses effective communication, shared decision-making, individualized assessment and perioperative care plan. The PSH model has been shown to significantly improve surgical outcomes in such areas as knee and hip arthroplasty, colonic surgery, and chronic obstructive pulmonary diseases (COPD) [4].

The PSH model is also highly cost-effective compared to current post-operative care.  PSH has been shown to reduce patients’ length of stay, admissions to skilled nursing facilities and costs of care in connection with knee arthroplasty. [5]

Anesthesiologists are the key players weaving together the various components of PSH.  Indeed, as one authority has stated, anesthesiology is perioperative medicine[6]. Although anesthesiology has long been viewed narrowly as a specialty focused on intraoperative processes, it can expand to become the leading specialty in PSH models; it has the potential to deliver significant results in reducing patient morbidity and mortality, and increasing patient satisfaction. [7]

With PSH models, patients and anesthesiologists can establish a trustworthy relationship at the time of admission to a surgical home. Instead of receiving disparate sedation from different anesthesiologists, patients can be looked after by a single provider. [8]

As a consequence, the field of anesthesiology is projected to evolve under the growing adoption of PSH models nationwide. Anesthesiologists may turn into “super-specialists” whose expertise and experience concentrate on fields related to adults, children, critical care, academic research, and pain medicine. [9]

Future anesthesiology education should also aim to integrate the role of the anesthesiologist in PSH models.  Anesthesiology‎ residents can face complex challenges such as patient mistrust, misunderstandings in consenting processes and the questioning of competence [10]. As adoption of PSH becomes more prevalent, more such challenges will arise. These can be preempted and addressed through medical education.

There are two types of challenges in moving towards PSH models: operational and fiscal. Hospitals may be reluctant to change surgical care teams to accommodate PSH models, and anesthesiologists may require additional training and guidance to take up leading roles in coordinating pre-, intra- and post-operative care. Moreover, the extra service provided by anesthesiologists may not be adequately reimbursed. Perhaps a bundle package compensation model may be more adequate than a fee-per-service one. [3, 8]

Though not a panacea, PSH-based models promise to significantly improve healthcare on a large scale. One such model has in fact been successfully implemented within the United Kingdom’s healthcare system.[11]

References:

  1. HHS Idea Lab, Peri-Operative Surgical Home, http://www.hhs.gov/idealab/projects-item/peri-operative-surgical-home-posh/
  2. Schweitzer M, Fahy B, Leib M, Rosenquist R, Merrick S. The Perioperative Surgical Home Model. ASA Newsl 2013;77: 58–9.
  3. Holt NF. Trends in healthcare and the role of the anesthesiologist in the perioperative surgical home – the US perspective. Curr Opin Anaesthesiol. 2014 Jun;27(3):371-6,
  4. Kash BA, Zhang Y, Cline KM, Menser T, TR Miller. The Perioperative Surgical Home (PSH): A Comprehensive Review of US and Non-US Studies Shows Predominantly Positive Quality and Cost Outcomes. Milbank Q. 2014 Dec;92(4):796-821.
  5. Helwick C. Perioperative Surgical Home Lowers Costs, Optimizes Care. Anesthesiology News. 2014 Dec;40(12)
  6. Rock P. The future of anesthesiology is perioperative medicine. Anesthesiol Clin North America. 2000 Sept;18(3): 495-513.
  7. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical Risk Factors, Morbidity, and Mortality in Elderly Patients. J Am Coll Surg. 2006 Dec;203(6):865-877.
  8. Kain ZN, Vakharia S, Garson L et al. The Perioperative Surgical Home as a Future Perioperative Practice Model. Anesth Analg. 2014 May;118(5):1126-30.
  9. Prielipp RC, Morell RC, Coursin DB et al. The Future of Anesthesiology: Should the Perioperative Surgical Home Redefine Us? Anesth Analg. 2015 May;120(5):1142-1148.
  10. Bould MD, Naik VN, Hamstra SJ. Review article: New directions in medical education related to anesthesiology and perioperative medicine. Can J Anaesth. 2012 Feb;59(2):136-50.
  11. Knott A, Pathak S, McGrath JS et al. Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study. BMJ Open 2012;2:e001878.

 

Anesthesia: A Historical Overview

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Twenty-one million people in the U.S. will receive general anesthesia in a typical year.  But the ability to artificially induce any of the defining components—analgesia (insensitivity to or prevention of pain), paralysis, amnesia, and sedation/unconsciousness—is relatively new. The word anesthesia itself only first appeared in the dictionary in 1751, and was first used to describe the mental state that follows from the inhalation of ether vapor by the prominent physician, Oliver Wendell Holmes, Sr.

Only 300 years ago, surgical pain relief options were limited to the consumption of alcohol or opium (to the point of stupor), or the powers of suggestion or “positive thinking”. Magnets and hypnosis, or ‘Mesmerism’ were used to cure various ailments. Around May 1812, the English novelist Fanny Burney wrote a compelling account of her experience undergoing a mastectomy without anesthesia:

“I saw the glitter of polished Steel – I closed my Eyes. I would not trust to convulsive fear the sight of the terrible incision. Yet – when the dreadful steel was plunged into the breast…I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incision – & I almost marvel that it rings not in my Ears still [?] so excruciating was the agony. When the wound was made, & the instrument was withdrawn, the pain seemed undiminished..I concluded the operation was over – Oh no! presently the terrible cutting was renewed – & worse than ever”

In contrast, the gratitude felt by the first mother to receive chloroform for the delivery is clearly expressed by the name she gave her baby—Anaesthesia.

 

Anesthesia Through the Ages

 At Xenon Health, anesthesia is our specialty.  But how did our field progress from the prescribing of a few shots of whiskey prior to surgery to the precise science of administering by gas, injection, and infusion drugs that act on different and overlapping sites in the central nervous system? This post reviews the landmark discoveries that led to the evolution of anesthesia over the centuries, and pays homage to the innovators that shaped the field.

400 BC

  • Hippocrates recommends opium poppy use for pain-relief.

13th Century   

  • Theodoric of Lucca, an Italian physician and bishop, induces unconsciousness prior to surgery by holding sponges soaked with opium, mandrake, and hemlock under patients’ noses.
  • In 1275, the Spanish chemist Raymundus Lullius synthesizes ether, which would become the first reliable, general anesthetic—though this would not be recognized for almost 570 years.

 

16th Century  

  • Ether is first used on animals by Paracelsus in 1525. Fifteen years later, Valerius Cordus repeats Lullius’ synthesis by distilling ethanol and sulfuric acid.
  • In Malta, patients to be operated on were made unconscious with a wooden hammer.

 

17th Century  

  • Opium is first administered intravenously.

 

18th Century  

  • In 1745, the French explorer Charles-Marie de La Condamine publishes the first written account of curare, a paralytic poison derived from a plant that he observes is used on arrows by South American tribes to kill their prey. Note: This property will become important in 200 years as future anesthesia techniques will require the control of muscle relaxation.
  • Nitrous oxide (NO), commonly known as laughing gas, is isolated by Joseph Priestley in 1772. This substance became a heavily researched topic, with Dutch chemist Martinus van Marum publishing 35 papers on his studies and the nitrous oxide experiments performed during the last years of the century by Thomas Beddoes and Humphry Davy demonstrating the gas could be inhaled with analgesic effects.
  • The engineer James Watt makes two related inventions—a machine to produce NO and a “breathing apparatus” to inhale the gas.
  • In 1778, Antoine Lavoisier discovers oxygen (O2).

 

19th Century  

  • In 1805, morphine is discovered by Friedrich Serturner, who names it after the Greek god of dreams, Morpheus. It becomes the first product launched by Merck in 1827.
  • Chloroform is simultaneously discovered in 1831 by scientists in three countries. Although frequently used for about 50 years after it is discovered to have anesthetic properties in 1847, a concern about fatalities emerged just 2 months after it is introduced. It was later found to cause death from paralysis of the heart in about 1/3000 patients (and also to be toxic to the liver and to depress most other organs) and by 1940, was replaced by safer alternatives.
  • General anesthesia is officially born in 1842, with William E. Clarke administering ether from a towel to a patient about to undergo a tooth removal. Its first documented use as a gas for surgical pain relief is by Crawford W. Long, but since he waited to publish this until 1849, the credit was instead attributed to a Boston dentist, William Morton. A leg amputation and a lower jaw removal followed. Results are first presented to the medical community at the meeting of the Boston Society for Medical Improvements on November 9, 1846. Two days later, patent No. 4848 granted to Morton and his mentor, Charles Jackson, 10% of all profits from the surgical use of ether. This is met with swift opposition from the medical community and is not enforced.
  • In 1853, the discovery of the hypodermic needle, the syringe, and the injection of morphine are innovations made possible by Alexander Wood. He invents a hollow needle that fits on the end of a piston-style syringe and uses the device to successfully treat pain by morphine injection. Note: Today, the majority of anesthetic drugs are delivered intravenously—which would not be possible without the invention of the syringe.
  • Local anesthesia, in which pain is only blocked in specific locations, comes onto the scene in 1884 with the discovery of injectable cocaine. The renowned Baltimore surgeon William Halsted first injected 4% cocaine into a patient’s forearm and observed that the arm became numb only below the injection site.
  • The first spinal anesthesia is also performed that year in Germany when Leonard Corning injects cocaine between the vertebrae of a 45-year-old man and causes the patient’s legs and lower abdomen to become numb. Note: Synthetic drugs will replace cocaine in the next century, with the discovery of Procaine (Novocain) and Lidocaine in 1905 and 1948, respectively.
  • In 1891, the German physician Heinrich Quincke introduces the technique of lumbar puncture—later used to administer medications directly into the cerebrospinal fluid (CSF) during spinal anesthesia.
  • The blood pressure cuff is introduced by Scipione Riva-Rocci in 1896.

 

20th Century  

Once a patient is anesthetized, there is a critical need to closely monitor the body’s vital signspulse, respiratory rate, blood pressure, temperature, and oxygen saturation. This century heralded improvements in patient monitoring techniques, and a wider selection of synthetic anesthesia agents.

  • The electrocardiogram is developed in Holland by Willem Einthoven in 1903.
  • In 1905, a Russian physician describes the sounds—now bearing his name, “Korotkoff sounds”—heard through a stethoscope placed over a peripheral artery as a blood pressure cuff is deflated. This allows the systolic and diastolic components of blood pressure (BP) to be determined. This measurement gives the anesthesiologist important information during a procedure; a low BP may indicate anesthetic overdose, hemorrhage, or heart dysfunction, while a high BP may be evidence of patient distress due to inadequate anesthesia levels or uncontrolled hypertension.
  • In 1913, endotracheal anesthesia is invented when Sir Ivan Magill develops a technique to place a breathing tube into the windpipe, and that same year Chevalier Jackson reports the ease with which using a laryngoscope allowed the insertion of an endotracheal tube.  This was a landmark both for the field of critical care medicine because of its impact on resuscitation, and surgery, as operations of the abdomen and chest would not be possible without the ability to protect and control the airway.
  • The cuffed endotracheal tube, which allows positive-pressure ventilation (PPV) into a patient’s lungs, is discovered in 1928 by two University of Wisconsin physicians, Arthur Guedel and Ralph Waters.
  • Dr John Lundy changes the standard of care for inducing general anesthesia when in 1934 he introduces the intravenous anesthetic, sodium thiopental. Compared to the pungency of inhaled ether, a Pentothal injection was more tolerable and became the chosen method for sedation.  Propofol, introduced in 1981, has since replaced Pentothal, but the delivery of anesthesia still almost always begins with the intravenous injection of some anesthetic drug.
  • The American Society of Anesthesiologists is founded on Feb 13th, 1936.
  • The paralyzing effect of curare became important as muscle relaxation was a necessary step to allow the insertion of endotracheal tubes. This ancient arrow poison was first deliberately applied to surgery by the Canadian doctor Harold Griffith in 1940.
  • World War II and the Korean War battlefield medical inventions include shock and resuscitation units used to save the critically ill and wounded. Post-Anesthesia Care Units (PACU’s) and Intensive Care Units (ICU’s) are developed as extensions of these.
  • Inhalation anesthesia is forever changed, when in 1956, British chemist Charles Suckling synthesizes halothane. Unlike ether, halothane has a pleasant odor, high potency, fast onset, low toxicity, and is non-flammable. Halothane replaces older “vapors” and is the forerunner to the modern inhaled anesthetics that followed: isoflurane, desflurane, and sevoflurane.
  • Stanford anesthesiologist Dr. William New develops the Nellcor, the first commercially available device to allow pulse oximetry monitoring Prior to this date, it was not possible to measure a patient’s oxygen saturation and the first sign of low oxygen levels was often a cardiac arrest. A unique feature is an alarm that lowers the pitch of the pulse tone as saturation drops, giving providers a warning that their patients are in danger of oxygen deprivation.

 

21st Century  

Today, modern anesthesiologists utilize dozens of medications and apply sophisticated high-tech medical equipment, requiring on average four years of training beyond medical school.  What will the next “advance” be?  New drugs, new delivery routes, and new delivery systems are the areas where research is focused. This includes:

  • Transmucosal drug delivery—which can be nasal, buccal, ocular, rectal, and mucosal, and is similar to how a patch works, with the advantage that mucosal membranes are thinner and more highly vascularized so the onset of action is faster and the dose needed is lower.
  • Intravenous anesthesia evolving towards a continuous drug infusion rather than an intermittent bolus approach. Related to this development is the optimization of Patient-Controlled Analgesia (PCA), a precision drug delivery technology enabled by an electronically controlled infusion pump which allows patients to self-administer (up to a prescribed threshold) until sufficient pain relief has been achieved. PCA has been found to result in less over-or under-dosing and more optimal drug delivery; patients also resume mobility more quickly and can be discharged sooner.

Interested in reading more on the topic? These are the sources referenced:

Anesthesia Fact Sheet. National Institute of General Medical Sciences Web site. http://www.nigms.nih.gov/education/pages/factsheet_anesthesia.aspx Updated May 2015 Accessed October 7, 2015.

Eger II EI, Saidman LJ, Westhorpe RN .The Wondrous Story of Anesthesia. New York, NY: Springer; 2014

Timeline of important dates and events in the development of anaesthesia History of Anaesthesia Society Web site. http://www.histansoc.org.uk/timeline.html Accessed October 7, 2015