How might anesthesia be delivered in 2020?
From a cockpit, where a single anesthesia provider seated before a bank of screens and monitors will oversee several surgical patients at once, communicating with the OR team, monitoring patients' physiologic data and, with the aid of decision-support software, adjusting their infusion rates.
Remote-controlled care. That's how John P. Abenstein, MD, an associate professor of anesthesiology at the Mayo Clinic in Rochester, Minn., sees the future of surgery.
This cockpit model is already working in intensive care and post-cardiac units across the country, says Dr. Abenstein. That such a model of delivery would eliminate the requirement for skilled personnel is not lost on him.
"How do you respond to an increased demand and a decreased supply of anesthesia providers?" he asks. "Not by having 1 highly skilled [anesthesia provider] per patient. One anesthesia provider per 1 patient is the road to oblivion. Who do we really need in the OR?"
Industries that have succeeded have used technology to improve efficiency, says Dr. Abenstein. "We're 10 to 20 years behind the technological advances that have gone through other industries."
Telemonitoring and decision-support systems can also monitor and analyze trends and sound alarms before problems reach a critical level. Often the decision-support system "sees" a problem before the anesthesia provider does.
"None of this is ground-breaking technology," says Dr. Abenstein. In fact, the Mayo Clinic tested a closed-loop anesthesia control system in the 1950s. What has improved, he says, is the technology's ability to process, transmit and present the information generated.
As more surgery centers become affiliated with regional health networks, telemonitoring may become more affordable for surgery centers because they would be able to piggyback on the more powerful networks of large medical centers, says Dr. Abenstein.
How might surgery be paid for in 2020?
The private insurance market's pay-for-performance incentives will drive payment policy for ASCs, predicts Marian Lowe, a partner and senior vice president of federal health policy for Strategic Health Care, based in Washington, D.C. In addition, the gap between Medicare reimbursement rates for ASCs and hospital outpatient departments will probably narrow, says Ms Lowe. Currently the average ASC payment is 59% of what an HOPD earns.
What if the surgical facility and the surgeon no longer received separate fees? A global fee could be on its way, in which reimbursement of the physician and the facility would be bundled into 1 payment, says Ms. Lowe. CMS has already started pilot programs that bundle fees for inpatient procedures. If the concept were expanded to outpatient procedures, the surgical facility could make out well, depending on its relationship with the physicians. "That will be a difficult contract-negotiating challenge," says Ms. Lowe.
Another issue is the accountable care organization model, which is designed to hold providers responsible for the overall cost of patient care and encourage collaboration between physicians, hospitals and other providers in a community. The collaborative organization would be rewarded or penalized based on whether its members reduce costs, improve quality or reduce the rate of growth in spending. Any savings would be shared between Medicare and the organization.
This concept likely favors large medical institutions and health networks, says Ms. Lowe. If the concept catches on, a non-affiliated surgery center could face challenges when the larger institution believes it can save money within its system and exclude local ASCs. However, if the institution sees a surgery center as a partner, where procedures can be done for less than in the hospital and the savings could be shared, the larger institution may actually send procedures to the surgery center, says Ms. Lowe.
How Did Our Predictions for 2010 Turn Out? | ||||
Prediction |
YES |
NO |
INC |
Comments |
Incisions will become smaller |
X |
Laparoscopic cameras, graspers, ultrasonic scalpels and tissue sealers can now pass through a 5mm trocar. |
||
Surgeons will train with video games | X | Surgeons use virtual training tools, including the Nintendo Wii, to improve laparoscopic, robotic and endoscopic techniques. | ||
More single-use instruments will be reprocessed | X | Reprocessing is predicted to continue growing, by 12% each of the next 4 years. | ||
More hospital and ASCs will become partners | X | In many communities, regional health systems and surgery centers have stopped seeing each other as competitors and teamed up. | ||
Surgeons will wear heads-up monitors | X | The heads-up concept is catching on in ophthalmic surgery, where some surgeons look at a high-def monitor rather than through the microscope eyepiece. | ||
ORs will have voice recognition to control lights, tables and devices | X | A futurist's favorite, you'll hear this one again. For now, its use has been sporadic. | ||
GI surgeons will use a miniature sewing machine attached to the end of an endoscope to place sutures | X | Endoscopic suturing is used in only a few surgical locations, with marginal success. | ||
Surgeons will be able to access the patient's EHR in the OR | X | Federal mandate calls for an EHR for every patient by 2014. | ||
* To see the story from our September 2000 issue, go to www.outpatientsurgery.net/2000/09/outpatient_surgery_2010.php. |
What new same-day cases might we see in 2020?
If Medicare lets ASCs perform unicompartmental knee replacements in 2009, what will it allow freestanding facilities to host in 2020? Level-1 spine fusions, says Joyce Deno, RN, chief operations officer for the eastern region at Regent Surgical Health in Westchester, Ill.
Natural orifice translumenal endoscopic surgery (NOTES) procedures may make their way into day-surgery facilities once the techniques are refined and surgeons get over the learning curve.
Eventually, procedure times will become shorter, says Gloria Van Milligan, RN, MSN, CNOR, a healthcare consultant with the Sg2 consulting group in Skokie, Ill.
In the coming years, general surgeons may incorporate more endoscopic techniques into their practices. "The growth of NOTES and endoluminal procedures for GI diseases will make it a necessary skill for general surgeons who wish to offer a full menu of therapies," says Steven Schwaitzberg, MD, FACS, chief of surgery at Cambridge Health Alliance in Massachusetts. As medicine advances, general surgeons will need to adopt the therapies that allow them to better treat the diseases of the abdominal organs. "The change from cut to scope will not mean the surgeon will stop taking care of those diseases," says Dr. Schwaitzberg. "It is likely that some procedures for GERD or morbid obesity will emerge."
However, there's a long way to go. Using NOTES techniques, a cholecystectomy currently takes 4 hours to perform. Bariatric procedures may be among the first NOTES procedures performed in an outpatient setting. One possibility is transoral gastric stapling, an incisionless procedure in which a stapler is passed down the throat.
Currently the procedure requires general anesthesia and takes between 1 and 2 hours. Patients go home after 24 hours. Eventually, the device used in the transoral gastroplasty (TOGA) could be modified for use with conscious sedation on an outpatient basis, says Sreeni Jonnalagadda, MD, FASGE, a professor at Washington University School of Medicine in St. Louis, Mo., and an investigator for a TOGA study. "This is a part of the evolution of technology. Open bypass to laparoscopic bypass to endoluminal therapy with general anesthesia to, hopefully, endoluminal therapy with conscious sedation, or same-day discharge following endoluminal therapy with general anesthesia," says Dr. Jonnalagadda.
Endoscopy's offshoot, robotics — long touted as the next big thing — has yet to arrive in outpatient surgery centers because of the cost and setup time for each procedure. U.S. hospitals, on the other hand, have purchased 825 robots in spite of the $1 million to $1.7 million cost.
But the 2020s might be the decade for robots to emerge in outpatient surgery. Just as lithotripsy and MRI machines have become smaller, robotic tools will be scaled down in coming years. It's inevitable. "A lot of first-generation instruments are bigger," says William Hanson, MD, director of surgical intensive care at the Hospital of the University of Pennsylvania and author of The Edge of Medicine: The Technology That Will Change Our Lives (Palgrave Macmillan, 2008).
Today's robots are bulky. But smaller versions and new designs are on the horizon. British researchers are developing the i-Snake, an articulating tube about the diameter of a penny. The robot, which incorporates a camera and instruments at the end, will slither through the GI tract and airways and leave no external scars. The combination of smaller diameters, smaller instruments and better imaging capabilities will let surgeons make increasingly smaller incisions, says Dr. Hanson.
But for robots to make their way into surgery centers, the price will have to drop well below current levels and more surgeons will have to know how to use the robots, says Ms. Deno.
Other procedures that will become more common in surgery centers include liver biopsies, new ablation treatments for Barrett's esophagus and implantation of gastric pacemakers, says Ms. Van Milligan.
More complicated and equipment-intensive same-day procedures, such as endoscopic retrograde cholangiopancreatography (ERCP) — a procedure to treat the liver, gallbladder, bile ducts or pancreas using a combination of fluoroscopy and endoscopy — will remain in hospitals, says Steven Morris, MD, JD, chief executive of Atlanta Gastroenterology. In contrast, fewer GI procedures will be done in physicians' offices because the cost and requirements of mandatory quality assurance measures and accreditation agencies such as the Joint Commission will make them no longer practical, says Dr. Morris.
On the other hand, virtual colonoscopies, which do not require sedation, may be performed in an office setting, says Ms. Van Milligan. Currently virtual colonoscopies are not covered by Medicare because of insufficient evidence of efficacy. But that may change when more studies come out. The technology may become more interesting to Medicare when more people are added to government healthcare spending and Medicare is forced to stretch reimbursement dollars as far as possible. "This question is tied up in the future reimbursement plan for the nation as we move toward nationalized health care," says Ms. Van Milligan.
How might anesthesia change in 2020?
Machines might do a lot of the thinking and heavy lifting for anesthesia providers in the not-too-distant future.
Meet McSleepy, a device that measures depth of hypnosis based on EEG analysis, pain with a pain score algorithm and muscle relaxation using phonomyography to record the low-frequency sounds created during muscle contraction. McSleepy then uses a series of algorithms to control infusion pumps that deliver the best mix of anesthesia medication for the situation in less time than it would take a human anesthesia provider to make the calculations for proper dosage. McSleepy could reach the market in 5 years, says Thomas Hemmerling, MD, DEAA, an anesthesiologist at McGill University in Montreal, Canada, who along with colleagues has created the McSleepy prototype.
A similar computerized sedation system might appear in endoscopy suites first. This spring, an FDA advisory panel recommended approval of Sedasys, a computer-assisted personalized sedation (CAPS) system for use with propofol during colonoscopies and upper GI tract procedures. The CAPS system automatically adjusts the propofol dose based on monitoring of oxygen saturation, respiration rate, heart rate, blood pressure, end-tidal carbon dioxide and patient responsiveness. When it detects signs of oversedation, the machine automatically reduces or stops the flow of propofol, increases oxygen flow and instructs the patient to take a deep breath, according to the manufacturer, Ethicon Endo-Surgery.
How might cataract surgery change in 2020?
Lasers may soon be used in cataract procedures. "Within 5 years, I foresee using femtosecond lasers in the OR or pre-op area to perform some of the surgical steps prior to incising the eye," says David Chang, MD, an ophthalmic surgeon and researcher in Los Altos, Calif. The laser would be used to create the phaco incision, to correct astigmatism with corneal relaxing incisions, to perform the capsulorhexis and to pre-chop the nucleus into multiple fragments for aspiration.
Patients might not be going home with eyedrops, says Dr. Chang. "We would inject a tiny sphere of medication that would last for a week and replace the need to use any other post-op eyedrop medications. There would be no medication instructions or questions to answer."
Eye surgeons may be using light-adjustable IOLs to fine-tune the refractive result. "Two weeks following surgery, the patient would return and have any residual refractive error corrected — like having LASIK, but performed on the IOL itself. We would even add multifocality if the patient wanted," says Dr. Chang.
What might ORs look like in 2020? One of the biggest changes in the OR will be fewer cables, says Dr. Schwaitzberg. Signals will be sent from imaging devices to monitors wirelessly. As batteries become more efficient and have greater capacity, more devices will become battery-powered, which will eliminate even more cords. Wireless technologies will also help improve safety, as radiofrequency identification systems for sponges and instruments become more common in surgical suites, says Dr. Schwaitzberg.
Will we really be paperless by 2020?
In 2020 the federal government's goal of a universal application of electronic health records may have become a reality, to some degree. Thanks in part to federal incentive funding, healthcare facilities will have installed EHR systems. Whether all these systems will be able to speak to each other and send health records back and forth is a big question mark.
Ms. Van Milligan doesn't see the medical record flowing seamlessly from 1 provider to next, especially when the providers belong to different health systems. "It will move within the system," she says. However, sending an EHR outside a health system network or regional network will remain a challenge because of lack of standardization.
One thing future-watchers do agree on is that as EHRs become more common, so will data collection for pay-for-performance analysis. EHRs will make it easier to gather information that documents that clinical processes were done correctly because the information will go directly into the electronic record. Mandatory reporting and cross-comparisons will be part of everyday life, says Dr. Morris.
Although information capture will be much easier, it will still be more work for providers, especially nurses who will have to wade through the systems. The graphical interfaces may become more user-friendly, but each EHR will have more pages, or screens, of data and check-boxes for nurses and physicians to click through, says Ms. Van Milligan.
In spite of the extra work, data collection will change the way your facility operates. As more data on outcomes, medical errors, patient satisfaction and adherence to safety and quality guidelines becomes available, facilities will constantly be fine-tuning their operating procedures in order to improve their scores and, in return, their reimbursement from Medicare and insurers.
Currently CMS penalizes hospitals that do not report quality data. But there's no level of quality that providers need to meet in order to receive the full market basket update each year. "It's essentially ???pay-for-reporting,'" says Ms. Lowe.
However, under a demonstration run by Medicare for inpatient hospitals, providers who meet certain criteria based on how they follow protocols and standards of care for procedures such as hip and knee replacements and coronary artery bypass grafts receive bonus payments from Medicare. Providers that do not meet target scores sacrifice payments if they continue to participate in the voluntary program, says Ms. Lowe.
In the future, facilities with good quality scores will use their ratings as a marketing tool. Some already are. "Hospitals are using it now to empower themselves," says Dr. Morris.
How else might the face of outpatient surgery change by 2020?
For one thing, more and more surgery will be done on an outpatient basis. Today, more than 77.5% of all surgeries are outpatient procedures and 41% of all outpatient cases are done in ambulatory surgery centers, according to Outpatient Surgery Magazine estimates based on state data. Fueled by continuing advances in less invasive surgery and safer anesthesia, both of those numbers should continue to rise.
"Ten years ago, laparoscopic cholecystectomy was only inpatient and now it's a common outpatient procedure," says Ms. Deno.
For another, surgery will continue to migrate from hospitals to ambulatory surgical centers. Medicare spending on ASC services grew annually by an average rate of 9.7% between 2000 and 2007, according to a study by KNG Health Consulting. About 70% of the growth in Medicare services provided by ASCs was attributable to procedures — particularly ophthalmology and gastrointestinal — moving from the hospital setting to ASCs, says the report.
For example, the ASC market share of GI services grew from 17.3% to 36.6% between 2000 and 2007, while the HOPD market share of those procedures fell from 75% to less than 60%. The market share for physicians' offices remained around 5%.
What the study did not find was any merit to the charge lodged by ASCs' critics that physician-ownership of surgery centers leads to overutilization of services. "We find little evidence that induced demand is a driver of ASC service volume," the authors write. "Most of the growth in Medicare services since 2000 resulted from a movement of services from the HOPD to the ASC."