HealthTrust Physician Advisor Weighs Value of New Technology in Quest for Higher-Quality Care
David Alfery, M.D., an anesthesiologist and inventor in Nashville, Tennessee, is one of a team of physician advisors who help HealthTrust expand member access to innovative products that meet the mandate of higher-quality, lower-cost, patient-centered care. He talked to The Source about the advantages and disadvantages of rapid changes in technology in the field of anesthesiology, and his process for determining whether a technological advance is marginal or actually significant.
What role does technology play in providing anesthetic care?
Since an unconscious patient can’t tell you how he’s feeling and what’s going on with his body, technology is necessary to monitor him properly. In the 19th century, the only method for putting a patient to sleep consisted of ether dropped into a gauze mask over the patient’s face. And the only monitoring of that patient was simple observation: “The patient is turning blue, and his pulse is thready.” They weren’t even able to record a blood pressure.
Now we rely on very modern and sophisticated anesthesia machines for all physiological parameters, such as circulation, pulse, blood pressure, respiration, intravascular pressure and level of consciousness. These elaborate medical devices allow us to give anesthesia with great precision, but they can cost as much as a new car.
How has technology evolved over the lifetime of your practice?
As one would expect, across the 35 years of my practice, technology has progressively gotten more sophisticated and advanced the profession. The difference from the first day of my practice to now is like night and day. When I started out, we had to measure blood pressure manually. We might have had an EKG and a temperature monitor available to us, but that was about it.
One major advance has been the safeguards built into the machines. For instance, these new machines automatically prevent you from giving a hypoxic mixture. Administering such a mixture could be a potentially fatal mistake, but these machines don’t even allow it. If one part of the machine fails, redundancies are built in so that critical functions continue.
Another advance is the level of monitoring possible. Pulse oximetry allows us to monitor the patient’s oxygenation beat by beat, and end-tidal CO2 monitoring allows us to see how much carbon dioxide is being exhaled by the patient. With that, if I have a disconnect from the ventilator, I can detect it right away. Technology also provides a way to monitor the level of consciousness, giving us better assurance that patients are fully asleep.
You’ve shared many ways how advances can be a blessing. How can they be a curse?
The curse involves the sheer complexity of data that we have at our disposal. There is so much information being fed to us in the operating room. We have to sift out what is truly important, and what is noise. An example of the noise: Every monitor has an alarm system, but not all alarms are important. They can give many false positives, which leads to alarm fatigue. Anesthesiologists have to decide which monitors’ alarms to turn off and which to pay attention to.
Another challenge is the complexity of our equipment. Each machine we use has its own set of instructions: A guide to a modern anesthesia machine can be 100 pages long—I just want to turn it on and use it!
These are amazing machines, but sometimes it’s not intuitively obvious how they operate. Learning how to use some of these machines is like learning a whole new software program. You can even have problems finding the on and off switch. Obviously there are some groundbreaking and important changes, but most changes are marginal in terms of improvement and probably not worth adopting unless you need to replace old equipment.
How do you decide which new technologies to put into practice?
You have to ask a number of questions: First of all, what is the evidence that this new technology will advance my patient care? Is there medical literature to that effect?
Next, consider whether it enhances what you do in a truly meaningful way or does it represent a marginal advance. Is it just putting a bow or pretty wrapper on what you already have?
Third, does adopting this technology allow me to work more efficiently or perhaps save money? An example of that would be the newer anesthesia machines that run very low fresh gas-flow rates. The GE ecoFLOW system allows us to introduce a very low flow of oxygen while we deliver our gas. That’s important because the more oxygen that’s delivered to a patient, the more anesthetic gas—one of the high-cost items—is consumed. If you can lower your flow rate of oxygen, you can lower consumption of anesthetic gas. But in order to do that safely, you need to have very sophisticated monitoring. Some of these newer machines allow us to run gas flows low enough to the point where over the course of the machine’s life you might be able to pay for the machine itself in the cost savings of the gas.
There are a lot of marginal items that make it difficult to determine whether they really represent a significant advance you need in your practice. Here’s where many heads are better than one. HealthTrust’s Physician Advisors Program puts thought leaders together to help ascertain which new technologies are truly innovative in advancing care.
Having said all of that, there are some technologies that fall into a category I like to define as the parachute effect.
What’s the parachute effect?
The parachute effect refers to technologies that you don’t even need evidence-based medicine to adopt. The phrase came from a 2003 BMJ article that looked at all the randomized, double-blind, prospective studies that might show that parachutes would favorably impact the negative gravitational effects of jumping out of an airplane. In other words, do you need to wear a parachute when you jump out of an airplane? Obviously it’s a very tongue-in-cheek article, but the point is serious: The authors argue that there are some things that are so intuitively obvious—like parachutes—that you don’t need a study to introduce such items into your practice.
An example of this is pulse oximetry. There doesn’t need to be a study of pulse oximetry to know that it significantly decreases patient morbidity; it’s put on every single patient in every operating room and ICU in America. Some technology is so intuitively obvious that you simply recognize it for what it is and adopt it. The authors concluded their article with an invitation: “For those of you who disagree, we invite you to be the first subjects of the study for the parachute article.”
What are your thoughts on electronic medical records (EMRs)? Have they been a great leap forward for medicine, or have they been problematic in practice?
EMRs have been a mixed blessing. Our primary job in the operating room is to take care of the patient and then to do the record as best we can during the course of an anesthetic. In most cases it’s easy to have a complete anesthetic record, but for some critically ill patients you barely have time to fill out a record at all. So, technologies that auto-fill information to the record, such as vital signs, have been an advance and also save time and energy. Our records are now much more complete and accurate than when we did them by hand.
One problem, though, is that the EMR asks for so much information that it can take away from the vigilance of taking care of the patient. A lot of this record-keeping is regulatory-mandated, so we simply have no choice. Another challenge is the complexity of an EMR. It introduces yet another software program that you have to learn how to use. It can be daunting if you work at several hospitals and use different types of EMRs.
Finally, if your EMR is cloud-based and it fails in the middle of an anesthetic, it is a disaster. Imagine you’re doing a complicated cardiac case and you’re halfway through when the EMR goes down. If the record is unavailable for any length of time, you’ll have to reconstruct that work from memory while you continue the case for the next two hours.
EMRs have been a blessing but it can also take us away from taking care of our patient. Think about the last time you went to your primary care physician. He or she likely sat there with an iPad and spent much of the time checking boxes rather than making eye contact and conversing with you about what brought you in.
What technological advances would you like to see in the future?
I have no doubt we’ll see lots of new technology that is not particularly important or useful. I think for the things I will find useful, we have to go back to those original questions: Is this something that truly enhances the care and safety of a patient? Is this something that makes my care more efficient? Is this something that can save money in patient care?
After my first invention, the head of product development for the company I was working with said, ‘David, I think there’s another invention in you, but let me give you some advice. It’s not the product, it’s the problem.’ In other words: You’re not going to think of a product first; the key is to think of the problem. True advances of the future will be devices that actually solve problems.
Talk about some of your inventions and the “aha” moment when you realized this one is really going to work.
I had done a thoracic anesthesia case in which we had to deliver continuous oxygen under constant low pressure to a non-ventilated lung to provide enough oxygen to the patient. In order to do that, we had to jury-rig a system of a valve, an oxygen source, an inflatable bag and a number of items that were quite cumbersome. I remember driving home and daydreaming until a thought just popped in my mind: Why couldn’t we just have a little such-and-such?
The such-and-such turned out to be the CPAP System, my first invention. Of course it took several years of trying to find a corporate partner, convince them of what a great idea it was, and get a patent. I learned very quickly what Thomas Edison had alluded to: Inventing was 1 percent inspiration and 99 percent perspiration.
My next invention was a bite block. Previously, we made a makeshift bite block by taking some gauze, wrapping and taping it around a tongue blade, and putting it in the mouth. As I was doing this in the OR one day, I thought, wait a minute—there’s got to be an easier way to do this. From that thought came the product—my bite block, called the BiteGard, which people like because it’s so simple. The best inventions are simple.
What do you see as your role as a Physician Advisor and what are you excited about the committee doing for HealthTrust members?
First of all, I want to stay engaged in medicine since I’m now teaching in my group instead of being in the operating room. Through HealthTrust, I hope to be able to interact with other physicians in analyzing technology and trying to separate the wheat from the chaff. Is there something out there that we’re not using that we should? Ideally, we will partner with HealthTrust to better define and then make joint decisions on which specific technologies are truly needed.
I’m excited about physicians and supply chain leaders sharing perspectives on the priorities each is tasked with, and then collaborating to make related product choices in an intelligent manner. There is no way supply chain people will have an understanding of everything that happens in an operating room, yet physicians have to realize there are limited resources so they need to choose wisely.
What advice do you have on navigating difficult conversations between supply chain leaders and physicians related to preference items?
It starts with leadership in the anesthesia department. You have to have a leader whom the anesthesiologists respect and trust. They should feel free to communicate to that leader the critical medical devices that they do not wish to compromise on, but they should also be honest about which devices are just preferences. A strong leader is one who is willing to make some individuals unhappy as he or she discerns which devices are critical to patient care and which are preference items.
Productive conversations require a combination of honest communication about problems and needs as well as trust between physicians in the specialty and between physicians and supply chain.
David Alfery, M.D., received his medical degree from Louisiana State University School of Medicine, completed his surgery internship at the University of Kentucky, and did a residency in anesthesiology and fellowship in cardiothoracic anesthesia at the University of California, San Diego. He’s practiced for 35 years, primarily with the Anesthesia Medical Group (AMG), which is affiliated with multiple hospitals in Nashville, Tennessee. Alfery has invented four medical devices that have multiple patents and are sold worldwide. He has written 40 peer-reviewed articles and 10 chapters in anesthesia textbooks. He retired from clinical practice in January 2016, but has remained as lead physician educator for PhyMed Healthcare Group. He has also participated in medical missions for Operation Smile.