In Reply

We thank Drs. Saluja and Kamdar for their comments on our recent editorial view entitled, “From Heroism to Safe Design: Leveraging Technology” which appeared in the March 2014 issue of Anesthesiology.¹  We agree that technology has been proposed as a healthcare solution and is also viewed as an impediment to clinical care by many. This dichotomy is typical of an under-engineered system in which technical capabilities exceed the cultural and workflow processes that use the technology. We are not suggesting that technical solutions should or even can replace clinical decision making and acumen. However, the example of narcotics overdose is often used to highlight failures of our current system. The responses of patients to narcotics are highly variable, and our reliance on clinical acumen to prescribe the correct dosage results in the unnecessary deaths of hospitalized patients every year. Technical systems already exist to prevent or dramatically reduce these deaths. However, as suggested by Drs. Saluja and Singh, these solutions may not be acceptable to hospitals because they are perceived as simply increasing the complexity and noise in the care system. This is precisely why we believe that the engineered approach needs to integrate technologies not only with other technologies (such as the electronic health record) but also with the needs of patients and the practice of clinicians.

We also agree that healthcare technology development is largely driven by well-intentioned innovators and market forces. Manufactures work hard to create technologies that they believe will help patients. However, our current incentives are not aligned with promoting integration and efficiency. It is our responsibility as healthcare providers to promote and work toward integrated and efficient systems. In other industries, the productivity gains achieved through systems design and engineering have driven the relative costs of technology down—and this is particularly true as the costs of manpower increase.

The development of the World Wide Web and the open standards that it employs is a highly instructive model. Indeed, it is not enough for device companies to share data—but we do believe that this is a starting point for the kind of initiative described by Drs. Kamdar and Hofer. Although the development of the World Wide Web is instructive, there are some crucial differences between the development of Web standards and the requirements for such standards in medicine. Most importantly, the World Wide Web was initially developed entirely through government contracts by academics. Only when the power of the Internet was demonstrated, did it begin its march toward commercialization and wider development. Another example is the development of modern military aviation systems. In this case, the U.S. government recognized that the lack of systems integration in military aircraft was both a safety and financial liability. Working with engineering partners at government-sponsored laboratories, the government specified open integration standards for the aviation industry. The key to the adoption of these standards was that industry recognized that the only path to purchase was by adopting the standards—because the U.S. government was the sole purchaser.

The current healthcare landscape is incentivized very differently. The U.S. Food and Drug Administration (FDA) exists largely to assure the safety of devices and not to create standards. Healthcare purchasing organizations are often blind to standards and are much more attuned to cost of ownership. Finally, there is no sole purchaser and in the case of health care the federal government can only use indirect measures, such as meaningful use, to affect adoption of standards and purchasing of technology.

Ultimately, federal and state governments, the FDA, industry, healthcare organizations, and academic centers will need to work together to develop these standards. As with the agreement to open data sources to clinicians and patients, newly developed standards will threaten some existing business and clinical care models, but they will open us to a world of development and improvement that other industries have enjoyed.

Finally, we do have a “long way to go” until we can move beyond heroism and adopt a culture, technology, and system of safety. Although the path is likely to be difficult, we believe that it is a path worth taking and the only one that will allow us to achieve the best for our patients and society.