The Big Fix
by donya currie
Engineering's role in repairing America's broken health care system.
It didn’t take long to come up with this story idea. It seemed like just about every time the Dean was in an editorial meeting, he would ask why we hadn't written about health care. He’d speak about how the College must produce good citizens of the world, not just great engineers. So here’s our ode to the Dean, a man who truly inspires, through a story on engineering a better world through health care.
Health care might be the most difficult system in the universe, considering all the things that can go wrong.
It’s unpredictable. No two patients are guaranteed the same quality of care on any given day. A clinic waiting room can become packed at any moment, overwhelming an already stressedout health care staff. A seemingly minor error can be deadly.
As U.S. lawmakers grapple with how to overhaul the nation’s unwieldy and costly health care system, they would do well to consider systems engineering’s long track record of streamlining industries to eliminate fraud, waste and errors. Medical mistakes are linked to 98,000 yearly deaths and 1 million injuries.
“If you look at the health care system it’s just, to put it bluntly, a big ugly system,” said Joseph Hartman, professor and chair of the UF College of Engineering’s Department of Industrial & Systems Engineering. “You’ve got people and services needing to be moved around quickly and efficiently.”
And then there’s that “uncertainty” factor. As in, how do you know exactly how long a doctor will need to spend with a particular patient? In an emergency department, how can you predict the number of people who’ll be packed into the waiting room on any given hour of the day or night?
"Systems thinking allows us to at least ponder how we can do things better"
Kids these days, or anyone younger than 35, might not remember a time when doctors couldn’t simply order an MRI and moments later hold a picture of a patient’s brain in their hands, said Bruce Wheeler, interim chair of UF’s Pruitt Family Department of Biomedical Engineering. Thanks to that “spectacular bioengineering triumph,” as Wheeler called it, there’s no need to saw through a patient’s skull for a look at the brain.
Wheeler’s father-in-law checks his blood pressure at home daily and phones the results into a computer that automatically uploads the information for his doctor, saving him a trip to a clinic. Pacemakers, cochlear implants, artificial skin — the contributions engineering has made and continues to make to the field of medicine save and improve countless lives.
That engineering/medicine relationship needs to go a step further, though, especially in light of a health care system where 30 cents to 40 cents of every dollar is spent on costs linked to “overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency,” according to a landmark 2005 report, Building a Better Delivery System: A New Engineering/Health Care Partnership.
Enter engineering, the epitome of efficiency.
The report, the result of an alliance of the National Academy of Engineering and the Institute of Medicine, grew out of the idea that systems engineering tools — the same practices that keep Wal-Mart, Boeing and the rest of corporate America going — could transform the way health care is delivered. Those tools include simulation, supply-chain management, game theory, value-at-risk, optimization and data mining. For the patient, this translates into a better experience and a smaller bill.
Systems engineering can help in the design of operating rooms, management of human resources (how many nurses should be on the night shift, anyway?), scheduling of patients and staff and more. The marriage of health care and engineering can, and should, result in not only more efficient health care, but also better quality and fewer deadly mistakes.
“If you look at what has to happen in a hospital, you’ve got really difficult problems because of the uncertainty,” Hartman said, pointing again to the need for a systems engineering approach to grease the gears of the health care industry. And that’s exactly where engineering can help health care.
“There really is great opportunity for improving the quality, safety and productivity of health care delivery by bringing these fields and disciplines together,” said Proctor Reid, director of programs for the National Academy of Engineering and study director for the committee that authored the Building a Better Delivery System report.
Reid can list countless areas where engineering approaches could improve health care. For example, hospitals might be making strides in adopting information technology for things like electronic patient records, but how about using IT and systems techniques to improve clinical operations?
“Progress has been very slow, and, I think it’s fair to say, disappointing,” Reid said. Yet he pointed to “islands of progress” like Vanderbilt University’s health system.
During a 2008 workshop on using systems engineering to improve traumatic brain injury care in the military health system, Vanderbilt professor Dr. William W. Stead, who also is the Vanderbilt University Medical Center associate vice chancellor for strategy and transformation, presented a case study that should have hospital administrators taking notice.
Stead proposed hospitals shift from “expert-based practice” to “system-supported practice,” which, of course, uses engineering to improve patient care. In this case, patients on ventilators need complex, specialized care and are prone to many life-threatening complications. A systems approach, Stead theorized, could tackle the problem.
“The idea behind system-supported practice focuses on the system’s performance; teams of people, a well-defined process, and information technology tools work in concert to produce desired results consistently,” Stead wrote in his case study. The experiment focused on intensive care units and was based on a design that could be implemented in 45 days or less.
Stead said a major breakthrough in the development of the system-supported practice was the “process-control dashboard.” This shows a patient’s status as a set of red, yellow or green lights, using a line for each patient and a column for each element of the standardized practice. A green light means everything is as expected, a yellow light means action must be taken but there is still time to do so, and a red light means take immediate action.
One reason the Vanderbilt system ended up working well, Stead said, was that it operated as a “closed-loop control,” meaning the output of the system feeds back directly to change the inputs.
He likened the system to the interaction between a thermostat and a furnace. When the thermostat senses room temperature is falling below the set limit, it calls for heat, the temperature rises, and the thermostat approaches the upper control limit and turns off the heat. If someone opens a window and changes the inputs to the system, the thermostat adapts to that change without reprogramming.
“The desired performance is achieved without programming complex interactions among inputs or modifying the program as inputs change,” Stead wrote. “This is what is needed in health care.”
For that to happen, though, hospitals and clinics need to agree on an end-to-end plan of action and have real-time measurement to show what is happening and display a patient’s status and how that fits into the plan.
Because, as the report cautions, a run-of-the-mill application of engineering just won’t do. Hospitals are more complicated than giant retail super-centers, and the human body is more complex than an airplane.
UF engineers and medical researchers are constantly looking at creative ways to improve health care. The contributions they are making are patient game-changers that will build on the work programs like Vanderbilt have done to make the internal workings flow more efficiently.
Dr. Paul Carney, director of the UF Epilepsy Research Laboratory, is himself both a neurologist and biomedical engineer and teaches in the medical school and College of Engineering. He sees endless opportunities to meld engineering with medicine to improve health care.
Epilepsy is a seizure disorder that affects 50 million people worldwide. An estimated 25 percent of people with the disease aren’t helped by drug therapy. In five to 10 years, Carney hopes to be able to offer them a tiny device that will be implanted in their brain and deliver signals to prevent seizures. In working on that neural prosthetic idea, Carney recognized it needed a specialized, engineering/medical approach.
“I realized we were really doing systems biology,” Carney said. “We do strive to combine experimentation with computation around the system, in this case the epilepsy system. We constantly bump into having to understand the brain as a system.”
“Systems thinking allows us to at least ponder how we can do things better,” said Hartman of the Industrial & Systems Engineering Department. “I think the more people you bring into this arena to ask these questions is a healthy thing.”
Or consider associate professor Benjamin Lok’s Virtual Patients Project. In a twist on video game technology, it allows medical students to examine and relate to life-size patients and learn everything from bedside manner to better diagnostic techniques. Aside from appearing a little wild-eyed, the virtual patients are surprisingly realistic, and they can actually be more effective than human actors when it comes to stimulating patient/doctor interaction. A virtual patient, for example, could show symptoms an actor couldn’t fake, such as different pupil sizes.
Carney said UF is particularly well-positioned to foster the engineering/health care partnership because the College of Engineering and medical school are physically close, and faculty are willing to work across disciplines. One course, BME 6010, links engineering students with a preceptor in the medical school, and the student comes up with a solution to a problem. That course has spawned real-life medical innovations such as a device that could detect air in a premature baby’s abdomen before deadly infection set in. Another student came up with a hand-held brain monitoring system for intensive care patients that could tell a nurse whether a patient was asleep, awake or having a seizure.
“There are a lot of problems out there, and I think the solutions are within reach,” Carney said. “A systems approach is great because it forces people to interact. We have to meet in the middle and try to leverage each other’s expertise.”
National Academy of Engineering member William Pierskalla said a systems approach is most useful on the operations side, helping countries like the United Kingdom deliver effective and efficient dialysis treatment.
“Basically, what systems engineering is pretty good at is handling waste or inefficiency,” said Pierskalla, a retired engineering professor from the University of California Los Angeles and Wharton School at the University of Pennsylvania who’s still active in engineering research. “But health care has been slow to adopt it, as well as a lot of IT in general.”
With a 2009 economic stimulus package that earmarked $19 billion for health information technology and a spirited national health reform debate brewing, timing could be perfect for more systems engineering to be woven into the health care fabric.
“We just have been disappointed that we haven’t been able to
move this further along,” Reid of the National Academy of Engineering
said about incorporating more of a systems approach to
health care. “But I’m optimistic.” 
© 2008 university of florida college of engineering. all rights reserved.