Editorial

Health Technology
José Wilson Magalhães Bassani
CEB - Centro de Engenharia Biomédica

This issue of MultiCiênciabrings about matters on Health Technology. Plenty of prospective and hope seem to lie ahead over new technologies. A significant amount of work has been carried out, and significant advances are noticeable in every single area. Nevertheless, one needs to consider carefully the meaning of owning and using health care equipment based on more advanced technology. What are the benefits and problems that may ensue?

It is not hard to figure out the amazing benefits brought about by miniaturization of diagnostic devices. This issue presents new ideas on equipment for clinical analysis (diagnostic devices). A clear trend towards lab-on-chip using the microfabrication and miniaturization technology will most likely flood the market in the next few years. Brazilian research can effectively bring contributions to this field, as shown by Luiz Otavio Saraiva Ferreira in his article, also warning us about the new challenges. As the author points out, “one may conclude that a cultural change involving the entire community dealing with diagnostic devices is under way affecting equipment operators, maintenance crews, personnel in charge of equipment specification, and health system managers”. Innovative technologies will require new approaches regarding their use and incorporation.

Maybe no other area in medicine has benefited more from technology from a practical point of view than medical imaging. From a deeper knowledge on anatomical structures gained from the application of non-invasive procedures, to the realm of the structure-function association, technological advances have brought about innovations and improvements regarding the medical practice, both for diagnosis and for surgical treatment support. It is unquestionable that nuclear magnetic resonance and other techniques developed from nuclear medicine have contributed significantly, as analyzed and richly depicted by Eduardo Tinóis da Silva in his article. Positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) exemplify how image technology has made the unknown accessible, rendering visible what formerly seemed transparent.

Nowadays, it is virtually impossible to ignore the myriad of new products constantly becoming available. Digital electronics changes rapidly. Millions of people all over the world have incorporated to their daily lives cell phones, produced with new shapes, colors, and functions of increasing complexity. Yet, how many of them do not hesitate to exchange more essential products for new cell phones, in order to play those little keyboards, talk to friends, and get so many messages at any time or place? Computers may be seen as another trivial example. Nevertheless, how many computer owners can actually use a computer for more than “browsing the Internet?”

The big issue is that health equipment cannot be considered an exception. However, from the sphygmomanometer routinely used for blood pressure measurement, to the complex equipment for nuclear magnetic resonance, the problems are the same: How to procure, maintain and use medical equipment correctly and safely? When update or consider them obsolete? Using equipment poorly installed and maintained, or kept in improper environment and/or operated by untrained personnel may be catastrophic. As well shown by Gerson Florence and Saide Jorge Calil in their article, much of the risk (i.e., potential sources of damage) involving medical equipment stems from the environment, rather than from the equipment itself. There are ways to minimize the risk, but actions ought to be taken at several levels.

The risk factor is a systemic issue. It is not legitimate to say "making errors is human"! In the hospital environmenterrorsdo not necessarily occur due to negligence. There are a number of error-generating factors, and most of them can be targeted. Advanced centers where health systems are carefully controlled, more than five people die due to errors every hour in USA hospitals (1), and in UK, errors have harmed as much as ten per cent of inpatients, which corresponds to about 850,000 cases per year (2).

Medical equipment ownership and use do require special care and financial resources for maintenance. In 1995, the Brazilian Ministry of Health (MH) revealed that medical equipment in bulk quantities worthing billions of reals were inoperative due to poor maintenance. It can be figured that 10 to 20 per cent of the total available medical equipment in Brazil would fail if submitted to safety inspection tests. The awareness of such a situation has triggered reaction from the MH, which recently has initiated a program for personnel training in medical equipment maintenance management practices (3).

Data has being issued by the MH regarding medical equipment in health facilities (HF) in Brazil. From the data available in 10/19/2004 for São Paulo State ( http://cnes.datasus.gov.br), we can estimate that all equipment would be worthing from a minimum of R$ 8,150,631,150.00 up to a maximum five times greater (source: ECRI - Emergency Care Research Institute, USA). Therefore, if the equipment is to receive adequate maintenance, at least 6% of their nominal value should be spent yearly, or R$ 489,037,869.00 based upon the minimum above. We believe that less than 10% of the public hospital network have being able to apply effectively 2% to 6% of their equipment investment in maintenance and technological updating. Deterioration is therefore inevitable, and the amount of inoperative equipment thereby will also increase, all together increasing the risk for the patient. The foregoing deals only with maintenance, which certainly is not the sole factor to be considered. If other aspects are also taken into account, one may conclude that the scenario is quite complex and may have an overwhelming impact over the entire population.

Health technology evolution implies stepping up robustness. The more robust a system is, the easier its operation becomes. Small mistakes do not disturb the outcome, for the equipment is able to resist to certain disturbances and flaws, up to a certain point. As a result, however, vulnerability increases. The good news is machines can issue diagnosis. Vulnerability lies in the operation of such machines by someone trained exclusively with keyboard operations, as once learned when dealing with mobile telephones. Although terrific images may be produced by computerized tomography, the patient is the one who takes the burden of being heavily exposed to X-rays should the utilization criteria be relaxed, or the former (often safer) technology be abandoned just because a new one has shown up.

It has become very easy and appealing to undergo ultrasonography during pregnancy. Even against the recommendation of the American College of Osteopathic Obstetricians and Gynecologists, about 70% of pregnant women are submitted to an echogram at least once. With an increase in power by 5 million times, little difference is observed in the image produced by the most modern ultrasound equipment, but this is not so regarding the risk of ultrasound undesired effects. As it has being emphasized, no law states that only the lowest power should be used. One should consider, as well, the extreme variability in competence of all those involved with the operation of such equipment (4).

Our statistics in the management of equipment maintenance for UNICAMP’s health area show that about 1.5% of all equipment sent for repair at the Center for Biomedical Engineering are not deranged, andthe malfunction cannot be attributed to operation error. What would possibly be the reason for the malfunctioning? After detailed study and advances in this specific area, we are now able to identify the main reason: electromagnetic interference (EMI). This is not necessarily related to the inadequacy of the electrical circuitry. Undisputable and solid data on the effects of cell phone use in the hospital environment are presented by Suzi Cristina Bruno Cabral and Sérgio Santos Mühlen in their article, where the authors remind us the wider question of crossed interference among pieces of equipment. “One of the most effective ways to avoid EMI is to build equipment providing for electromagnetic compatibility under pre-established conditions”.

Wireless communication inside a hospital may turn out to be an electromagnetic ocean with unpredictable “waves”. This is a concrete and a definitely unresolved issue! Should we make believe it is inexistent, or are we going to engage ourselves in an effort to make it visible to the point that it may be considered as a managerial risk?

Solutions to enhance safety in the use of health technology need to be systemic and multidisciplinary. The article by Binseng Wang presents a realistic proposal of framework towards planning, incorporation and management of medical technology. One important point is that the approach should include a health policy defined in a broader scope, and the various phases of the technological incorporation would require adequate strategic planning by the very health promoting institutions. As policy and rules from government must permeate through the whole process, the feedback from health facilities might and should serve to regulate the process within acceptable levels and according to the conditions of each country.

We are not aiming at expressing pessimism or skepticism towards what is our greatest motivation in Biomedical Engineering, namely, to pursue solutions to face new challenges and society wishes. Our goal is to emphasize the importance of a careful and thorough analysis of all aspects of a given problem. Assessment and incorporation of medical technology based on political or bureaucratic reasons do not demonstrate an effort to improve the service. Such attitudes add up problems, rather than solving them, leaving no room for a healthy competition among available technologies. Should the country be unable to use and maintain such technologies, it will as well be unable to offer future benefits to all who are in the greatest need of health care: the patients (that is, all of us).

See also into the Interdisciplinary Network:

“Análise quantitativa do termo interdisciplinaridade no período de 1970 a 2004” (Quantitative analysis of the term ‘interdisciplinarity’ between 1970 and 2004) de Lorena Dall´Ara Guimarães e Miriam Plaza Pinto; “Análisis em inteligencia tecnológica ¿Qué es para que sirve?”(Analysis in Technological Intelligence: What Is It and What It Is Used For?) de Q. Luzselene Ricón Arguelles e Victor Gerardo Ortiz Gallardo, e “Quintais domésticos e sua relação com estado nutricional de crianças rurais, migrantes e urbanas” (Household Backyards and How They Relate with the Nutritional Condition of Rural, Migrant and Urban Children), de Ana Paula Branco do Nascimento, Marcelo Correa Alves e Silvia Maria Guerra Molina.

Bibliography:

1 - Bogner, M S. Stretching the search for the ‘Why’ of error: The systems approach. J. Clinical Engineering, 27: 110 -115, 2002.

2 - Rigg N. Department of Health. An organization with a memory: Report of an expert group on learning from adverse events in the National Health Service. Norwich, U.K.: The stationery Office, 2000.

3 - Brasil. Ministério da Saúde. Secretaria de Gestão de Investimentos em Saúde. Projeto Reforsus. (The Medical Hospital Equipment and the Maintenance Management:Web based training). Editora do MS, 720p, 2002.

4 - ACOG practice patterns. Routine ultrasound in low risk pregnancy. evidence-based guidelines for clinical issues. N. 5, August 1997. American College of Obstetricians and Gynecologists. Int. J. Gynaecol Obstet., 59 (3):273-278, 1997.

José Wilson Magalhães Bassani

Master and Doctor in Electrical Engineering by UNICAMP (with focus on Biomedical Engineering).

Chaired professor – Biomedical Engineering – Electrical and Computing Engineering College, Department of Biomedical Engineering – UNICAMP

Director of the Center for Biomedical Engineering between 9/18/1998 and 9/8/2005.

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