Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate American College of Healthcare Executives
High Tech Needs High Touch in Program Delivery
At the outset, we need to develop an understanding of the meaning of "High Tech / High Touch" and what will be presented here. In the strict sense, "High Tech" refers to technological advances in the medical field. Typically this brings to mind instrumentation such as Computer Assisted Tomography, or CAT scans, and other such equipment. As we look around the veterinary marketplace today, we discover a plethora of new technological advances; everything from telemedicine to blood glucose monitors for home use. Instrumentation is undoubtedly a large part of advancing medical science, but to truly take advantage of the "High Tech" approach to veterinary practice, we must look beyond instrumentation. Indeed, we must even look beyond the veterinary and medical fields. Scientific developments in laboratory technology are allowing more rapid, more accurate and more cost effective diagnosis of diseases well known to our profession as well as those on the frontiers of veterinary knowledge. New medicines allow us to treat bacterial infections that defied our earlier armament. We can now even treat viruses to some extent. New medications allow safer treatment of endocrine, parasitic, neoplastic, degenerative, autoimmune diseases and even congenital and developmental abnormalities as well as infectious diseases and much more. The list is endless.
More than 75 years ago Aldous Huxley predicted test tube babies and genetic engineering in his book Brave New World. Consider the advances in Genetic Predisposition Identification in the last decade (PCR testing). We are only beginning to scratch the surface of the impact that genetic engineering and other forms of gene management may have on our future and the future of medicine. The completed mapping of the human genome in 2000 opened the door to far reaching changes in medicine and life as we know it. Man will utilize this new found knowledge to try to intervene and improve the quality of his life. We now hold in our hands the power to fight disease, enhance life spans and even influence looks and abilities. Genetically engineered recombinant vaccines are a reality. Recombinant subunit organism, gene-deleted organism and vectored nonpathogenic organism vaccines are already in common use. The problem is that veterinary clients are unaware that we are taking advantage of this futuristic technology. Clients do not understand that recombinant gene vaccines make it much less probable that vaccinations will cause problems. We need to educate them to the fact that genetic engineering has a useful purpose other than the high profile research on cloning and that it is already helping create a safer world for their pets. So what about cloning? Experts inside the human genetic field expect to see the first cloned human child within the next five to ten years. Scientists have already cloned animals. People are depositing their favorite pet's tissues into the "Savings and Clone" corporation where they can order a clone of their pet on demand. It is not a question of when controversial technologies like cloning and stem cell research will arrive but rather a question of how they will be applied. The Genie is already out of the bottle, and she's not going back in. We can expect to see continued debates, misuse and even legislation in this area, but in the veterinary field this is already a reality. Cloning is not in common use at this point, but the automobile and penicillin were not in common use at one time either.
Take a look outside the medical professions, into the world of business. Consider the impact that computerization has had on the world and specifically on the business function of veterinary practices in the last twenty years. It is truly revolutionary. Any practice operating without the assistance of up-to-date practice management software based on efficient hardware is handicapping itself. Today's practice management software systems provide management information that we formerly guessed at or was so cumbersome to calculate that we didn't bother and as a result the management efficiency of our practices suffered along with the net income. Beyond the scope of internal practice management, the newer software systems are impacting the clients. They are fast, efficient, accurate and friendly. They generate educational information for clients; provide marketing opportunity, and personalized invoices and other documents with pictures and client / patient specific information.
One cannot consider computerization, these days, without appreciating the Internet. Many veterinary practices are logged in continuously to provide quick access to search engines that provide a wealth of up-to-the-minute medical knowledge. The Internet and its associated capability promise to have a greater impact on the business world than the invention of the computer itself, and it will take place in a shorter time frame. E-commerce and on-line pharmacies are realities and they are having an impact on veterinary practice. There is too much money and power at stake for them not to. E-marketing is occurring daily, and the rate in the veterinary profession is increasing. E-mail itself has already had an impact on the postal services and all indications are that it will eclipse them, if not render them obsolete. On-line information sources such as VIN and VSPN, to name a couple of veterinary specific ones, are a way of life, enhancing the dissemination of information and ideas at the speed of light. The Internet presents the problem of a totally un-referred communication medium disseminating volumes of misinformation. The challenge to the veterinarian in practice is really to steer his clients in a direction where they can get accurate information on veterinary subjects that they are researching. Many practices have established a practice website containing client educational information agreeing with practice philosophy and core values, targeted specifically toward the practice client base.
Look at other advances of the computer age. Accounting software, communication software, organizational tools, handheld computers, cell phones, CDs, DVDs; the list is endless. In fact it is difficult to think of a functional hardware advancement that has not been touched by computerization. Consider advancements in business strategy, improved service, customer psychology, revised sales techniques, improved demographics; another endless list. Improved patient appointment scheduling techniques such as concentrated booking and high density booking, hospital zoning and staffing for efficiency and elevation of staff to a more productive role as veterinary extenders are all advanced veterinary practice concepts. Check out the recent developments in medical record transcription styles that promote continuity of care, integrate a client response system and spawn a recall system handled by hospital staff so that clients who defer treatment or elect to try symptomatic therapy do not "fall through the cracks." This is patient advocacy at work.
It actually boggles the mind to consider the volume of these advancements and the speed at which they are engulfing our society. It is difficult to keep up. It is impossible to keep up without a conscious effort. The point here is that the veterinary profession, as a whole has not been known for being the first on board with cutting edge technology. In fact it seems to be tradition for us to lag considerably behind, undoubtedly preferring the "fur-lined rut" of our known world. Employing technological advances involves moving with the times and that involves change. It necessitates venturing out of that comfortable "fur-lined rut" into unfamiliar and possibly unexplored, uncharted territory. Veterinarians must, by all means, develop the habit of looking beyond "what is," "the way we've always done it," the "That won't work here" attitude. It is incumbent that we begin to look beyond the limits of our veterinary imagination in order to not only thrive, but to survive. "How scary can it get?" The question is, "How much opportunity abounds outside our cozy "fur-lined rut?" "What is possible?"
The First "Surveillance" Lab Test
The ERD® (Early Renal Damage® in-house Snap-Type test by Heska®) was introduced, granted without a clear "narrative" being established and his a major academic condemnation. The academic position, it was not disease specific for early renal disease, etc.
The fact is, the ERD was never a disease test, it just checked for microalbumin coming out of the kidney in the urine. So, when does microalbumin normally come out of the kidney? - Like never dude - only when damage is occurring! What can cause a "false positive" for microalbumin - blood can cause a positive. So, when do RBCs normally come out of the kidney? - Like never dude - only when damage is occurring! So while it was never a Early Renal Disease test, it was right on target for Early Renal Damage!
It took the academics over 5 years to accept that an ERD screen was a critical screening step (70% of the positive ERDs are from extra-renal causes); it economically and quickly screened for the kidney damage syndromes.
In general companion animal practice, it fits perfectly into the semi-annual screening programs for the semi-annual life cycle consultations for younger adults, as promoted by the AVMA (www.npwm.com).
This starts with client relations just stating, "Don't forget to bring a fresh urine sample", when making the appointment....... sometimes followed by, "Carry a pie pan out for the morning walk, slide it under the squat, and transfer it into a margarine tub with a tight lid before you bring it in". It continues with the OPN asking, "Did you bring the urine sample or do you need help collecting it?" It is a quick Snap-Like test, able to be run by staff, with about 70% being good news - finding nothing- which they call the client and celebrate! The other 30%, the doctor calls and sets up a new diagnostic plan (note - any pre-clinical signs are good news also).
The natural rationalization is, "Why bother? If it's not broken, don't fix it?" It is progress. The greatest companies in the world pursue progress for the sake of progress. They have entire divisions devoted to progress. The general public, our clients, are aware of the frontiers of medicine, business and society. They are intrigued by new developments. They are impressed when we provide advanced techniques, instrumentation, and systems to enhance their veterinary experience and the quality of veterinary healthcare. We are in the business of selling "peace of mind" to our clients. They do not buy Fluffy a vaccination, they buy Fluffy protection from disease. In the same light, if there is a better diagnostic technique, more advanced instrument, better treatment method, more convenient system or more economical procedure, our clients want it. They deserve it, for the peace of mind it affords them and the quality of healthcare it brings their animals.
Veterinarians have long prided themselves on being the self-appointed guardians of the client's wallet, frequently to the detriment, not only to our own wallets, but even more importantly to the quality of healthcare that we offer our patients and clients. How many times are we guilty of not running tests or doing a procedure or using the best treatment modality because we fear that the client will say it's too expensive or the test results will be negative after they have spent money on the test? Negative test results are not a failure, but they are a good thing. They tell us and the client what is not wrong. They bring good news to the client. They offer peace of mind. If CT scan results are negative for intracranial pathology, that is a good thing. Clients are relieved to know there is not a brain tumor and that means that the cause of a seizure disorder may be treatable. Peace of mind.
What about expense? These technological advances are expensive, right? Some are, and some are not. Will clients pay for the use of these new and advanced techniques? Of course they will, for the peace of mind they offer. However, it is up to us as professionals to educate out clients on the "value" of these new techniques. Though they may be aware of them, they will likely not understand the value as it aligns with the fee charged for new technology. Educating clients on the value of services is what highly successful practices do well. The channel to get clients is much deeper than just telling staff to tell clients. The channel involves leadership to persuade staff to "buy in" to the value, training and coaching to get them good at using new instrumentation or techniques and support to help them achieve self confidence in new technology. When these things have been achieved, we do not have to ask staff to teach the value to our clients. Their pride in the practice and its capabilities, their confidence in themselves and their attitude of patient advocacy and service to patients and clients naturally causes staff to educate and, yes, sell these advances to clients.
Critical Diagnostic Advancement
About 30-60 percent of all puppies and kittens coming out of shelters or pet stores (usually from "puppy mills") have been exposed to Giardia, and this is the #1 zoonotic protozoan diseases of people in the USA today.
The Snap-Like test will find it pre-sign, yet the educational VTH syndrome teaches young vets to watch for explosive diarrhea.........surveys of clients have shown to the last person, no one wants explosive diarrhea on their carpet or kitchen floor. Wellness care dictates we offer the very best in pre-symptom/sign diagnostics, and initiate treatment to prevent the spread of a dangerous disease/organism.
BTW - Cat Scratch Fever is now linked to Bartonella (it was an unknown cause ten years ago to new graduates)..........now there is a reason to ask about elderly or HIV patients at home, and start screening cats if there is a "at risk" population in residence.......but most practices have not added these questions........so high tech knowledge goes unrecognized as a high touch concern. :>(
Should one consider purchasing all the new technology available? Unfortunately, many of us have made "High Tech" purchases that have not worked out so well financially. The number of ultrasound machines, laser surgery units and telemedicine instrumentation covered with sheets, gathering dust in some obscure corner of an astounding number of veterinary practices is appalling. Example: ultrasound screening of long-haired cats for polycystic kidney does not require a veterinarian to do the procedure........Purdue offers a technician course in ultrasound......it is not a too, used by physicians, in human healthcare, it is always a technician function........ yet in veterinary medicine, doctors want to control, the machine, so we cannot offer it at staff pricing for screening techniques, and the animals suffer. There are a large number of practice owners who purchase powerful computer systems, then use them basically as point of sale cash registers. These are expensive "toys" to cast aside or underutilize after becoming disenchanted with their capability, ease of acceptance or lack of understanding. We must explore methodology to avoid these mistakes. Realism and planning are necessary. Commitment is essential.
Finally, take a bird's eye view of your practice. Give some thought to what needs of your clients and patients remain unmet, and which ones can be addressed by staff. For that matter, look for community veterinary healthcare needs that beg for attention. There are enough opportunities in most communities to use the High Tech / High Touch approach to create niches within the practice to improve diagnostics, service or treatment modalities to provide valuable services to clients and increased patient advocacy as well as cash flow.
The petMap has allowed the OPN to do a blood pressure screen before the doctor enters the consult room. The petmap is 40% cheaper than the Cardell 9401, which was the only other machine easiest enough for routine consult room use.
The lead II ECG as a screening tool has Dr. Larry Tilley's endorsement, as does echo cardiology. Both can be nurse technician screening techniques, yet academics condemn anything less than a seven lead ECG by a specifically-skilled veterinarian.
The use of the Canine Photonics Cold Laser (660 nm), using acupuncture points, has amazing potential for superficial muscle and tendon pain management (about $80 per 30 minute treatment, using an economical instrument purchased at less than $900), yet as of the end of 2007, less than 400 were in use America-wide.
The use of specialists for CT scans, diagnostic ultrasonography, MRIs, traveling surgeons, etc., has become more common, especially in metroplex communities, but there are still old timers who do one ACL a month and consider themselves providing a quality service........which is the misnomer of the year!
The byproduct of these type services is an enhanced practice image. Look to provide services that are not available, or at least not common, in your community. In the eyes of your clients, cutting edge technology is clearly better. It is clear to them because the entire practice team has made it clear to them in a prescribed personal heart felt caring manner. All of this produces an image that makes your hospital a clear choice for the best practice in your community. Can you imagine what happens to your image when this process is replicated across the spectrum of forward thinking concepts?
Planning for most high tech purchases usually goes something like this: The practice owner is at a veterinary meeting and strolls past a booth in the exhibit hall that features some gadget he has been "wanting" for a while. He engages in a conversation with the company representative (whose job it is to sell the company product) and find out there is a "show special" on the gadget under scrutiny. Excitement builds and the conversation ends with an order being placed. No planning. None. Remember the old adage, "Failing to plan is planning to fail." Now when the equipment arrives, there is no action plan for it. There are no standards of care involved in its use. It's a neat piece of equipment with great potential so the doctor uses it vigorously for a few weeks then tapers off to little or no use. Out comes the sheet to cover the telemedicine unit. Out of sight, out of mind (also out of pocket).
Before rushing into the purchase of a high tech piece of equipment, take a reality check. Why do you want the new gadget? What will you do with it, precisely? How does it enhance service to clients and patients? Will it offer peace of mind to clients? How will you get your clients to accept this new technology? Do you intend to use this new technology to generate a profit? What is the reasonable lifetime of this strategy or instrumentation? Here are the step-by-step factors to consider:
Can you write a "job description for the new piece of equipment?
Can you get the equipment on a 90 day lease/purchase/return deal?
When is training being done, before procurement or concurrent with procurement?
If it is not used as planned, will you commit to its return?
Proforma versus Job Description
In fancy consultant talk, each new capital expense equipment purchase will answer the above questions in a proforma break-even analysis of equipment use. In reality, the doctors must agree on the utilization plan and write a "job description" for the piece of equipment before it can be purchased.
Many practices get a 90 day lease from a vendor with a "loaner," then test their plan. If it works, they buy a new one; if it falls short, no loss of capital expense budget monies occurs.
Sound reasoning must be employed before making any equipment purchase, and forward thinking (cost-benefit planning) must be used when making a cutting-edge equipment purchase. A practice owner can choose to make the purchase for any reason they want to, including just to have an expensive toy in the practice. However, Medical Director expectations must be realistic. Getting a return on investment in high tech concepts presupposes that the concepts will be utilized in the practice and that there will be some type of tangible benefit from their use. This leads one to believe that the more often the concept is used the greater will be the return on the investment. That telemedicine equipment in the corner under the sheet is not improving cash flow, enhancing patient care or improving client satisfaction. A commitment to use the new technology is required before anyone can even think about a positive return on investment. This means setting and following policies for the use of the new technology. It frequently involves establishing standards of care that support, even demand, its use.
Part of the plan must include staff training as well as the doctor's commitment. The training must involve leadership techniques such as persuasion that the technology has value to the client and patient. Turning a profit is an acceptable secondary motive for veterinary staff but it is not an acceptable primary motive. All staff must be trained in the value of the equipment, procedure, etc. to the client and patient. They must all understand why it is important and how it works. They must have a clear understanding of the charges associated with its use. They need to know what the plan is for the use of the new technology in the practice. Technology usually improves standards of care. Staff needs to understand this. Training must be thorough, down to the process of actually composing narratives that will be used as a team to explain the procedure and the value of the procedure to clients. All messages given to clients should contain identical information. The practice message must always be cohesive, though it may have differing style or delivery between team members. Once the team understands the value of the technology, the process of how it works and how it will be implemented in the practice, pride and patient advocacy will cause the staff member to carry that information to the client. In veterinary practice, clients frequently do not know or understand what seems to us to be simple or obvious unless we tell them. They may not know that some of the medicines and techniques we use or services we offer are cutting edge, state-of-the-art technology. The practice staff may not know either. Make sure they do. Ensure proper and thorough training.
Be realistic about the longevity of the new technology. It will figure into its value to the practice. We are living in a rapidly advancing world. New computers are obsolete in two years. The next generation product has already been designed and likely produced before we buy the current generation product. Many high tech purchases will have a finite life, whether that is until it is worn out or, more likely, until something better causes it to be obsolete. We must calculate a method of achieving the desired return on investment over the life of the product.
Tips for High Tech Purchasing
What is new today will be out of date tomorrow so some of yesterdays state-of-the-art technology, even gently used equipment, may provide a great deal of value compared to slightly more advanced new models. A few years ago, human pediatric endoscopes flooded the secondhand market, and made great veterinary diagnostic tools at very low costs. Dental x-ray units from human pre-owned sources are currently following the same trend.
Some of the new concepts will have variable formats so it is usually a wise decision to go with the one that seems to be winning the popularity contest. The marketplace winners of the format race will ultimately be better supported, more widely used and more easily upgraded.
Similar products are usually available at variable prices. Choose quality over price or quantity. You usually get what you pay for. It is OK to get a good deal but before you determine what constitutes a good deal, decide exactly what your needs and expectations of any new technology are. There is no need to pay extra for unneeded technology but a good price on a piece of equipment that will result in a compromise in functional quality is a poor investment.
Assess "need" versus "want". Some gadgets look and sound good when presented by the company sales force, but are really more sizzle than steak. An honest evaluation of what is the practice's need for the technology and how it is going to help is in order. Consider if your current technology is acceptable and to what degree before upgrading to something shiny and new and expensive.
Shop around. Research what is available, what features are offered in the technology in which you are interested. Find out who sells it and compare prices, especially pre-own from human healthcare sources. Be sure to compare apples to apples or clearly understand the differences. You can't have too much information before making a big purchase.
New products don't always perform as promised. Some of them are not adequately tested before entering the marketplace or encounter obstacles in the real world that were not anticipated in the research and development of testing phase. If you purchase a product and it doesn't perform as advertised, complain about it. Loudly; publicly, if you must.