The past 28th to 30th of September a very interesting congress took place in Alicante organized by the IVF-SPAIN Foundation and Merck Serono. The main focus were new technologies for human reproduction, especially time lapse predictive technologies, but also genomic and endometrial technologies. This video shows in short the congress best moments. What do IVF technologies mean for employees and patients? Despite all the focus on clinical and technical aspects, one question that was often heard in informal conversations was “what do these technologies mean for our embryologists and what or they mean for our patients?” Predictive time lapse technologies like Eeva (Early Embryo Viability Assessment) can identify in a more accurate way than embryologists, which embryos are more likely to implant. As a matter of fact, studies show higher implantation and pregnancy rates when using Eeva. Diego Ezcurra, technology head of Merck Serono, stated during the congress (see TV news in Spanish) that there are already prototypes for automated cell injection; a pretty artisanal work of embryologists. Other automation possibilities are sperm vitrification and embryo assessment too. Anthropologist Sarah Franklin describes in “Biological Relatives” the paradox of IVF labs as a sort of high tech uterus (ex vivo) with a highly degree of manual and artisan work of the pre-industrial sort. Definitely by 2020 the artisan component of the embryologist’s work will, if not disappeared, be almost extinguished.
Sarah Franklin describes also how the embryologist’s work and the lab themselves are a mystery to the patient, who often does not understand well how embryos develop (usually an intimate process related to sexuality and the own body) in this high tech setting (not intimate and outside the body). The patient finds herself in front of a black box. Seldom patients assign a sort of “mystic” attributes to the process; ethnographic observation in IVF clinics shows that patients bring into treatments cultural and social beliefs: religious, spiritual, superstition or self-constructed mental schemes, for instance related to genetics (see articles by Paxson, Inhorn, Gurtin). Nurses and assistants report the same in my observation. Also forum analysis shows that superstition and self-made mental schemes belong. Automation technologies like Eeva promise to put an end to the mystic and black box character of the embryology lab and make all the process easy to understand and transparent to the patient. But, will technology bring more transparency? Do technologies make clinics more patient centered or more self-centered? Historical experience tells us that technologies are primarily developed and bought for companies’ sake, not for customer or patient convenience: Labor cost reduction, productivity increase and customer data have been since the early 1800s and still are main drivers for technology development. Why should lab automation technologies be different? In fact, research and experience suggests that massive medical technification has been one of the main reasons for the decline of a more personal patient-physician relationship. A technification that has saved many lives, but that might have contributed to open a gap between doctors and patients; more precisely, organizing healthcare institutions around technology and thus changing the doctor’s role. This is the only the opinion of Gabriel Heras – intensivist at a Madrid Hospital- (see video in Spanish with English subtitles) who runs a very interesting blog pleading for the re-humanization of intensive care. Literature is divided, some authors argue with Dr. Heras that technology took patients out of the center (see this article) and others see evidence that it is rather the contrary, like this experience in a neonatal unit. A good balance between both positions can be found in these findings of the American Medical Association. In this sense, the described evolution would support the initial thesis, that all technologies are developed for the organization’s sake; customers and patients would only benefit indirectly insofar their benefits means more income, productivity or efficiency for the organization. Is patient centered technology enough? This might be true for classical medical technologies where IT has played a major transformation role: IT assisted blood and other fluid and tissue analysis, scanning and ultrasound and also e-health. And, of course, ERP, quality, CRM and management IT systems that force patients and professionals to go through paths previously designed by experts and consultants; thus more oriented to the organization’s self-interest. Of course, it is a relative truth: many technologies have been developed for the patient’s direct benefit, like surgical techniques, tomography, etc. Yet it is true, that many technologies have obtained more rejection than acceptance and for this reason, more and more designers work with user or patient centered approaches. Including the patient context, insights from family, caregivers and other approaches has been undoubtedly very helpful. UX methodologies and living labs have contributed to greater patient acceptance of medical technologies,
But is this enough? In many cases it is, in other, for instance, e-health for elderly (what is known as ambient assisted living or AAL) this approach has not lead to the expected results. Cardineaux et all question in this paper (by the way, a good review of all AAL technologies) that privacy of patients is ensured with a 24 hour monitoring. For me the main sign that patient centered approaches are not enough is the failure of the AAL market and that the European Union still has to pour money in a sector that in the past 7-8 years has not taken off. Many of the solutions proposed, despite that the EU, explicitly demands user involvement for funding, do cut elderly from their already thin family and social relations. Furthermore, trying to control and monitor as many variables as possible and automate healthcare, many elderly feel as their independence and their ability to help themselves are reduced. Exactly this, and the high cost these technologies still have, prevents the market from working. The digital revolution and patient driven technology Of course patient centricity is a big progress and of course many AAL and medical technologies have clear benefits. The difference between a patient centric technology and putting the patient in the centre is not the technology, nor the design technology (if it is human centred or not). The question is if it is patient driven and empowers the patient. Empowering the patient means a paradigm shift for organizations: getting from an industrial perspective of economies of scale to a personal perspective. This is the reason why digital technologies and the web 2.0 are such a success: they create direct relationships between patients, professionals, organizations and companies that paradoxically are not possible within the organizational framework, where people interact face to face, and are possible on screens, where people do not interact face to face. The difference is the social setting. If you read José Maria Cepeda’s blog on 2.0 for healthcare professionals Salud Conectada, you will see that at the end all is about direct and more open and free relationships. This means, that they are not open and free within the hospital or the clinic. Personal medicine versus cost management Getting back to the embryo predicting technology, why does it work at IVF-SPAIN as a tool for patient centricity, and not (only) as a lab automation tool and time saver? Because since 2012 the organization is co-creating with patient insights to reshape step by step all processes to make them patient centric. So, a couple demanding Eeva in a boutique clinic will get personal advice about embryo development, decision making choices, transparency on how a lab works and understandable information on biological embryo development. A couple demanding Eeva in a big industrially organized IVF group will be attended quicker and get nice videos on embryos for marketing reasons, but will never participate in the decision making process about embryos.
This is possible in boutique clinics with private customers. Is it possible in a public hospital? Is it possible without a cost and waiting list explosion? Here is where the patient or de industrialist approach make the difference: as a healthcare technology company manager you have to decide whether to develop a technology that allows more personal interaction with patients and more (or better or more frequent) time for patient-healthcare professional relationship or just another time and cost saver based on economies of scale. As a hospital manager you have to decide which technology to buy and how to use it from a patients benefit point of view.