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Concerning technology: thinking with Heidegger.

In human lives, technology holds sway in mundane and extraordinary ways, such as in the ways we work, entertain, transport, and feed ourselves, and importantly in the ways we encounter and manage health, disease, illness, and death. A significant area of Heidegger's later work is questioning technology. Unlike many current inquiries that centre on contemporary technology's function, utility, and positive transformations, Heidegger offers a radical way of thinking about technology through developing an inquiry that uncovers technology's essence of revealing. In this article, Heidegger's thinking about technological modes of revealing in regard to bodies, health, and illness is explored. In Heidegger's view, the ordered revealing of modern technology has overshadowed other modes of revealing. This article highlights how remembering concealment and unconcealment in its many modes can be relevant to nurses and others involved in health care. Through tracing Heidegger's thinking about technology, a more critical approach to the effects and outcomes of modern technologies within health care systems can be generated.

Biomedical Technology↗

Cost-effectiveness analysis in the assessment of diagnostic imaging technologies.

In many ways, diagnostic technologies differ from therapeutic medical technologies. Perhaps most important, diagnostic technologies do not generally directly affect long-term patient outcomes. Instead, the results of diagnostic tests can influence the care of patients; in that way, diagnostic tests may affect long-term outcomes. Because of this, the benefits associated with the use of a specific diagnostic technology will depend on the performance characteristics (eg, sensitivity and specificity) of the test, as well as other factors, such as prevalence of disease and effectiveness of available treatments for the disease in question. The fact that diagnostic tests affect short-term, or "surrogate," outcomes, rather than long-term patient outcomes makes evaluation of these tests more complicated than the evaluation of therapeutic technologies. This article will trace the history of technology assessment in medicine, address the role of cost-effectiveness and decision analysis in health technology assessment, and describe unique features and approaches to assessing diagnostic technologies. The article will then conclude with a consideration of the limits of medical technology assessment.

Cost-Benefit Analysis↗

Medical and surgical applications of space biosensor technology.

Researchers in space life sciences are rapidly approaching a technology impasse. Many of the critical questions on the impact of spaceflight on living systems simply cannot be answered with the limited available technologies. Research subjects, particularly small animal models like the rat, must be allowed to function relatively untended and unrestrained for long periods to fully reflect the impact of microgravity and spaceflight on their behavior and physiology. These requirements preclude the use of present hard-wired instrumentation techniques and limited data acquisition systems. Implantable sensors and miniaturized biotelemetry are the only means of capturing the fundamental and critical data. This same biosensor and biotelemetry technology has direct application to Earth-based medicine and surgery. Continuous, on-line data acquisition and improved measurement capabilities combined with the ease and flexibility offered by automated, wireless, and portable instruments and data systems, should provide a boon to the health care industry. Playing a key role in this technology revolution is the Sensors 2000! (S2K!) Program at NASA Ames Research Center. S2K!, in collaboration with space life sciences researchers and managers, provides an integrated capability for sensor technology development and applications, including advanced biosensor technology development, spaceflight hardware development, and technology transfer and commercialization. S2K! is presently collaborating on several spaceflight projects with dual-use medical applications. One prime example is a collaboration with the Fetal Treatment Center (FTC) at the University of California at San Francisco. The goal is to develop and apply implantable chemical sensor and biotelemetry technology to continuously monitor fetal patients during extra-uterine surgery, replacement into the womb, through birth and beyond. Once validated for ground use, the method will be transitioned to spaceflight applications to remotely monitor key biochemical parameters in flight animals. Successful application of NASA implantable biosensor and biotelemetry technologies should accelerate the advancement of this and other modern medical procedures while furthering the exploration of life in space.

Aerospace Medicine↗

Interests in health care technology assessment (HCTA) and HCTA training needs in eight European countries: COMETT-ASSESS.

Between mid-1991 and mid-1992, nearly 300 different organisations involved in European health care contributed their views to a survey covering a range of topics relevant to health care technology assessment (HCTA) and economic appraisal of health technologies. Organisations who participated included manufacturers, health care institutions, professional associations, health care reimbursement or funding agencies, academic institutions and policy making agencies in eight European countries. The study was carried out as part of a larger project, COMETT-ASSESS, funded partially by the EC COMETT programme, to design and deliver training in health care technology assessment and socioeconomic evaluation. The survey demonstrates a high level of interest in assessment of health care technologies among European organisations, regardless of the type of organisation. Eight out of ten organisations report high-medium levels of interest in using HCTA in their decision making. A similar proportion report high-medium interest in increasing their general understanding of HCTA, and 2 out of 3 in carrying out assessments. All organisations clearly identify a need to train their staff in HCTA. The two key groups of staff requiring training are managers and clinicians. Manufacturers also report a need to train their marketing staff. The principal reason for training is in order to improve the use staff make of HCTA in their decision-making. This finding indicates that it may not be sufficient for European countries to develop effective HCTA dissemination strategies which improve the flow of information on technology assessment results; decision-makers within the organisations targeted will also need training, if they are to use this information effectively. As well as a need to train decision-makers, organisations also report a need to train their researchers, and to a lesser extent their own trainers. When it comes to the types of technologies which need to be assessed, organisations consistently report that they are interested in assessment of accepted health technologies, as well as new or recently introduced ones. In contrast, to date the major emphasis in many HCTA programmes has been on technologies which are yet to enter the service setting. More thought now needs to be given to developing methodologies for assessing technologies once they have reached the service setting. For this the presence of a skilled and well-trained group of health personnel will also be necessary.(ABSTRACT TRUNCATED AT 400 WORDS)

Cost-Benefit Analysis↗

Preserving humanity in an age of technology.

Preserving humanity in the present technological age can be a challenge for all health care workers, but perhaps particularly for staff working within an intensive care environment. This article highlights some of the potential effects of such technology on staff, patients and relatives, particularly bringing to light some of the disadvantages brought about by the use of such technology. Areas considered include the role of nurses within a technological environment, patients' and relatives' reactions to technology, the potential effect on autonomy and responsibility for both patients and nurses, economic issues, and finally ethical and moral issues raised by the advent of further technology. Despite many positive contributions to nursing care which arise from the use of technology, there are disadvantages attributed to technology which have only been mentioned superficially in previous literature on this subject. The question arises as to whether nurses are able to balance preserving the humanity of patients with the extensive use of technology in an intensive care environment today.

Humanism↗

Population health technologies: emerging innovations for the health of the public.

At the beginning of the 21st century, we are at the dawn of a possibly unprecedented era of scientific discovery and promise. Emerging technologies, including information and communication technologies, genomics, microelectromechanical systems, robotics, sensors, and nanotechnologies, provide enormous opportunities for population health improvement. Population health technology refers to the application of an emerging technology to improve the health of populations. Emerging technologies present an opportunity for addressing global health challenges-in both developed and developing countries. Health issues ripe for the application of new technologies include disease surveillance and control, environmental monitoring and pollution prevention, food safety, health behavior change, self-care, population screening, and chronic disease and injury prevention and control. If appropriately applied, population health technologies may greatly enhance existing health intervention models. However, potential adverse consequences could arise related to privacy, confidentiality, and security; quality and effectiveness; sustainability; and the technology divide. To ensure the optimal development and diffusion of population health technologies will require balancing these risks and benefits while simultaneously adopting new mechanisms of public and private support for research and development in this potentially important new domain of public health.

Biomedical Technology↗

Perioperative nurses' roles in managing new technology.

The scientific knowledge base for medical technology doubles every two years. Whether new technologies will improve health care depends on how appropriately they are used; therefore, purchasing appropriate technology is crucial. Appropriate technologies include those that are valid, adaptable, acceptable, and affordable. Perioperative nurses can facilitate acquisition and use of appropriate technology in the OR by applying the process of technology assessment--a five-step process that examines the need, safety, effectiveness and efficacy, economic appraisal, and social impact of new technology. This article details the technology assessment process and provides methods of preparing perioperative staff members to use new technology.

Humans↗

The relationship between per capita income and diffusion of medical technologies.

It is commonly known that per capita income is correlated with the level of health care spending and that technology is a major factor in explaining the increase in health care spending. This study examines differences in the rate of diffusion of medical technologies in Organization for Economic Cooperation and Development countries between 1975 and 1995. We find that the importance of income in explaining the long-term availability of a technology generally declines over time and becomes insignificant for some technologies. In other words, more affluent countries are earlier adopters of new technologies, but access to technology becomes less dependent on income over time. The evidence also suggests that the effects of reimbursement incentives are greater for purchases of diagnostic technologies than for lifesaving technologies and that reimbursement incentive effects are less significant for older technologies.

Biomedical Technology↗

The triad of science foundations, instructional technology, and organizational structure.

Over the centuries and across all societies educational achievement does not improve. The attempt to improve the instructional process has concentrated on instructional technology. But these attempts have overlooked the importance of two other factors: the science that should underlie the instructional technologies and the organization that must operate those technologies. A considerable step forward in handling the problems of instructional effectiveness has been the derivation of instructional technologies based on Skinnerian science. But the instructional technologies based on Skinner's analysis of behavior are promoted as if they were to operate in an organizational vacuum. The division of labor, and its necessary coordination and control, is taken for granted. But in any large scale enterprise, the organization of the division of labor must fit the technology through which that enterprise achieves its mission. Educational technology must tie directly to a pertinent science and to a proper organizational structure. To teach effectively requires an overhaul along three lines: 1) a relevant science that reflects and encapsulates an accurate understanding of behavior; 2) a contingency-based technology of instruction that directly derives its practices upon proper scientific principles; and 3) a suitable organization based on teaching teams that operate the new instructional technology.

Behaviorism↗

A signalling theory of excessive technological adoption.

Technology adoption has been identified as one of the main elements behind the growth of health care expenditures. It has been argued that the health insurance arrangements in the US justify, to a certain extent, the technology-driven rise in costs. Moreover, it eases the adoption of less cost-effective procedures and devices. This paper presents an additional argument by which excessive technology investments may occur: providers of care invest in technology as a way to "signal" their intrinsic (and unobservable) quality. Providers face the option of adopting a new technology. The decision of adoption in itself may convey information about his/her quality: for example, patients conjecture that providers who display newer technology are of higher quality. Providers, being aware of this, may invest in technology to reveal themselves as high quality. Thus, technology adoption could result only from the desire to attract patients. The investment is self-defeating in the sense that if all providers invest, no information about quality is transmitted to patients. We evaluate the argument in a context of demand for health care services where patients have initially no information about the quality of different providers. We show that an incentive to invest as a way to signal quality may or may not lead to overinvestment. It is also possible that only some providers invest. They reveal themselves as high quality providers. The analysis suggests that the argument is more important for some services than for others. Overall, an additional argument for overinvestment in technology in some circumstances is provided.

Attitude of Health Personnel↗

The 'NICE' approach to technology assessment: an economics perspective.

The National Institute for Clinical Excellence has published guidelines for economic evaluations for considering whether new health care technologies contribute to the efficient use of National Health Service resources. The analytical basis of the guidelines is a comparison of the costs and consequences of new and existing methods for dealing with particular conditions using the incremental cost-effectiveness ratio (ICER). However, this fails to provide an explicit and systematic basis for addressing the dual objectives of health maximisation and equitable availability of technologies in the context of a fixed NHS budget. We show that information on the costs and consequences of a particular technology is insufficient to address issues of efficiency of resource use. In addition, information is required about the total resources available and the alternative uses of those resources. Moreover, because these factors are unlikely to be identical for all settings, it is unlikely that the efficiency of using resources to support a new technology will be the same for all settings, even if the cost and consequences of the technology are the same across settings. Instead of improving the health outcomes from NHS resources, we show that using NICE guidelines to inform decisions about new technologies may lead to increased resources allocated to new technology, increased local variations in the use of new technologies and concerns about the sustainability and affordability of public funding for new technologies.

Canada↗

Health technology assessment in the ICU: noninvasive positive pressure ventilation for acute respiratory failure.

Critical care practitioners have a number of health-related technologies at our disposal to provide the best possible care for our critically ill patients. Although certain technologies may improve outcomes in the intensive care unit (ICU), many technologies are disseminated without rigorous evaluation. Health technology assessment (HTA) in critical care is a complex and dynamic process, which is a powerful tool to assess a health technology for its initial use or continued application in the ICU. This article applies an HTA framework to the use of noninvasive positive pressure ventilation (NPPV) for patients with acute respiratory failure (ARF). The strongest evidence to date supports the use of NPPV in patients with ARF caused by exacerbations of chronic obstructive pulmonary disease (COPD); the benefit for patients with acute nonhypercarbic, hypoxemic respiratory failure is less clear. The success of NPPV technology depends on operator education and experience. The cost effectiveness of NPPV has been evaluated in patients with ARF caused by COPD, and cost reduction is attributed to the prevention of ventilator-associated pneumonia by avoiding endotracheal intubation. An HTA framework can help health care practitioners make important decisions regarding the acquisition of new technologies and the evaluation of current technologies. Careful evaluation of health technologies in the ICU should be an ongoing priority.

Acute Disease↗

Hospital inpatient prospective payment system: incorporating new technology.

New technologies in the impatient prospective payment system are discussed. On December 21, 2000, Congress passed Public Law 106-554 that includes a requirement to establish a mechanism to more expeditiously incorporate the costs and establish qualifying criteria for payment of new services and technologies into the hospital inpatient prospective payment system. The final ruling of this law states that a new service or technology must demonstrate substantial improvement, be inadequately paid under the DRG system, and be "new." The intent of these criteria is to identify new technologies that offer substantial improvement over existing technologies and to provide supplemental payment that encourages physicians and hospitals to utilize the new technology. In November 2001, drotrecogin alfa (activated) received fast-track FDA approval because of the robust findings from the PROWESS trial. Drotrecogin alfa (activated) is the first agent proven to reduce mortality in patients suffering from severe sepsis associated with acute organ dysfunction who are at a high risk of death (i.e., APACHE II score > 24). In August 2002, drotrecogin alfa (activated) was one of four such new technologies and the first agent approved for new technology payment under the prospective payment system (PPS). This decision offers confidence that the PPS is effectively striving to incorporate new medical services and technologies at a pace similar to that of innovation. Providers may receive up to $3400 in additional reimbursement when drotrecogin alfa (activated) is administered in the Medicare population. Pharmacy and patient accounting personnel should develop a collaborative process to identify, document, and capture this new source of payment.

Centers for Medicare and Medicaid Services, U.S.↗

Neuropsychological technologies in rehabilitation.

OBJECTIVE: To provide an introduction and a conceptual context for the articles presented in this special edition of the Journal of Head Trauma Rehabilitation on neuropsychological technologies. SUMMARY: Many clinical assessments in neuropsychology are metamorphosing from a psychometric search for a lesion to a functional image of the working brain. Behavioral probes increasingly employ technology to provide more ecologically valid stimuli to elicit diagnostically relevant responses. Intervention strategies include an expanding range of assistive devices and technologically based treatments. The advent of the microprocessor and discipline specific programming have allowed certain aspects of rehabilitation practice to incorporate these new assessment and intervention strategies. For example, the development of neuropsychological technologies has already lead to computer based prosthetics and orthotics, cognitive probes with millisecond accurate links to functional imaging, virtual reality managed ecological assessments, cognitive retraining, assistive devices, and online, and "real-time" database-driven evaluations. Emerging technologies offer the potential for personal, portable, everyday brain imaging and rehabilitation systems. Few psychologists, physiatrists, or allied health professionals are formally trained in technological development. What has emerged thus far is a collection of individual efforts that remain to be integrated into more comprehensive tools for the rehabilitation professions. The selective history of neuropsychological technologies presented here is meant to illustrate past difficulties in the emergence of this sub-specialty and point to new applications and technological integration that may prove fruitful. The convergence of neuroengineering, adaptive assessments, everyday neuroimaging, neuroinformatics, and educational neuroimaging, presage such future developments in neuropsychological technologies.

Biomedical Technology↗

Technology transfer in digital mammography. Report of the Joint National Cancer Institute-National Aeronautics and Space Administration workshop of May 19-20, 1993.

Digital mammography is one of the most promising novel technologies for further improvement of early detection of breast cancer, offering important potential advantages: 1) improved image quality; 2) digital image processing for improved lesion contrast; 3) computer-aided diagnosis for enhanced radiologic interpretation; and 4) teleradiology for facilitated radiologic consultation. The Diagnostic Imaging Research Branch of the National Cancer Institute (NCI) recently funded an international, multidisciplinary, multi-institutional Digital Mammography Development Group for collaborations between NCI, the academic community, and industry to facilitate the integrated development and implementation of digital mammographic systems. Currently, however, digital mammography faces a number of fundamental technological roadblocks: 1) cost-effective digital detectors and displays for imaging systems; 2) the need for novel algorithms for image processing and computer-aided diagnosis; and 3) high performance, low cost digital networks to provide an "information superhighway" for teleradiology. To solve some of these technological problems, the Diagnostic Imaging Research Branch of NCI joined efforts with the Technology Transfer Division of the National Aeronautics and Space Administration to pursue a federal technology transfer program in digital mammography. The authors discuss the findings and recommendations of the workshop entitled "Technology Transfer in Digital Mammography," which was organized and held jointly by the NCI and the National Aeronautics and Space Administration in May, 1993. Numerous innovative technologies of varying degree of promise for digital mammography were presented at the conference. In this article, specific technologies presented at the workshop by the federal and federally-supported laboratories are described, and critiques of these technologies by the leaders of the medical imaging community are presented.

Breast Neoplasms↗

Tentative findings of a study of the technology needs and use patterns of persons with mental retardation.

An examination of the technology use patterns and needs of 680 persons with mental retardation was conducted as part of a grant application process in response to P. L. 100-407, the Technology-Related Assistance for Individuals with Disabilities Act of 1988. Important trends which were deemed valuable for state technology planning purposes were revealed which have implications for other states desiring to develop comprehensive technology systems. Responses obtained from participants indicated that needs for technology were evident in all areas of life functioning, with computer technology being reported as the area of greatest need. Most respondents reported spending less than $1000 for their technology and more than half expressed that a credit plan would have been helpful in purchasing needed technology. Transportation services was reported to be an area of need for many persons participating in the study. More than half the participants indicated the need for more information relating to technology.

Activities of Daily Living↗

Technology, job satisfaction, and retention: rural mental health practitioners.

CONTEXT: Job satisfaction as it relates to retention of mental health professionals is a major problem in rural areas. Several authors have suggested that technology can positively influence job satisfaction and thus improve retention. OBJECTIVES: This study examined technology use and technology expertise in relationship to job satisfaction. It is based on a theoretical framework that asserts as technology use increases, communication among providers and access to educational and consultative resources increase as well, resulting in a boost in professional support and a reduction in isolation. METHODS: Surveys were sent to 320 providers in rural southeast Ohio; 163 returned usable surveys. FINDINGS: There was a statistically significant relationship between the combination of technology use and expertise and job satisfaction. Use alone, however, was not significant. Despite the fact that over 90% of respondents had access to both a computer and the Internet, just 45% used technology to communicate with peers and nearly 96% indicated that they never or rarely used the Internet for educational programs. CONCLUSIONS: The results challenge the assertion that technology plays a major role in job satisfaction and rural retention since access and perceived expertise did not guarantee technology usage. Decisions to stay or leave a rural practice involve a complex array of factors. Technology, with its ability to link providers to resources outside the geographic bounds of an individual's practice, may play a role, but since its adoption can be costly in both time and money, future studies need to determine its place in the retention model.

Adult↗

Beyond usability: designing effective technology implementation systems to promote patient safety.

Evidence is emerging that certain technologies such as computerized provider order entry may reduce the likelihood of patient harm. However, many technologies that should reduce medical errors have been abandoned because of problems with their design, their impact on workflow, and general dissatisfaction with them by end users. Patient safety researchers have therefore looked to human factors engineering for guidance on how to design technologies to be usable (easy to use) and useful (improving job performance, efficiency, and/or quality). While this is a necessary step towards improving the likelihood of end user satisfaction, it is still not sufficient. Human factors engineering research has shown that the manner in which technologies are implemented also needs to be designed carefully if benefits are to be realized. This paper reviews the theoretical knowledge on what leads to successful technology implementation and how this can be translated into specifically designed processes for successful technology change. The literature on diffusion of innovations, technology acceptance, organisational justice, participative decision making, and organisational change is reviewed and strategies for promoting successful implementation are provided. Given the rapid and ever increasing pace of technology implementation in health care, it is critical for the science of technology implementation to be understood and incorporated into efforts to improve patient safety.

Diffusion of Innovation↗