This month, TechNation asks the experts about purchasing and repairing rigid endoscopes, including what to look for when purchasing to ensure device longevity and how best to approach repairing the delicate equipment, whether in house or through a third party. Responders include Wendell Haight, vice president of sales and marketing for MedServ International, Inc., which manufactures and repairs endoscopy equipment; Dennis Leiner, CFO of Lighthouse Imaging, which manufactures endscope testing equipment and Ron Nemeth, a service specialist at Mclaren Healthcare who specializes in in-house endoscope repairs.
TechNation: What are the biggest trends right now in the rigid endoscopy equipment market?
Haight: Smaller diameter scopes linked to HD cameras to present the largest and best possible visual image. As an example, the majority of laparoscopes sold today are 5 mm in diameter when as recently as a couple of years ago, most all laps were 10 mm in diameter. For the patient, this trend is a good one. With the improved optics, which allow more light through the scope, coupled with an HD camera, the image projected on the monitor is now a full-screen image with extreme detail using 1920 x 1080 pixel resolution, which is equivalent to your HD television picture today.
In addition, everything is autoclavable these days, from the scopes to the cameras to cables. Facilities are actively engaged in upgrading and replacing their existing non-autoclave to autoclavable equipment.
Leiner: Stereo laparoscopes seem to gaining some traction, used with or without robots. Also we are seeing the increasing use of endoscopes with camera sensors at the tip of the shaft instead of rod lens endoscopes with dozens of lenses stacked in a tube. Lighthouse has developed many of these “chip-on-tip” scopes over the last 10 years; recent improvements in CMOS video sensors have made these systems higher quality and much more cost effective.
Nemeth: Right now high definition video systems and high-resolution endoscopes are some the biggest trends. Also single port procedures are trending. Although articulating rigid endoscopes are not new, they have become the trend in aiding in single port procedures. Note, the term high definition should not be used when referring to endoscopes with optics; high definition should only be used in regards to video systems. Resolution or high resolution is the proper term when describing a rigid endoscope’s optical systems.
TechNation: How will the market for rigid endoscopy equipment evolve in the next five years? How will that affect service of the equipment?
Haight: Robotics such as the da Vinci Surgical System will continue to grow in market share and expand by specialty as well as wireless technology with cameras, light sources and monitors becoming commonplace. Intuitive will continue selling their system, and there will be others to enter the marketplace, and the surgical specialties robotics focus on will also escalate, in turn increasing the market for scopes. However, these scopes can be very, very costly to replace. They go down frequently, so from a repair standpoint it’s extremely expensive, and that’s where the smaller, more rural hospitals are at a disadvantage. They don’t have capital to afford robotic systems nor the ongoing maintenance and repair. So I think you’ll see the use of robotics escalate first in the larger metropolitan areas where the patient population and demographics support the investment.
Leiner: 2D rod lens endoscopes will still dominate. However, stereo and video rigid endoscopes will continue to be an important part of the mix. This will put pressure on the independent service organizations to stay current in the new technology and require hospitals to be vigilant in maintaining the quality of their scope inventory.
Nemeth: The rigid endoscope market will evolve into a more cost effective sustainable market. The market needs to shift to a U.S.-based market and not be based on an almost 100 percent foreign-born industry; currently none of the major endoscopes are produced in the U.S. With that said, the U.S. has no control over any of the costs associated with purchase or service of rigid endoscopes for all the major endoscopes manufacturers. When a U.S.-based endoscope manufacturer springs to life, cost and quality can be maintained within the hospital. Parts for servicing these devices will also free up. With the parts being manufactured here in the U.S., hospitals will no longer be at the mercy of the current overseas medical device manufacturers.
TechNation: What are some of the biggest challenges of purchasing and servicing rigid endoscopy equipment today?
Haight: Unfortunately much of modern technology is only affordable for the “haves” (hospitals with ample revenues) who will continue to build and install digital suites in their operating rooms, versus the “have-nots” (based upon a Novation survey, the 20 percent of hospitals who are operating on negative cash flows) that will seek the highest quality devices, accessories and services at the lowest price. At that point it becomes survival. I think those are going to be some of the greatest challenges coming up. We already know it’s unlikely our federal government will increase reimbursement, and normally private insurers will follow the same pattern, so there’s only going to be more strain on hospital budgets, and although we’re seeing today lots of mergers and acquisitions, they don’t reach out into the most rural areas, where you don’t always have the healthiest of populations. So there remains demand for high-end surgical procedures, but they’re going to have to meet that demand by acquiring quality equipment and keeping an eye on service budgets.
There’s really two ways to look at service. A trend that is escalating rapidly now is to outsource the management of surgical trays to include service on the equipment that goes in the trays. Many hospitals are already outsourcing those services, which allows them to fix their costs; however, we are beginning to see where that’s evolving down in the central sterile processing with the management of surgical trays, to ensure the equipment is in top operating condition at all times and that there are no delays in the OR. We know that the cost in the OR, should there be a delay, can run as much as $50 a minute, so if equipment goes down in a procedure, the clock’s ticking and the hospital could potentially lose substantial amounts of money because of capped reimbursement for OR procedures. That being said, many of these outsourced companies will have backup trays so they can reduce that downtime in the event of equipment failure during a procedure thus enhancing efficiency.
Another trend is for biomedical engineers to get engaged in the repair process. I’ve been in this industry for over 20 years, and I’ve seen that model tried on numerous occasions. The issue is this: To be able to effectively do repair on high-end devices, it takes years of experience and knowledge, and to be able to train someone and make them proficient to be able to do that in a short period of time can lend itself to issues where there’s potentially further damage done to the equipment, which in turn only increases the repair costs. There just aren’t that many biomeds out there today who are going to be proficient at scope repair, or facilities that are going to be able to handle the time commitment or justify to investment with volume. Hence, should biomedical engineers wish to be involved, they can be trained on methods to troubleshoot common problems with the scopes and educate the staff on proper care and handling techniques that reduces preventable damage where the payback can be significant.
Leiner: HD endoscope cameras in the OR put pressure on the endoscope optics to be of the highest quality. Hospitals spend significantly more on servicing their rigid endoscopes than in purchasing new products. Independent service organizations are generally less expensive than the OEMs, but their quality needs to be validated.
Nemeth: Cost of servicing and availability of parts would be the two big ones. Initial purchase cost isn’t a real challenge. The market has shifted the production cost from the initial purchase to the service side, and some rigid endoscopes can only be serviced by the OEM. Knowing this, the initial purchase cost is lower, but service costs are rising and rising fast.
TechNation: Please share your advice for people in hospitals that are faced with these challenges.
Haight: When evaluating equipment for purchase and / or service providers, look carefully at the differentiating factors / benefits and seek a trial period for evaluation against the same set of criteria establish for the incumbent equipment.
When it comes to repair services, know upfront there are rarely apple-to-apple comparisons for selecting your partner company. This is mainly because there are so many variables that occur such as whether a rigid autoclavable scope is closed with a laser welder to insure autoclave integrity. Unfortunately too many facilities make repair decisions based solely upon pricing alone and do not ask the key questions to properly qualify a vendor. This often can lead to a situation where there are frequent repairs because of shoddy work and materials being used, which results in a higher repair budget at the end of the year.
With over 60 percent of equipment going out for repair services due to preventable damage, it is important to remember prevention is one of the best ways to control and contain repair budgets. The more hands that touch the equipment, the more likely preventable damage will be done. Staff education on proper care and handling techniques is paramount to reducing the frequency and associated cost of repairs.
Leiner: Hospitals can save money by monitoring the quality of their rigid endoscopes. They need to know that scopes being sent out for repair truly need the repair. They also need to know that their scopes have been returned with the repairs done properly.
From a regulatory perspective, The Joint Commission has confirmed that endoscopes, both flexible and rigid, are considered medical devices. This implies that endoscope quality needs to be verified before the scopes are placed into service in the OR.
Nemeth: Shift your focus from the initial purchase cost to the long-term cost and sustainability of servicing rigid endoscopes.
TechNation: What else do you want TechNation readers (biomeds) to know about purchasing and servicing rigid endoscopy equipment?
Haight: Biomedical engineers can be a great partner with their facilities because there’s nobody more able or equipped to look at issues pertaining to purchasing and repair cost containment. They’re often looking at and managing the operation of MRI and CT equipment where repair costs can run in the thousands of dollars, so they understand the complexity of equipment, and how not being diligent can have a significant impact on whether you stay below budget or go over budget. We enjoy working with biomedical engineers because they understand what we offer and how we can become a strong partner with them in addressing the challenges they face on a daily basis. We have seen the evolution of decision making on equipment purchases and services on that equipment transcend from the department nurse manager, to material management to the trend now where we’re seeing more and more biomeds being solicited and engaged in the decision making process, which we feel certainly is headed in the right direction.
Leiner: Biomeds already maintain virtually all complex medical devices used in hospitals. It is a natural fit for them to be involved with rigid endoscopes. To stay relevant, the biomed needs to include rigid endoscopes in his/her technical portfolio. There are tools available (including those from Lighthouse Imaging) that will let you evaluate your hospital’s endoscopes, light sources and light cables. Preventive maintenance on endoscopes saves your hospital money and improves patient safety.
Nemeth: Choose a device that suits your hospital best. Stay away from specialty scopes, unless nothing else can be used. If you find a device that holds up to the hospitals liking and if it is cost effective, stick with it. And remember, “Don’t fix it if it isn’t broke.” Right now not all new model scopes are better than there old model, so buying the latest and greatest can lead to costly future with no visual improvements.