In Toronto, Techna Institute Leaders Move Forward on New Medical Technology
A growing number of academic medical centers in the United States have been developing and expanding test-bed centers, in which their leaders are developing and in some cases, commercializing, new technologies and solutions from inside the healthcare system. But innovation of that type isn’t happening only in the U.S. North of our border, exciting things have been happening in Toronto, where the University Health Network, in conjunction with the University of Toronto, together sponsor the Techna Institute. As the website of Techna explains it, “We lead, manage, and implement health technology productization programs and projects in a hospital environment. We shorten the time interval from technology discovery and development to application for the benefit of patients and the health care system.” The focus, the website notes, is around the “design, operationalization, and execution of projects and programs in health technology innovation,” focusing on surgery, imaging, radiation medicine, data, marketing, and consulting services. And though University Health Network (UHN) and the University of Toronto are legally separate entities, there is a very strong level of collaboration between the two entities, and many at UHN are faculty members at the University of Toronto. The work of the Techna Institute leaders has been interesting the leaders of U.S. patient care organizations, including colleagues at UCSD Health in San Diego, whose leaders have been interacting fruitfully with Techna Institute leaders.
The senior leader at the Techna Institute is Joseph Cafazzo, Ph.D., executive director of biomedical engineering at University Health Network, and a professor at the University of Toronto. Cafazzo spoke recently with Healthcare Innovation Editor-in-Chief Mark Hagland about the pioneering work taking place at the Techna Institute around nurturing technological innovation in the context of an academic medical center. Below are excerpts from that interview.
Tell us about the context of your organization’s work, particularly given that many Americans won’t be familiar.
Well, we’re affiliated with Toronto General Hospital, the largest research hospital in Canada, and a $2.5 billion organization. And though University Health Network and the University of Toronto are separate legal entities, a lot of us at UHN are faculty members at the University of Toronto.
Meanwhile, about 20 years ago, my predecessor had this vision of creating a center within the hospital system where people with ideas and who were subject-matter experts, could come, as well as people who design, build, and evaluate technologies—that they could all come together. My center is actually three floors above the Emergency Department. So we’re not on the university campus or in an industrial plaza. He made the decision to embed what he called the “misfits” into a hospital setting, and to make sure there was a lot of cross-pollination. Often, people would come in with ideas, and we’d work together, and we’re still doing that, 20 years later. A lot of graduate students are involved, and we know what the needs are and work really closely with clinicians, patients, and families, to build the technologies they really need.
When were you and your team created?
There was an initial $6 million government grant that we received in 2002. We really opened our doors in the summer of 2004. It was created using both federal and provincial money, half-half.
How does governance operate at the Institute?
In many instances—we often refer to products already on the market, for instance. Sometimes we decide that we don’t want to do a project if it won’t be impactful. For instance, we don’t want to build a tool that’s a website or that’s only used for research purposes. We want to have a huge clinical impact. And we know where the pain points are in the health system. So we tend to be patient-facing, building tools for patients to use, and also ones dealing with chronic disease. We want to make the hospital a place of last resort.
Is the Canadian policy and payment system organized to drive this kind of innovation?
I would honestly say that the U.S. has more upside in that regard, because there’s more money in the system, and that allows for more speculative innovation in the system. But government does step in here, philanthropies do step in here. In the U.S., there’s more of a willingness to pay out of pocket and there are more opportunities for health systems to find a way to finance innovation. But in Canada, funding is a challenge; and our demand for health services far outstrips supply. So any way in which we can improve throughput of patients or eliminates low-value care, those are all opportunities—whereas in the U.S., there’s a risk that you’re putting someone out of work or are affecting remuneration.
We have a spinoff company, and our Canadian strategy is different from our U.S. strategy. In the Canadian context, let’s take the example of an application that helps patients manage heart failure; here in Canada, organizations are looking at budgets for a service; in the U.S., it’s based more on a per-use service, and how much a physician can bill for a service. Whereas here, it’s out of the hands of individual physicians and in the hands of institution.
Can you share a few examples of the test-bed work you and your colleagues have done?
A good example is Medly, our heart failure application. It allows patients to perform self-care on a daily basis using an algorithm that tells them what to do on a day-to-day basis, including titration of medication and self-care. We’ve used it to reduce the number of hospitalizations. It asks each heart failure patient—they’re asked to take their blood pressure, their weight, and their symptoms, and the algorithm tells them what to do. It may ask them to increase their dosage if they’re gaining weight because of fluid retention, or back off a medication if their weight has become too low or are having blood pressure issues. And we have about 1,000 patients at UHM using it on a day-to-day basis; the average age is in their 60s, but we do have a lot of older adults involved. And in fact, we take pride in the fact that older adults will use a tool like this if it’s well-designed.
What kind of design timeframe has been involved in the development of Medly?
It really was a question of the iterations and evidence basis. We have 26 peer-reviewed articles dating back to 2012. It was more than ten years in development. And that’s one of the big issues in digital health development, validating a tool through clinical trials and evidence basis. Medly is in its third version now; the original version was on a Blackberry. The first major study came out in 2012, one year after its development. It’s been refined and refined; it looks totally different than back then, and its capabilities are much different. It started out as a PhD students’ idea, working with cardiologists.
How does the funding mechanism work for these development projects?
It’s challenging; we don’t receive any funding from the hospital. We get grants; there’s some philanthropic support. We also do a lot of work on a fee-for-service basis with industry as well. Companies come to us to trial some new technologies, and we evaluate them. We make a margin on that work, and we reinvest it into research. Other than my own salary, everything else is funded separately. My salary is funded through University Health Network. And we have more than 70 staff, and they are all funded through activities, through grants, industry engagement, or philanthropy.
What have been the biggest challenges in your work, apart from funding?
That’s a good question. I think that although we work in an area that sees change happen very rapidly—the digital health space and the science space around that—and we see so much progress in those areas, quite frankly, HC doesn’t always move that quickly. And innovations in the healthcare space have always been slower than we’ve expected. The HC system has a lot of inertia; HC people are certainly not Luddites, because some of the most advanced technologies exist in HC, but the breadth and depth are slow and limited. So one of the challenges is finding pathways to scale this innovations to help as many people as possible, in the most cost-effective way.
And what have the been the biggest lessons learned so far?
We couldn’t have done this without industry. And I know that people in academia and the hospital sector have some reservations about engaging so much with industry; I perhaps as an engineer didn’t have as many reservations as clinicians might have. And you mention pharma or device companies, and alarm bells go off. But we wouldn’t have gotten as far as we have without them helping us to advance our agenda. And I just don’t think you can get to where you need to, without their support.
What kind of advice might you be able to offer leaders in other healthcare organizations, particularly in the U.S.?
UCSD Health wasn’t the first organization to approach us about our model. I would say that there are two keys to success in all of this: the first is proximity, really encouraging direct interaction; you need to get your hands dirty in the clinical environment and observe and experience that first-hand. I’m actually shocked by how many engineers and designers don’t spend much time in the environment they’re designing for. And the second has to do with how clinicians and academics are incentivized, which is often for number of publications and grants, and so on; but if you could incentivize them for the impact on their environment. How have you changed the way people practice, and how have patients benefited? That should be the measure, not silly things like how many first-author papers you’ve published. As far as I’m concerned, the papers are a means to an end.
And I wouldn’t be here speaking with you if it hadn’t been for the decision to embed this center into the health system. If that initial money had been spent over in an industrial park or something, it would have atrophied over time. But because all of our staff, including myself, are hospital staff, that makes all the difference. There are a number of PhD-trained faculty who are cross-affiliated with the university and who teach and get stipends, but our employers happens to be the university health network.
More information can be found at the following websites: https://technainstitute.com https://www.uhn.ca/ https://humanfactors.ca/ https://www.centrefordigitaltherapeutics.ca/
