Photography: Ber Murphy
Normally, when you think of a “community hospital,” images of futuristic devices like robotic surgery machines and atom-smashing cancer treatments aren’t what immediately come to mind.
But they’re exactly what the University Medical Center of Princeton (UMCP) in Plainsboro, New Jersey, has begun to employ.
Even the building itself has a number of high-tech features, including a state-of-the-art “co-generation” power plant, built by NRG Energy’s distributed generation division, which has cut the new building’s energy costs by 25% and reduced its carbon footprint by 50%, all while providing the special air-handling and multiple layers of redundancy that are critical to the success of a 21st-century hospital.
Some of the new technologies, such as the power system, can be money-savers in the long run. But, at a time of widespread concern about rising health-care costs, hospital administrators face tough choices over which technologies are good investments.
“When a new solution that is meaningfully better comes on the market, we’re inclined to purchase it,” says Barry Rabner, CEO of the Princeton HealthCare System. Sometimes, he says, patients demand it, and he acknowledges that the hospital needs to offer the latest and greatest if it wants to maintain market share—and persuade patients that they don’t need to travel to New York or Philadelphia when they have a serious problem.
More Robots, Fewer Incisions
At about $2 million apiece, the robotic surgery simulators at UMCP are no small investment. But take one for a short ride, and you’ll understand what all the fuss is about.
The procedure plays out on the surgeon’s video console: internal organs appear in vivid 3-D, many times their normal size, as tiny surgical tools hover over them, responsive in minutest detail to intuitive hand controls.
For surgeons like Heather van Raalte, chair of Obstetrics and Gynecology at UMCP, the hospital’s two robots have already changed everything. Surgeries such as hysterectomies, which can require six-inch incisions in the abdomen and at least a few days in the hospital, are now simple, bloodless procedures that often allow the patient to go home the same day.
“I’ve done maybe one incision in the last year,” van Raalte says.
Robotic surgery also tracks every move a surgeon makes and can preserve video images of every procedure, bringing a new level of analytics to surgical technique and promising new tools for training. After watching a robotic-surgery procedure, it’s not hard to imagine telesurgery, in which a doctor could operate from a remote location.
The Power to Save Lives
The state-of-the-art imaging, radiology and robotic surgery technologies at the University Medical Center of Princeton are matched by its standalone “microgrid” for power generation, which was built to meet the energy industry’s highest standards for efficiency, resiliency and sustainability and follows best practices for green construction.
Although he initially planned for the new hospital to build and operate the energy plant itself, Barry Rabner, CEO of the hospital’s parent company, eventually decided to outsource the plant’s construction and operation, and the hospital’s search for a partner ended near home, with the distributed generation division of NRG Energy, Inc. of Princeton, New Jersey.
Among the benefits of the partnership was NRG’s agreement to fund the project, saving the hospital’s capital budget for investments in health care. Beyond that, the plant’s use of an environmentally friendly “co-generation” system—one that produces not only electricity, but also steam for heating and sterilization and chilled water for air conditioning—entitled the hospital and NRG to millions of dollars in grants and loans from the local utility, the New Jersey Development Authority and the federal government.
The main energy producer in the plant is a 4.6 MW natural gas-fueled turbine, coupled with a heat-recovery steam generator and backed up by three diesel-powered generators that, if all else fails, can keep the hospital supplied with energy for two weeks. The system includes a solar array, chillers, boilers and a million-gallon Thermal Energy Storage (TES) system, which supplies chilled water at a fraction of what it would otherwise cost at times of peak usage. At other times, the plant saves money by selling energy to the grid.
That exchange with the grid is managed by one of several layers of advanced software that operate the plant’s control systems. Energy-optimization software not only forecasts energy market volatility in advance of the local utility’s published pricing, but also uses proprietary algorithms to manage everything from water pumps to cooling tower fans, allowing the 30,000-square-foot facility to be managed by a full-time staff of nine.
Not all of the plant’s innovations are about savings. CEO Rabner figures the hospital saves about a quarter of what it would otherwise be paying for electricity but admits it’s an inexact calculation, in part because of tradeoffs they have made to provide better patient care.
“One of our uncommon commitments is to use 100 percent fresh air in all patient areas of the hospital,” he says. “From an energy standpoint that’s pretty inefficient, which is why office buildings and airplanes use recycled air. That’s a tradeoff of efficiency for reduced infection.” Which just translates to a different form of efficiency - the kind that saves lives.
With the potential of such medical technology looming large, it’s no wonder why Google and Johnson & Johnson recently agreed to team up to develop robotic surgery systems, although their exact plans are not yet public. For now, the main instrument for robotic surgery is the da Vinci® Surgical System, from a California company called Intuitive Surgical.
The procedure takes a similar approach to conventional laparoscopy, a common technique for abdominal surgeries, in which a tiny video camera and several thin instruments are inserted through small incisions in the body. But without the help of robotics, the surgeon has to manipulate the long instruments directly, by hand, limiting their range of motion and sometimes even the precision of the procedure. The tiny robotic instruments, by contrast, can move in any direction, and the camera and high-resolution video give the surgeon much better visibility, which—it goes without saying—can be critical.
“The three-dimensional images and the high definition—you can’t beat it,” says Bruce Pierce, also an obstetric and gynecological surgeon at the Princeton hospital. “Surgery is all about seeing, and if you see better, you operate better.”
The machines can be used for a variety of procedures—hysterectomies, gall bladder surgeries, prostate surgeries, removal of fibroid tumors, and even some heart procedures. Patients who have undergone minimally invasive procedures can often recover in days if not hours, and the scars are minute.
But as with any pioneer—human or robotic—the da Vinci system has its skeptics. In fact, Intuitive Surgical has come under fire for allegedly pushing hospitals to allow insufficiently trained surgeons to use the machines. Lawsuits have been filed, and lengthy disclaimers about the dangers of surgery accompany all of the da Vinci system’s marketing materials.
Perhaps most damning, a 2013 study in the prestigious Journal of the American Medical Association said outcomes for da Vinci hysterectomy procedures were no better than those for laparoscopy, and the da Vinci procedures cost a third more.
Rabner acknowledges that the hospital loses money on every robotic surgery procedure it performs but says, “to a person, the doctors all tell me how much better the work is.”
A Three-Dimensional Look—At Your Esophagus
Anish Sheth, a young doctor who specializes in gastrointestinal conditions, was working at the Yale School of Medicine, where he had developed a unique expertise in the fast-growing field of esophageal medicine. He was, a few years ago, the kind of up-and-coming talent who you’d imagine might be most comfortable in a big city teaching hospital. But then he started talking to a medical practice in Princeton.
He was interested in coming on, but he had a condition: To continue his advances in the field, he would need access to the same kind of state-of-the-art laboratory and equipment he had at Yale. That included the prospect of a new imaging system that would make it possible to diagnose dangerous esophageal cancers far more readily.
As it happened, UMCP was gearing up to move into its new facility, and Rabner was all too happy to put his weight behind the program. “It was met with overwhelming support,” Sheth recalls.
Now, Sheth and his colleagues are about to become among the first in the world to use the new esophageal imaging system created by a startup called Nine Point Medical. In simple terms, the technology involves inserting a probe down a patient’s throat to get a close-up, three-dimensional look at the wall of the esophagus.
The new technique is a breakthrough for the estimated 3.5 million people in the U.S. who suffer from a condition known as Barrett’s Esophagus, in which long-term acid reflux actually changes the nature of the esophageal cells. Barrett’s Esophagus is a known precursor to cancer, but until now it has been very difficult to know when a merely unpleasant disease might turn into a fatal one.
“It’s much needed,” says Sheth. “We’ve been very basic in our ability to diagnose and treat these conditions.”When a precancerous condition is identified, it can then be treated with another technology, known as radio frequency ablation. In that procedure, a balloon containing many tiny electrodes is inserted into the esophagus and inflated; an electric current is then passed through it, which kills the diseased cells in the esophageal lining, making way for healthy cells to grow back in their place.
For Sheth, the high-tech tools are a critical dimension of his practice, helping to ensure the kind of referrals that will keep his practice on the cutting edge. “I was concerned that I would have to fight against the bias of people going to New York or Philadelphia,” Sheth says. World-class technology makes that a non-issue.
To Rabner, that is exactly why it makes sense to bring new technologies to community hospitals—not just because of the competitive edge but simply to increase the quality of care.
Another example he cites with pride is the UMCP’s use of the TrueBeam linear accelerator, an advanced system for the radiation treatment that is often a part of cancer therapy. The machine can reduce the time that each treatment takes by half or more, and the beam can be directed with a precision measured in increments of less than a millimeter. Rabner says the equipment cost about $2.5 million, and the room where it’s used, with high-density lead and concrete walls, cost about the same.
Having such breakthrough technology in community hospitals, Rabner says, is part of a larger ambition for medicine today: getting health care closer to patients.
“We’re always looking for ways to provide care close to home,” he says. “Things that were done best at an academic medical center are being done as well at community hospitals. Things that were done in the hospital are now done on an outpatient basis. Things that were done outpatient are in physicians’ offices. And more and more is even being done at the patient’s home. All medical care is migrating that way.”