8 Trends Shaping the Present & Future of Gastroenterology

Gastroenterologists Richard Zelner, MD, of Orange Coast Memorial Medical Center in Fountain Valley, Calif.; Lawrence Kosinski, MD, MBA, Managing Partner of the Illinois Gastroenterology Group in Elgin; Bob Cleary, MD, of St. Joseph Mercy Hospital in Ann Arbor, Mich.; and Jeff Barnett, MD, of Huron Gastroenterology in Ypsilanti, Mich., discuss eight trends that are affecting how gastroenterology is practiced now and how it will be practiced in the future.
1. Healthcare-driven structural changes. "Cost constraints and legal intervention have had a tremendous impact on medicine. The legal necessity of medical facilities and physicians performing low yield diagnostic testing and the ever tightening patient care budget raises alarming concerns for the future of rationed care," says Dr. Zelner. Accountable care organizations and the shift towards consolidation within the healthcare industry will have an impact on how and where gastroenterology is practiced.

2. Shift away from nonprocedural services. The shift in reimbursement for colonoscopy has drastically changed how gastroenterologists practice. Prior to 2000, it was a struggle to obtain reimbursement for colonoscopies, but now a large portion of gastroenterologists' income stems from performing these procedures on a regular basis. "Our field has become so procedural it is losing some of its identity as an intellectual science," says Dr. Kosinski. He suggests that gastroenterologists need to begin a shift towards nonprocedural lines to expand services within the field. Business line trends include: inflammatory bowel disease, nutrition, Hepatitis C, women’s GI needs and geriatric GI conditions. These business lines hold promise for the future of gastroenterology.

Dr. Barnett3. EHR & support technology
. Electronic health records are having an enormous impact throughout the medical field and gastroenterology is no exception. Whether the benefits or hassles will take the lead in physician opinion is yet to be determined. "On the downside, during our patient encounters, we spend a lot of time working a mouse and a keyboard as we stare at the computer rather than looking at and listening to the patient," says Dr. Barnett.

On the other hand, EHR allows for a more rapid, portable method of communication with our offices and therefore with nursing, scheduling and patients. "Everything is compressed in terms of time and efficiency. I can take care of my tasks off site during the day," says Dr. Barnett. "EHR has a long way to go; we are experiencing it during the rapid change and 'sorting out' phase. Looking back in five to 10 years, people will think we were at a relatively primitive phase."

Dr. Kosinski is currently working on an initiative called "Project Sonar," which is a patient engagement tool using a portal through which Crohns Disease patients can send status reports of their condition and stay in touch with the physicians charged with their care. "In many ways technology will improve patient engagement and this will be key to our ability to manage risk," he says.

Another major component of technology affecting gastroenterology is the advent of clinical decision support tools (CDS). These tools, though still at the early stages of development, will intervene at the point of care and guide physicians through the treatment of patients. "We will be able to mold and shape care and better predict outcomes," says Dr. Kosinski.

4. Patient outcomes tracking
. Programs such as the National Surgical Quality Improvement Program, sponsored by the American College of Surgeons, are providing gastroenterologists with a wealth of reliable data. "These large databases are maintained by highly trained staff and provide power to the studies because of the large numbers. This allows us to more rigorously study problems with quality outcomes," says Dr. Cleary. Active participation in databases gives gastroenterologists the ability to draw upon trustworthy data that can be used to improve patient outcomes.

Dr. Cleary is involved in an Enhanced Recovery Initiative, which provides patients with preadmission education and knowledge of the entire procedure process. As a part of this process, patients are drinking Gatorade just before their procedure to prevent muscle wasting and dehydration and are drinking liquids shortly after surgery as soon as they are awake and alert. Patients are being released two days after colon cancer surgery and even the next day in some cases, rather than six to seven days later. "This is a model that can be applied to several different procedures and different hospitals," says Dr. Cleary.  

Dr. Cleary5. Endoscopic imaging and instrumentation. "As colonoscopy continues to evolve, certain imaging techniques that now accompany it can make small polyps more visible," says Dr. Cleary. As endoscopic technology becomes more sophisticated, scopes are allowing gastroenterologists safer, easier access to different areas of the GI tract and high definition capabilities are improving diagnoses. Minimally invasive surgery is beginning to overlap with endoscopy.

"Diseases that in the past required open surgery are now being treated noninvasively, sometimes even with an endoscope.  Also, our endoscopic techniques and optics have improved to the point where we can practically predict a polyp's histology by its endoscopic appearance. In the future, we may be able to remove some polyps without the need for pathologic examination, which will save effort and costs," says Dr. Barnett.

6. Robotic surgery is becoming more common. Robotic surgery was first adopted in the field of urology and then gynecology. Today, it is a continually growing trend in several fields, including colorectal surgery. Dr. Cleary first explored minimally invasive surgery through laparoscopy during his fellowship in the early 1990s, but laparoscopic surgery is not a simple procedure. "Only about 50 percent of colorectal surgeons trained in laparoscopic surgery actually perform laparoscopic surgery in practice," says Dr. Cleary. He has performed over 200 robotic surgeries in his practice, and predicts that GI surgeons will increasingly adopt the procedure until it becomes the dominant form of minimally invasive colorectal surgery.

Dr. Kosinski7. Revolutionary treatment and research continues to evolve. Research is discovering that the bacteria residing within the human body, the fecal microbiome, have a significant influence on health in areas such as obesity and cancer. "This is where so much research effort is being exerted now," says Dr. Kosinski.

Another area for research and innovation is antiviral therapy. Gastroenterologists are gaining a new command over viral replication. "Antiviral therapy for hepatitis C is revolutionizing the way we treat this disease," says Dr. Kosinski. "There have been a number of new antiviral agents for hepatitis C that may eliminate the disease in the majority of afflicted individuals," says Dr. Zelner.  

8. Biologics are increasingly used in GI procedures. “Crohns Disease and ulcerative colitis, two of the most destructive GI illness, account for about 20 percent of a gastroenterologists' revenue. Unfortunately, the overall cost of care for these illnesses is rising and must be brought under control. CDS and Patient Engagement tools will enhance our ability to accomplish this,” says Dr. Kosinski.

“Biologics are going to continue to shape how these patients are treated as they become more available and less expensive. Gastroenterologists must be in the forefront in the care of these serious digestive illnesses," says Dr. Kosinski.

There will be "a greater use of medications and biologic agents that will target our genes and eradicate disease; the concern is the cost of these medications and how and who society will allow to use them," says Dr. Zelner.

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