How do you measure a year? That’s the question 24×7 Magazine posed to six of the top luminaries in HTM. 

Below, Jovito “Jojo” Gonzales, BSHA, CBET, CHTM, lead BMET, clinical technology department, Kaiser Permanente San Diego Medical Center; Clarice M.L. Holden, BSE, supervisory biomedical engineer, Dallas VA Medical Center; Gordon Hosoda, chief, healthcare technology management, VA Portland Health Care System; Samantha Jacques, PhD, FACHE, director, clinical engineering, Penn State Health System; Matthew F. Baretich, PE, PhD, president, Baretich Engineering; and Jeffrey Ruiz, TriMedX, technology manager, healthcare technologies, Holland Hospital in Michigan; discuss the biggest headlines from 2019 and what to expect in 2020 and beyond. Don’t miss out. 

24×7 Magazine: In your opinions, what have been the top issues in HTM in 2019? 

Clarice Holden: The biggest issue in 2019 has been retaining institutional knowledge at my medical center. Many in the HTM field are either eligible to retire or are looking to make lucrative career changes. When technicians and engineers leave their positions at hospitals, it creates gaps for the remaining staff to manage. If an HTM department isn’t planning for redundancy, cross-training, and sharing information, then it remains susceptible to failure through attrition and loss of knowledge. 

Security of medical devices has also been a big issue as additional viruses run roughshod over well-intentioned medical networks. These hazards, such as BlueKeep and Urgent 11, serve as poignant reminders of the critical nature of keeping medical devices free from “sickness” (i.e. virus infection). 

Gordon Hosoda: I believe the biggest issue we have experienced at our site is the inability to quantify our service and cost-savings to the medical center. Even though our HTM section has service contracts on high-dollar equipment, such as CTs, MRIs, angio equipment, and cath lab equipment, we always per- form first-call responses after calling the service contract vendor. About 85% of the time, we can get the equipment operational in 15 to 30 minutes. This eliminates the need for patient cancellations, costly outsourcing, etc. 

Overall, for data-driven C-level hospital leadership, proving the value of HTM and increasing HTM staff to reduce patient outsource costs, increases in wait lists, etc., with hard data has been a continual challenge. 

Jojo Gonzales: To me, it’s the pace of change. There’s been some rapid and significant changes in the industry recently with regards to technology, innovation, personnel, regulations, standards, and more. As an industry, I believe we’re struggling to keep up; HTM is like a swimmer caught in a storm in the middle of a vast ocean, kicking and paddling like crazy but barely keeping [his/her] head above water. 

Jeffrey Ruiz: Filling the HTM opportunities that exist, which is a challenge for hospitals, ISOs, and manufacturers. So, how do we correct this? One way is to reach out to the traditional pipelines of high schools and colleges, lateral career-changers, and the U.S. Armed Services/veteran sectors. But, also, we may need to think of areas not traditionally considered—such as individuals outside of the United States, people in the healthcare IT industry, and those directly in healthcare (like nurses and nursing assistants). At our hospital, we’ve seen a big transition from clinicians to IT analysts; couldn’t we do the same with HTM? 

The other issue is the nearing of the end for small community hospitals. It pains me to see this, but it’s continuing to happen on a local and regional level. So, what will happen to those remaining hospitals? And, more importantly, how will their devices be serviced? With many hospitals being acquired, the larger organizations are adding the [acquired hospital’s] devices to their programs. However, for those that remain, we are seeing some HTM providers leaving this space while shifting their focus to the larger systems. Unfortunately, I don’t believe there is a positive outcome and this is indicative of the merger/activities that continue to occur in healthcare. 

Samantha Jacques: Cybersecurity. There have been many cybersecurity events throughout the year, including the Medtronic implantable cardiac devices issue and the more recent Urgent 11 notifications. How HTM departments process these events and mitigate the risks is still a work in progress that has continued to evolve in 2019. 

Matthew Baretich: One of the biggest developments has been the growing adoption of alternative equipment maintenance, or AEM, programs by the HTM community. When I wrote the AEM Program Guide for AAMI a couple of years ago, there was limited knowledge within the community. Now, there is widespread recognition of the cost-reduction potential of a comprehensive AEM program. We know it’s possible to reduce the time spent on planned maintenance while complying with accreditation standards and maintaining high levels of patient safety. 

There’s been a lot of innovation with- in the HTM community, which is now informing AAMI’s efforts to create an official AEM standard. And if you tell Joint Commission surveyors that you don’t have an AEM program, they’ll ask why not. 

24×7: “Artificial intelligence” (AI) and “predictive analytics” are two of the buzziest terms in healthcare. How do you think AI and predictive analytics will affect the HTM sector? 

Gonzales: The HTM sector is not ready, but it will need to adapt quickly as there is no slowing down the innovators who continue to learn more and apply artificial intelligence and predictive analytics into the infrastructure. They are leveraging enormous amounts of technical and clinical data to enhance diagnostic capabilities, create predictive models, improve operations and equipment lifecycle management, and more.

Hosoda: I think that AI could potentially be used to help determine weak points, configuration errors, accessible IP addresses, etc., that could make networked medical equipment systems vulnerable to cyberattacks. In the same way that [Denial of Service] and Robo attacks are used to breach firewalls, hack passwords, etc., AI could be used to help ensure defensive, protective structures (firewalls, virtual LANs with port control, etc.) are as strong as possible. I envision it as the AI version of human hackers that are hired by the FBI/[National Security Agency] to help support and protect the networks they once tried to hack. 

Ruiz: Having data predict when a device will fail is an ideal benefit. And there are examples of healthcare systems that are studying key error codes to identify a service event. As this service strategy becomes more readily available, how will the HTM industry implement it? More importantly, how will CMS and the regulatory agencies evaluate such a strategy? We have key requirements that [determine] when an AEM strategy is allowed on a certain device and when it’s [not allowed.] Will AI trump some of this? I think this will lead to some heavy debates as it becomes available. 

Baretich: I think HTM is just beginning to make good use of the vast amounts of data we collect. One of the most important areas of application is to help us move from being reactive to proactive. 

For example, many performance metrics we use go something like this: Do the work. Key it into the CMMS. Wait until the end of the month, plus maybe 30 days. Produce a writ- ten report. Put it on the manager’s desk to read as time allows. Realize we missed the early signs of a problem that started months ago. AI techniques can support predictive analytics that raise the red flag much sooner.

Jacques: AI has great promise in analyzing data and predicting events. HTM should be using this data to look at medical device failures and help predict future failures, future optimizing AEM programs and providing industry information on better device designs throughout the industry. In broader healthcare, AI should be used to improve patient outcomes and drive out costs from the healthcare system. 

Holden: Artificial intelligence in medical devices may help HTM staff by performing self-diagnostics and direct reporting to technicians to identify when an issue is present. AI may also grow to assist doctors and clinical staff in reading diagnostic images or interpreting other medical data; however, it may be more difficult for HTM staff to identify if there are glitches that negatively affect that [intelligence] or lessen its impact. 

Moreover, predictive analytics—if HTM staff can collect enough information on device maintenance issues and the underlying reasons for them—will enable HTM professionals to further develop alternative equipment maintenance schedules for devices. Systems that provide predictive analytics for determining patient status and likelihood of deterioration would be new devices for HTM teams to under- stand and maintain, but they will likely become a normal part of the repertoire of medical instrumentation in acute-care settings. 

24×7: From a cybersecurity perspective, what are some steps HTM professionals can take to promote device security and patient safety? 

Jacques: The first step in any robust cybersecurity program is to have a full and complete inventory of all devices, their [media access control] and IP addresses, and how they connect to various network hardware and software in your infrastructure. Most hospitals struggle with this basic step—and so mitigating risks that arise are complicated by the fact that one doesn’t know what they have. The next step is prioritizing the risks and building a program that helps manage these risks.

Hosoda: I believe that we need to keep pressuring OEMs to focus on the design, development, and retrofit-strengthening of device and network security. OEMs are continually focused on patient safety since they are litigation-adverse. However, tying in the aspect of cybersecurity as a part of patient safety and the ensuing liability risk should also help [the industry] promote overall device security as well as patient safety. 

Holden: Education and awareness can never be stressed enough. HTM professionals should be on the front lines talking with clinical staff leadership to encourage safe practices (such as never allowing a vendor or staff member to plug in an unscanned USB drive to a medical device). Safeguarding patient information is a requirement of our jobs via HIPAA, but making sure devices are free of viruses and performing as designed is also key to delivering excellent patient care. 

Ruiz: First, partner with our fellow IT brothers and sisters. By working together, we can work on our respective strengths to mitigate cyber-risks while providing top-notch patient safety. Secondly, we must be careful when selecting a provider for our Cyber-Security Continuous Vulnerability Assessment tools. There are many providers out there, so who do you select? Especially given the fact that many of them [are new to the market.] 

KLAS, for instance, recently published its “Standout Vendors” in the IoT space, which illustrates the changes to this young market. The KLAS report helps provide some independent assessments to help better educate the industry. 

Gonzales: First, learn the language. HTM professionals should embrace the challenges brought on by interconnectivity. Continuing education must remain an integral part of the growth and development of HTM professionals. Finally, remain vigilant. Incorporate cybersecurity countermeasure practices into the PM procedures. Even the simplest checks of device physical security—logging off when finished and making sure users do not have passwords written under their keyboards—can make a big difference. 

24×7 Magazine: We are only weeks away from a new year—and decade. From an HTM standpoint, what do you think will be the biggest issues in the field in 2020? 

Baretich: I think we must find a way to be much more involved in crafting regulations, rather than simply responding to them. Too many times, organizations that develop regulations do so in a vacuum. As a result, we are left to devise inefficient work- around practices to achieve nominal compliance with requirements of dubious value. 

But we can’t put all the responsibility for that on the regulators. In my opinion, the HTM community does not have an effective advocacy structure in place. Therefore, we should push our professional associations to develop good working relationships with regulatory, standards-making, and accrediting organizations so that all relevant stakeholders—including HTM—are part of the process at all stages. 

Gonzales: I think the struggle with recruitment and retention will continue in 2020. With rapid changes and ever-increasing demands on HTM professionals, many are opting for career change or retirement. We, as an industry, need to do a much better job of taking care of our current [workforce] to keep them in the field. We cannot continue to increase HTM workload without compromise and not expect any adverse effects. Inevitably, when retention suffers due to discontent, recruitment becomes even more difficult. 

Ruiz: Will we have talent to serve the industry? It would be great to see the manufacturers execute a shared strategy with the ISOs, allowing manufacturers to focus on their higher-acuity [devices] and subcontract out the lower-acuity ones to the ISOs and hospital-based systems. If the healthcare industry eventually shifts to a single-payer system, some version of this solution could be a [good path forward for medical devices.] 

Does this also impact our ‘Right to Repair’ dialogue? I think so. We, as an HTM community, must work on being more collaborative in the service we provide to clients and our patients. The 2019 AAMI meeting talked of collaboration between manufacturers, ISOs, and hospitals. I hope to see more movement in this space in the coming year. 

Holden: Retention of institutional knowledge, in addition to hiring new engineers and technicians. So many of the staff at my hospital are at retirement age or years-of-service (especially in our imaging section), that if a few of them decided to retire today, (They would be well within their right!) over 90 years of experience would walk right out the door. A huge initiative we are working on at our hospital is presenting at local universities and developing pipelines for interested students to apply for positions. Getting the word out as to what the HTM field is and kindling interest will be a big concern for the new year. 

Hosoda: I believe cybersecurity of networked medical systems will be a growing concern in 2020. However, I do not believe hackers will be specifically focused on affecting the operation of just the isolated medical equipment or networked systems, but rather using that as an entry point to gain access to the main hospital network databases that contain protected health information of both staff and patients for the purposes of identity theft or ransom. I suspect that hospitals are currently low-value targets for hackers, due to the gain- to-effort ratio required to steal data. 

However, I believe that network security for medical equipment and networked medical equipment has not been a key focus of medical equipment manufacturers, and therefore security standards are significantly behind industry standards. Due to this, even though the amount of gain of identity theft may be lower than massive sites, such as, the ease of effort to access these systems may shift the gain-to-effort ratio so that hospital network systems may become more desired targets. 

Jacques: I don’t think that cybersecurity is going to be resolved anytime soon, but I have seen an increase in local governments and states looking at ‘Right to Repair’ legislation. If passed, this will have impacts on the field for years to come. 

24×7: What would you tell someone looking to pursue a career in the HTM field and why? 

Jacques: This is a wonderful field full of ever-changing technologies that allow those in the field to be at the intersection of patient care and medical devices. We have the unique role to help patients improve their lives through technology. 

Gonzales: Learn networking and [device] security. It’s inevitable that more medical devices will become interconnected, and HTMs must know how to support and protect that infrastructure. In addition to technical proficiency, I would encourage everyone to continue developing their soft skills. Also, seek and work with a mentor. This is someone who can provide invaluable information about the HTM field, become a sounding board when you’re faced with challenges, guide your career, and more. 

Also, join and be active in your local HTM association. It provides an excellent opportunity to network with fellow HTMs, vendors, manufacturers, educators, etc. It also affords you the chance to give back to the industry. And finally, get certified. 

Hosoda: Since most medical equipment and equipment systems are now networked, obtaining a strong background in networking and cybersecurity is becoming a necessity. 

Holden: I would tell them to always keep a student’s eye and ear, as continuous learning is part of the HTM fabric. Keep an interest in always learning and learn to cope with change. These are some of the skills I look for in new hires; because if someone is eager to keep learning and applying what they have learned, then they will [be ready to handle] the influx of new technologies in a hospital. 

Ruiz: If you are looking for a challenging field, look no further. This is a great opportunity to manage various changing healthcare technologies that benefit patients as well as their caretakers. We are no longer becoming just a break-fix solution. We provide capital acquisition selection/implementation, systems engineering, systems troubleshooting, device integration (EHR) implementation/support, incident investigation, project support, and so much more. 

Baretich: Never stop learning. There have been times in my career when I wished I could just coast along on what I already knew. The problem is that knowledge grows and the world changes. We must all find ways to keep up.