Anthony DiGioia III (M.S. 1982), A Pioneering Engineer for Patient-Centered Care
The following has been adapted with the permission of Dr. DiGioia from Chapter 6 of Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs.
In our aging population, total joint replacements have become one of the leading Medicare expenditures. In 2010 in the United States, there were 900,000 knee and hip replacements at a cost of $4.8 billion. This staggering number is approaching what Dr. Anthony DiGioia III (M.S. '82; Adjunct Professor of Biomedical Engineering) calls "epidemic" levels. DiGioia is a pioneer in developing new technology for total joint replacement surgeries; but more than that, as is true for many Carnegie Mellon graduates, he is an innovator who has created a whole new approach to treating patients.
Merging Engineering and Surgery
DiGioia is the eldest of eight children in a Pittsburgh family. As a tight end for Carnegie Mellon’s football team, he became interested in the mechanics of the human body after suffering from a knee injury in his freshman year. However, following the footstep of his father, a Ph.D. in civil engineering, his passion was in civil engineering and he had no sense that he would become one of the nation’s leading experts on the very joint he had injured.
Upon graduation, he advanced to the master’s program in biomedical engineering at Carnegie Mellon, where he started to develop an intense interest in the application of engineering to medicine. Working under the supervision of Dr. Albert Ferguson, an orthopedic surgeon who understood the importance of bringing engineering to solve problems in medicine, DiGioia collaborated with residents and physicians on engineering challenges in orthopedics. On Dr. Ferguson’s advice, he then applied and was admitted to Harvard Medical School. He entered Harvard with his mentor’s advice to “bridge the gap between surgeons and engineers.”
After an internship in general surgery and residency in orthopedic surgery at the University of Pittsburgh Medical Center (UPMC), followed by a fellowship focusing largely on hip and knee replacements at Massachusetts General Hospital, DiGioia headed home to Pittsburgh in 1992 and joined an orthopedic practice. At the same time he did something highly unusual for a young surgeon: he started a research lab where he pulled together an interdisciplinary team of engineers and computer experts from Carnegie Mellon to advance the science of orthopedic surgery.
Breaking Through to Innovation
At the time, the science of robotics was developing rapidly, and Carnegie Mellon was (and remains as) one of the leaders in the field. DiGioia and his team combined robotics with computer-assisted surgical tools, receiving one of the first National Science Foundation grants in medical robotics. They figured out how to use robotics as a navigation tool, creating what DiGioia describes as “a GPS system for surgeons.” It proved to be a breakthrough. Robotics and computer-assisted tools allowed for a more precise alignment of an implant. “Better alignment means fewer problems with wear or dislocations,” says DiGioia. “To be able to reproduce the technique with such precision meant consistently better outcomes for all patients. It reduces variation and tightens the best practice.”
DiGioia wanted to build a successful orthopedic surgical practice, but he also wanted to research and innovate. After just a year, he broke out on his own, starting a solo practice. “The best situation for me is when I am helping to lead the way,” he says. “When I am in a situation where I don’t have an opportunity to lead the way and have an impact on clinical practice, I don’t get as excited. It became clear that to continue to be able to do the things I enjoy and want to do and that I felt were my strength, I would have to start my own practice from scratch, and that is what I did.”
While in solo practice he worked with others to organize a conference on computer-assisted orthopedic surgery (CAOS). His practice steadily grew and soon several additional surgeons began working in his joint care center at Western Pennsylvania Hospital, the first focused care center in western Pennsylvania for patients needing hip and knee replacements.
Focusing on the Complete Picture
In the early 2000s, DiGioia realized that for all his focus on technology, the places with the best and most reproducible outcomes “were the ones looking at the entire care experience and not just the surgery. How do you best prepare a patient for surgery? How do you most effectively do pre-op testing? And when? What kind of anesthesia regimen works best? What is the most effective pain management? What is the most successful rapid rehab? How do you get the physical therapists all on the same page? How do you follow up with the patient?”
DiGioia had always prided himself on cross-discipline collaboration, and yet he now realized that he had been working within “a computer-assisted orthopedic surgery silo.” Like most surgeons he viewed the surgical process through a narrow prism, seeing the actual operation itself as the event, with everything else as ancillary. But he now saw it differently—that rehab, for example, was just as important to a quality outcome as an accurate surgical technique and that pain management was essential to effective rehabilitation.
“You had to look at the whole patient experience,” DiGioia says. “Traditionally, if you are a surgeon, you are very, very focused on the surgery you perform. We found out that yes, the technique is important, but most times the biggest impact on outcomes was everything else.” And along with that clarity came his belief that it was also essential to include the patient’s family in every step of the process because he could see that family members played an enormous role in a patient’s life—before, during, and after treatment.
Redesigning the Patient Experience
“Every industry must listen to the end user,” he says. “No industry that has survived has failed to focus on the end user. And in health care we don’t do that. The industry cannot survive in the current model if we follow a path where we do not listen to the end user and engage them in the design of new approaches. “You can’t go wrong with a focus on patients and families. You just can’t.”
Around 2005, it became clear to DiGioia that gradually he and his team had revamped the process surrounding surgery and that the newly evolved method—designed from the patient’s and family’s point of view—was more effective than the traditional approach. He described it as a “low-technology, systems-based approach” to improvement—“the redesign of patient experiences so resources and personnel are organized around patients, rather than around specialized departments and practitioners in a hospital, and through the full cycle of care.”
DiGioia began calling this new method the Patient and Family Centered Care (PFCC) Methodology and Practice, which focuses the attention of healthcare providers on the total patient experience, not just on the clinical procedures. It contends that our current resources, when properly used, are already more than enough to match the demand.
A Bold Move
The more he tested and improved the PFCC Methodology and Practice, the more convinced DiGioia became that it could be applied to just about any care experience and any organization and facility, inpatient or outpatient, to achieve similar results not only for orthopedic patients but for all patients. To prove that it would work beyond orthopedics, eventually he reached the bold decision to move to Magee Womens Hospital, at the time a 280-bed facility devoted to women’s health issues, although it had begun to offer broader services.
“People thought we were crazy,” he says. “They would say, ‘why are you moving to a women’s hospital that doesn’t even have orthopedics?” But DiGioia and his team saw it as a great opportunity to take PFCC to a new level. He saw that at Magee he could develop a subspecialty hospital within the walls of an existing hospital—a “hospital within a hospital.” Thus was born the Bone and Joint Center at Magee Women’s Hospital of UPMC, where DiGioia has been practicing in the new Orthopaedic Program since February of 2006. Another part of his efforts at this time was to have the UPMC fund an innovation center to promote the dissemination of the PFCC Methodology and Practice.
Spreading the New Paradigm across the World
Thus far the PFCC Methodology and Practice has already spread to numerous UPMC hospitals. It has been implemented in doctor’s offices, outpatient facilities, as well as various kinds of hospitals—large and small, tertiary to community, and specialty to teaching. “By refocusing existing resources and using the tools and techniques of the PFCC Methodology and Practice, we break down silos between departments,” says DiGioia. “We maintain an unwavering focus on seeing the care experience through the eyes of patients and families, and achieve measurable improvements in patient satisfaction, caregiver satisfaction, and cost savings for the organization.”
The PFCC Methodology and Practice affects the cost of care in a number of ways. The key is an acute awareness of every step in the care process and identifying which steps most effectively serve patients. Anything that is not value added for the patient is eliminated. The team-based nature of the methodology further plays an important role in waste reduction. DiGioia’s patients were able to go home on average much more quickly than the national average (after 2.9 days for knee replacement patients compared to 3.8 days nationally and after 2.5 days for hip replacement patients compared to 4.9 days nationally).
Now DiGioia is determined to spread the PFCC method across the world. “We don’t want little pockets of success. We want acceleration and widespread adoption. We are not saying we have the exact solution to all your problems but we have a methodology for you to get there.”