Engineering-medicine as a transforming medical education: A proposed curriculum and a cost-effectiveness analysis

The current US medical care system faces many challenges. While the cost is very high, the overall quality is disappointing, particularly in access and equity. Facing an increasing demand of medical care, efforts to improve medical care in fulfilling the triple aims of “better care, better health, and lower cost” called for by the National Academy of Medicine are at the front and center in the healthcare debate. In this paper a transformation of current medical education by incorporating engineering principles into traditional medical teaching is introduced along with a proposed curriculum, followed by an economic evaluation of such transforming educational changes. A brief cost-effectiveness analysis on such an engineering-medicine education, from a societal perspective and under a set of assumptions, results in a positive cost-effective outcome. Therefore, on health economic grounds, an engineering-medicine education could be implement in a small subset of students as a proof of concept study. *Correspondence to: Lawrence S Chan, University of Illinois College of Medicine, 808 S Wood, Suite 380, Chicago, IL USA, Tel. (312) 996-6966; Fax. (312) 996-1188; E-mail. Larrycha@uic.edu


Introduction to Engineering-Medicine, a Transforming Medical Education
Before we discuss a transformation of medical education, we should first delineate briefly the reasons for the change and define the parameters for improvement. For that, we start with the current status of medical practice and medical education.
First, there is the high cost of healthcare in the US. Measuring the healthcare spending world-wide, it has been determined that US has the highest per capita expenditure in healthcare [1]. Second, there is the healthcare inefficiency in the US. Despite its high cost, US healthcare efficiency has been ranked as one of the lowest among the wealthiest countries [2]. Specifically, the access, efficiency, and equality of healthcare for US people were ranked last or near last among the developed nations [2].
Regarding the current curriculum of medical education, there is a lack of up-to-date training in technology utilization [3][4][5][6][7][8], as well as a need to improve efficiency [2]. Accordingly, there have been calls for healthcare and medical education reforms by the nation's medical education leaders. Realizing the problems of high cost and low overall quality of healthcare, the National Academy of Medicine (formerly Institute of Medicine) has called the medical professions to fulfill a triple aim of goals [9].
• Better care: Improve access and equity of care [9].
• Better health: Since better care does not necessarily lead to better health, the National Academy of Medicine emphasizes this point to encourage medical professions to think about other determinants towards the ultimate health outcome, not just the intermediate step of healthcare [9].
• Lower costs: Faced with increasing costs, the National Academy of Medicine is urging medical professions to think of ways to improve efficiency to reduce the cost of healthcare delivery [9].
Recognizing the essential roles of medical education in fulfilling the triple aims called for by the National Academy of Medicine, American Medical Association has called for reform by the medical educators, with emphasis on the following areas [10].
• Increase technology training • Increase team-approach training • Increase systems practice training That leads to the consideration of medical education reform through a novel engineering-medicine curriculum. Since the characteristic engineering education goals are efficiency, team-based, systems-approached, and technology-oriented, it has been proposed that incorporating engineering principles is one possible way to reform medical education [11]. The argument supporting such reform are that engineering education dove-tails with medical education [11,12] and that the potential impact of Engineering-Medicine education in future medical practice could be significant [11]. The National Academy of Medicine also recognized the potential role of engineering in healthcare transformation and has called for the partnership between engineering and medicine. As early as 2005, the Institute of Medicine (now the National Academy of Medicine) has encouraged the building of a partnership between engineering and medicine to help in solving healthcare delivery challenges [13]. While it is prudent to consider training established physicians in incorporating engineering principles • Calculate the Cost-effectiveness Ratio: Once the cost and effectiveness are determined, this ratio will provide substantial help to the decision-making process. The formula of this ratio is the difference of cost (between the new one and the competing alternative) divided by the effectiveness (between the new one and the competing alternative). Since both cost and effectiveness are determined in dollar terms, a ratio smaller than one (1.0) would indicate that the increase of effectiveness outweighs the increase of cost, thus indicating the program in consideration is cost-effective.
• One-way sensitivity analysis: In this analysis, we will test the sensitivity of projected outcomes when we vary the input assumptions (one variable) in different directions.
• Two-way sensitivity analysis: Finally, we will test the sensitivity of projected outcomes by varying both the cost side and the effectiveness side of the equation.

Curriculum Frame Works for Engineering-Medicine Education
Before we proceed to the actual cost-effectiveness analysis, it is important that we determine the parameters for such analysis. Along this line, we should first delineate what an engineering-medicine education will teach the medical students in such a novel curriculum. Towards this end, the following engineering-medicine curriculum, as a supplement, not a substitution, to a traditional medical curriculum, is developed for such analysis. A truly engineering-medicine curriculum, is more than just increase of teaching of technology in medicine, it requires the change of mind-set and approach. "Think like an engineer and act as a physician" is the central aim of engineering medicine. From the time commitment perspective, it is estimated that this engineeringmedicine curriculum would occupy about 25% of a four-year medical college curriculum, with the remaining (75%) time spent in the conventional medical curriculum:

Course A. Introduction to Engineering-Medicine
The learning objective is to familiarize the students with the current state of US healthcare, the call for medical care and medical education reforms by the Institute of Medicine, and the American Medical Association, and the potential role of engineering-medicine in transforming the future medical education. • Topol E. The creative destruction of medicine: How the digital revolution will create better health care. Basic Books. New York, NY. 2013 in their practices, changing physician behavior is hard to accomplish in a sustained manner [14]. Medical students, on the other hand, being at a knowledge-acquiring stage of their lives, would likely be more open to accepting these new ideas. Thus, incorporating engineering concept at the medical school level would be the optimal solution. A few medical educators have accepted the concept of incorporating engineering principles into medical education. An EnMed program established by the Texas A & M University will start its new medical education program in 2017 [15] and a new engineering-based medical school will start its inaugural class in 2018 [16]. The goal of this paper, is, therefore, to encourage the development of more such programs by proposing an engineering-medicine curriculum and analyzing its cost-effectiveness from a societal perspective.

Defining the Rationale and Methods of Cost-Effectiveness Analysis on Engineering-Medicine Education
Having stated the potential impact of Engineering-Medicine education in the future medical practice, we now turn to the next question: Can we determine if such education is cost-effective from the health economic perspective?
Let us first define the key elements of this particular cost-effectiveness analysis. Cost-effectiveness analysis in healthcare is a scientific method conducted in a systematic manner with the purpose to assist education leaders in making logical decisions on interventions or programs meant to improve health [17,18]. Such methods will help healthcare managers focus on what works and reduce the chance of decision error or waste. In short, the "whole point of cost-effectiveness, after all, is to examine the optimal course of action when there is considerable uncertainty" [18]. Since uncertainty is one element of cost-effectiveness analysis, there is no absolute guarantee for its outcome. Accordingly, the key elements of cost-effectiveness analysis include the following [17,18]: • Perspective: Before going about the cost-effectiveness analysis, it is imperative that the perspective of the analysis is delineated, whether it is from the perspective of the institution or from the perspective of the society, since the benefits to these entities are different. For this project, the perspective will be from the society as a whole.
• Competing alternative: Although this point seems to be obvious, it needs to be clarified. To make a decision on a new intervention or program, we need to compare both the cost and effectiveness of the new one with that of the existing one (or the conventional or traditional one). For this paper, the competing alternative for engineering-medicine education is the traditional medical education.
• Determine the costs: It is essential that the new intervention or program will not be cost prohibitive even if it is more effective. In this project, the costs used for comparison will include the physical facility, IT infrastructure and maintenance, faculty, and staff. We will estimate such costs in dollar terms.
• Determine the effectiveness: This point is front and center of the analysis, as the new intervention or program should be at the minimum as effective as the existing one, if not more effective. The obstacle here is that there is no school of engineering-medicine currently in operation. In the absence of such data, the best effort is made to collect existing studies analyzing interventions or programs utilizing engineering principles that resulted in improving healthcare effectiveness. The assumption is that these interventions or programs, if incorporated into medical education, would have the similarly effective outcomes. We will define the effectiveness as cost saving for the healthcare system in dollar terms.

Course B. Engineering Principles Overview
The learning objective is to provide a basic frame work of how engineering works and what are the goals of engineering.

Course D. Introduction to Systems Biology
The learning object is to help students appreciate that the entire human body functions as a large interconnected coordinated system, rather than many small independent systems.

Course E. Invention & Innovation
The learning objectives are to open students' minds to the world of innovation and invention, which are the signature characteristics of engineering, to understand the importance of invention and innovation in building the future medicine, and to guide the students to hands-on real-life projects of medical invention and innovation.

Course F. Systems Integration
The learning objectives are to familiarize the students with the engineering concept of system integration, to help the students in discovering potential use of integration for improving healthcare delivery, and to guide the students in applying integration in real-life medical encounters.

Course G. Efficiency
The learning objectives are to familiarize the students with the engineering concept of efficiency and the importance of efficiency in healthcare delivery, and to guide the students for their individual projects in improving real-life medical encounters.
Expected learning outcomes when students complete the course: • Understand the importance of the engineering concept of efficiency.

Course I. Design & Optimization
The learning objectives are to familiarize the students with the engineering principle of "design & optimization" and the potential application of this principle in medicine, and to guide the students in their group projects for design and optimization of real-life medical encounters.
Expected learning outcomes when students complete the course:

Course M. Big Data Analytics and Statistics
The learning objectives are to familiarize the students with what Big Data is, what potential roles does Big Data have to improve the health care, and what are the challenges and road blocks that could prevent Big Data from fulfilling its potential. In addition, a brief lesson of statistics will be taught to help the students in understanding its role in healthcare.

Course J. Precision
The learning objectives are to familiarize the students with the engineering principle of precision and the importance of precision in medical practice, and to guide the students in their individual projects in applying precision-medicine principles to real-life medical encounters.

Course N. Health Quality Management
The learning objectives are to familiarize the students with the engineering principle of quality management and the importance of quality in health care, and to guide the students in their group projects of conducting quality management in real-life medical encounters.

Cost analysis
First, let us delineate our analytical assumptions. For the purpose of this analysis, we will assume the new medical college, regardless if it is an engineering-medicine college or a traditional one, will have an inaugural class size of 50.
With our assumptions set, the cost data were collected by the following manner:

Facility costs: conventional vs. engineering-medicine
To estimate the cost for a new medical school education building, we will examine the costs of similar buildings in some recently completed facilities. For example, University of North Dakota, built a new educational building in 2013 with a total of 325,000 square feet space that cost $125 Million [19]. Another example is the new educational building of Cooper Medical School of Rowan University which cost $139 million, with the capacity of 200,000 square feet to accommodate 100 students per class [20]. Another new medical education building to be completed in 2016 for University of Texas in Rio Grande Valley cost $54 million with the capacity of 88,250 square feet, including classrooms, conference rooms, study rooms, faculty offices, simulation center, digital anatomy lab, an auditorium, a library/learning center, and a student lounge [21]. For a new medical school with a projected class size of 50, it is estimated that we need an educational building of 100,000 square feet, sufficient to contain some small class rooms, an auditorium with the size to accommodate 250 attendees (50 students/class X 4 classes +50 faculty and others), some laboratories, and a simulation center, an anatomy lab, as well as some study rooms for students and office spaces for faculty and staff. An estimate of $80 million is considered sufficient for a conventional school. Let us further assume that the more technology-intense Engineering-Medicine curriculum will require a facility that is relatively larger and equipped with more advanced instrumentation than the conventional medical college. We will make an assumption that 15% more a price tag is required for the education building of the engineering-medicine school of the same size, equating to $92 million. If we assume a 5% interest loan amortize the building expense to a 25-year usage, the annual expense for the medical education building will be $5,676,196 and $6,527,626, for the conventional and engineering-medicine schools, respectively (Table 1)

Information Technology (IT) costs: conventional vs. engineering-medicine
Let us also assume that IT cost in the more technology-intense Engineering-Medicine curriculum will require an expense in IT infrastructure and maintenance that is 10% higher than the conventional medical college. If we set the annual IT cost for conventional school to be $500,000, the corresponding cost for engineering-medicine school will be $550,000 (Table 1).

Faculty costs: conventional vs. engineering-medicine
On the faculty equation, the engineering-medicine curriculum will obviously require a new set of engineering faculty, in addition to the medical faculty. [22][23][24]. In terms of number of faculty relative to number of students, currently there is no standard to follow and there is a wide variation among medical schools in the US.  [25]. Obviously, there is no good correlation between the faculty to student ratio and the quality of education per se, but the better schools tend to have at least a 1.3:1 ratio. It is not clear, however, to what extent these faculty members participate in direct medical student teaching. Thus the exact direct teaching contribution of these faculty members is not defined. For the purpose of this analysis, we will use a ratio of 1.3:1. Thus for the full capacity of student body of 200, we will aim for the faculty members of 260, including both basic science and clinical faculty, for the conventional medical school calculation. In terms of ratio of basic science to clinical faculty, there is also no standard. We will make the assumption of 25% basic science and 75% clinical faculty. Thus we will need 65 basic science and 195 clinical faculty members for a conventional medical school. Using salary data from University of Florida, the average annual salary pooled from 18 specialties of clinical faculty was approximated to be $249,000 [22]. For the engineering-medicine school, we will calculate additional 13 engineering faculty members (of Associate Professor level), one for each of the engineering subjects depicted in the curriculum in the section above. According to a higher education survey, the average biological science and engineering faculty annual salary (2015-16) at the Associate Professor level are $67,932, and $97,023, respectively [24]. Thus an additional $1,261,299 annual cost for engineering faculty members will be calculated into the engineering-medicine equation. The detailed calculation of cost will be depicted in Table 1.
Administration costs: convention vs. engineering-medicine. For this item, the assumption is that there will be no increase of cost between conventional and the engineering-medicine schools. We estimated that 100 staff members are needed (Table 1).
Comparison total costs between conventional and the engineeringmedicine school: According to recent (2015) data, the total number of medical graduates per class in the United States is 18,705 [26]. This total graduate number multiplied by 4 and then divided by 50 will give a factor of 1,496, which will be used to multiply by the annual cost of a 50-student-per-class school to obtain the nation-wide total cost (Table  1). Finally, we determined by extrapolation that the engineeringmedicine school, if operated for the entire United States, will cost $3,235,442,584 ($3.235 billion) more than the conventional medical school annually (Table 1). Having determined the cost differential, we now move to examine the effectiveness.

Effectiveness Analysis
As we did for the cost analysis, we will also define the following analytical assumptions: Effectiveness will be defined by the healthcare saving in dollar terms, whether it is accomplished by increased efficiency or by reducing cost [17,18].
With the assumptions set, the next step will be data collection. Since circulatory, musculoskeletal, respiratory, and endocrine group of diseases, along with ill-defined conditions, account for the top 5 disease groups where the US health system is spending its largest sum of money, it is logical to collect as much data in relation to these diseases, for the purpose of this cost-effectiveness analysis. In 2012, one organization estimated that US national expenditures were estimated to be $241 Billion, $186 Billion, $157 Billion, and $138 Billion, for circulatory, musculoskeletal, respiratory, and endocrine diseases, respectively. [27].
Healthcare System Savings on Musculoskeletal Disease: Geriatric hip fracture is a rather common medical problem among senior citizens [28,29]. It will be prudent to consider ways to improve clinical outcomes and to reduce cost in these clinical encounters. Utilizing the engineering concept of integration, an implementation of integrated, collaborative, standard treatment protocol called the Geriatric Hip Fracture Clinical Pathway (GHFCP) resulted in improvement of clinical outcomes and in reduction of provider manpower utilized for each fracture occurrence. Specifically, the length of hospital stays in the surgery and recovery were reduced by 6.1 days and 14.2 days respectively (an overall 50 % reduction). In addition, the post-operative pneumonia infection rate was reduced from 1.25% to 0.25% (a 1% reduction) [29]. According to a study, the medical expenditures for osteoporotic fractures in the US in 1995 was estimated to be $13.8 billion, with about $8.5 billion spent for hip fractures, for which the hospital costs were about 65% [30]. Thus, the total costs of in-patient hip fracture care will be about $5.5 billion each year. For a 50% reduction of hospital stay, the healthcare saving could be near $2.75 billion annually for the US, even without counting the potential saving from reduction of post-operative pneumonia by this new pathway, assuming no increase of cost in the implementation of this integrated system of GHFCP.
Healthcare System Savings for Diabetes: Diabetes is a major endocrine disease where the engineering principle of integration could help reducing the cost, which was estimated between $100 and $245 billion in the US for the year of 2012 [27, 31,32]. The estimated expenditure in physician office visits is 9 %, accounting for $15.5 billion (0.09 X $175 billion, which is used as the mid figure between $100 and $245 billion). Among the common non-acute diabetes complications and their required corresponding primary and specialty physician office visits are: high blood pressure and stroke (primary care & neurology), hyper-and hypo-glycemia (endocrinology), heart diseases (cardiology), neuropathy (dermatology & podiatry), retinopathy (ophthalmology), gastroparesis (gastroenterology), and kidney malfunction (nephrology) [33]. If we use a conservative estimation that on average a patient with diabetes will encounter 50% of these complications, then a patient would need to see 5 different physicians to control their disease co-morbidities. Without integrative care, these patients would need to set up appointment and commute to see 5 different physicians in 5 separated times. During physician office visits, each of these 5 physicians would need to take a history, perform physician examinations, order diagnostic tests, and prescribe appropriate treatments. Engineering integration could help improve effectiveness by transforming the care delivery to an integrated diabetes center. Like that of a cancer center where patients with cancer will get all the necessary and coordinated cancer-related care in one place, an innovative diabetes center will provide all the necessary and coordinated diabetes-related care in one place. Logistically, patients with diabetes will be able to make appointments with all 5 physician office visits in an integrated manner. During the coordinated office visits, the patient will first see a primary care physician, who will take a comprehensive history and physical examination, order common laboratory tests, and prescribe non-specialty treatments, then send the patient to be seen by the first specialty physician within the diabetes center in the same day. The first specialty physician will then utilize the medical record completed by the primary care physician (that contains most essential history, physical findings, lab results, and treatments), perform a focused specialty-related physician examination, order specialtyrelated lab tests and treatments, and then send the patient to the second specialty physicians also located in the same diabetes center, and so on down to the 5 th physician. This kind of engineering-based integrative care will not only save patients' time for arranging and commuting to 5 physician visits, it will importantly, also save physicians' manpower. If we conservatively estimate that on the average 30% of a physician visit is spent in taking the history, we will save equivalent physician manpower of 1.2 office visit (0.3 visit X 4) for each diabetes patient we care for, or overall a physician manpower saving of 24% ((0.3 X 4)/5). Extrapolating this saving to a nation-wide equation, we could potentially save $3.72 billion ($15.5 billion x 0.24) annually, assuming no cost increase will be needed to implement this integrated care system. Other potential saving from this integrated diabetes care will be the reduction of the expenditures on duplicated lab tests. In addition, a societal benefit will be the reduction of non-productive time and energy of the diabetes patients. If we assume each of the 24 million diabetic patients in the US will have one annual visit to their respective physicians [34], and if we conservatively estimate that each physician visit will cost a patient non-productive time of 1.25 hour (30 minute in commute, 45 minutes in office visit), the total annual cost will be 6.25 hours. On the other hand, the integrated visit will cost non-productive time of 3.35 hours (30 minutes in commute, 171 minutes or 2.85hour (45+(45 X 0.7 X 4)) in office visits), we will potentially save 69.6 million hours of productive time (6.25 -3.35) X 24 million) for diabetes patients annually. Using a minimum wage of $15/hour, we could easily save the US society $1.04 billion annually. Other potential savings to the society include reduction of expenses on gasoline, automobile repair and depreciation.
Healthcare System Savings for Heart Disease: Cardiovascular diseases as a group has the second highest costs of healthcare in the US. Among this group of diseases, heart failure has a substantial cost: In 2012, the direct cost of heart failure in the US was $21 billion, 80% of which was the cost of hospitalization, accounting for $16.8 billion annually [35]. The mean cost of a single congestive heart failure readmission is $13,000, with a 25.1% readmission rate [36]. In a study published in 2011, healthcare systems in the State of Maine leveraged an integrated care system, which was able to reduce the heart failure readmission by 5.83% (from 18.5% to 12.67%) [37]. If readmission accounts for 25% of total hospital admissions of heart failure, this integrated system could potentially reduce the cost of hospital readmission of congestive heart failure by $245 million ($16.8 billion X 0.25 X 0.0583) annually in the US, assuming there is no increase cost in implementing this integrated heart failure care system. According to the above calculation with the said assumptions, the engineering-medicine school would be cost-effective.

One-way sensitivity analysis
• Assuming there is a 30% reduction on the side of effectiveness due to increased cost in implementing the clinical integration: (Ratio) = $3.235 billion/($7.755 billion X 0.70) = 3.325/5.4285 = 0.61 Costeffectiveness is still achieved.

Two-way sensitivity analysis
Assuming 75% efficiency of the physician effectiveness: Assuming also the cost of engineering-medicine school will be more than initially projected: The IT cost is 20% above the conventional medical school, staff requirement for the engineering-medicine school is increased by 10%, and the engineering faculty requirement is increased by 30% to 17 (Table 2). With the above modifications, we still find engineeringmedicine school to be cost-effective, with the ratio calculated to be 0.82 [$4.788 billion/($7.755 billion X 0.75)].
Assuming the efficiency of physician effectiveness is reduced further to 50% and the costs are also increased the same amount as above: {Cost-effectiveness Ratio} = $4,788 billion/($7.755 X 0.50) billion = 1.23. Now the engineering-medicine school is no longer costeffective.

Summary
Through data collected or estimated for three major diseases where engineering principles could save healthcare dollars, we showed, based on limited available data, that engineering-medicine education has the potential to help generate healthcare savings and it could be costeffective from the societal perspective. This analysis revealed relative doi: 10.15761/BEM.1000142 Volume 3(2): 9-10 insensitivity to variation of efficiency of physician effectiveness alone in a one-way sensitivity method, but demonstrated relative sensitivity to combined variation of cost and efficiency of physician effectiveness in a two-way sensitivity method.

Conclusion
Having determined its potential cost-effectiveness, engineeringmedicine education should be appropriate to conduct in a small segment of undergraduate medical schools as a proof of concept project. If successful, it could prove to be a good model for future medical education reform. Since the cost-effectiveness is demonstrated from a societal perspective and not necessarily from a medical college (institutional) perspective, the additional cost for training these engineering-physicians should probably be bored by society which would stand to benefit from this novel path of education.