The rehabilitation field has not always been regarded as the most glamorous or commercially promising section of medical care. But changing attitudes and demographics in many industrial countries have led to increased recognition of opportunity to provide services for individuals with disabilities and those in need of chronic care. As hospitals are under increasing pressure to offer rehabilitation services, this article focuses on three different technologies developed in three different countries, Sweden, the United Kingdom, and the United States.

Chinese hospitals in the 1980s are in the midst of a technological revolution. Based upon data from several regions in China, this paper describes the political, organizational, economic, and philosophical changes which have accompanied the shift in focus from primary care medicine to high technology tertiary care. The increased authority of physicians, greater contact with the West, and increased funding for medical equipment are key factors in these changes. Although the Chinese state continues to control the administration and financing of most hospitals, the decentralizing reforms of Deng Xiaoping have undermined its ability to effectively plan for, and assess new technology. At present, limited resources prevent most regions from excessive technology acquisition, but the state must rebuild its planning capacity in order to foster rational allocation of scarce medical resources.

During the past two decades a great deal has been learned about the role of physicians in generating medical costs and about ways of changing physicians' behavior so as to reduce those costs (8;10;19;30;34). Unfortunately, very little is known about how cost reductions affect the quality of care.

Technological aspects and early clinical experiences are arousing great enthusiasm over magnetic resonance imaging (MRI). However, influences such as regulation, reimbursement, and increasing competition also are playing important roles in determining the diffusion of this new technology. Of these considerations, competition among providers seems the most important. Competition related to MRI is manifested as direct competition over MRI services, using MRI to improve a provider's strategic position and competition among specialties. In making decisions concerning MRI acquisition and operation, providers are drawing upon their experiences with computed tomography (CT) to help them determine when would be the best time for acquisition, how to decide whether acquisition is appropriate, and how best to acquire, operate, and market the technology.

Total joint replacement has restored function and provided comfort to many patients who would otherwise have suffered. However, success and widespread diffusion of this procedure pose a number of important questions. The patient's and the doctor's criteria of success may not be the same: Which are to be used? Health resources are becoming limited: Should money be spent to restore function and for pain relief to those late in life or past their work life? Who makes this choice? A medical technology is tested in the best of settings but routinely practiced in many: How should society and health care professionals monitor the results of surgery? Who should do surgery and where should it be done?

A common criticism of high technology is that therapeutic objectives are sometimes secured at too high a price in loss of quality of life. Certainly some interventions serve only to prolong life that is already of unacceptable quality to the patient (some rescues in intensive care and salvage surgery for cancer). Others leave the patient with less good quality of life than he enjoyed before treatment, either because the crisis that called for rescue had lasting effects (incomplete recovery from severe head injury) or because the intervention itself had inevitable adverse effects (mastectomy, laryngectomy, colostomy). Yet some life-extending technologies can improve dramatically the quality of a patient's life (renal and heart transplantation), while others are directed primarily at improving quality of life (hip replacement and coronary bypass surgery). When the ultimate result of technological intervention is improved quality of life or a reasonable extension of life of quality, then some temporary impairment of life's quality may be justifiable. The problem is to discover in which clinical circumstances the benefits expected from high technology are both great enough, and are also likely enough to be realized, to justify the resources that have to be expended by society and the inevitable burdens that have to be borne by the patient (11).

Modern industrial society and its industrial processes can sometimes discourage the practice of traditional medicine. The existence and use of traditional Chinese medicine for several thousands of years indicates that it has sound elements. As has been true with features of other ancient, highly developed civilizations, the discipline of traditional Chinese medicine offers a valuable resource in the treatment and prevention of disease. Its scientific aspects and valuable experiences must continue to be developed according to Western scientific methodology. China has initiated a program to utilize modern industrialized technology in the integration of the traditional Chinese and modern Western medical systems. The policy and process aimed at integrating traditional Chinese medicine with Western medicine are presented in this paper.These measures have resulted in considerable utilization and development of the traditional Chinese medicine system, and have had a major impact on the development of public health care, as well as medical technology and science. The positive interactions between these fields of study and existing problems are discussed, and some comments on future expectations are presented.

Our assessment of influences affecting MRI acquisition, described in Part I of this paper, also elicited interesting parallels between the acquisition, operation, and marketing of this new technology and experiences with x-ray computed tomography (CT). We noted that acquirers' personal experiences with CT and how individuals perceived the occurrences surrounding the diffusion of CT in general strongly determined their approach to MRI. Specifically, we found that potential and actual acquirers of MRI had learned three categories of lessons from experiences with CT: (a) “Optimal” timing for acquiring MRI; (b) how acquisition decisions are made; and (c) how to best acquire, operate, and market MRI.

The classical equation for the production of goods and services, that is, the combination of labor, capital, and knowledge, constrained by the time dimension, may also be used to examine the production of medical and hospital services. However, this is qualified by the special nature of the “capital” used in health care, particularly medical technology. Because of the particular nature of health services, the adoption and the use of technology follows rules that are different from those in the industrial sphere. These differences are examined in some detail as are the implications for the health field in general, and for the hospitals where most of the new (and often costly) technology is located.

Extracorporeal shock wave lithotripsy (ESWL) for upper urinary stones has been in use in the United States since 1984. It was accepted immediately by hospitals and physicians, and its diffusion has been and continues to be rapid. Government payment and planning policies do not seem to have slowed this diffusion, although they have had some effect on the ownership of lithotripters and the manner in which ESWL is provided. An unintended but foreseeable result of ESWL's popularity with hospitals, physicians, and patients is that ESWL is not only rapidly replacing traditional surgery but is being used on many patients who would not have had surgery. It is likely that many more upper urinary stones are being treated aggressively now than before ESWL was introduced.

The problem that I will discuss in this essay is marvellously illustrated in the title given to me by the editors. The word “interface” is itself part of the jargon of technology, the technospeak needed by those who develop, use, and discuss functions, things, and relationships that had not existed previously in the human world. They must make up new words to describe new realities (and, unfortunately, allow new and ugly words to obscure old ones). An “interface” presumably describes the way in which one electronic system contacts another so that the first energizes the second. In the old world of human experience, an “interface” is impossible. The face of one human being is visible to another; two faces, smiling or frowning at each other, communicate. The mind behind one face can interpret the movements of another. Never does one human face interpenetrate or merge with another.

This paper assesses the impact of mechanisms for financing intensive home health care services in the United States on their utilization. As lengths of stay have decreased in response to prospective payment methods for hospitals, demand has increased for intensive and complex services provided to patients in the home. Third-party payers, however, are willing to satisfy only some of this potential demand that their reimbursement policies have generated. It is the policies of payers rather than the safety and effectiveness of devices and procedures that are the major constraints on the expansion of intensive home health care. We describe the effects of these policies on who receives intensive home health care services, who provides them, what services are provided, how their quality is monitored, and what they cost.

We analyzed the cost-effectiveness of nonemergent treatment for esophageal varices commonly used in Japan (endoscopic injection sclerotherapy, nonshunting direct interruption procedure, and selective shunt). We assessed the cost per survivor from the perspective of the Japanese government and other payors. Epidemiologic and economic data from published Japanese literature and from Japanese hospital-cost information were applied in decision analysis. While sclerotherapy is the most cost-effective treatment, the popular surgical procedures save the most lives, thus raising difficult ethical issues regarding trade-offs of cost and quality.

Sweden's first, and so far only, ESWL unit for kidney stone treatment became operational on April 1, 1985. This paper presents some intermediate results from an integrated medical, economic, and technical evaluation of the new technology. Seventy-eight percent of 477 patients were defined as successfully treated, totally stone free or fragments less than 4 mm in size, after a follow-up of four weeks. After six months, the share of successfully treated patients had increased to 82%. Successes were closely related to the stone situation; the smaller the stone, the greater success of treatment. Patients' experiences with treatment were also studied and showed that less than 5% of the patients perceived the treatment as unpleasant, frightening, and/or time consuming. Epidemiological data reveal that one unit can replace all open surgical operations on the kidney.

Great variation exists in the health care delivery systems throughout Latin America and the Caribbean. In general, medical technology is concentrated in large cities at private hospitals that serve a small, elite segment of the population. What is missing in most of these countries is a clearly defined social policy guaranteeing distribution of medical technology to all segments of society. While data is scarce, it appears that political and economic concerns, rather than medical concerns, determine what and how much technology will be available to all segments of the society. Products are sometimes imported that compete with domestically produced ones. Moreover, transfers of technology often fail to include the necessary knowledge to make imported technology truly useful. However, current economic crises throughout the region are forcing changes in policies; as a result, there is a new emphasis on domestic production of technology over imports and the evaluation of medical technology for its appropriate use in Latin America and the Caribbean.

A rapid development in health care delivery has been the increasing use of technology. Technology will continue to transform medical practice and all health care workers are involved with technology by accident or design. This has resulted in technology dominating many health policy decisions (4).

This paper discusses both the current interest in and approaches to the employment of advanced medical technology in Taiwan. It describes the formation of the national policy, including funding, reimbursement, and regulatory processes, on adopting innovative and expensive medical technologies. Using the case of extracorporeal Shockwave lithotripsy (ESWL), the key players who affect organizational decision making on the adoption and diffusion of medical technology have also been analyzed. Finally, it examines some of the salient features of medical technology adoption and assessment in Taiwan, and in other countries which depend heavily upon imported advanced medical technology. It is hoped that an understanding of Taiwan's attempts to use innovative medical technology wisely while incorporating the practice of technology assessment and appropriate policies, will assist other countries with similar conditions to gain maximal benefit from technological advancement.

The title which I have been given suggests that in my particular consideration of technology the emphasis should be not on professional attitudes, but on public attitudes, and what might be done to inform and if necessary improve them. At first glance, a sensible approach might be to conduct some kind of survey among “the public” to discover what proportion of people hold particular attitudes towards technology. With little in the way of regret, I shall foreswear that approach, not because I am unacquainted with such surveys, but because I perhaps know them too well. If you ask a completely unloaded question, such as “What is your view of medical technology?”, you will probably get answers, but you will not be able to determine how much they are preconditioned by how much the person knows, and in particular how any recent experience of medical investigation has turned out. That in turn may owe more to the nature of his problem than to the skill with which investigations have been selected and performed. On the other hand, if you ask loaded questions, such as “Is medical technology free of risks?,” you will bias the proportion of replies, and still find the answer no easier to interpret.

“From a distant vantage the [Mandelbrot] set resembles a squat wart-covered figure eight lying on its side. The inside of the figure is ominously black. Surrounding it is a halo colored electric white, which gives way to deep blues and blacks in the outer reaches of the plane.

Approaching the Mandelbrot set, one finds that each wart is a tiny figure shaped much like the parent set. Zooming in for a close look at one of the tiny figures, however, opens up an entirely different pattern: a riot of organic-looking tendrils and curlicues sweeps out in whorls and rows. Magnifying a curlicue reveals yet another scene: it is made up of pairs of whorls joined by bridges of filigree…, and in the center of these curlicues another version of the Mandelbrot set is found.

The magnified version is not quite the same Mandelbrot set. As the zoom continues, such objects seem to reappear, but a closer look always turns up differences. Things go on this way forever, infinitely various and frighteningly lovely.” (4)