Healthcare Asia (November 2017 - February 2018) by Charlton Media Group

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THE COMPUTER WILL SEE YOU NOW HOW ARE ASIAN HOSPITALS MAXIMISING THE POTENTIAL US$3T ARTIFICIAL INTELLIGENCE MARKET?

THAI HOSPITALS STUCK IN TECH-COST DEADLOCK INDONESIA’S UHC STRUGGLE SINGAPORE TURNS TO ROBOTS FOR AGED CARE WHY IT’S HARD FOR THE PHILIPPINES TO RAISE COMPENSATION FOR DOCTORS

DATO’ SERI DR MOHD AZHARI YAKUB CEO NATIONAL HEART INSTITUTE OF MALAYSIA p14

DR YOON-SOO KIM PRESIDENT, ASIAN HOSPITAL FEDERATION p16

CASE STUDY: HOW MACKAY MEMORIAL HOSPITAL RESTRUCTURED PATIENTS’ ACCESS TO MHEALTH p22

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FROM THE EDITOR This issue of the Healthcare Asia magazine features a comprehensive report on how artificial intelligence is being maximised in healthcare as illustrated by mobile platform Xbird. It uses AI to help diabetics understand how hypoglycemic attacks work and when these occur. But experts warn that physicians should not depend on these technologies as error rate for AI systems functioning without physicians go up to 7.5%.

Publisher & EDITOR-IN-CHIEF Tim Charlton production editor Karen Lou Mesina GRAPHIC ARTIST Elizabeth Indoy cover Karen Mukai

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We also delved into Malaysia’s budding aged care industry. Senior living remains a relatively new concept to Malaysia. Presently, nursing home is the place that focusses on the final stages of care and majority are run by charitable organisations. How does the government plan to catch up with the silver population?

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We also give you a glimpse of what transpired in the HIMSS Asia Pacific 2017. Start flipping the pages and enjoy. As always, we wish you all the very best of health.

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Editorial Enquiries If you have a story idea or just a press release please Email: ha@charltonmedia.com and our news editor will read it. For a personal message to the editor, put the word “Tim” in the subject line. Media Partnerships Please Email: ha@charltonmedia.com and put “partnership” on the subject line and it will forward to the right person. Subscriptions Email: subscriptions@charltonmedia.com Healthcare Asia is published by Charlton Media Group. All editorial is copyright and may not be reproduced without consent. Contributions are invited but copies of all work should be kept as Healthcare Asia can accept no responsibility for loss. We will however take the gains.

2018

Healthcare Asia Forum

Distributed to all CxO, board levels, doctors, and healthcare professionals of major private/public hospitals and health ministries in ASEAN and Hong Kong. HEALTHCARE ASIA

CONTENTS

cOUNTRY REPORT

How Malaysia’s young aged care industry will keep up with the silver population

Asian Hospital Federation’s president eyes boosting membership count

fEATURE pROFILE

ceo INTERVIEW

Malaysia’s Institut Jantung Negara eyes

14 new 150-bed cardiovascular centre FIRST 04 Thai hospitals stuck

HEALTHCARE INSIGHT 12 AI brings healthcare industry

in tech-cost deadlock

to new digital frontiers

for aged care

EVENT COVERAGE 20 How healthcare firms

OPINION 30 Opportunities for medical

can monetise digital health

08 Why it’s hard for the Philippines

26 How will Taiwan push value-based healthcare forward?

05 Indonesia’s UHC struggle 06 Singapore turns to robots

ANALYSIS

to raise compensation for doctors

device companies in China’s reforming healthcare industry

CASE STUDY 22 How MacKay Memorial Hospital

32 Slowing the biological clock

restructured patients’ access to mHealth

Published Tri-annually Bi-monthly on on the the Second Second week week of of the the Month Month by by Charlton Media Group 101 Cecil St. #17-09 Tong Eng Building 2 HEALTHCARE ASIA Singapore 069533

To access the stories online, visit the website

www.healthcareasiamagazine.com

FIRST for the patients. I’m not qualified to comment on behalf of the sector, but talking about the equipment that hospitals buy, I think investing on these kinds of technology still puts the hospital in a good position despite shelling out cash,” said Gavin Wadell, international head marketing executive of the business development department of Phyathai International Hospital.

DIGITALISATION DILEMMA MALAYSIA

Datuk Dr Kuljit Singh

Healthcare Asia interviewed Datuk Dr Kuljit Singh, medical director of Prince Court Medical Centre, as he discusses digitalisation amongst Malaysian hospitals and how Prince Court Medical Centre is catching up. What steps are Malaysian hospitals doing to catch up with the fast pace of information technology? All new govt hospitals built today are equipped with total hospital information system. For private ones, it depends on the budget of the hospital but by and large most new private hospitals are fully built with IT systems. The older hospitals are trying to change into IT system but in phases. The main issue is always cost but the other problems would be migrating old data into IT system. There would be huge written volumes of info that need to be transferred. Then the isssue of getting the doctors and nurses to learn the new IT system also compounds the problem. What dangers are there for Malaysian hospitals that can’t keep up with digitalisation? The number of patients have increased and without digitalisation, the entire delivery of healthcare is going to be very slow. Speed in healthcare is now becoming important from getting appointments, tracing results, prescription of medication, and viewing of images. What opportunities are there for healthcare firms in assisting the country to achieve UHC? Not every hospital have modules that will help them achieve universal healthcare coverage, some will usually adopt modules from other parts of the world, which could be quite costly. Not every hospital will be able to afford this much expenditure for digitalisation. So for opportunities, some firms can come up with easier, simpler and cheaper modules that Malaysian hospitals can adopt. 4

HEALTHCARE ASIA

Both public and private hospitals are caught up

Thai hospitals stuck in tech-cost deadlock Thailand

hen the Thai parliament passed a policy requiring private hospitals to take in emergency cases before passing them to public facilities, it did not come with the necessary investments from the government side. Public hospital players in the country still do not have enough training and the private and public sectors lack partnerships to strengthen collaborative abilities in terms of taking care of patients. Dr Surangkana Techapaitoon, hospital director at Samitivej Children Hospital, said that patients have high innovation expectations from their hospitals at little to no cost. However, both public and private facilities are hard-pressed without patients willing to shell out additional baht. Despite what seems to be a stalemate between the patients and the hospitals, administrators remain committed to providing the best healthcare at the most affordable price possible. “We spend a lot of money in buying the latest technology to provide what we can

Public and private facilities are hard-pressed without patients willing to shell out additional baht.

Higher pay The healthcare industry in Thailand also ensures that its doctors are compensated well, if not better than their ASEAN counterparts, to encourage them to stay in the country. Dr Techapaitoon said that at the moment, private practitioners are paid way more than their colleagues in the public hospitals. General practitioners receive US$889 per month if they are in government hospitals, but once they move to private hospitals they can get as much as US$2,965. She added that the industry must address issues on how to balance the cost, the patients’ needs, and business strategies to benefit all parties involved. Meanwhile, Joni Java, international marketing executive at Vejthani Hospital, said that as a private hospital, they can only decrease their prices up to a certain point. To address such dilemmas, Dr Techapaitoon said private-public partnerships must be strengthened to improve healthcare and keep costs at a reasonable level. In the meantime, the recent policy passed by the parliament can help bridge some gaps. Wadell said that so far, the government has been very helpful in assisting private hospitals to accept social security patients.

Per capita total expenditure on health

Source: World Health Organization

FIRST

Inequality and inaccessibility will keep plaguing the sector

Indonesia’s UHC struggle

indonesia

ime is ticking for Indonesia’s national health insurance scheme, Jaminan Kesehatan Nasional (JKN), as latest estimates show that only three in four of citizens have been enrolled since the launch of the programme in January 2014. Government authorities have been aiming to enroll the entire Indonesian population by January 2019 as part of their overall goal to ensure access to high quality healthcare services across the archipelago. However, with only two

months left, their initial aim might be pushed further down the calendar. Not enough infrastructure Analysts at BMI research said that the country remains lacking in terms of general infrastructure and government financing to support healthcare in the rural areas. As a percentage of the country’s gross domestic product (GDP), healthcare spending stood at a measly 2.9% in 2016. This will continue to weigh on the financial sustainability of

The country remains lacking in terms of general infrastructure and government financing to support healthcare in the rural areas.

Indonesia’s universal healthcare programme, as well as its full implementation. In the short term, Indonesia’s healthcare coverage will remain unequal and inaccessible to many. The country’s highly fragmented healthcare industry and underdeveloped medical system also pose huge challenges to true universal healthcare for all. BMI Research analysts added that these will result in stagnant medicine sales growth for the country’s drugmakers. At present, Indonesia experiences very diverse levels of access across the country. In 2016, the Special Region of Yogyakarta has 13 hospital beds per 10,000 people whilst the Central Sulawesi Region had only eight. Analysts believe that the short term will remain challenging despite the expansion of private healthcare providers such as Siloam International Hospitals.

Underfunded healthcare system

Source: -World Health Organizaton, BMI Research

The Chartist: SINGAPORE KEEPS LOSING FOREIGN PATIENTS Whilst Singapore still remains a compelling medical tourist destination in terms of service quality and clinical outcomes, foreign patient growth may decelerate gradually as competitive pressures from neighbouring ASEAN countries grow. For instance, IHH has seen a shift in patient mix over the past years. In 2013, local-to-foreign patient mix stood at 60:40 but has since shifted to 70:30. Going forward, UOB Kay Hian said it expects patient growth to stem largely from local patients, underpinned by favourable demographic trends such as ageing demographics as well as rising income levels. “Moreover, we continue to expect spillover effects from public hospital, taking into consideration that bed occupancy rate in public hospitals still remained very elevated,” it said.

Declining headcount

Sources: Ministry of Health

% change in population vs hospital attendance

Source: Ministry of Health

HEALTHCARE ASIA

FIRST NO BILLION-DOLLAR INVESTMENTS MALAYSIA

Singapore turns to robots for elderly care SINGAPORE

Fabian Boegershausen

Healthcare Asia caught up with Fabian Boegershausen, manager at Solidiance, as he shares his forecasts on Malaysian medical tourism growth. What is Malaysia’s current status in medical tourism growth? It would definitely grow somewhere above 10% for sure, but I haven’t done any formal forecast or detailed modeling, it’s just gut feel. If you see how it developed over the last couple of years, you’ll still see double digit growth, but it’s not going to be an explosive growth, like everybody else hopes for. The reason for that is there are too many bottlenecks to overcome, still many uncertainties in the system. Just look at the currency and how it’s performing. But if you think about how medical tourism is growing worldwide, how the demand is soaring in Southeast Asia, and how all of these things are slowly improving in Malaysia, I’d say we are going to see maybe 10% or 15% growth. It’s enough to say that the industry is improving--you can bet on that card, but you will definitely not be seeing billion-dollar investments anytime soon. What’s the most interesting change in the Malaysian industry? I think the most interesting thing is that it is working hard towards improving medical tourism. One of the key changes I’ve seen is the emergence of new business models. People would say “I can’t run a medical business myself but I can become an intermediary.” This means making the market more transparent and efficient, and competencies in treatments and procedures are traded over a platform. If we can get more people to use such platforms, then we can provide the SMEs and other smaller clinics in the country the chance to participate in the wider market and also force the larger institutions to become more competitive in the industry.

HEALTHCARE ASIA

ingapore’s growing elderly population may have just found its new best friends—ExoAtlet, Ohmni, and Loomo. These robots are some of the latest innovations in its evolving healthcare landscape which, despite huge leaps in technology, still needs to bridge several gaps in quality aged care. The need for quality private healthcare and private healthcare expenditure are expected to continue rising not only as a result of the ageing population, but due to higher prevalence of chronic diseases, rising affluence, population growth and healthcare inflation. Singapore’s medical tourism industry is also expected to bounce back after a flattish year in 2016. John Cheong, analyst with Maybank Kim Eng, said the government has boosted spending significantly to cater to the rising demand. Meanwhile, private health expenditure continued to increase, with Raffles Medical as the main beneficiary given its lead and its integrated business model. Dr Tan Jit Seng, director, Lotus Eldercare Health Services, said effective ageing requires a NEEDS model, which should either be preventive or supportive. “For it to

Higher spending for the ageing population

be preventive, there must be teleremote vitals monitoring, telepresence for isolation and loneliness, and verbal controls of appliances. Instant access to information On the ‘supportive’ aspect, there must be quick access to information for problem solving, teleconsultation, and day to day assessment and monitoring for deterioration and identifying reversible issues,” Dr Tan added. ExoAtlet, Ohmni, and Loomo have already provided solutions to some of these needs in augmented For it to be aged care. For instance, Ohmni allows preventive, there must be families or caregivers to engage over the internet and check on the elders’ teleremote safety, medication adherence, and vitals diet. Geriatric specialists, nurses, and monitoring, telepresence doctors can also simultaneously dialin on-demand to provide services. for isolation Meanwhile, ExoAtlet provides and exoskeletal support to prevent falls and loneliness, aide elders to maneuver any terrain. and verbal Loomo, on the other hand, features controls of daily routine support amongst others. appliances.

event watch

ASIA PACIFIC MEDTECH FORUM TACKLES INNOVATION SINGAPORE

With the accelerating pace of disruptive technologies emerging across the region, innovative care delivery models are challenging traditional practices and propelling MedTech players to rethink business models and channels. The scale and speed of change across the entire healthcare value chain is unprecedented. Under the theme “Transforming Healthcare Through Innovation,” this year’s Asia Pacific MedTech Forum explored the multifaceted approach to healthcare innovation. Industry leaders, patients, hospital CEOs, and policy makers addressed how new forces can solve the region’s unmet healthcare needs for the future. The programme also focussed on critical areas such as the regulatory environment, ethical business standards, and the sustainable development of products and services to tackle the issues in Asia.

Dr Shawn Watson

co-published Corporate profile

Paving the way for the digital transformation of healthcare Siemens Healthineers developed a cloud-based network called “teamplay” to meet the demands of a digitalised industry.

ealthcare Asia caught up with Elisabeth Staudinger, President of APC, Siemens Healthineers, to discuss the industrialisation of healthcare, as well as how customers can get on top of the digital transformation. What healthcare trends are you currently addressing arm-in-arm with healthcare providers? Globally, and even more in Asia Pacific, we see the demand for healthcare, as well as the cost of healthcare rising. I believe that one way to address this challenge is through innovative products and solutions. Another trend is that of healthcare providers merging to gain competitive advantages through more specialised offerings. Within Asia Pacific, Australia is a good example for this consolidation: We are looking at only a handful of providers, who run very large scale operations. We notice this trend in most developed countries around the world: The average deal size for hospital acquisitions in the U.S.

Elisabeth Staudinger, Siemens Healthineers

has grown five times the volume size in just six years - from 42 Million USD to 224 Million USD. We are also witnessing an industrialisation of healthcare: Our industry is increasingly taking cues from other industries such as manufacturing. Just think of their success factors such as short waiting times, reduced space requirements or low error rates. That sounds familiar to our industry, right? To meet this demand, we at Siemens Healthineers have developed a cloud-based network called “teamplay”. How does it work? It allows users to analyse, benchmark, optimise and standardise the utilisation of their imaging equipment across multiple sites. Idle times of machines but also waiting times for patients can be reduced. Especially for large consolidated healthcare providers, standardisation and delivering the same level of care within all parts of an institution is very important. What are Siemens Healthineers’ plans in expanding and strengthening its foothold in the Asia Pacific region? Asia Pacific is a very diverse region in terms of economics, language and culture – and hence, market requirements. We as Siemens Healthineers are present in every major country in the region. What’s more, we can count on an extensive network of carefully selected partners, which we are continuously expanding, especially to increase coverage in rural areas. On top of that, we clearly have the right portfolio and a great global reach: Every single hour, more than 200,000 people worldwide are being diagnosed or treated with our devices. And in the past year alone, we’ve launched a variety of products under our new name. Let me give you two examples: For one, in the field of Laboratory Diagnostics, we’ve developed Atellica Solution, a new lab automation system. It comes with a special sample transport technology which makes it ten times faster than conventional technologies. Furthermore, it delivers the industry’s highest productivity per square meter – more than 400 tests per hour. Secondly, in the field of value-based healthcare, we’ve introduced SOMATOM

Go., an entirely new platform for computed tomography (CT) at a very affordable price. It offers automated, standardised workflows that help users achieve profound clinical results. The multi-year service packages and corresponding high financial reliability help our customers to run their business predictably and successfully. What are Siemens Healthineers’ top three priorities for Asia this year? We are keen on helping healthcare providers to get on top of the ongoing digital transformation. The aforementioned ‘teamplay’ is one part of the puzzle. Based on teamplay’s technology, we’re currently building a platform, a Digital Ecosystem, which is linking healthcare providers and solution providers, as well as their data and knowledge. We have already teamed up with partners whose offerings will be integrated into our Digital Ecosystem. And we are keen to grow this platform further, paving the way for the digital transformation of healthcare. We have set ourselves ambitious goals: Worldwide, we would like to connect 1,000 customers via teamplay in the course of this year. Furthermore, we are currently expanding our eHealth offerings, e.g. for teleconsultation, or patient and physician portals. Recently, we have entered into the field of population health management by forging a global alliance with IBM Watson Health. By that we aim to help hospitals, health systems, integrated delivery networks, and other providers deliver value-based care especially to patients with complex, chronic and costly conditions such as heart disease and cancer. We’re continuously expanding our value-added services. We have been entering into so-called long term enterprise services contracts with customers. Those agreements have life spans of up to 40 years. Only recently, we agreed with a newly constructed hospital in Perth, Australia, on procuring, installing, and managing the entire base of medical devices. And we have a team on-site in charge of running biomedical services within the hospital. These kinds of projects make me very proud as they show that customers are having great trust in us. Disclaimer: “The

products/features (here mentioned) are not commercially available in all countries. Due to regulatory reasons their future availability cannot be guaranteed. Please contact your local Siemens organization for further details.” HEALTHCARE ASIA

FIRST

Why it’s hard for the Philippines to raise compensation for doctors

Gleneagles’ $51m ANNEX

PHILIPPINES

n apple a day may keep the doctor at bay, but in the Philippines, it is the higher pay of overseas assignments that keeps luring them away from the local health system. Elvira Dayrit, director for Health Human Resource Development Bureau (HHRDB) of the Department of Health (DOH), noted that the government has set up a plan to mitigate the dearth of doctors the country is currently facing. Citing data from the Commission on Filipinos Overseas, Dayrit noted that the cumulative migration of doctors has been steadily increasing since 2005 when a total of 297 doctors migrated. By 2015, CFO recorded 3,082 doctors who took the flight abroad. Dayrit pointed out that this has led to the country being the second top exporter of doctors next to India. “Our strength is that we really have good quality doctors who can speak English and with good rapport,” she said. However, looking at how this affects the Philippines, the prospect is not quite healthy. Referring to a 2007 data, Dayrit revealed that seven in 10 deaths were not attended by medical authorities. The trend was prevalent in all other provinces outside the National Capital Region. And although she stressed that this

was already reduced to four in 10 deaths, the trend remains alarming. Doctors fleeing The migration of doctors may very well be due to the low compensation they are getting, Dayrit argues. According to data from HHRDB, resident private doctors earn as low as US$358 monthly. A medical assistant in the US earns up to US$59,317 per year, compared to around US$4,151 annually for a local private physician. “Can we blame them for running away?” Dayrit asks. She said that the blame could not be thrown at the Department of Foreign Affairs for not limiting immigration of health workers. “The DFA does not want to limit immigration of health workforce because it brings in money to the country. In general, we do not want to limit migration and mobility,” she argued. Given that the government could not control the migration of doctors, Dayrit said that there should be controls embedded in the code of practice instead. One solution is the utilisation of nurses, which the Philippines have a supply glut of. “Only half of nurses pass the exams. The government is now thinking of using nurses in doing other tasks,” she said.

Healthcare Asia recently caught up with Dato’ Dr. Adzuan Rahman, CEO of Gleneagles Kuala Lumpur, as he shares the hospital’s recent strategies in keeping up with the industry digitalisation. It has recently built a new annex which was part of a RM220m (US$51m) investment to upgrade the hospital’s facilities. The new building increased the hospital’s bed count by 100 beds along with 50 new consultation suites.

SINGAPORE

What are some of the challenges facing Gleneagles Kuala Lumpur and how do you plan to address them? The country is facing economic uncertainties that have affected the private healthcare consumption. Being frugal means spending your money wisely--the review or complication rate matter, and may cost the patient more in the longer term with increased morbidity and affecting work productivity. There are significant costs in setting up quality healthcare services that many may not be aware of. GKL has invested much in ensuring that the commitment is delivered, looking at investments that are evidence based and with good outcome measures while continually communicating these to the public.

When Varun Panjwani and his friends saw that there was not enough healthcare infrastructure in Asia to capture the exponential rise of medical tourism, they thought of a way to bridge the widening gap. Doctor booking systems became the industry’s immediate response to the problem, but there was still not much to ensure that patients get the best care from the most Global Health and Travel UI affordable providers in the most convenient way possible. Together with Thomas Masterson and Narender Panjwani, Varun sought to come up with a solution to the real challenges-lack of information amongst providers and low transparency of pricing and treatment options across the industry. Global Health and Travel is dubbed to be the first and only regional healthcare and wellness e-commerce platform. Varun said their digital solution aims to be a hybrid between well-known online Varun Panjwani travel websites Expedia and Trip Advisor.

What are your biggest achievements so far? GKL has made a mark as an international centre of excellence in specialties of orthopaedic, neurology and neurosurgery, as we accept complicated cases from far afield as Libya. We are also one of the centres regionally for cardiothoracic surgery, especially for children. We recognise that medical tourists are different from Malaysian residents. Therefore, providing them with a seamless experience by truly understanding and supporting their needs is key. Patients with good experience are the powerful promoters for the hospital. As part of the initiative, we recently launched a WhatsApp service (+6016-3393000) for both Malaysia and international patients, through which patients can make enquiries on specialists or arrange for clinic appointments.

MOBILE APP

GHT taps into uncharted medical tourism e-market

Dr Adzuan Rahman

HEALTHCARE ASIA

CO-PUBLISHED CORPORATE PROFILE

The high cost of medication errors Improving the outlook through better management of alert fatigue

Medication errors are preventable especially with evolving healthcare technology

hen a viral outbreak threatens or claims hundreds of lives, it dominates the news cycle. Yet a more destructive, persistent, and deadly threat receives much less attention — medical errors. Comparable to an ongoing public health disaster, medical errors — defined as unintended acts, execution errors, and care planning mistakes — cause the deaths of nearly 550 people daily. In fact, research published in the British Medical Journal named medical errors as the third leading cause of death in the U.S. Adverse drug events (ADEs) — or injuries resulting from taking a medication — are one of the three most common and harmful categories of medical errors. There are approximately two million ADEs in the U.S. annually, causing a staggering 100,000 deaths and increasing healthcare costs by about $136b. Research on medication errors in Asia is limited. A 2015 review article analyzed several studies from Southeast Asia and found administration and prescription errors accounted for the majority of medication errors. This included omission or wrong dose and time of administration and wrong medication prescribed by the pharmacy. This

HEALTHCARE ASIA

could be attributed to handwritten orders the effectiveness of warning information and the lack of checks and balances of an decreases because a clinician is more electronic system. inclined to override alerts without serious While industry awareness of the problem consideration. Industry research points has existed for some time, efforts to reduce to a direct link between overrides and preventable medication errors have faced medication errors. For example, an analysis challenges in the U.S. For instance, clinical of medication errors reported through the decision support Pennsylvania (CDS) and alerting Patient Safety “SIMPLY PUT, too much mechanisms System “noise” is drowning out real Reporting introduced with identified 583 opportunities to enhance electronic health medication error patient care BY REDUCING records (EHRs) are events in one designed to reduce MEDICATION ERRORS. OVERRIDES year where a the potential for CAUSE BY ALERT FATIGUE ALSO clinician overrode ADEs by providing an automated CONTRIBUTE TO THERAPEUTIC clinicians with alert that could COMPLICATIONS AND HIGHER potentially have helped the COSTS.” relevant warning clinician notice information at the and avoid the point-of-care. error. Simply put, too much “noise” at the However, the benefits clinicians receive point of care drowns out opportunities to from these systems are often diminished enhance patient care by reducing medication because they generate too many alerts errors. Overrides caused by alert fatigue and cause alert fatigue — a psychological also contribute to therapeutic complications phenomenon that arises when clinicians and higher costs. For example, if a clinician are exposed too frequently, to too many disregards a medication allergy alert when alerts that are not relevant to their patient administering a medication and the patient care issues. Once alert fatigue sets in, goes into shock, the patient will require

CO-PUBLISHED CORPORATE PROFILE

Dr. Raj Gopalan, Vice President of Innovation and Clinical Informatics, Wolters Kluwer

additional medications, extra provider time and a longer hospital stay. Providers can end up absorbing unnecessary costs that negatively impact their bottom line. Fortunately, technological advances, better collaboration, and a more holistic approach to system and content development are improving the quality and reducing the quantity of alerts. By combining functionality that considers contextual patient information with better filtering and user input in developing strategies to suppress irrelevant alerts, healthcare organizations are helping clinicians make better decisions and identify important patient safety issues at the point-of-care. In Asia, there is a fresh opportunity for electronic systems to focus on the most prevalent medication errors and provide specific, meaningful and effective alerts while avoiding the trap of alert fatigue seen in the U.S. CDS Alerts: Opportunities and challenges Rapid adoption of EHRs in recent years has increased the healthcare industry’s awareness of the scope and effect of medication errors. Data housed in these systems provides new information about errors that could not be gleaned from paper charts. These insights allow medicationrelated alerting systems to address common sources of error including dosing,

interaction, duplications, and allergies. These areas are also the focus of recently introduced CDS regulatory requirements. Examples of these insights include knowledge that: (a) drug dosing errors tend to be common in pediatric patients where body mass index varies greatly; (b) drug interactions commonly occur when a combination of drugs impacts the normal metabolism of particular medications, elevating drug levels and toxicity; and (c) because of duplication of active ingredients in combination medications, patients can potentially receive double or triple the dosage amount. CDS and embedded drug data solutions help address these issues by identifying potential drug errors and alerting physicians at the point of ordering. Historically, systems worked in generalities not focused on unique patient characteristics, producing a large number of false-positive alerts that clinicians— particularly specialists—found irrelevant to their patients. Alerts designed around generalized drug data did not consider important patient-specific factors including the condition being treated and co-morbidities (e.g., diabetes, kidney failure, etc.). For instance, a drug combination warranted for complex conditions such as diabetes or kidney failure may be deemed toxic for average patients. The result is 40 to 90% of alerts are overridden, according to industry data. This alert response is problematic since industry data also finds 50% of alerts are valuable and relevant to patient care. Thus, the industry is challenged to advance CDS strategies such that clinicians pay attention to and act on alerts. Advanced drug data solutions are already screening drug alerts by patient, age, gender, diagnosis, lab

results, and medications prescribed–an important first step to building context. The next steps require teamwork and specific functionality. A holistic approach to alert fatigue Clinical and IT teams must collaborate to identify ways to customize, filter, and suppress alerts based on clinical evidence and patient risk. This strategy begins with a basic understanding of how many alerts are firing, factors that contribute to high volumes of alerts, and why alerts are being overridden. Advanced analytics infrastructures support these efforts with a dashboard showing clinicians’ responses to alerts. With the right infrastructure, healthcare organizations can identify the top 20 adverse drug events generating 80% of alerts and uncover patterns associated with alerts in the top tier such as patient demographics, disease states, provider specialty, etc. Often, specific patient profiles emerge, and clinical and IT teams can work together to suppress unneeded alerts or apply user customization to improve relevancy. In terms of functionality supporting a holistic approach to alerts, organizations should consider systems that permit user controls on organizational, departmental, patient profile, and specialty context levels. Functionality should also support deployment of tiered alerts based on the above criteria and methods to update clinical content regularly to ensure decisionmaking relies on the latest evidence. The potential for CDS to impact patient care is significant. By implementing systems that support a holistic approach to alerts, healthcare organizations can make decision support more impactful while improving the outlook on medication errors.

Clinical and IT teams must collaborate to identify ways to customize, filter, and suppress alerts

HEALTHCARE ASIA

Healthcare insight: AI-ASSISTED HEALTHCARE

The doctor is online

AI brings healthcare industry to new digital frontiers Patients and providers will benefit from innovations such as quicker diagnoses and elaborate cognitive systems.

hen Chinese web provider Baidu rolled out its AI-powered medical assistant Melody, not only did users receive instant and real-time access to medical expertise, doctors also found what a day is like without the long check-up queues they’re used to. As tech firms increasingly expose users to the myriad benefits of digitalisation, more countries in Asia are expected to embrace artificial intelligence (AI) and integrate it within their own industrial ecosystems. In fact, Asia is considered to be one of the most promising markets for AI, with an estimated US$1.8t to US$3t added value by 2030 in terms of total AI investment and revenue across all industries. John Kelly III, senior vicepresident, cognitive solutions and research, IBM, said that the region is extraordinarily well-prepared to 12

HEALTHCARE ASIA

Medical providers will soon be faced with more choices for more effective and effective digital solutions, from treatment options tailored to suit each patient to real-time health monitoring of their patients’ vitals.

lead in the Cognitive Era, due to its massive wealth of talent in the fields of data engineering and science. India, for instance, is home to one of the largest populations of developers in the world. Meanwhile, Sundeep Gantori, analyst, UBS, said that Asia’s healthcare industry stands to benefit from its talent pool, tech expertise, freedom from legacy assets and massive amount of data being collected. The region is also currently underserved, with significantly low physician density in key countries such as China (1.5) and India (0.7). These numbers are way below statistics in developed markets such as the US (2.5) and the European Union (3.5). Gantori added that with these factors in mind, the key applications where AI holds promise in the region include decision-making support during clinical trials, robots to assist

in surgery and patient monitoring, and managing healthcare data. Pioneering initiatives For the past few years, Asia has already been seeing quite a number of AI-related innovations in the healthcare industry. Analysts at McKinsey Global Institute revealed that machine learning is already being applied in payments and claims management, but a wider application of AI may be seen across all aspects of healthcare soon. Medical providers will soon be faced with more choices for more effective digital solutions, from treatment options tailored to suit each patient to real-time health monitoring of their patients’ vitals. Through partnerships with medical providers like Memorial Sloan Kettering Cancer Center, IBM has taught its cognitive system, Watson, how to analyse cancer and enable clinicians to provide personalised medical care to their patients. Watson, which is now being deployed all over Asia, is helping doctors identify personalised treatments and keep pace with the massive volume of new cancer research every year. Arnab Basu, partner and leader,

Healthcare insight: AI-ASSISTED HEALTHCARE technology consulting, PWC India, said AI is also being used to monitor patient vitals as a way to create a baseline for health and well-being. Mobile platform xbird uses AI to help diabetics understand how hypoglycemic attacks work and when they will occur. Xbird uses over 20 sensors from mobile devices to add up personal and environmental data points and create an automated personal diary, which may be cross-referenced against blood sugar levels. Patients are then encouraged to share the data with their doctors in order to manage diabetes and uncover unique hypoglycemic triggers. Need for human touch Whilst already on the crest of their third wave, AI systems still function best when there are humans that monitor and supervise them. Basu said that the 2016 CAMELYON Grand Challenge for metastatic cancer detection revealed that there is 0.5% error rate for physicians augmented by physicians, but this number increases when physicians work alone (3.5%) and goes up further when AI systems function without physicians (7.5%). Kelly added that IBM does not refer to Watson as merely AI, they call it cognitive computing because it does not work alone and needs the assistance of people. “Our cognitive system, Watson, is already a key part of everyday life for many of us – it’s expected to help more than one billion people this year. For example, Watson is helping people in the United States do their taxes better through our partnership with H&R Block, and thanks to IBM’s partnership with Quest Diagnostics, it can analyse the genomic makeup of a tumor and identify treatment options or a clinical trial for that patient,” Kelly added. Dominic King, clinical lead, DeepMind, elaborated that AIassisted healthcare should not only involve the machine and the clinician, but ensure that the patient is involved every step of the way. King said that outcomes are better when patients and clinicians decide together, a principle that should also be

applied when developing healthcare technology. “We continue to run regular public and patient involvement and engagement workshops with patients, and have appointed a patient lead to engage patient and public groups, and to ensure that our work is always in touch with patient needs. We also work incredibly closely with clinicians in developing our technologies,” King said. DeepMind’s collaborative principle is evident in its clinical app called Streams. After a few weeks of going online, nurses who used the app reported that Streams has been saving them up to two hours a day, allowing them to reduce time in routine administration and speed up direct patient care. Whilst DeepMind is not yet available in Asia, tech firms in the region can learn from the collaborative principle to gain greater trust from their patients. “Deep learning algorithms that are opaque to users could create hurdles in domains such as healthcare, where diagnosis and treatment need to be backed by a solid chain of reasoning to buy into patient trust. Trustworthy AI systems are built around the following tenets: transparency (operations visible to user), credibility (outcomes are acceptable), auditability (efficiency can be easily measured), reliability (AI systems perform as intended), recoverability (manual control can be assumed if required),” Basu added. The prognosis for AI At present, AI systems in Asia are still mostly focused on several pocket of initiatives in single institutions across the region. However, analysts at McKinsey Global Institue said that machine learning is suited to analysing data in millions of medical histories in order to forecast risks at the population level. “This could be an early win for AI because it brings the potential for large savings and would not require the regulatory scrutiny to be expected when trying to anticipate individual health risks,” they said. As AI or cognitive systems move forward into the fourth industrial revolution, much work needs to be

Arnab Basu

Dominic King

John Kelly III

Sundeep Gantori

done in order to keep up with the pace of innovation in more advanced industries such as manufacturing and finance. Gantori said that the global AI industry is expected to grow at a 20% compound annual growth rate (CAGR) to reach US$12.5b in 2020. Once AI has become mainstream, it is expected to continue reaping revenues of up to tens of billions of US dollars by 2030, with Asia a key revenue contributor. “However, Asia still lags developed markets like the US and the UK in terms of innovation and has not yet developed a robust AI-based ecosystem. We believe AI puts 30–50 million jobs in Asia at risk in the medium to long term. AI presents the most risk to manufacturingdriven economies like China, whilst services-driven economies like Hong Kong, Singapore and India should be less affected. However, within Asia, AI should also create many new categories of jobs, ranging in the millions; so the net job losses should be far less and manageable, in our view,” Gantori said. It does not come as a surprise that currently, Singapore leads the ASEAN region in terms of digital innovations in healthcare. Rising demand for services due to an ageing population, rising affluence, and higher prevalence of chronic diseases have resulted in greater spending by the Singaporean government and increased expenditure in private healthcare. A big chunk of investments have also been directed to robotics, AI and chatbots that continue to greatly benefit the country’s ageing population.

Healthcare robotics shipments, 2016-2021

Sources Tractica

HEALTHCARE ASIA

The institute also eyes expanding its inhouse facilities, particularly in related expertise like renal, genetic, hypertension, and endocrine. We will expand in these fields. Our core services will still be around cardiac but we will strengthen it with an integrated capabilities with peripheral areas.

Datoâ&#x20AC;&#x2122; Seri Dr Mohd Azhari Yakub Predee Daochai CEO President National Heart Kasikornbank Institute of Malaysia 14 HEALTHCARE ASIA

INTERVIEW

Malaysia’s Institut Jantung Negara eyes new 150-bed cardiovascular centre CEO Dato’ Seri Dr Mohd Azhari Yakub said that the new cardiac hospital is aimed at targetting international cardiac patients from Singapore and Batam, Indonesia.

ealthcare Asia recently caught up with Dato’ Seri Dr Mohd Azhari Yakub, CEO of Institut Jantung Negara (National Heart Institute) of Malaysia as he shares the hospital’s biggest achievements over its 25 years of existence. He also shared cost-optimisation measures the institute has carried out and what the establishment has achieved under his wing. What are new initiatives in place at Institut Jantung Negara and how have these helped the hospital so far? We have been striving to be the centre of excellence for cardiovascular care in the region and globally, and I think we are now right on the dot to achieving that. The multinational clinical trials are usually initiated by a group of internationally renowned cardiologists. They then look at different centres. As many of our doctors and consultants are key opinion leaders in matters of cardiology, some of us are in that circle of peers. Thus, they may have at one point visited IJN, knows of our system and how reputably high the standards of cardiac care are kept, prompting them to collaborate with us. Our intention is to be the global centre of excellence in cardiovascular and thoracic care whilst our pecuniary objective is to merely be financially selfsustainable and not profit making. What are the best changes you’ve see in IJN over its 25 years of establishment? We are very proud of what we have achieved over the past 25 years. I think that the founders of this hospital are pleasantly surprised with the milestones that we have achieved, some of which goes above and beyond their expectation when they first conceptualised IJN back in 1992. We have allocated about RM2 to 3 million for some attractive treatment packages that we will subsidise to the public as our way of saying thank you for their confidence in us and their continuous support. We are also actively seeking foreign patients to boost the medical tourism for the nation. As one of the elite members of the Malaysian Healthcare Tourism Council (MHTC), we are indeed in the best position to make it happen. In terms of cardiac surgery, probably I have set a high standard of heart surgeries that the next generations of surgeons could outdo mine. In terms of management, it is to set the business plan and systems in place for future sustainability and for IJN to always be at the cutting edge of cardiac care in the country and the Asia Pacific region. I wish for IJN to scale greater heights and be an internationally acclaimed centre. How is IJN right now in terms of medical tourism? IJN’s medical tourism has seen double digit growth in

revenue. IJN provides for the heart care needs of both developing and fast-developing countries. It also addresses the problem brought about by mismatch between high demand for cardiovascular care services and available home expertise. Another selling point in IJN is our highly competitive cost. IJN maximises the opportunity in medical tourism to be financially self-sustaining through constant anticipation of growth in the number of foreign patients. In this light, IJN takes pride in having more than adequate capacity to accommodate both international and local patients. It is actively and closely working with the MHTC, and also works with other partner hospitals all over the world. As an internationally accredited heart centre, IJN has consistently passed the tough Joint Commission International (JCI) vetting since 2009. Not many hospitals are JCI-accredited. Actually, fewer hospitals are being accredited like us, three times in a row. What are the biggest plans in the pipeline for IJN? We will have our presence outside the current headquarter in Jalan Tun Razak. The memorandum of understanding between IJN and Permodalan Nasional Bhd (PNB) for the construction of a cardiac hospital in Taman Perling was signed in mid-August. The hospital will enable IJN to tap larger customer base in the region as it was positioned to attract Singaporeans and Indonesians entering Malaysia via land link. The 150-bed hospital will be offering medical services to between 20 and 30 patients for cardiology and other heart-related treatments. IJN has also developed sub-specialties in other niche areas like pediatric cardiology, electrophysiology, and mitral-valve repair centre. The institute also eyes expanding its in-house facilities, particularly in related expertise like renal, genetic, hypertension, and endocrine. We will expand in these fields. Our core services will still be around cardiac but we will strengthen it with an integrated capabilities with peripheral areas. There is greater competition in Malaysia now as more centres are coming up with private hospitals offering similar services. Cost is a problem due to the depreciation of ringgit as well as GST. To make sure IJN weathers these challenges, it carried out cost-optimisation measures which resulted to savings of between RM20-25m in terms of operational expenditure last year. We have to be firmly at the frontier of cardiac care. It is best to position ourselves with new technology and new expertise. Since we invest in people, we can ride on these challenges by continually delivering the best and latest affordable cure. Financially we are strong. However, we want to get more private patients so that we become less dependent on government patients while at the same time we can continue to cross-subsidise. HEALTHCARE ASIA

feature profile

AHF aims to bring together top doctors and healthcare professionals

Asian Hospital Federation’s president eyes boosting membership count Through an accessible platform, the Asian Hospital Federation envisions more hospitals and member countries will learn more about high-standard hospital management.

sia’s ageing population continues to put a strain on the current structure of healthcare systems in individual countries, which are already experiencing rapid developments in medical tourism, urbanisation, and digitalisation. For instance, Korea’s medical expenses significantly increased because of the changing demographic and Korean hospitals are also beginning to experience difficulties in terms of low premiums paid by subscribers. The Asian Hospital Federation (AHF), one amongst many hospital federations in Asia, aims to allay the sting of these increasingly complex challenges, as it brings countries together through the expertise of top doctors and healthcare professionals. As an example, when typhoon Haiyan devastated the Philippines, a host of Korean hospitals came to the rescue and donated US$30,000 to the rehabilitation and post-disaster efforts by the hospital association in the country. Led by Dr Yoon-Soo Kim and outgoing AHF president Dr Jacob Thomas, the AHF was able to promote the federation in the Philippines through an opportunity meeting with then vice-president Jejomar Binay. Dr Kim, who has been leading the AHF since 2016, revitalised the AHF with pioneering efforts in terms of building a strong network and providing innovative platforms for intercountry

HEALTHCARE ASIA

If the AHF gathers the power of the Asia healthcare industry, we can conduct projects together with international organisations.

exchange. Established in 1971, the AHF was first chaired by the Philippines, which also played a huge role in initiating regular country discussions and knowledge transmission. Leading the AHF Former president of the Korean Hospital Association (KHA), Dr Kim brings topnotch education and experience to his leadership role at the AHF. He finished his degree in medicine at the Korea University College of Medicine and his internship and residency courses at the Korea University Hospital, after which he acquired a license to practice orthopedics. After receiving his doctorate degree from the same university, Dr Kim studied at the Cleveland Clinic in the United States. In 1979, Dr Kim opened his own clinic and consequently, in 1987, Daeyoon Hospital, where he has been treating patients up to this day. When Dr Kim joined the AHF, he envisioned a federation that will play a central role in nurturing Asia’s healthcare industry. “If the AHF gathers the power of the Asia healthcare industry, we can conduct projects together with international organisations, especially to improve the level of medical services in developing countries. The rich-get-richer and the poorget-poorer phenomenon in the healthcare services and

feature featureprofile profile visible in a couple years. We are planning to create the AHF’s website and publish online journals so that the hospitals in the network can exchange data and information.

Dr Yoon-Soo Kim, president

imbalance in the quality of medicine and healthcare amongst countries need to be resolved. We need to seek ways to grow together for Asia to become a world leader in healthcare,” Dr Kim said. Advanced hospitals, wide networking platform With a view to advance hospitals in Asia and serve as a networking platform amongst hospital associations in the region, AHF has fourteen member countries including Korea, Japan, Malaysia, Philippines, Hong Kong, Taiwan, and Indonesia, amongst others. Dr Kim aims to increase the number of member countries by the end of the year, when he will also be finishing his term as president. “There has been much discussion looking to find ways to increase the number of the member countries. Some of the ideas include exemption of the membership fees for developing countries, and the first year’s membership fees waived for those who are interested in joining the federation. Such effort will be continued even after my tenure,” Dr Kim said. At present, the AHF is funded by annual membership fees and holds an annual board of governors’ meeting to discuss the function and development of the federation as well as the healthcare status of its member countries. One of Dr Kim’s priorities at the moment is the development of an online platform for sharing knowledge and best practices. “The AHF has cooperated with conferences and seminars in many different countries for the growth and networking

amongst hospitals in Asia. Now, we are in need of an online platform to exchange information. We are planning to create the AHF’s website and publish online journals so that the hospitals in the network can exchange data and information,” Dr Kim added. To boost membership, Dr Kim has printed AHF promotional brochures and talked to many Asian healthcare leaders at Hospital Management Asia. “Already we see some interests from some non-member countries and some of them have already joined the membership. We will invite new members to the next AHF Board of Governors’ Meeting which will be held in November 8, 2017 in Taipei, Taiwan,” he said. Traditionally, the AHF meeting is held in the country of presidency but this year, since the 41st IHF (International Hospital Federation) World Hospital Congress is held in Taiwan, the AHF has decided to hold the meeting there. In the Congress, Dr Kim shared that he will also meet many healthcare experts and leaders in Asia and promote the Asian Hospital Federation. He also admitted that so far, the AHF has a weak online platform. “We need to boost the online activities through social networking sites, website, online journal, and webinar. We don’t have an official AHF website yet. We need to open an official one and provide healthcare data and information that members could share. We can also host a webinar to boost the academic activities,” he said. In the past, the Korean Hospital Association has led the Asian Hospital Federation twice before Dr Yoon-Soo Kim. When Dr Kwang-Tae Kim (AHF president during 20082009) was the president of Asian Hospital Federation, he has put all the resources together and founded AHF Permanent Fund. Dr Kwang-Tae Kim later became the president of the International Hospital Federation. This fund is stored aside from annual fund for important activities and project, like donation and healthcare development project for the developing countries. Dr Yoon-Soo Kim will finish his term as the president of the Asian Hospital Federation by end-2017 but these efforts will be continued by the next president. The organisation will also elect the next president in the next AHF meeting. Dr Yoon-Soo Kim’s efforts could be the stepstone for the next president and the results could be

AHF aims to publish online journals

HEALTHCARE ASIA

cOUNTRY report: MALAYSIA

Nursing homes are the only institutions focussing on the final stages of care

How Malaysia’s young aged care industry will keep up with the silver population Senior living is still a relatively new concept to Malaysia, and healthcare firms are all scrambling to keep up with the higher demand for elderly care.

n the regional context, Malaysia is above the emerging markets in per capita spending for healthcare but still far below a benchmark country like Singapore. An ageing population and ongoing urbanisation impacts the overall need for healthcare, the mix of healthcare requirements, and the population’s ability to finance its healthcare needs. The economy has performed sluggishly in the past years, hampered by low oil prices and lower FDI investments, better than the Middle East but behind emerging markets. Fabian Boegershausen, country manager at Solidiance, enumerated some of the high level observations on healthcare in Malaysia. “Overall healthcare spending has consistently outgrown key indicators in Malaysia by almost twice the growth factor, following the global and regional trend. Public healthcare budgets remained stable and recently picked

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up again but are expected to grow only slowly in the mid-term future as government income is constrained,” he said. Private spending is expected to keep outgrowing public spending, making up for the lack in public coverage — which is technically universal but full of gaps and bottlenecks. The supply of private healthcare facilities is ill-balanced. Since 2014, private facilities have tended to reduce capacity and may pick up only slowly. “The coverage by private insurance is still very low, people focus more on general savings and life insurances. No easy-to-use, micro-level models yet,” he added. High healthcare spend Malaysia has a healthcare spending per capita of US$455, which is one of the highest in ASEAN where the government plays an active role. However, despite increasing healthcare expenditure, the country’s

healthcare infrastructure still lags global averages and some of its neighbouring countries. “Almost 70% of the approximately 50,000 healthcare staff in Malaysia are serving in public hospitals but the Ministry of Health still records a shortage in healthcare staff at public hospitals. Public hospitals hold 75% share of the total number of hospital beds in the country, but trends show that private hospitals are gaining

Government keen to push medical tourism higher

Source: Malaysia Healthcare Travel Council

cOUNTRY report: Malaysia more share during the past decade. Malaysia has one doctor for every 633 people and one nurse per 333 people. Seventy four percent of doctors are serving in public hospitals and the rest are in private hospitals. In the past decade, the number of doctors in the public and private sectors increased by around 50% and 20%, respectively,” Boegershausen said. In terms of the number of nurses, there was an increase of about 40% in public sector nurses, and more than 50% increase in private sector nurses during the past decade. Suresh Ponnudurai, CEO of Malaysiahealthcare.com and World of Wellness, wonders what strategies are being rolled out by healthcare firms and hospitals that keep luring medical tourists in, what trends are currently in play, and what challenges are players likely to encounter due to these trends. Medical tourism is a US$55b industry that has opened up the doors to quality treatment for people everywhere. “This industry has expanded by leaps and bounds whilst constantly evolving to surpass previously set standards. It supports the government’s view to make Malaysia the premier destination for medical tourism,” Ponnudurai added. Ageing population challenges Senior living remains a relatively new concept to Malaysia, Boegershausen explained. Presently, nursing home is the place that focusses on the final stages of care and majority are run by charitable organisations. The population who are 65 and above remain below 10% of the total population of Malaysia. A recent study shows that approximately 70,000 active 54-year old EPF contributors have average savings of just below RM167,000 in 2013. As the average Malaysian is expected to live until 75, this means that for one to retire at 55, the average monthly expenses can only be at around RM700. A growing senior population will most certainly drive up demand for healthcare, in particular long-term care as well as non-communicable diseases. To achieve the healthcare targets, private hospital beds must grow at 5% CAGR to provide 24%

of the target capacity, and private hospitals beds must grow at 2% CAGR to 65%. The remaining 10% will be catered by homes and medical centres. Ponnudurai added that the ageing population in Malaysia and the rest of ASEAN is rising sharply as quality of life improves significantly. By 2035, Malaysia is expected to have reached the status of an ageing nation with 15% of the population above the age of 60. This is projected to reach 20.4% by 2050. This is a dilemma not only for Malaysia but also for other nations, coupled with significant shortages in aged residential care. The ageing population requires more in terms of healthcare services for nations that have homes to cater for aged care living. Healthcare providers and stakeholders must look to eliminate waste and explore alternative care delivery models like retail clinics, telehealth, and medical tourism for “everywhere care”. These firms are using mergers and acquisitions as well as alliances to consolidate into large health system for economies of scale and to reach more patients. Priorities must be delivering care through mHealth, telehealth, and EMR/PHR, as well as incorporating wearables and social media into their care plans to deliver value in a competitive environment. Additionally, they must address the cost curve and managing health populations with public and private sectors transitioning to financial incentives from the “breakfix” model, to prevention and predictive maintenance. Technology and healthcare Ganesan Satimuti, head of biomedical engineering in Parkway Pantai, Malaysian Operation Division, said that adoption of technology in the healthcare sector of any country is critical in enhancing delivery of quality healthcare services. Malaysia practices a dual healthcare delivery system. Datuk Dr Kuljit Singh, medical director, Prince Court Medical Centre in Kuala Lumpur, Malaysia, enumerated some of the challenges in converting into digital technology in Malaysian healthcare.

Dr Kuljit Singh

Fabian Boegershausen

Suresh Ponnudurai

He cited that the industry must tackle traditional thinking amongst hospital players, elevated costs, more training, partial digital conversion, the system’s 100% dependency, and confidentiality. “The public sector provides about 70% of healthcare services in the country. With policy of equal roles of the public and private healthcare delivery services, there is a high competition for health professionals, especially on doctors/specialists between the public and private hospitals. Only 18 public hospitals are equipped with either fully integrated or partially integrated HIS since the Telehealth initiative was launched over 10 years ago, which shows low adoption level of HIS in Malaysia,” Singh said. Use according to need Malaysia, as of 2013, had 3,616 government health facilities, which included 135 public hospitals. Critical cases are mostly referred to the 18 fully or partially equipped hospitals by other public hospitals and some private hospitals. 1Care for 1Malaysia was launched in 2009 with the intention of reform based on the principle of “use according to need, pay according to ability”, but little progress towards its implementation has been made. Public hospitals have the country’s best healthcare equipment and facilities apart from having specialists in the field. However, the main drawback is the shortage of staff in public hospitals compared to the number of patients seeking treatment which has led to long queues. Private hospitals are mostly located in urban areas and are equipped with the latest diagnostic and imaging facilities.

Per capita healthcasre spending (nominal)

Source: EconsMalaysia

HEALTHCARE ASIA

event coverage: HIMSS ASIA PAC 2017

Effective integration of digital solutions

How healthcare firms can monetise digital health

It is time that hospitals realise that apart from monetary gains, digital health solutions produce better clinical outcomes and better patient relationship.

he 11th HIMSS AsiaPac17 Conference and Exhibition was designed to cast a spotlight on understanding the everevolving influence that technology, information and data have in an increasingly growing connected ecosystem of health, and how this is enabling greater collaboration between governments, healthcare practitioners and institutions, and patients. The four day event welcomed more than 1,200 healthcare professionals – doctors, nurses, as well as health technology experts and developers, and members of health institutions – from over 30 countries. The regional conference hosted three pre-conference workshops focused on educating and equipping members of the healthcare ecosystem with the knowledge to navigate the challenges and opportunities of technology. In addition, there were six main conference tracks on Population Health, Nursing, Data and Technology, Collaborative Care, and Value-Based Care, as well as the Integrated Health Information Systems Singapore, track to showcase 20

HEALTHCARE ASIA

Technology is an important enabler, as it opens up new ideas, new possibilities and allow us to translate these new ideas into reality.

the best in Singapore healthcare. To celebrate first-hand the best in-class implementation and utilisation of information technology applications in Singapore, HIMSS Asia Pacific also facilitated tours of Ng Teng Fong General Hospital (NTFGH) and Jurong Community Hospital (JCH) – both EMRAM award recipients at this year’s HIMSS Asia Pacific Awards Dinner 2017. Speaking at the Opening Ceremony, H. Stephen Lieber, CAE, President & CEO Emeritus of HIMSS shared, “Doctors today can no longer work alone and expect the same quality of care without input and leadership from the rest of the care team. The care team in turn cannot function seamlessly without technology enablement: predictive analytics, artificial intelligence, electronic medical records, internet of things, mobile technology, and so on. This combination of great teamwork and great use of technology is the formula to value-based, patient-centered, team-based care. It is with this in mind that the HIMSS team has put together this conference to accelerate our progress in this direction.” “HIMSS continues to support

the transformation of health through the use of information and technology. This is at the heart of everything we do”, added Harold ‘Hal’ Wolf III, President and CEO of HIMSS. “It was wonderful to see so many attendees participate in various dialogues and learnings over the course of the event. This year there was a strong emphasis among a growing coalition of peers to find new capabilities to drive better care through integrating and implementing a team- based approach which includes the use of the HIMSS maturity models for EMRs, Analytics and Innovation Pathways.” Uniting patients and providers Chee Hong Tat, Senior Minister of State, Ministry of Communications & Information and Ministry of Health said, “I am glad that the theme of this conference is “Unifying Patients and Providers” – bringing different stakeholders together through smart use and appropriate use of technology, to be able to deliver better care for our patients. As we move forward in our care transformation efforts and into more team-based care, our healthcare professionals could keep in mind the 3 ‘C’s of Collaboration, Connection, and Co-creation. Technology is an important enabler, as it opens up new ideas, new possibilities and allow us to translate these new ideas into reality.” Bringing together thought leaders and distinguished speakers, HIMSS AsiaPac led discussions around the importance of transforming towards an integrated, team-based care model; clinical efficiency improvements through greater adoption of technology; upskilling of nurses in the digital age for better patient care; mitigating cyber security threats and the safe management of patient data; and how hospitals can transform their healthcare practices through a multi-disciplinary approach involving IT architecture, solutions design, standards and policies.

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Case study: MacKay Memorial hospital

MacKay Memorial Hospital rolled out its own mHealth programme

How MacKay Memorial Hospital restructured patients’ access to mHealth

This Taiwanese hospital believes it is not enough to provide a digital solution in healthcare; the important thing to consider is whether it adds value to users and helps improve their therapeutic outcomes.

ill organisers and medicine reminder charts had been considered the best memory aides for dosage skippers, up until the development of various mobile health (mHealth) apps. Despite this progress, most mHealth apps in the market seem to work best in Englishspeaking countries, and fail to boost medication adherence in countries with a different culture and language. Determined to bridge this digitalisation gap, MacKay Memorial Hospital in Taiwan rolled out its own mHealth programme with a Mandarin user interface and a QR scanning option for prescription notes and drug packages, amongst many innovative features. MacKay Memorial Hospital’s move to come up with a Mandarin-based application is also influenced by rising cost pressures amidst an ageing population in Taiwan. The hospital’s mHealth app, which is the first of its kind, boasts of a collaborative solution that has helped improve physician-patient interaction and medication knowledge in the country. The app recently bagged Outstanding Innovation award at the Asia Pacific HIMSS-Elsevier Digital Healthcare Award 2017 for being a fast, creative solution in improving processes and driving more effective outcomes for patients. Dr Shou-Chuan Shih, superintendent, MacKay 22

HEALTHCARE ASIA

Non-adherence and knowledge gaps amongst patients often result in unnecessary medical expenditure.

Memorial Hospital and core member of the mHealth programme, said that one of the ways in which patients can contribute to better disease management is through religious adherence to medication regimens. Tailored for Taiwan Whilst quality healthcare in Taiwan is considered highly accessible and affordable, Shih noted that non-adherence and knowledge gaps amongst patients often result in unnecessary medical expenditure. In the United States alone, estimates by the Centre for Disease Control and Medication reveal that poor medication adherence contributes to 125,000 deaths and costs up to US$3b every year. According to the World Health Organisation (WHO), only 50% of patients with chronic diseases adhere to long-term therapies. This is especially true considering the number of elderly patients who are hindered to diligently take their dosages because of cognitive decline and polypharmacy. MacKay Memorial Hospital’s mHealth programme brings medication adherence and knowledge to a new level, with its patient-centered design concept tailored for Mandarin-speaking users. For the more elderly users, the developers of MacKay’s mHealth app included a unique family-friends care circle

Case study: MacKay Memorial hospital feature so patients can have greater accountability in their medication and treatment. In the case of medication tracking and adherence, popular mHealth apps such as MediSafe, DoseCast, and MyMeds have proven effective in reminding patients of their daily dosages. As more apps are released into the market, MacKay Memorial Hospital noted the low adoption rate of these apps in Taiwan and grabbed the opportunity to develop something that would pique the interest of locals. MacKay Memorial Hospital observed that language is the greatest barrier to adoption, thus they pioneered a culture-based app with a Mandarin interface. MacKay Memorial Hospital also leveraged on the growth of integration in Taiwan’s digital landscape by including a QR code system for the prescription process, which addresses a major complication in terms of the digital platform of the app. According to Shih, the initial problem was interoperability between the cloud-based mHealth platform and the hospital information system (HIS). MacKay Memorial Hospital launched the QR code system in response to the challenge of creating an mHealth app based on the existing architecture without causing additional burdens on the HIS, such as transformations on the original framework and additional development costs. Shih said that the QR code system works by scanning codes on prescription notes and drug packages whilst offline and synchronising the information with the existing HIS once online. Patients can then access personal medication information such as dosage, frequency, drug photos, side effects, and warnings, through the mHealth app, which also automatically notifies users when it’s time to take their medicine. Shih noted that the two-step design of the QR code system proves effective as it does not cause additional burdens to the existing HIS infrastructure. “In addition to facilitating medication compliance through reminder notification in our system, users are encouraged to record their symptoms or discomforts as well as global self-assessment for their treatment period. As a patient-centered design concept, the key features of our mHealth system are to reflect patients’ actual medication utilisation status as well as the time and severity of symptoms developed to their healthcare providers so that healthcare teams and patients could function in a collaborative manner,” Shih added. Physicians who use

Dr Shou-Chuan Shih, superintendent, MacKay Memorial Hospital

Medication refill with the help of the programme

Users are encouraged to record their symptoms or discomforts for their treatment period.

the mHealth system are sure to benefit from the patient’s medication usage reports, from medication schedule to completion rate to symptoms, in order to improve consultations and follow-ups during return visits. MacKay has taken the collaborative principle further, as users can share the stored information not only with their hospitals and physicians, but also with family and friends for mutual support and improved medication adherence. Shih said that the family-friends care circle feature was included to particularly help patients with chronic diseases, as they are considered to be in need of an additional tool to solve low medication adherence and polypharmacy. This feature includes an alarm system through which members of the family or friends circles are notified when someone failed to take their medication. On a larger scale, aggregated data from the mHealth app can help administrators better understand medication usage behaviour. Shih said that MacKay Memorial Hospital was able to provide objective measures of populationbased medication utilisation, reported for the first time and beneficial to improving the quality of hospital administration. Tried and tested MacKay Memorial Hospital utilised several promotion mechanisms in raising awareness about the benefits of the mHealth app, including launching it on the iOs and Google Play platforms. Shih said that to inform their patients and their patients’ family and friends, the hospital implemented a widespread publicity campaign through the use of posters, flyers, and videos across the hospital. To further assist users in downloading the app and as way to respond to their questions, the hospital set up a helper desk at several specific locations in the hospital, such as the pharmacy and reception counter, where most of the patients and their loved ones go. Shih added that for patients with specific diseases, the hospital promoted the mHealth programme in consultation rooms and partnered with medical care providers to deploy the app at outpatient clinics in the city. Physicians also involved themselves in the promotion process by encouraging their patients to use the app for better physician-patient interaction. Despite learning about the programme through widespread promotion within the hospital, patients are more HEALTHCARE ASIA

Case study: MacKay Memorial hospital symptoms and inquire about drug functions. Other than the symptom record, Shih said that the medication reminder system is one of the first desirable features of the app.

Promotion campaign during roll-out

convinced to try when their doctors vouch for it. MacKay Memorial Hospital also made sure to provide instruction manuals and pre-discharge consultations to smoothen the transition from in-hospital to out-hospital. Local users have been receptive of MacKay Memorial Hospital’s mHealth app, with a total of 25,909 users recruited, average seven-day active users of 500, and 15.4% (± 3.9) seven-day retention rate during the implementation period. Since the retention rate is quite low, Shih said that the hospital continues to study the critical factors behind the number in order to improve it and make the app more accessible and engaging for the entire Taiwanese population. Furthermore, Shih added that users preferred to scan the drug packaging rather than the prescription note, with medication information surfing increasing to 3,445 times during the fifth month. This suggested that patients were already familiar with the system as a means to educate themselves. The hospital also noted that in their test, the users who engaged with the app were mostly composed of young adults and males. At the clinical level, Shih noted that physicians from various specialisations such as cardiology and immunology found the system helpful in caring for patients with complicated medications and those with difficulties managing their medications on their own. Meanwhile, administrators can look at the data from a population lens as the the mHealth app clocked in a total of 25,267 scanning counts including 97 different categories of medications in the implementation period alone. “We can list the ranking of drugs scanned by the users and track the trends of completion rates of specific medications. These data were the objective measures of patient’s medication utilising status at a population level, which would be valuable information for the hospital’s administrative quality improvement measures and further policy-making,” Shih said. The instant success of MacKay Memorial Hospital’s mHealth programme may be seen in the positive online feedback received by the mHealth app regarding the usability of the interface, the availability of drug information, and the quality of reminders and connectivity of family-friends care circles. The app’s Google Play rating hit 4.493 points out of 5, with users complimenting how the app helps them record disease 24

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Going forward Shih further noted that although plenty of users were recruited during the implementation period, the seven-day retention rate is in fact very low. “The high attrition rate for mobile app intervention may reflect the user’s interest in the novelty of the app but is rapidly declining as the novelty disappears. It means that the human factor issues play an important role in developing a better patient-centered mHealth app and increasing the retention rate,” he added. MacKay Memorial Hospital expects to work on initial observations for upcoming versions of the app. One of The high these observations include well-designed versions for attrition rate elderly users who prefer to use the app on wider and bigger for mobile app devices, such as seven-inch tablet. intervention Another observation is the fragmented completion may reflect the rates of drug usage, indicating that users did not take user’s interest medications or did not even use the app despite receiving in the novelty notifications from the system. “The phenomena suggests of the app that making the users continue record their medication but is rapidly utilisation status is the next stage for improving our declining as mHealth system,” Shih said. the novelty Whilst technology plays a huge role in determining disappears. the success of a digital solution and eventually, better healthcare, MacKay Memorial Hospital remains hinged on the value of placing their patients at the centre. At the end of the day, Shih said that healthcare still revolves around humans: patients, their loved ones, and the hospital’s medical staff. As a leader of the hospital, Shih believes that he has a duty to relate not only to his patients, but also to his employees in, order to be more effective in the management of the hospital. In fact, Shih said that in order to take care of their patients, the hospital has to be able to take care of its employees too. As their mHealth app further develops, Shih said that they believe that the quality and design of their digital health solution for personal medication and health management could be integrated into other hospitals. He added that app may be the foundation that allows healthcare institutions to provide a more versatile and personalised approach toward advanced healthcare. MacKay Memorial Hospital has been a pioneer in digital solutions in Taiwan, providing other innovative tech-based services such as a Cisco-based Unified Communications (UC) solution comprised of a patient infotainment system and e-whiteboards. The UC system was implemented in response to the challenge of providing real-time care amidst the growing number of patients in the hospital. Through the system, nurses can access a central patient terminal which allows them to take patients’ calls via a wireless phone and respond to needs at the moment they are expressed. The e-whiteboards also provide a common platform for doctors and nurses to access their patients’ real-time status, staff assignments, and duty roster, resulting in greater hospital productivity and patient satisfaction.

RECOGNISING

TRAILBLAZING INITIATIVES IN THE

HEALTHCARE SECTOR 17 MAY 2018

SINGAPORE

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Analysis: VALUE-BASED HEALTHCARE

The public’s worries about increasing costs motivated the government to explore value-based healthcare

How will Taiwan push value-based healthcare forward?

A value-based approach to healthcare is gradually gaining traction in Taiwan, as the country’s healthcare system confronts the opportunities and pressures of innovative new medical treatments.

aiwan’s citizens benefit from one of the oldest government-administered, insurance-based national health services in Asia, and one of the few in the region that provides universal coverage. Established in 1995, the single-payer model health insurance programme is now managed by the National Health Insurance Administration (NHIA) and covers 99% of the country’s population. Expenditure on health accounts for a comparatively low 6% of the GDP. The system is notable for comparatively low costs, comprehensive benefits, short waiting times, and completely free access to doctors, clinics and hospitals of the patients’ choice. The benefits package includes a list of thousands of prescription drugs, according to Joey Kwong, collaborate researcher at the National Center for Child Health and Development, Tokyo, Japan . Taiwan’s health system ranked 45th in the Global Burden of Disease Study’s 2015 Healthcare Access and Quality Index, out of 195 countries and territories surveyed. The Index, which measured mortality from causes “amenable to personal healthcare”, was previously compiled in 1990. The single-payer structure of the Taiwanese system enables it to set and regulate fees, as well as impose a global budget, helping the NHIA to control costs, a 2015 article by the Brookings Institution pointed out. Jasmine Pwu, director 26

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Our healthcare providers have complaints about the design of our national health insurance.

of the National Hepatitis C office under the Ministry of Health and Welfare (MOHW) and a former director of the Health Technology Assessment (HTA) division at Taiwan’s Center for Drug Evaluation (CDE), said the government is being challenged about how it evaluates research, the brand value of drug manufacturers and, to a greater extent, the patient’s perspective. “Our healthcare providers have complaints about the design of our national health insurance,” she said. “Pharmaceutical and medical device companies ask questions about how reimbursement decisions are being made, and the patient voice has been increasing over the last two to three years.” Institutional history The HTA of new medicines is not a new concept in Taiwan. The CDE, a private, not-for-profit nongovernmental organisation, was created in July 1998 to provide value-based evidence for decision-makers. In December 2007, the agency established a new division of HTA, now known as the National Institute of HTA (NIHTA), to allow for greater focus on comparative (clinical) and cost-effectiveness analyses of new drugs and medical devices, as well as the impact of new medical innovations on the country’s healthcare budget. The

Analysis: VALUE-BASED HEALTHCARE CDE also became a founding member of HTAsiaLink, an international organisation of HTA issues dedicated to developing collaborative networking amongst regional HTA agencies, in 2011. The Institute was commissioned with the authority to both reduce the burden of drug costs and to avoid unnecessary medical waste and uses methodologies that are “well-developed and transparent”, according to Ms Kwong. Research institutes use a range of measurements familiar in Europe and other countries where HTA is common, including quality-adjusted life years (QALYs), disability-adjusted life years (DALYs), incremental costeffectiveness ratios (ICERs), willingness-to-pay thresholds (WTPs) and benefit-cost ratios and net benefit. Measurements Without a broader structure for integrating these metrics, however, they are not required in the National Institute of HTA’s dossiers, according to K Arnold Chan, a professor at National Taiwan University (NTU) College of Medicine and director of the NTU Health Data Research Center. “Those metrics are familiar to most people, but there is no framework to incorporate them into a very rigorous system yet,” he added. “It’s not the very top priority of senior officers of the NHIA.” The MOHW compiles vital statistics and life expectancy data, whilst the the ministry’s Health Promotion Administration conducts surveys on major diseases and risk factors, he noted, but other broader outcomes are harder to measure. Indeed, although the NHIA routinely does population surveys, these usually show that much of the public merely rates the health insurance system favourably for accessibility and low co-payments, Dr Chan said. “This is routinely used as an indicator that the system is not broken,” he added. “But there is no systematic basis to discuss patient outcomes. We do metrics on hard endpoints, but there is little effort to look at patient quality of life.” There are scattered examples where the government is trying to rectify this gap, including a page on the NHIA website for rheumatoid arthritis on which patients can comment on their experiences with certain drugs and medical equipment. Yet, such options have yet to be rolled

The public’s worries about increasing costs led to the exploration of using value-based measures

Those metrics are familiar to most people, but there is no framework to incorporate them into a very rigorous system yet.

Doctors pending enough time with patients during consulation

Source: EIU

out on a full-scale basis. Taiwan’s HTA body is extremely adept at building reliable quantitative models, according to Yi-Hsin Hsu, associate professor in the School of Health Care Administration at Taipei Medical University. “The calculations are very rigorous,” she said. “We build good models and have good references and parameters.” If Taiwanese agencies do not have their own parameter information, she adds, they use “data collected from foreign literature to build the decision tree and model for each kind of disease”. Yet, often conclusions about how to interpret the results are not as clear-cut, she added. Whilst the HTA Institute can calculate the cost effectiveness of a novel cancer drug for the lives it saved, the drug’s impact on national productivity and the budget is more complicated once the discussion moves to committees of different stakeholders, particularly government officials who may be responding to political pressure in their assessment of value. In particular, there has also been limited effort, so far, to apply HTA to full care pathways, as opposed to individual therapies or medical interventions. Both Dr Chan and Ms Hsu observed that measures such as QALYs are of more use for HTA for new medicines, and that no guidelines or thresholds exist on how they can be translated more broadly. “Most [HTA] staff are coming from a drug background and only think about the drug from the drug perspective,” said Dr Chan. “We need to think about a drug and how it fits into treatment. It needs to be a top-down holistic approach.” In 2013, the MOHW commissioned the CDE to operate the Preparatory Office of the National Institute of Health Technology assessment to gradually integrate HTA services on health policies, healthcare services and the allocation of health resources. Expenditure remains a worry Although Taiwan’s health system is relatively efficient, the public’s worries about increasing costs have been a driver of greater exploration in using value-based measures to assess treatments and outcomes, several of those interviewed said. “Although we are spending just over 6% of GDP on healthcare, there is still a widespread belief that because individuals are responsible for paying a part HEALTHCARE ASIA

Analysis: VALUE-BASED HEALTHCARE health decision makers within the government to include cost-effective metrics based on population health data when evaluating intervention programme, especially for cancer.

Overuse of the healthcare system is a recurring problem for Taiwan

of the insurance premium, public opinion is especially sensitive to any growth in premiums. This pressures the government to show that it is making good use of resources. Overuse of the system, especially with regard to medicines and hospital treatment, is a particular problem for Taiwan, one that is exacerbated by the fee-for-service system, Ms Hsu said. “Our people have not become healthier, they just get more healthcare,” she said. “So the problem in Taiwan is the use of resources, not quality. These resources have been taken for granted and used extravagantly.” At the same time, she observed that any efforts to reform the way the system is financed can lead to a political backlash. There have been some efforts to introduce so-called “pay for performance (P4P)” programmes in chronic disease areas such diabetes, where payments are made for treatment outcomes, according to Ms Hsu. “In terms of value, we are slowly turning to ‘pay for performance’, but ‘fee for service’ still counts for a larger part,” she said. “Pay for performance is our effort in recent years to revise our behaviour. In the past, we paid little attention to results and to disease control, in favour of providing what was needed at that instance.” Experimentation still ad-hoc Taiwan’s NHIA piloted a number of projects looking to reward outcome-based effectiveness between 2004 and 2012. Specific pilots covered infectious diseases (tuberculosis), chronic illnesses (breast cancer treatment, asthma and diabetes) and preventative health with a focus on cervical cancer screening, according to Dr Chang, who oversaw many of the pilots during his tenure at the NHIA. Following an initial pilot, Taiwan’s Center for Disease Control decided to implement an outcomes-based programme to control tuberculosis. “We started early, and had various degrees of success and setbacks, but in my opinion we haven’t been moving fast enough into an outcome-based, cost effectiveness-based payments system,” Dr Chang said, citing both “the global financial crisis and the difficulty in convincing the public that the system should put in more resources rather than setting a cap on paying for new medicines”. Hsiu-Hsi Chen, a professor of epidemiology and statistics at NTU, noted that he spent ten years convincing 28

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We use different approaches and different tools to make sure we are making the best of our budgets.

Cost effectiveness One area in which cost-effectiveness has been widely used in policy development is in cancer screening programmes, Ms Pwu says, noting that the Health Promotion Administration (HPA) has looked at the effectiveness of screening for breast, colorectal, cervical and oral cancer.“We use different approaches and different tools to make sure we are making the best of our budgets,” she added. “When it comes to screening, our governor will commission cost effectiveness analysis to support decisions. However, in the case of treatment, because of time and quantity, it’s not possible to incorporate costeffectiveness consideration for every Application.” The government also has tried to measure the impact of wider public health measures outside the realm of screening programmes and direct medical treatment. In the case of the Tobacco Hazards Prevention Act, a smoking control programme that came into effect in September 1997, step changes in the tobacco surcharge in the period up to 2009 accompanied a fall in the overall smoking rate to 18.7% in 2012, down from 29.2% in 1996, just before the act came in. Amongst men, the rate fell even more steeply during the same period to 32.7% from 55.1%. As we have seen, Taiwan has used a variety of valuebased measure across its health system for some time; however, the lack of a coherent framework for discussion or guiding principles undermines consistency and transparency. The health system has embraced the concept of cost-effectiveness in the evaluation of new technology and preventative health programmes over the past decade, but the implementation can be uneven. Moreover, there is little evidence of efforts to look at the value of other sorts of interventions and procedures, let alone assess existing care pathways or guidelines. There is also no concerted effort so far to identify treatments in current use that fail to provide value for money, many of those interviewed point out. New challenges and paths forward Taiwan’s government has been looking at the UK’s National Institute for Health and Care Excellence, which provides advice to the health service on cost and comparative effectiveness of treatments. Taiwanese health bodies are also looking further afield for models of valuebased care. “We do have a small group on a pilot basis trying to copy this know-how, but it is still limited,” said Dr Chang. “One thing that limits our moving toward this direction is that we lack the institutional capacity. The government hasn’t been able to put in the resources to have the institutions, and you need to put in a lot of analysis and lots of professional staff. The government has been working on this for 15 years.” Another area where the government could do more is in establishing not only which procedures and treatments offer high value, but which are at the opposite end of the value spectrum and

Analysis: VALUE-BASED HEALTHCARE should be eliminated in order to help save scarce resources. “Despite the long history of universal coverage in Taiwan, and a relatively mature framework for using high-quality evidence and economic analysis in the universal coverage scheme, the concept of what constitutes ‘low value’ healthcare is an untapped area,” Ms Kwong noted. “A modest body of evidence is available on healthcare system burden associated with potentially inappropriate medications, using claims data from the National Health Insurance Research Database. However, there is currently a lack of nationwide involvement in raising awareness of the consequences of medical waste,” she added. The Choosing Wisely initiative, which originated in the US and is being employed in parts of Europe as well, could be usefully employed in Taiwan, she added. Raising the profile of patients as stakeholders in healthcare evaluation and decision-making is also important, Dr Chan said. “Patient advocacy is in its infancy in this culture, and that is also a fact in the current environment and mentality of government officers, because [patients] are not seen as a major stakeholder,” he said. “It is important to listen to patients, and so value from a patient perspective is important. In the 21st century, that is what health providers should be valuing as well.” At the same time, despite a Chinese culture in which patients traditionally listen to their physicians and don’t always recognise value as a consideration, Taiwanese patients are gradually learning to become more demanding consumers. Comparative surveys of patients in different countries found that Taiwanese patients were the second least likely to agree that their doctor had spent enough time with them during consultations, and least likely to agree that their doctor had provided “easy-to-understand answers” to their questions. Use of P4P Ms Pwu cited anecdotal evidence of patient groups under development as a signal that patients are eager to be involved in the decision-making process and that their views should be incorporated. Those advising such groups are increasingly suggesting that they “should be very original and not just ask for access”, she says. Finally, the use of P4P should be expanded further, Dr Chen adds, noting that providing incentives, such as paying health Doctors providing easy-to understand- explanations

Source: EIU

Performance in the healthcare and quality index, select economies 2015

Source: EIU

providers bonuses for catching cancer at stage 1, could result in significant benefits. For more than a decade and a half, Taiwan has burnished its credentials as not only the regional health system with the most comprehensive coverage in Asia, but also the one with the most advanced understanding of the importance of using value measures to invest wisely in its healthcare system. At the same time, albeit it has put in place institutions for carrying out HTA of new medical treatments and devices, and albeit it has found ways to make use of its extensive trove of population-based health data (especially in the case of preventive healthcare), there are gaps in its ability to apply this experience consistently across the board in the health system. The system could do more to identify examples of “low-value” care as well as those treatments that are worthy of further investment. Zooming out As part of this process, Taiwan’s health policymakers need to take a broader overview of disease areas, from prevention to diagnosis to treatment, in order to identify where the greatest value is to be found. Public education could also help people make better use of healthcare resources. In particular, whilst cost-effectiveness analysis has been used in pilot projects related to cancer screening and some outcomes-related feedback has been collected from patients on the NHIA website, there has been no effort to introduce these measures across care pathways. This is due, in part, to the lack of integrated healthcare outside of a handful of demonstrations projects. Finally, although elements of the value conversation are becoming part of healthcare evaluation, there has been an absence of a widely understood language for initiating value discussions. Doing so will also help to empower patients to play a greater role in their care. Taiwan has the opportunity not only to greatly improve the value it gets from its own healthcare dollars, but also to act as a model for other healthcare systems in Asia that are only just grappling with concepts of value. By investing in further development of the value-based healthcare system and by encouraging patients to play a greater part in this process, Taiwan can continue to be a leader for the region. From The Economist Intelligence Unit’s “Value-based healthcare in Taiwan: Towards a leadership role in Asia” HEALTHCARE ASIA

OPINION

Michael Custer

Opportunities for medical device companies in China’s reforming healthcare industry

MICHAEL CUSTER Consultant, Solidiance

tarting in 2015, Chinese authorities began a series of major reforms to its healthcare system. The goal of the reforms is to increase the efficiency and sustainability of the system in preparation for three macro trends that will lead to a significant increase in healthcare costs for the national government. 1) Slowing economic growth – As the Chinese economy enters the ‘New Normal,’ year-on-year economic growth will continue to slow. Slower economic growth leads to slower growth of tax income, impacting the government’s ability to fund future healthcare costs that are projected to grow at a rate nearly double that of the economy. 2) Rapidly Aging population – China’s population will age at an unprecedented rate, a result of the one child policy. An older population will increase the growth of healthcare expenditure, increasing government expenditure on healthcare. 3) Greater incidence of costly non-communicable diseases – Chinese citizens are also becoming more and more at risk of developing chronic diseases such as diabetes, hypertension and COPD. The combination of the impacts of these three trends will inevitably lead to a significant increase in healthcare costs. We have forecasted out four future scenarios for the percentage of China’s governments budget that will be spent on healthcare based on projected demographic changes and economic development. All four of these scenarios would result in the Chinese government spending the highest or amongst the highest proportions of its government expenditure on healthcare in the world. The system, thus, must be reformed to become more sustainable, efficient and affordable. Impact on medical device firms The reforms affecting the medical device sector have two main goals: 1) downward price pressure and 2) support of the technological development of local companies. To put downward price pressure on device companies, new regulations aim to cut out extraneous middle men and change the hospital reimbursement system to one based on disease groups (i.e. ACL treatment) vs services provided (i.e. MRI). The government will also likely increase direct pricing pressure on device companies in the bidding and approval process. Regulatory authorities will support the technological development of local companies through favorable device approval policies and locally produced purchase requirements for hospitals. Taken together, the reforms rightly have worried most multinational device companies in China and have caused a rethink of many companies’ China strategy. However, even with these reforms, there remains profitable strategies to take advantage of the fast-growing China healthcare market. Local Acquisitions and multiple product lines - Purchasing a local, low cost player is a way for a multinational company to 30

HEALTHCARE ASIA

Investing in early diagnosis MY

preserve brand value whilst still competing and profiting from the growing market. It also helps MNCs meet requirements for local purchases and provides them with enhanced market understanding and local relationships – an important key to success in China and other emerging markets. Profitable strategies One good example of this is Stryker’s acquisition of Trauson, a local Chinese device manufacturer that specialises in spine and trauma devices. At the time of the acquisition, Trauson was a direct and lower cost competitor of Stryker for several product lines. The acquisition allowed Stryker to maintain its own brand value whilst still profiting from the fast-growing orthopedic segment through Trauson, its local subsidiary. Overlooked market and Innovative products: Boosted by government support, local companies will enter and quickly dominate larger, well-publicised device markets as well as markets that don’t require as much technical knowhow. This clustering of local companies in certain segments will cause downward price pressure in those device markets, decreasing the profit margin for foreign players. However, many opportunities will still exist in smaller and overlooked markets such as those devices that treat relatively rarer diseases. These overlooked device markets will still offer highly attractive profit margins for MNC firms. Similarly, it is also important for MNCs to continue to invest in R&D and bring to market innovative products that maintain their technical advantage over local competitors. Innovative and unique devices will continue to demand a price premium in post reform China.

CMY

2018

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OPINION

Brian Kennedy

Slowing the biological clock

Professor Brian Kennedy Director, Centre for Healthy Ageing, National University Singapore

he world is getting rapidly older and governments have started taking notice. As a result of improved sanitation, healthcare, infectious disease prevention and other changes in the last two centuries, life expectancy has more than doubled. Coupled to this in most of the developed world is a dramatic reduction in birth rates. Put this together and by the mid-21st century, there will be never-before-seen demographics, with up to 40% of people in many countries over the age of 65. Asia is “ground zero”, with Japan, South Korea, Singapore and Hong Kong leading the way. Most of the rest of Asia is not far behind and China in particular has the fastest changing demographics, with rapid increases in healthcare coupled to the one child policy. Put simply, ageing populations may well be the biggest medical challenge of the first half of the 21st century. A problem in search of a solution People are living longer, but healthy life expectancy is going up at a much slower pace than life expectancy. Long-term chronic disease management is the major driver of increasing healthcare costs. This is not going unnoticed. In the recent National Day Speech, Prime Minister Lee Hsien Loong noted that “on average, Singaporeans live to 82 years and out of these 82 years in old age, we experience eight years of ill health.” Recognition of the problem is a major step forward; however, strategies at all levels to reduce chronic disease and improve human healthspan remain elusive. Projections suggest that if the current trends (longer lifespan, low birthrate and increasing prevalence of chronic disease) continue, there will be major impacts on future economies. Healthcare providers will be increasingly burdened and in most cases senior living options are already limited. Adapting society to incorporate high numbers of elders requires a rethink at many levels whilst also offering opportunities. Changes in everything from architecture to social programme to pensions must be evaluated. In terms of medicine, there are two broad strategies that generally fall under the categories of ageing management and prevention, with both offering private sector opportunities. Managing ageing involves strategies to maintain life quality as people get older, and includes a range of medical strategies and applications. Medical devices, including apps that measure physical functions and monitoring devices that detect falls, are, for instance, being developed specifically for elders. One challenge is to create a user interface that is appealing for elders. Another growth market is the development of assisted living communities, rehabilitation centers and “ageing in place” support strategies that help elders find places to reside that maximise their health and functionality. The concept of preventing ageing has been considered by people going back millennia, but only in the last two decades has science made this possibility tangible. Lifespans have doubled in the last century not because ageing is being slowed, but because 32

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Medicine is aimed at treating mostly age-related diseases

of a dramatic reduction in age-extrinsic causes of mortality. In essence, the dramatic rise in the chronic diseases of ageing are a product of success in other areas of medicine. What has emerged is an awareness that ageing is a driver of disease and that by slowing ageing it will be possible delay the onset of many diseases simultaneously and maintain life quality at higher levels as we age. Largely academic research over the last several decades has helped (1) define the genetic and molecular determinants of ageing and (2) develop a range of interventions from lifestyle modification to pharmacologics that may extend lifespan and healthspan in humans. Recently, biotechnology companies have started to enter the fray in significant numbers and are testing different strategies to target ageing directly. Biomarkers of ageing have also been developed that likely will serve as endpoints in humans to determine whether interventions are having the expected impact. The stage is set for human testing and if interventions are validated, implementation to improve healthspan at the population level can proceed. Currently, medicine is aimed at treating (mostly age-related) diseases. Targeting ageing as a means to prevent disease is a potential medical revolution that, if successful, will keep people healthy and active longer, as well as delaying or even preventing the debilitating diseases that are escalating healthcare costs dramatically. The increasing numbers of elders is looked at with concern, but it is actually a huge opportunity. Older people have experience and wisdom that can be of great use. If kept healthy and adequately empowered through retraining programmes and new opportunities for meaningful engagement, elders will add tremendous value to society at all levels. The countries that effectively combines efforts to “manage” and “prevent” ageing will be well placed for success in the changing demographics of the 21st century.

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COLLABORATING TO CREATE EFFICIENT CONNECTED CARE

We’re committed to helping the healthcare community better align patient care with patient outcomes. But we can’t do it alone. That’s why we’re collaborating with physicians, hospital administrators, payers, and patients across the care continuum to create more sustainable models of care. Our goal? Better patient outcomes for everyone.

Let’s take healthcare Further, Together. Learn more at medtronic.com/apac