Healthcare Asia (July to October 2015)

The magazine for healthcare administrators and policy makers

| www.healthcareasiamagazine.com

Display to 31 October 2015

bumrungrad’s growth strategy Dr. Num Tanthuwanit, CEO of bumrungrad Hospital in Thailand, reveals plans to build on two new sites to extend the campus over the next three years

Asia’stelehealth

movement

Booster shots for

workforce shortage

Case Study: SingHealth Volume vs value in healthcare

Institute of Mental Health’s paradigm shift in Singapore

feature profile

analysis No need to look farther for Asian medical tourism

OPINION Medical tourism in the Red Dot: A Peter Pan model

first When public and private healthcare merge

PAge 14

PAge 22

PAGE 30

PAge 06

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FROM THE EDITOR Since we released the maiden issue of Healthcare Asia last year, we have been speaking with various healthcare professionals – from hospital CEOs to health ministers to heads of health organisations. In this issue, we feature exclusive interviews yet again – this time, with the CEOs of Bumrungrad Hospital in Thailand and the Institute of Mental Health in Singapore.

Publisher & EDITOR-IN-CHIEF Tim Charlton PRODUCTION Editor Roxanne Primo Uy Editorial Assistant Ephraim Bie

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Our team flew all the way to Bangkok, Thailand to speak with Dr Num Tanthuwanit of Bumrungrad Hospital. He shared that though they are currently expanding their facilities with two new buildings under construction, their strategy is not to grow by geographically scaling operations.

We also have a comprehensive feature on the Institute of Mental Health – Singapore’s only tertiary psychiatric care hospital and largest provider of mental healthcare. Find out how they managed to evolve from being a constrictive mental asylum to a modern, restructured and community-based psychiatric home as CEO Adj A/Prof Chua Hong Choon shares his insights.

Our channel checks reveal that Asian countries are implementing different strategies powered by advanced telecoms to deliver health services to previously inaccessible rural communities. For instance, India has healthcare kiosk stations in 400 rural villages, while Malaysia has a telemedicine consultation model allowing doctors to remotely diagnose patients.

There are a lot of exciting trends emerging in Asian healthcare, and we hope this issue gives you a glimpse of what’s happening and what’s yet to come.

As always, we wish you the very best of health.

Tim Charlton Healthcare Asia is available at the airport lounges or onboard the following airlines:

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HEALTHCARE ASIA 1

CONTENTS

report: Malaysia 18 cOUNTRY Malaysia’s stellar healthcare story challenged to go rural

profile IMH ushers in a new paradigm in 14 feature mental healthcare in Singapore

cEO INTERVIEW

CBumrungrad Hospital’s CEO dead set on 12 having a single centre-of-excellence campus

FIRST 04 Booster shots for Asia’s

workforce shortage

05 Volume vs value in healthcare

HEALTHCARE INSIGHT

ANALYSIS 20 Healthcare sector struggles to meet

rising demand while reducing costs

05 The Chartist: What boosts

22 The market next door: No need to look farther for Asian medical tourism

06 When public and private

24 What the healthcare industry can learn from other sectors

Singapore Healthcare REITs’ profits?

healthcare merge

08 Why health applications could be

10 Asia heralds the telehealth

movement in rural areas

OPINION 30 Medical tourism in the Red Dot:

A Peter Pan model

32 Adopting evidence-based clinical

practices in healthcare systems

vital in life or death situations

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

2 HEALTHCARE ASIA

To access the stories online, visit the website

www.healthcareasiamagazine.com

WELLNESS AND PREVENTION BETTER USE OF PATIENT REDUCING COSTS DATA AND ANALYTICS IMPROVING QUALITY OF CARE

What is Your Vision?

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OPERATIONAL EXCELLENCE

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50% reduction in readmissions Cost savings of $24 per discharge, $127 per bed $10M saved in one year in one department 30% reduction in mortality Clinical evidence that helps meet five of the six JCI patient safety goals

Make an appointment to meet us at HIMSS AsiaPac15.

Call us at +65 6549 7139 or send an email to Micromedex@truvenhealth.com.

©2015 Truven Health Analytics Inc. All rights reserved.

FIRST budget, there is now a large disparity in remuneration between public and private sector healthcare professionals. “Coupled with extremely high patient loads and long working hours, this drives healthcare professionals to private sector practice, further increasing the shortage in the public sector,” says Sabnis.

Being tech-savvy is not enough

While electronic medical records have driven doctors to spend less time with their patients, the technology is nevertheless helping them make quality treatment decisions. A recent survey conducted by Accenture revealed that nearly half of 2,500 physicians in six countries including 200 in Singapore believe that IT has decreased the amount of time they spend with their patients while the majority (85%) said it has improved the quality of their treatment decisions.

The survey also found out that physicians today are more proficient in healthcare IT compared to two years ago. “The number of doctors who routinely are notified of their patients’ interactions with other health organisations has increased by 40% since the last survey, to 21%, versus just 15% in 2012,” says Accenture.

Technology is not the only key According to Corissa Leung, managing director for Accenture’s health business in Singapore, despite the rapid rise of EMRs, the healthcare industry is realizing that digital records alone are not enough to deliver better, moreefficient care in the long run.

“The findings underscore the importance of adopting both technology and new care processes while ensuring that existing shortcomings in patient care are not further magnified by digitalisation. Although nearly all doctors in Singapore said that better functionality (7%) and easy-to-use data-entry systems (78%) are important for improving the quality of patient care through healthcare IT, many (42%) said that the electronic medical record system in their organisation is hard to use.”

4 HEALTHCARE ASIA

Limited government funding causes staff shortage

Booster shots for Asia’s workforce shortage

W

hen Asian doctors consider serving in a public or private hospital, most choose the latter due to the high pay disparity, and analysts argue that governments may need to explore smarter solutions rather than try to match private compensation rates. New healthcare approaches such as non-medical workforce retraining and healthcare process may prove to be a smarter use of limited government funds.

There is a shortage of doctors as well as paramedical staff in developing Asia, says Milind Sabnis, director for healthcare, Asia Pacific at Frost & Sullivan, a problem that can be attributed to limited government funding. He cites how healthcare expenditure in most Asian countries hovers in the three to five percentage of GDP: Singapore (5.8%), Malaysia (4.3%), Thailand (4.2%) and Indonesia (3.3%). This small fund is further divided among programs for disease treatment, disease prevention and infrastructure development, leaving only a fraction for medical and nursing schools and for salaries of public sector healthcare professionals.

Given the meager government

Yong Chern Chet

Milind Sabnis

New healthcare models Developing Asian nations might have their hands tied when it comes to increasing the salaries of public healthcare professionals, but new, smarter models such as retraining, segmentising, and regional healthcare hubs could provide workarounds to this limitation.

“Some governments are already looking into the retraining and reskilling of resources from non-medical professions to take up medically-related jobs within the allied health category whose vacancies are not being able to be filled via the traditional basic and academic training route,” says Dr. Yong Chern Chet, healthcare sector leader at Deloitte Southeast Asia.

“Another avenue to the solution could be along the lines of physically breaking up the healthcare processes into segments, but maintaining complete seamless information flow integration via a unified platform or hub for example,” says Yong.

High functioning medical personnel will be relieved of duties such as patient registration or financial counselling so they can instead focus on critical roles such as diagnosing or performing surgical procedures.

Trend of general practitioners (GPs) and specialist doctors in Indonesia (2010-April 2014)

Source: Ministry of Health

FIRST

Paul Barach

Stephen Leyshon

It’s all about meeting long-term treatment goals

Volume vs value in healthcare

A

sian populations are becoming increasingly wealthy and are demanding better outcomes from healthcare services, which, in turn, has put pressure on providers to move to a value-based approach from a volume-based one.

“Value-­based healthcare is an exciting concept that shifts the focus from the volume of activity to the long­-term outcomes that are delivered as a result of the way care is provided,” reckons Stephen Leyshon, deputy director, healthcare strategic research and innovation, DNV GL.

“In value­-based healthcare, the move will be from a health system organised around what clinicians do and towards a person­-centered system co­-created with individuals and communities around what patients and populations need.”

Leyshon says a value-based system will require policy makers and providers to focus on the full cycle of patient care. This will also mean putting less emphasis on short-­term treatment goals and evaluating success through simple measures such as mortality rates.

Instead, a value-based healthcare system will ensure the continued

health and independence of individual service users as well as the long-term public health and well-being of populations.

The merits of a value-based healthcare system are compelling, but critics question if it can be sustained in the long run as it can be costly to implement. Proponents believe the first step is to upgrade Asia’s healthcare payment systems.

“Implementing episode-of-care and comprehensive care payment systems could help address the cost and quality crises in health care,” says Paul Barach, clinical professor at Wayne State University.

“Providers will need to change their internal processes and champion new methods of coordination, and even organisational structures to actually create better and more reliable care. Payers and regulators will need to hold providers more accountable to variable and uneven outcome,” adds Barach.

Healthcare expenditure per capita

Source: Frost and Sullivan; World Bank

The Chartist: what boosts singapore Healthcare REITs’ profits?

Not even the slow economic growth in the Asian region could impede the robust growth of Singapore healthcare REITs. They continue their strong performance caused by the intense demand for elderly care services for the city-state’s ageing population. According to Fitch analyst Hasira De Silva, the healthcare sector’s revenue and net property income (NPI) grew by 5% due to organic and acquisitive growth.

De Silva says financial metrics have weakened marginally due to leveraged acquisitions, as the REITs attempt to rebalance their capital structure. “The net debt/investment property ratio had risen to 33% by end-March 2015 from 30% at end2014, and FFO fixed-charge coverage was down to 6.3x from 6.5x,” he adds.

Healthcare REIT assets

Source: Company reports, Fitch

Higher LTV, lower coverage

Source: Company reports, Fitch

HEALTHCARE ASIA 5

FIRST

When public and private health care merge

ASEAN healthcare delivery drivers

W

ith public and private healthcare both fraught with a distinct set of challenges, some analysts are beginning to consider the merits of merging both markets in order to pool risk and reap mutual benefits. “What could be an interesting approach would be to imagine healthcare services which uniformly operate on a single open market,” says Dr. Yong Chern Chet, healthcare sector leader at Deloitte Southeast Asia.

“In this scenario the financing system could be in the form of a basic national insurance system that funds basic tier healthcare services providing universal care for the resident population.” Yong argues that a single open market leads to risk pooling, more medical coverage for the needy and increased flexibility when availing premium healthcare services.

“People with needy backgrounds would receive more support and subsidy in the form of co-funding of their healthcare insurance premium or healthcare needs while those who are well-to-do would receive less subsidy or minimal assistance,” says Yong. “For those who prefer the comforts of a premium healthcare service, there is the option to upgrade their insurance coverage to unlock higher level of comfort or more luxurious facilities.”

Benefitting from shared services

The public and private healthcare sectors could benefit from shared service arrangements that allow them to share hospital beds, says Natasha Gulati, industry manager at Connected Health, Asia Pacific.

Gulati cites how in Singapore and Australia, public hospitals are burdened with more patients and have longer waiting times compared with private hospitals.

Meanwhile, private hospitals tend to bring in state-of-the-art equipment that suffers from low usage. Given these challenges, shared service arrangements could alleviate overcrowding in public hospitals and increase equipment efficiency in private hospitals.

The financing system could be in the form of a basic national insurance system that funds basic tier healthcare services.

Healthcare sector shifts focus from product to delivery The mindset in the healthcare industry of simply generating more inputs, more products and more procedures is slowly becoming outdated. A paradigm shift is looming, where the weight starts to shift to companies and how they can mould their business models.

According to a recent report by Bain, the innovative healthcare sector would shift its focus from the product arena to the healthcare delivery sector.

“Indeed, the shift in emphasis from managing inputs, like the rate of adoption of new products, toward delivering outputs, like patient satisfaction, clinical outcomes and overall system savings, is already well underway,” says Bain analyst, George Eliades.

Meanwhile, companies would also need new business models to take advantage of the new opportunities brought about by the changing healthcare landscape.

6 HEALTHCARE ASIA

There are two sides to healthcare delivery in the Southeast Asian region—the side ushering in the era of digitised medicine, and the side struggling to catch up with providing universal healthcare.

According to a recent report

by Deloitte, a myriad of drivers would affect the systems of healthcare delivery in ASEAN countries by the year 2020.

“Indonesia sees rising investor interest in healthcare space.

The Negative Investment List stipulates that foreign investors may now own up to 67% (previously 65%) of healthcare related businesses. Ownership in the pharmaceutical sector is capped at 75%,” says Sachin Shah, an analyst with Deloitte Southeast Asia.

Prioritising quality Shah also says that Thailand’s attention to quality will likely bolster its already well-developed healthcare sector.

“Thailand is increasingly more attractive for medical tourism but falls behind in the provision of healthcare for the local population,” she adds.

For Malaysia, Shah predicts a significant increase in healthcare budget as the nation aspires to reach developed country status by 2020.

“Big opportunities for digital healthcare were expected from 2010- 2014 as the government pushed to expand IT in medical care, health education, and health services system management,” she says.

Meanwhile, Shah says Singapore’s aging population and focus on improved healthcare are strengthening investments.

FIRST

Why health applications could be vital in life or death situations

W

hen patients want to call nurses, the usual protocol meant the administration desk had to relay a message to the nurse, eating up precious minutes that could mean life or death for the patient, but the emergence of healthcare apps has cut out the inefficient middleman and sped up reaction times.

Hospitals are using healthcare apps integrated with intelligent nurse call systems that enable patients to press the nurse call button which then sends a direct notification to the assigned nurse or caregiver’s mobile device. This is only one example of how such apps are assisting healthcare professionals improve their quality of care.

“Nurses can leverage healthcare apps and other Internet based platforms on their smart phones and tablets to minimise medical errors, improve workflows, educate, and enhance the overall patient-to-caregiver experience,” says Robert Grey, director at Azure Healthcare.

“While there are still few who are skeptical and remain reluctant to adopt the use of healthcare apps, the benefits are proving to outweigh the risks when reliable and secure technology is chosen.”

Aside from nurses, other medical professionals are also beginning to use cutting-edge apps to improve patient care outcomes. The WeCare app, for example, is

drawing on the technology of Google Glass and the big data from SAP HANA to provide medical professionals with real-time insights into patient data, which helps lead to better outcomes and more efficient healthcare services.

“This helps medical professionals make decisions faster, eliminating unnecessary delays while increasing efficiency. This technology can also help hospitals reduce errors due to human negligence, potentially saving lives,” says Andy David, healthcare director for Asia Pacific Japan at SAP. Apps for consumers The intelligent nurse call and WeCare apps shine because of how they provide easier access to information and enable healthcare professionals to make better clinical decisions, but another emerging category of healthcare apps is consumer facing ones, says Azure Healthcare’s Grey. The high penetration rate of mobile devices throughout the Asian population has created an opportunity for consumer healthcare apps, especially those that promote higher patient and disease awareness.

But while healthcare apps are changing consumer behavior among Asians to more proactively take care of their health, most apps that consumers are using are confined to fitness apps, or those that are related to

Robert Grey

Rhenu Bhuller

tracking heart rate, steps or food intake, says Rhenu Bhuller, partner and senior vice president, healthcare at Frost & Sullivan.

“There is still low awareness and uptake of apps that support in terms of management of chronic diseases, which in studies conducted in the United States have been shown to be able to reduce overall healthcare costs due to better monitoring of the disease condition and taking action whether it is lifestyle change related or treatment related,” concludes Bhuller.

healthcare WATCH

Almac Group unveils first clinical packaging facility Located at 9 Changi South Street, Singapore, Almac Pharmaceutical Services is the company’s new facility to expand the company’s unique suite of clinical trial primary and secondary packaging, distribution, technology and consultation solutions offered from within the region.

Led by Dr Robert Dunlop, president and managing director of Almac Clinical Services, the facility aims to create better clinical trial supply management in the region and support Interactive Response Technology delivery.

“Almac took a key strategic decision to introduce manufacturing facilities within Singapore, to ensure that our full operational service offering was available globally. This will be the first clinical packaging facility within Singapore to complete a successful Health Service Authority (HSA) Inspection,” adds Dunlop.

8 HEALTHCARE ASIA

Returns storage area

Jim Murphy and Dr Robert Dunlop of Almac Singapore

Primary production (capsule counter)

Label control unit

HEALTHCARE ASIA 9

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healthcare INSIGHT: Access to Healthcare

Max Healthcare partnered with Health Point Services

Asia heralds the telehealth movement in rural areas

Governments are riding on telemedicine and mobile health models to run down the problem of inadequate healthcare services for rural Asians.

W

hen India was having trouble reaching rural patients, Max Healthcare, one of the top five private hospitals in the country, asked Health Point Services to set up healthcare kiosk stations in far-flung towns in South Punjab. These kiosks were placed near safe drinking water delivery points and have proven effective, with Max Healthcare doctors delivering 17,000 diagnostic tests to rural patients across 400 villages.

India’s kiosk system is one of the many healthcare models emerging in Asia that are powered by advanced telecommunications and widespread mobile phone usage, and are proving effective in delivering health services to previously inaccessible rural communities. “Interesting models are coming from developing and smaller nations and are currently running in pilot phases. In the next five to 10 10 HEALTHCARE ASIA

Malaysia has been testing a telemedicine consultation model where patients give a ‘missed call’ to the call centre.

years the scale of these operations is expected to increase, making a significant impact on the rural set up,” says Dr. Siddharth Dutta, transformational health industry manager at Frost & Sullivan.

“While the urban areas will adopt more gadgets and applications, the rural areas will adopt some of the unique models that make healthcare services affordable and reachable,” adds Dutta.

Malaysia, for example, has been testing a telemedicine consultation model where patients give a ‘missed call’ to the call centre, making the initial contact free from telecom charges. The doctor then calls back, conducts a diagnosis of the patient remotely and then creates an electronic health record with which My Doctor (or known locally as “Mera Doctor”) will be able to track the patient’s status over time. After

the diagnosis, the patient will be able to receive a mobile text message containing medical advice and a prescription for over-the-counter drugs, if needed.

The promising effectiveness of Malaysia’s telemedicine consultation model is a breakthrough for the country as it looks to deliver better quality and more affordable healthcare services to the 44% of its population currently residing in rural areas, especially in East Malaysia which does not have direct access to the mainland.

Rural revolution Across Asia, the quality and access to healthcare services in rural areas have lagged behind those in urban areas, the latter of which attract more resources and are more preferred by doctors. But analysts believe that the emerging telehealth and mobile health models can help close this gap.

“In Asia, we are seeing greater disparity in quality and access to care in urban versus rural communities,” says Fernando J. Erazo, senior director, Hospital to Home at Philips Health Systems, Asia Pacific.“One of the critical challenges that Asia is

healthcare INSIGHT: Access to Healthcare facing is the capacity and resources of local health systems required to educate and attract sufficient clinical personnel to rural communities. At the same time, funding for initiatives beyond basics like immunisation and control of infectious diseases is also complex and inconsistent across Asia.”

“Rural areas are characterised by low density. These areas lack infrastructure and other avenues of entertainment. Under these circumstances, senior doctors are unwilling to settle in rural areas as they find difficult to educate their young children,” says Girdhar Gyani, director of Association of Healthcare Providers in India, on why rural areas continue to receive the short end of the stick when it comes to healthcare access.

Though Gyani sees more Asian doctors becoming motivated to practice in rural areas due to the increasing demand for services and connectivity of rural villages, he blames the poor connectivity of rural villages to urban centres, which discourages specialists to travel or relocate.

Given the slow pace of improving physical connectivity as it entails massive infrastructure investments, telemedicine models such as India’s kiosk system and Malaysia’s mobile consultation system are providing convincing alternatives. Still, there is much to improve when it comes to telemedicine and mobile health models. For example, the fee for service for telemedicine in most of the Asian countries is still too low to become an attractive option for highly paid specialists servicing urban areas.

“Due to the lack of benefits, specialists are not interested to commit for telemedicine consultations,” says Dr. Yogesan Kanagasingam, professor, School of Medicine at University of Notre Dame. “Doctors are busy providing services to the city based population.

They do not have time to connect to remote to rural areas.”

Kanagasingam adds that the number of doctors and specialists in less developed Asian countries are not increasing in proportion

to the population, which further limits the feasibility of telemedicine models that would still need to be manned by capable practitioners.

As an example, he notes how there are 800 ophthalmologists in Indonesia that cater to 250 million people; in Australia, there are 800 ophthalmologists that cater to only 22 million people.

Telemedicine health models Despite the challenges and initial kinks that come with implementing novel telemedicine and mobile health models, analysts seem to concur that they could revolutionise the way rural areas get access to healthcare.

“Telemedicine and mobile health are helping to bring quality healthcare to the rural areas. Asian countries are utilising these technologies to support the underserved in rural areas.

Malaysia, China and India utilise telemedicine to support the rural population,” says Kanagasingam.

He cites four trends in telemedicine and mobile health that will bring leaps of progress in rural healthcare access in Asia. First, Asian governments will begin to support telemedicine service and focus on providing more benefits to doctors when providing telemedicine consultations.

Second, telemedicine is steadily being integrated into mainstream healthcare delivery which should result in more funnelled resources and specialist experience in using such systems. Third, the rise in usage of mobile smart phones in rural areas is enabling doctors from metro areas to conduct consultations remotely.

And fourth, broadband is becoming more available in rural areas which will likewise improve access to quality healthcare remotely.

Across Asia, telemedicine and mobile health models are sprouting with local tweaks that adapt to the specific needs of each country’s rural demographic.

In China’s Guangdong province, Kanagasingam says a tele-eye care project his organisation launched in collaboration with the United Statesbased ORBIS, Australia-based CSIRO and World Diabetes Foundation, was able to connect 10 hospitals in rural areas to Zhongshan Ophthalmic

Siddharth Dutta

Girdhar Gyani

Fernando Erazo

Yogesan Kanagasingam

Centre in Guangzhou. This helped more than 10,000 patients and reached roughly 600 patients that needed laser surgery. Dutta estimates 80% of health and medical services in China are concentrated in cities, “which means that timely medical care is not available to more than 100 million people in rural areas.”

In Malaysia, the government is focussing its efforts on building telemedicine and tele-radiology facilities to provide low cost healthcare services in rural areas, says Dutta. While in Indonesia, point-ofcare testing to facilitate diagnostic tests in rural areas is gaining support.

The challenge for most Asian countries is to learn not only from these pilot models, but also from the lessons of neighbors while factoring in the unique demands in their country’s healthcare system.

“Today, 95% of people live within reach of a mobile phone signal; however, less than half have access to reliable healthcare. The biggest technological advancement we require to impact healthcare is already here - we can virtually connect everyone, everywhere, anytime. What if we combine technology, augmented with basic integration of health data and remote monitoring capability to benefit healthcare access to rural communities?” says Erazo.

“Asian countries must find alternative ways to leverage technology to multiply the efficiency of their scarcest resource in health systems: trained and capable personnel. Technology will play an essential role in shaping the future of healthcare. Digital technology offers new opportunities for more outcomebased health management.”

Comparison of healthcare infrastracture and resources in 2012

Source: OECD

HEALTHCARE ASIA 11

Dr. Num Tanthuwanit CEO Bumrungrad Hospital 12 SINGAPORE BUSINESS REVIEW | JANUARY 2014

CEO INTERVIEW

Bumrungrad Hospital’s CEO dead set on having a single centre-of-excellence campus Find out why Dr. Num says their strategy is not to grow by geographical scale and domination.

B

umrungrad Hospital is one of the top destinations for medical tourism in Asia, and is a forerunner for quality private hospital services in Thailand.

Healthcare Asia interviewed Bumrungrad CEO Dr. Num Tanthuwanit to get a glimpse of what it’s like to lead one of the most prestigious hospitals in Asia which cares for about 4,000 patients everyday.

How do you plan to improve your growth and success in medical tourism in Asia?

We have been looking after international patients for nearly 20 years, and continue to build on our strong reputation both within and outside the country. One of our main strategies is to recruit the best doctors in all the specialties, as well as investing more in our human capital that supports the doctors such as nurses, technicians, management and supporting staff. This is why we launched our training company, the Bumrungrad Academy, which focusses on ongoing professional education and training of all of our staff to improve the quality of care.

Over the next three years, we will be looking at

“As part of our medium-term plan we will be developing a second facility, which is on Petchaburi Road and located very close to our clinic current building.” expanding our facilities. One of them will be in Soi 1 Sukhumvit Road, which will add an extra 25,000 square meters of usable space. Part of that will be mainly for out-patient, stand-alone specialty clinics and this will also house our heavier diagnostic equipment. The Education and Training Centre, including our state-ofthe-art Simulation Lab, Research offices, and Conference facilities will also be there.

Also as part of our medium-term plan we will be developing a second facility, which is on Petchaburi Road and located very close to our clinic current building. It will be a building with 220 in-patient rooms, and we are currently in the final stages of planning. It will add nearly 80,000 square meters of usable space.

Our hospital is expanding, but our focus is really to make it a single campus facility that maintains high standards of safety, quality and service. This is made possible by a relentless focus on continuous improvement within a single location. Our strategy is not to grow by geographically scaling our operations, but instead to focus on treating a larger demography of potential patients at our hospital. We believe in having a facility all in one place with the best people

and the best doctors. This way, we can keep a close eye on the processes and systems, quality conditions, and technology. It’s like a single centre-of-excellence campus.

Please tell us about your experience handling the first MERS-CoV patient.

With the MERS crisis, international volumes weren’t affected but the Thai volume was. In the past, we’ve successfully prepared for other types of infectious diseases such as Ebola, Bird Flu, and SARS, so our infection control policies have always been of a very high standard, probably higher than what’s required by WHO, US CDC or Thai MOPH standards. It’s built into our culture of our team.

Our people were trained and we were able to very quickly detect the first case in Thailand. We were able to contain and transfer the patient to a government facility as required by the local authorities. We did everything to make sure that all our staff who were in contact with the patient were properly cared for and quarantined.

Our efforts led to the fact that there was no outbreak in Thailand, and that there was only one case that was successfully contained. None of our staff or other patients were affected.

I am very proud of our staff who handled this extremely well and prevented what could have been a disaster. This all comes back to our human capital; it’s our processes and culture that is supported by the technology and the facilities. Anyone with the capital can acquire technology.

They can buy scanners and the latest equipment, but the people, the training, the systems, and the culture, are 35 years in the making.

What are your current initiatives as well as future plans for Bumrungrad Hospital?

We continue to explore the opportunities to try and establish more relationships with the neighbouring countries: Cambodia, Laos, Vietnam, and of course Myanmar. We have also been working very hard to grow patient volumes from places like China and Indonesia and we’re starting to see some return. We also have representative offices in 23 countries around the world and we’re moving to explore opportunities worldwide.

Next year, our focus will be getting the College of American Pathology (CAP) certification for our laboratory. We always continue to push the bar higher with quality measures because our core values are “safety and quality with measurable results.” Safety and quality without measurable results are just two words so we need to benchmark ourselves. We will continue to invest heavily both in human capital and improving patient safety and continue to reinvent ourselves to keep getting better at this.

HEALTHCARE ASIA 13

feature profile

IMH CEO Adj A/Prof Chua Hong Choon with arts and crafts by IMH patients

IMH ushers in a new paradigm in mental healthcare in Singapore The Institute of Mental Health Singapore strives to change the negative perception of persons with mental health issues and reintegrate them back in the community.

D

usty window grills and rusted padlocks on display at the Institute of Mental Health (IMH) in Singapore today serve as a reminder of an antiquated approach to providing care to the mentally ill. They come from a time when mental illness was taken as incurable, and it was thought that patients were best locked away indefinitely in a safe place to receive care. This school of thought is a thing of the past, according to IMH CEO Adj A/Prof Chua Hong Choon, who says that mental healthcare in Singapore has made great progress, especially in the last 20 years.

“The evolution of IMH, the country’s only tertiary psychiatric care hospital and largest provider of mental healthcare, mirrors the progressive shift in attitudes towards mental health, and the approach to care system and services,” Chua says. “We have evolved from a mental asylum associated with confinement and social exclusion during our early years as Woodbridge Hospital, to a modern, restructured hospital within the National Healthcare Group, focused on mental wellness, recovery and reintegration.”

However, there remains a negative perception of mental illness that IMH is trying to change. “Many people still think that those with mental illness can never recover and

14 HEALTHCARE ASIA

The evolution of IMH mirrors the progressive shift in attitudes towards mental health, and the approach to care system and services.

that they might be dangerous,” he notes. “But mental illness is like any other illness, and patients can recover and go on to lead fulfilling lives.”

IMH has been working to reduce stigma surrounding mental illness - starting with its own premises. For example, the hospital removed the perspex panels at the outpatient clinic service counters, allowing patients and staff to communicate openly rather than through a small hole, similar to the open concept of most general hospitals. The concrete walls of the clinic reception have also been replaced with see-through glass. It also features lifesize cut-outs of patients turned mental health advocates, who share their experience with mental illness in order to help others and reduce stigma.

IMH has also set up a dementia-friendly inpatient wing whose design resembles an open-concept home rather than a hospital. The attached outdoor area features a garden of lantana and lilies with a gentle slope leading down a circular path to a wooden pavilion. Chua, who joined IMH in 1993 as a medical officer and was later appointed as CEO in 2011, feels that the hospital has come a very long way, but there is still more to be done to help people with mental illness lead meaningful lives in society.

His focus continues to be on reducing re-admission rates,

feature feature profile profile The Singapore government has played a significant role in the shift from a largely acute illnesscentered, hospital-based healthcare delivery system towards a communitybased model of psychiatric care.

Reminiscence therapy at the dementia friendly ward in IMH

shortening the average length of hospitalisation, and preventing patients from turning into “long-stayers” who cannot be discharged.

The Singapore government has also played a significant role in the shift from a largely acute illness-centered, hospital-based healthcare delivery system towards a community-based model of psychiatric care, which not only improves accessibility to services but also reduces the stigma associated with mental illness.

In 2007, with an increasing appreciation of mental health as a key component of overall health, the Ministry of Health launched the National Mental Health Blueprint (NMHB). The blueprint sets out to promote mental health, prevent the development of mental health problems where possible, and to reduce the impact of mental illness by focussing on four strategic thrusts: mental health promotion; integrated mental healthcare; developing manpower; and research and evaluation.

This initiative also introduced a range of programmes that tap on community resources as those on the ground, such as school personnel and general practitioners, are in a better position to observe early warning signs of mental health issues.

Targeted mental health programmes Under the NMHB, IMH spearheaded and runs several key programmes to address the needs of different demographic groups in Singapore and push for early detection.

These include the Community Mental Health Team (CMHT), Response, Early Intervention and Assessment in Community Mental Health (REACH), Early Psychosis Intervention Programme (EPIP) and the Community Health Assessment Team (CHAT).

CMHT addresses the healthcare needs of people aged 18 to 65 in the community. CMHT provides continuous care as patients make the transition back into the community. The multidisciplinary team visits patients in their homes to provide regular assessment, treatment and rehabilitation to promote their independence and help ease their social integration. This programme has resulted

in a reduction in the number of hospitalisations and the average lengths of stay for patients cared for by CMHT. The REACH programme focusses on the care of children of school-going age, mainly from 6 to 19 years old.

The team works with school personnel, community agencies, family doctors, and other members of the community who frequently interact with this demographic to spot emotional, behavioral and developmental disorders in the early stages. It provides intervention at the point of need such as in schools, student care services and at home.

EPIP provides care to those between the ages of 16 to 40 showing early signs of psychosis. Intervention in the early stages of psychosis has been shown to be effective in reducing the rate of deterioration. The aim of the programme is to reduce incidence of untreated psychosis, along with aiding in improving the quality of life for those afflicted with first-episode psychosis. This team provides specialized care, personal case management, intervention, and support groups for patients and their caregivers alike.

CHAT was launched in 2009 to reach out to youth to increase awareness of mental illness. With an online presence and a hub in the city’s main shopping district Orchard Road, CHAT was designed to provide a safe, relaxed and convenient environment for those aged 16 to 30 to learn about mental health issues and seek assessment or advice. CHAT also networks with and trains community partners who work with youth.

Focussing on inclusion Perhaps one of the largest changes taking place is the focus on providing continuous care and support once a patient has been discharged. Chua notes that patients often return home to “mini asylums” where their families box them into a life free from responsibilities and expectations. “You can exclude someone with the best of intentions, but it’s still exclusion, which does not help the patients reintegrate into society,” he adds.

The support system that awaits a discharged patient is absolutely crucial, as Chua learned at a young age. Just a short time after his arrival at IMH, the then-28-year-old

“GPs are trained to manage those with mild to moderate mental health issues in the community”

HEALTHCARE ASIA 15

feature profile

Multi-disciplinary teams from IMH visit patients in their homes to provide continued care

medical officer discharged a patient, only to learn that he later jumped to his death upon his return home. Chua’s view is that the rehabilitated should be encouraged to get back into the fold of society at every opportunity, be it through employment or going back to school, to make the transition easier.

He notes that one of his patients was able to successfully deal with her illness after suffering from severe bipolar disorder in her teen years. The patient went on to pursue a tertiary education, establish a successful career and is now engaged to be married.

Encouraging activity rather than confinement IMH is trying to develop an environment that encourages patients to be active. There is a patients’ choir called the VSOP, which stands for Very Special Outstanding Performers, that occasionally performs at events. Another unorthodox move is the initiative to get patients more involved in their care.

Looking to debunk the myth that the mentally ill cannot know what they want, IMH has organised focus groups to gather feedback from patients and their families on the treatment received at IMH. Aside from feedback regarding the facilities and services, IMH encourages patients to think and talk about their goals for their own recoveries.

Chua says that “It’s not about what we can do better but what we can do to help you do better.”

To this end, IMH has set up the Voices of Experience programme to formalise engagement with patients and caregivers. The platform allows them to take on roles as mental health advocates, peer specialists who share their experiences with those who have been diagnosed recently, or consultants who give input to shape new programmes and services.

Continuous engagement The community plays a large role in the promotion of 16 HEALTHCARE ASIA

IMH encourages patients to think and talk about their goals for their own recoveries.

mental health, especially for patients with early-stage illnesses and rehabilitated patients returning to society.

Chua has implemented various channels through which IMH can follow up with patients after they are discharged.

For example, case managers keep in close touch with discharged patients and enlist the help of community nurses and volunteers to visit them as well. He has also begun to link patients to community agencies to provide additional support to them and their families.

IMH also trains neighborhood general practitioners and polyclinic doctors to detect and diagnose common mental illnesses early. Given that these physicians are often the first point of contact for those who are unwell, they can play an important role in helping those with mental health issues get help early. Additionally, these doctors can provide more constant care to patients once they have been discharged from IMH. According to Chua, a key focus of IMH moving forward is to build partnerships with community agencies to better support people with mental health conditions in the community. The Community Mental Health Masterplan (CMHM) was launched in 2012 by Singapore’s Ministry of Health to scale up capabilities among community agencies and partners to provide accessible mental health services.

Under the CMHM, IMH plays a key supporting role for capability-building efforts at the community level. They provide immediate support and advice for patients, and members of the community involved in the care of these patients.

Developing specialized services Within the hospital, IMH has introduced several specialized services to better meet patients’ needs and optimize care. In 2011, Chua launched the Mood Disorders Unit to provide specialized inpatient treatment to those suffering from depression, bipolar disorder and anxiety. Previously,

The Mindset Rehabilitation Gym provides more specialised care management for patients

feature feature profile profile patients with mood disorders were treated with patients suffering from other mental disorders. The ward environment could be disruptive and was not optimal for the treatment of the patients with mood disorders. A multidisciplinary team, comprising clinicians, case managers, psychologists, medical social workers, pharmacists, occupational therapists and art therapists, now works together to provide a more customized treatment intervention that these patients require.

The Adult Neurodevelopmental Service (ANDS) was introduced in order to offer care for adult patients with neurodevelopmental disorders such as intellectual disability or autism spectrum disorder. Patients are reviewed by a specialist multidisciplinary team of medical and allied health staff, who work together to optimize care, including implementing care plans that will better address their mental health, behavioral and rehabilitation needs.

Besides direct clinical care, the team also supports the patients, their caregivers and other community agencies involved in their care through case management, outreach and training.

IMH established the Memory Clinic in 2013 to offer support, information, and advice to those with memory problems, along with assisting their caregivers. This unit takes patients exhibiting signs or symptoms of cognitive impairment, such as memory issues or personality changes.

The Sunshine Wing is a recently-established, dementiafriendly, 50-bed geriatric ward for psychiatric patients aged 65 years old and above. This ward’s facilities were specifically designed to improve the therapeutic environment for providing care to those suffering from dementia.

These facilities include a reminiscence room that has objects and materials that aid in evoking memories for patients. There is also a sensory room with a multi-sensory stimulating environment to help patients’ therapy.

The MINDSET Rehabilitation gym is another recently

IMH is the only tertiary psychiatric care institution in Singapore

IMH established the Memory Clinic in 2013 to offer support, information, and advice to those with memory problems, along with assisting their caregivers.

established initiative to provide more specialized care management for IMH patients. The facility features a Sensory Integration Gym and a Physical Exercise Gym. The Sensory Integration Gym provides sensory-based stimulus and intervention for adult outpatients who suffer from neurodevelopmental illnesses. The Physical Exercise Gym is more akin to a traditional gym, and is equipped with similar equipment. It serves the physical exercise and health management needs of IMH patients as certain medication may cause weight gain.

Headwinds still exist While IMH and its partners have made significant headway, challenges still exist. According to Chua, changing the approach to mental healthcare requires re-thinking mental health as not just a health issue but one that is also influenced by social factors.

Helping patients stay well in the community can also pose a challenge. Given the debilitated condition that some of them are in, even day-to-day tasks may be difficult. This is where the community support and regular contact with case managers become very important, as they help patients find normalcy.

Chua notes that the community is absolutely essential as “community services can help to provide support to those with mental health issues, improve access to mental healthcare services and reduce stigma.” Stigma remains one of the more pertinent issues that still exists to this day.

There is a need to promote awareness of mental disorders and de-stigmatise mental illness among the public.

According to Chua, “IMH finds that it is most effective when we partner with the community to do this and our team regularly collaborates with schools to hold events and roadshows to reach out to students.” Through such campaigns and activities, IMH hopes to change the public perception of mental illness and help those in recovery gain greater acceptance in society.

HEALTHCARE ASIA 17

cOUNTRY report: Malaysia

Malaysian healthcare Kuala Lumpur hospital

Malaysia’s stellar healthcare story challenged to go rural

Malaysia has proven itself as a model for successful healthcare programs, but must now overcome persistent headwinds to become world class.

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alaysia’s national healthcare system has made a significant headway in the past few years and has even been tagged by the UN Development Program as being a “model for other developing countries”. The World Health Organization (WHO) has also recognised Malaysia and said that the country “has made remarkable progress on all health related Millennium Development Goals.” About 55% of total healthcare spending is covered by government subsidies according to the WHO, and covers mainly public hospitals which serve as the country’s primary source of care.

The 2014 budget carved out a USD6.9 billion allocation to healthcare spending, which represents 10% of the government’s total spending. The government’s efforts have led to Malaysians

18 HEALTHCARE ASIA

The Country Health Plan 2011-2015 which is published by the Ministry of Health, points out that 60% of the country’s specialists work in the private sector.

enjoying high-quality care at very low prices, and life expectancy rising to an average of 76 years.

Headwinds in sight Despite these accolades, the country’s healthcare system still has a long way to go and faces significant challenges, especially in the rural areas. According to Ang Wei Zheng, a pharmaceuticals and healthcare analyst at BMI Research, there has been an overconcentration of medical professionals in the urban regions of Malaysia such as Kuala Lumpur. He notes that “sub-national data indicate while Kuala Lumpur had 2.5 doctors per 1,000 people in 2014, there were only 0.5 per 1,000 people in Sarawak,” which means that those in rural areas in need of healthcare have limited access to resources.

Zheng’s view is that the country has to make significant investments

in infrastructure, as well as putting investments in place to encourage doctors to work in rural regions of the country. The 11th Malaysia Plan (11 MP), the roadmap produced by the country’s Chamber of Commerce, included provisions to bolster the medical care in more rural areas of Malaysia. EY Malaysia’s managing partner for advisory services Chow Sang Hoe notes that the 11 MP’s focus area in healthcare was on extending healthcare services to the poor and low-income households in non-urban areas of the country.

The country is also implementing some programs that will bring more doctors and resources to these areas.

“Access to healthcare services is also enhanced through 1Malaysia Clinics, 1Malaysia Mobile Clinics and the Flying Doctor services,” according to Chow. However, the country still has to stem the outflow of doctors from public to private hospitals. The Country Health Plan 2011-2015, which is published by the Ministry of Health, points out that 60% of the country’s specialists work in the private sector, according to Ang. He goes on to say that as the government actively grows the medical tourism

cOUNTRY report: Malaysia sector, the situation could take a turn for the worse. Malaysia’s government has to put safeguards in place or implement new incentives for doctors in order to stop the widening gap between quality of care that is provided in publicly-run institutions versus private hospitals.

Infrastructure and modernisation On a related note, physical and social infrastructure also remain hindrances to providing high-quality care across the country. Modernisation of facilities and skills is one of the strongest headwinds to Malaysia’s healthcare system, according to Frost & Sullivan’s transformational health industry manager Dr. Siddharth Dutta. He explains that the government has taken action to address this, “offering incentives, such as tax exemptions on any capital expenditure involving the cost of building new hospitals and expenditures incurred in training medical personnel.”

He adds that Malaysia’s government is also offering to healthcare travel participant private hospitals a 100% tax exemption for the construction of new facilities, expansion and modernisation or refurbishment of existing facilities. In the long run, the government should move implied project returns to acceptable levels given investors’ hurdle rates, and spur more meaningful contributions to this sector. Dutta notes how this has already begun to manifest citing that “KPJ Healthcare Bhd is planning to spend RM1 billion to construct nine new hospitals in Malaysia over the next five years, while IHH Healthcare Bhd is developing three new hospitals in the country that are expected to commence operations by 2015.”

EY’s Chow explains that Malaysia will have to continue updating its medical practices as the world of medicine continues modernising.

To be at par with developed nations, he feels that policymakers must ensure that adequate allocations are made in the annual budget to ensure sustainable development in this space.

Chow notes that “Our policy mantra should be ‘better economic health depends on healthy people.’”

BMI’s Ang sees that the medical

Malaysia’s medical tourism generated RM730m in 2014 and is expected to grow 15% during the duration of the 11MP time frame.

Ang Wei Zheng

tourism sector is likely to develop rapidly in the foreseeable future, given the strong government support, competitive prices and the country’s favorable geographical location at the heart of Asia. According to Ang, “the Malaysia Healthcare Travel Council has been the key agency driving the government’s efforts in promoting medical tourism.” The agency has been promoting Malaysia as a viable destination in both developing markets such as China and developed countries such as New Zealand.

Establishing partnerships It has also been looking to coordinate partnerships between relevant institutions to promote the Malaysian Healthcare system, such as partnership between Malaysian Hospitals and Vietnamese Insurance Companies signed in 2015. Ang also explains that the agency has also facilitated an agreement with Malaysia Airlines to offer a 30% discount on airfare for Bangladeshi patients looking to seek medical care in Malaysia. The partnership was done through Green Delta Insurance Company’s subsidiary GD Assist, which has been acting as the Malaysian Healthcare Travel Council’s local agent in Bangladesh to promote medical tourism.

Chow outlines that the financial impact of this sector’s development could be significant for Malaysia in the future. “Malaysia’s medical tourism generated RM730m in 2014 and is expected to grow 15% during the duration of the 11MP time frame to an estimated RM2.0b

by 2020,” he adds. He also notes that the country has room to provide more incentives that can potentially boost this sector. The country still lags behind its regional peers in terms of Joint Commission International (JCI) –accredited healthcare providers with only 13, versus Thailand’s 42, South Korea’s 29, and Singapore’s 21. Fiscal and tax incentives should be put into place to increase the number of accredited healthcare providers.

For the next five years, Chow anticipates that the provisions in 11MP will bring improvements to healthcare access and quality of treatment in the country. Greater urbanisation should also lead to more focus on building healthcare support facilities in areas with much pent-up demand. He also notes that there are legislative moves in the pipeline that should be beneficial for the country such as the Pharmacy Bill and the National Social Health Insurance. After this initial phase of development, he expects a shift in the country’s focus within Medical Tourism.

Chow anticipates a shift towards focusing more on providing indemand niche services that are within the country’s strength. “Malaysia can better capitalise on its reputation as a centre of excellence for heart-related, eye-related surgeries or integrated / holistic healthcare maintenance programmes or services, e.g. herbal detoxification programmes or capitalising on its “halal” food (including herbs) production capabilities and pristine rainforests canopies” he says.

Total health expenditure by sources of financing (public vs. private)

Chow Sang Hoe

Siddharth Dutta

Source: Malaysian MOH, Health Expenditure Report

HEALTHCARE ASIA 19

ANALYSIS: HEALTHCARE priorities

Common goals, competing priorities

Healthcare sector struggles to meet rising demand while reducing costs

Healthcare companies often juggle different factors to keep up with a fast-paced landscape.

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cross the globe, governments, health care delivery systems, insurers, and consumers are engaged in a persistent tug-of-war between competing priorities: meeting the increasing demand for health care services and reducing the rising cost of those services.

And rising they are. Health spending is estimated to have increased by 2.8% in 2013 — an increase from 2% in 2012 — to total $7.2 trillion, or 10.6% of global gross domestic product (GDP).

As the global economy recovers from prolonged recession, health spending is expected to accelerate, rising an average of 5.2% a year in 2014-2018, to $9.3 trillion.

This increase will be driven by the health needs of ageing and growing populations, the rising prevalence of chronic diseases, emerging-market expansion, infrastructure improve20 HEALTHCARE ASIA

Health spending is expected to accelerate, rising an average of 5.2% a year in 2014-2018, to $9.3 trillion.

ments, and treatment and technology advances. Yet even as demand rises, the pressure to reduce costs and demonstrate value is intensifying. As a result of these contradictory forces, spending is likely to increase slightly more slowly than in the past decade, when growth averaged 7% a year.

Globalisation, however, is likely to bring problems, too, as countries struggle to make sure they have sufficient health care workers, facilities, and supplies to care for patients at a manageable cost. As they endeavour to balance competing priorities, health care stakeholders are also working to achieve common goals: innovate in new and exciting ways, and generate scientific, medical, and care delivery breakthroughs that can improve the health of people worldwide.

Most of the world’s regions are facing a formidable challenge to

manage the rapidly increasing cost of health care.

In Asia and Australasia, the rollout of public health care programs combined with growing consumer wealth are anticipated to boost health care spending an average of 8.1% in 2014–2018.

The strongest growth, at 15.2% a year, will be in India, with China following at 12.5% a year. One of the most depressed markets is Japan, where spending dropped by an estimated 17% in 2013 due to Yen devaluation and growth is expected to remain sluggish.

Demographic drivers In developing markets, population growth and rising wealth are also anticipated to drive health care spending in 2015 and beyond. By 2018, the number of high income households (those earning over $25,000 a year) will rise globally by

ANALYSIS: HEALTHCARE priorities about 30%, to nearly 570 million, with over one-half of that growth coming from Asia.

Governments in some of these markets are expanding public health care services to meet citizens’ rising expectations, while in all markets, advances in health technologies, the availability of antibiotics, and other factors should continue to push up costs.

Treatment advancements and government initiatives to increase access to care should drive sector expansion but pressure to reduce costs is escalating. Growing populations and consumer wealth are increasing demand for health care services but ageing societies and chronic diseases are forcing health payers to make difficult decisions on benefit levels.

In the midst of this tug-of-war, many historic business models and operating processes will no longer suffice.

Four trends are anticipated to impact stakeholders along the global healthcare value chain in 2015: cost, adapting to market forces, transformation and digital innovation, and regulations and compliance.

Cost Cost is the biggest health care issue facing most countries in 2015. Pressure to contain costs and demonstrate value is coming from all sides — governments, providers, health plans, life sciences companies, and consumers. Political uncertainty, persistent economic stress, and austerity measures in numerous countries are calling into question the sustainability of public health care funding.

In Japan, where the majority of health care spending is publically funded, the government has begun a number of initiatives to control spending, such as encouraging use of cheaper generic drugs, self-management of chronic diseases, and preventive care.

Moreover, government estimates of health care spending do not take into account discretionary consumer spending on a number of products and services, which adds considerably to the total. In another example of consumer cost-sharing, low spending on health care by

some governments places much of the burden on patients and their families. For example, consumer outof-pocket (OOP) spending—which comprises 69% of India’s total health expenditure—is among the highest in the world, and much more than countries such as Thailand (25%), China (44%), and Sri Lanka (55%).

Transformational change is taking place across the global healthcare sector. Several dynamic market forces, in particular are requiring providers and health plans to rethink traditional business models to better address shifting or emerging health care challenges and opportunities.

These forces include the increasing role of government, scale to prosper, competition for talent, improving access to care, and consumerism.

Increasing role of government Governments’ pivotal — and growing — role as payor, regulator, and market-shaper in the global healthcare sector cannot be understated.

The government wants a holistic health care system that is universally accessible, affordable, and dramatically reduces OOP expenditures.

Uneven distribution of caregivers is also a problem. Southeast Asia has a chronic shortage of medical personnel: the average number of physicians in SEA is 2.1 per 1,000.

Looking at individual SEA countries, Indonesia has only 0.4 doctors per 1,000 people.

The country loses a significant share of its domestic healthcare market spending because Indonesian residents travel to neighboring countries like Singapore and Malaysia to seek medical treatment — nearly 1.5 million Indonesians comprise overall medical tourism numbers, with a corresponding outflow of $1.4 billion yearly.

India has a ratio of 0.7 doctors and 1.5 nurses per 1,000 people compared with the WHO average of 2.5 doctors and nurses per 1,000 people.

The situation is aggravated by the concentration of medical professionals in urban areas, which have only 30 % of the population in India.

The industry needs an additional 1.54 million doctors and 2.4 million nurses to match the global average.

Doctors (per1,000 population) as compared with the total world population (millions)

Source: Economic Intelligence Unit

Consumer out-ofpocket (OOP) spending— which comprises 69% of India’s total health expenditure— is among the highest in the world.

Transformation & innovation Adoption of new digital Health Information Technology (HIT) advances such as electronic health records, mHealth applications, and predictive analytics is transforming the way physicians, payers, patients, and other healthcare stakeholders interact. Digital innovations are helping to facilitate new diagnostic and treatment options, increase process efficiency, and reduce costs.

Digital innovations are helping to facilitate new diagnostic and treatment options, increase process efficiency, and reduce costs.

Despite the promise of new science and technology innovations, challenges exist to widespread adoption. Technology advances can be prohibitively expensive for public health care systems already struggling to fund basic services.

Regulations & compliance The global healthcare regulatory landscape is complex and evolving. The primary drivers are patient health, safety, and privacy; however authorities’ approaches to protecting patients can vary widely from country to country.

Adding to this complexity are factors including rapid clinical and technology changes; increased scrutiny by governments, the media, and consumers; more sophisticated risk-monitoring techniques; and coordination across agencies and regions.

Much of health care’s regulatory focus is on drug and patient safety. Developing countries are also tightening up, although not without difficulty. By Mitch Morris, global healthcare sector leader, Deloitte HEALTHCARE ASIA 21

Analysis: Medical Tourism

Japan aims to develop medical tourism / The Jikei University Kashiwa Hospital

The market next door: No need to look farther for Asian medical tourism What can the Asian medical tourism industry learn from its neighbours?

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hen Dr. Meghann Ormond of Wageningen University in the Netherlands went to Malaysia to write about international medical travel, she noticed that the hospitals and health clinics in Penang, Malacca and Sarawak were not the only establishments that benefited from the influx of Indonesian medical tourists in the area. “Spending time in these places, we can easily see how locally owned eateries, markets, hotels and guesthouses, taxi drivers and shops benefit from the presence of Indonesian medical travellers,” she observes.

This made her think about the incongruence between the orientation of the medical tourism industry in Asia and the actual customers that they attract. “I think it’s time to acknowledge that the bulk of international medical travel is not from wealthy countries to lower­ 22 HEALTHCARE ASIA

“As of 2012, Asia comprised 9% of the global market for medical tourism.”

and middle-­income countries but, rather, between lower­and middle-­ income countries,” she says. “A lot of governments, booster organisations and industry folks are so caught up with trying to capture the elusive international patient markets from high-income countries that it seems like they’ve actively ignored or taken for granted the large numbers of people from neighbouring countries and countries in their regions.”

According to Kumudu Gunasekera, director of global consulting firm, Stax, as of 2012, Asia comprised 9% of the global market for medical tourism, a humble figure that belies the significant growth potential of the region.

Among the region’s most highly demanded service offerings are cardiology, urology, gastroenterology, dermatology, orthopaedic surgery, neurosurgery, dental, and cosmetic surgery. A significant driver is the

prospect of low-cost procedures delivered at international standards of care.

As of 2015, there are at least 439 hospitals across Asia accredited by the United States-based Joint Commission International.

According to Patients Beyond Borders, individuals travelling to one of these providers in India, for instance, can expect a discount of 65–90% on the cost of a comparable medical procedure in the U.S. In Thailand, a patient can expect a potential discount of 50-70%. Even in Singapore, where the cost of living is measurably higher, medical tourists are offered a discount of 30–45% on the cost of comparable procedures in the U.S. “Medical tourism in Asia will see significant growth over the medium term. Underlying the sector’s trajectory is the growing demand from developing countries such as

Analysis: Medical Tourism China ­with affluent patients travelling to the region for higher value medical services ­as well as among patients from developed markets including Australia, who are driven by cost concerns to look beyond their domestic healthcare system.

This is further facilitated by the improvements in accessibility, which has made it easier for patients to travel both within and to the Asia Pacific region,” says Ang Wei Zheng, pharmaceuticals and healthcare analyst at BMI Research.

Regional competition While Singapore, Thailand, and Malaysia have traditionally been the leading hubs in the region, countries such as South Korea and India have sought to make greater inroads into the sector. More recently, Japan affirmed its aim of developing its medical tourism sector as part of its revitalisation strategy, Ang adds.

Consequently, competition in the medical tourism industry will intensify in the Asia Pacific region, driving hubs to compete along several levels. “This is a focus that is beyond cost; Singapore, for example, seeks to offer moderately priced healthcare that is among the best globally,” Ang says.

Gunasekera notes that another reason for Asia’s popularity among medical tourists is the opportunity to satisfy individual needs on a spectrum from medical treatment to wellness tourism.

While there are service offerings aimed at treating or altogether curing a medical condition; ranging from extremely high-tech surgeries like transplants to relatively standard procedures such as hip replacements, there is also on the other end; “fringe medical treatments” such as Ayurveda, acupuncture, and wellness spas for tourists who merely wish to maintain their health or prevent future medical problems.

BMI Research’s Ang agrees.

“Competing hubs will seek to integrate their medical tourism sector into the wellness industry as well as the wider tourism industry. This will help to differentiate the competing countries and more importantly, align with the demands of medical

tourists as many would be keen in participating in activities beyond healthcare,” Ang says.

Meeting international demand Gunasekera notes that between ASEAN’s consumer base of 626 million and the trillion dollar economies of China, India, Japan, and South Korea, Asia is well-positioned in terms of both the demand- and supply-side of medical tourism.

For Dr. Ormond, the region has a lot to learn from healthcare­-related discussions and developments over the years in the European Union about ensuring citizens’ rights to health care and negotiating the terms around intra­regional cross­-border patient mobility, as well as working together to ensure baseline standards for treatment, equipment and pharmaceuticals.

She stresses, however, the importance of medical tourism industries in Asian countries understanding that they should market more to their neighbours than any other potential customers from the more distant parts of the world.

“It’s time to come to terms with the fact that so-­called ‘medical tourism’ hubs in Southeast Asia (and this is also true for other places in the world, like India and South Africa) are really actually, on the whole, catering more to the everyday healthcare needs and interests of people (whether in the upper, middle or lower socio­ economic classes) from the country next door than to people from halfway across the globe,” she says.

Gunasekera supports Dr. Ormond’s argument. Currently, it is the patients from neighbouring countries who make up the top five nationalities of medical tourists for any given destination in Asia. Even as the region ages, rising income thresholds bode well for the market.

The ASEAN countries—Indonesia, Thailand, Malaysia, Singapore, Philippines, Vietnam, Myanmar, Brunei, Cambodia, and Laos— currently make up the second-fastest growing economy in the region. Dr. Ormond believes acknowledging this could make a real difference, both in terms of economic strategies for profit making and investment and,

Recovery in medical tourism broken

Source: Singapore Tourism Board

High cost to disadvantage Singapore

Source: Medical tourism in Malaysia, Singapore and Thailand

Meghann Ormond

Chow Sang Hoe

Ang Wei Zheng

on a more macro level, of developing practical and responsible political relationships between medical travel source and destination countries.

“There needs to be more collaboration beyond the realm of government agencies and healthcare providers to include travel agents and regional air carriers in promoting affordable and integrated/holistic (logistically efficient) healthcare services,” says Chow Sang Hoe, Asean advisory leader for EY. Gunasekera notes that the choice of geographic market is a key decision in developing a country’s medical tourism sector. In order to know how and where to compete, healthcare providers in Asia must understand their target customer and the feasibility of travel between regions.

“Patient outreach and marketing efforts will differ based upon whether the target customer is an uninsured/ underinsured American looking for a cost-effective elective procedure coupled with a leisure trip or an Asian traveller seeking a quality surgical procedure unavailable within the geographic confines of their own country,” Gunasekera notes.

HEALTHCARE ASIA 23

analysis: measuring patient experience

What can patient satisfaction do to a business?

What the healthcare industry can learn from other sectors How to better understand patient experience and improve satisfaction.

F

or hospitals and health systems, patient satisfaction is likely to become an increasingly important source of competitive advantage. Yet many providers cannot measure the patient experience comprehensively, an important first step in improving it.

Most health systems currently use a survey developed by the Centers for Medicare and Medicaid Services (CMS)—the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)—to gauge how inpatients perceive their hospital stay as their basis for understanding patient satisfaction. While HCAHPS does provide important insights into the patient experience, it does not assess all of the important aspects of that experience.

Furthermore, it was not designed to provide the level of detail needed for hospitals to link patient satisfaction with business 24 HEALTHCARE ASIA

In other industries, high custoer satisfaction levels have been linked with stronger loyalty, sales, and profits.

performance. Health systems that want to use patient satisfaction as a way to improve business performance need additional feedback and data to identify the factors that matter most to the patients they serve. Armed with the combined information, the health systems can then determine which investments in improving the patient experience can best help them meet their business objectives.

Lessons from other industries In other industries, high customer satisfaction levels have been linked with stronger loyalty, sales, and profits. McKinsey research in multiple industries has shown that companies that routinely achieve high customer satisfaction scores rely on bestpractice measurement systems that: · Link improvements in the customer experience with desired business outcomes (e.g., repeat sales) · Enable the companies to identify

the most important drivers of customer satisfaction and measure ongoing performance in those areas · Uncover operational insights that enable the frontline staff to make continuous improvements in the customer experience.

To date, few health systems have achieved significant business results through patient experience initiatives. Yet, growing consumerism in the healthcare industry—a result of higher deductibles and copayments, network narrowing, and greater transparency into provider performance and costs—is likely to make patient-experience initiatives more of an imperative for the industry. The proliferation of provider-led health plans is also making it increasingly important for health systems to market themselves, and patient satisfaction could be a key differentiator in their marketing efforts. The steps outlined below can enable providers to adapt best practices from other industries to the healthcare environment.

Patient satisfaction and outcomes The first step for health systems is to determine the business outcomes they most want to focus on (e.g., total patient volume, patient retention, percentage of commercial patients). They should then conduct research to investigate the types of questions that will best enable them to gauge patient satisfaction in a way that ties into those objectives.

Next, health systems should conduct additional research to identify the factors that most strongly influence how patients respond to the chosen questions and the specific metrics that would enable them to assess performance in those areas. Over time, the combined data should permit the health systems to develop robust measurement systems that can uncover operational insights and enable continuous frontline improvements. To ensure that the measurement systems remain robust, health systems should repeat this fundamental

analysis: measuring patient experience research every few years so that their understanding of the patient experience is always current.

Influences on patient satisfaction To determine which factors most strongly influence patient satisfaction, health systems must accurately understand the end-toend inpatient journey, from preadmission scheduling and testing through to follow-up care, as well as the role that price, service offerings, physician referrals, and brand play in determining where patients seek care.

The inpatient journey should then be broken down into discrete elements to identify the factors that can influence patient satisfaction at each step of the journey. Both clinical and nonclinical factors should be included. In-depth qualitative research (e.g., focus groups) and quantitative research (e.g., patient surveys) should then be conducted to pinpoint which factors most strongly influence satisfaction levels in ways that correlate with desired business objectives.

When conducting this research, two points are worth remembering.

First, the factors with the strongest influence often vary by market and patient segment (e.g. expectant mothers, cardiovascular patients, emergency room patients). Thus, the journeys along different care pathways should be mapped separately to determine which factors influence each one. For example, a hospital in a competitive community that views its maternity services as a way to attract and retain patients would need to understand which elements of care during pregnancy, childbirth, and follow-up have the

Focus groups must be conducted

Many health systems make large investments to improve the patient experience but fail to achieve their desired objectives because they did not understand what really matters most to their patients.

Correlation: Derived importance of satisfaction for inpatient providers

Source: Consumer health insights survey, 2013

strongest impact on new mothers’ satisfaction levels. Second, what patients say is important to them may not correlate with how satisfied they actually were with their inpatient stay.

In our experience, many health systems make large investments to improve the patient experience but fail to achieve their desired objectives because they did not understand what really matters most to their patients. Leading customer-focused companies rarely make this mistake.

For example, a major rental car company conducted interviews and surveys to improve the experience of business travellers, its most profitable customer segment. The research established that the most important source of satisfaction for these travellers was not the variety of vehicles (as the company had hypothesised), but the experience from landing at an airport to leaving the rental facility. The research also showed that the key elements influencing that experience were the speed of getting the rental car and communication about the status of the reservations before arrival. As a result, the company invested to streamline the arrival process and used technology to give customers frequent updates. The result: higher retention of business travellers.

Uncover operational insights As the car rental company example illustrated, it is not sufficient to identify the factors that matter most.

Those factors must be broken down

into their constituent parts—ideally, ones that can be monitored regularly.

For example, if nurse empathy has a strong impact on patient satisfaction, health systems should track such things as total nursing time spent with each patient and timely response to call buttons. Similarly, if the most important factor influencing satisfaction with ER care is how quickly patients see a provider, health systems should routinely measure the average “door to doc” time.

Metrics such as these become key performance indicators (KPIs) that can be used to change behaviours in ways that improve the patient experience. The KPIs should, ideally, be assessed daily and results reported to the individual hospital units. The findings help the frontline staff determine where changes are needed and then test the changes to understand the impact they are achieving. The KPIs are thus an important complement to the monthly patient feedback survey scores. Although those surveys are the most important gauge of patient satisfaction, it may take weeks before the responses are processed and reported to the frontline. In contrast, the KPIs allow the staff to make meaningful, real-time adjustments to their activities and weave continuous improvement into daily operations.

As a consequence, patient satisfaction is no longer just a marketing initiative but a component of the organisation’s culture. By Brandon Carrus, principal, McKinsey & Company HEALTHCARE ASIA 25

Case Study : singhealth

Use warm white lighting instead of daylight lighting at waiting areas

SingHealth’s age-friendly design guide The 112-page design guide was compiled by a team of Facilities Development, Service Quality, Operations, Nursing and Marketing Communications professionals from SingHealth.

T

o provide patients and caregivers a pleasant and hassle-free experience, SingHealth has published a design guide that defines what makes a building or space age-friendly. The guide provides specific design guidelines to ensure safety, ease and comfort at different points of a patient’s journey. It covers areas such as drop off and entry points, entrances and exits, consultation room waiting areas, and common areas such as corridors, lifts and toilets.

Organising the guidelines into ten chapters allows planners to pick the right areas and use detailed specifications, right down to the ideal size and height of a chair seat, and the best font size for a signage, for example. While complying with Singapore’s Building and Construction Authority existing guidelines enables SingHealth to serve those who are wheelchair bound and visually impaired, the planners felt that healthcare facilities equally needed to meet the needs of able-bodied elderly who are frail and with poor vision.

In addition, busy caregivers who often accompany their loved ones want to be able to navigate around healthcare institutions quickly. To fulfill such needs, SingHealth expanded upon the BCA guidelines to suit healthcare facilities. The team also made a conscious effort to ensure the guidelines are cost effective to implement.

Mr Gan Kim Yong, Singapore’s minister for health and minister-in-charge of ageing issues, commended the ini26 HEALTHCARE ASIA

All SingHealth institutions will feature age-friendly design as they are being renovated or built.

tiative, saying, “I encourage others to leverage SingHealth’s research and insights to apply these age-friendly design principles. It is a positive step towards tapping on our collective wisdom to create an age-friendly environment for our seniors, so that they can move around safely, easily and confidently.”

Intuitive wayfinding The improvement in wayfinding starts even before the patients enter the hospital. The team understands that good external signage on the building facade as well as at dropoff points allow patients to locate the right entrance easily.

Information counters at strategic locations give patients the option of seeking directions by asking staff on duty.

Colour-coded directories, wall and ceiling signage, wayfinding stickers on the floor, and a full set of healthcare pictograms have also been introduced.

The age-friendly design is a welcome change for both staff and patients. With the use of colour coding and pictograms, staff are now able to give clearer directions to elderly and illiterate patients.

It is also easier for older patients with poor memory to identify specific locations by their colour coding. With clear signage at strategic locations, patients and their families navigate around SingHealth’s facilities with greater ease.

According to the “Report on the Aging Population” by

Case Study : singhealth Geylang and Tampines Polyclinics

This is the preferred placement for wheelchair lots as it allows caregivers to sit beside patients

Singapore’s Ministry of Community Development, Youth and Sports published in 2006, one out of five residents will be aged 65 years old and above by 2030.

As the largest public healthcare provider in Singapore, SingHealth served more than one million elderly (aged 65 and above) patient visits in 2014, and this figure is set to grow.

The proportion of elderly patients it sees is significant.

For example, more than 40% of patients admitted to SGH last year were above the age of 65. In 2014, 26% of patient visits across SingHealth institutions were elderly, compared to 22% in 2010.

Professor Ivy Ng, group CEO, SingHealth, said, “We are taking a proactive approach to ensure that our facilities and buildings are ready to meet the needs of Singapore’s ageing population. This is why a team of healthcare professionals from SingHealth came up with the 112-page Singapore Healthcare Age-Friendly Infrastructure Design Guide. The Guide details how we want to transform the built environment to be safe, age-friendly and most importantly, a warm, welcoming and healing environment for all our patients.”

All SingHealth institutions will feature age-friendly design as they are being renovated or built. The Ministry of Health has also shared the guide with all public healthcare clusters in Singapore.

Although developed for the healthcare setting, the age-friendly design principles can be applied to any public space - including train stations, retail shopping malls, and general public facilities such as community centres and walkways.

For example: 1. Guidelines on the Main Directory which can be

The surge in this patient demography motivated SingHealth Polyclinics to implement a series of age-friendly features to improve patients’ experience.

Out of the 1.5 million patients SingHealth Polyclinics see each year, there is an increasing number of elderly patients. They now account for up to 30% of patients who visit its nine polyclinics and 50% of SingHealth’s total patient visitors. The surge in this patient demography motivated SingHealth Polyclinics to implement a series of age-friendly features to improve patients’ experience.

The transformation began at the Geylang Polyclinic which reopened in May 2013, followed by Tampines Polyclinic which reopened in November 2013.

Construction was going to take up to five months, so the plan began with building a temporary clinic next to Geylang Polyclinic to handle the patient load.

Geylang and Tampines Polyclinics underwent major renovations incorporating the Singapore Health Age-Friendly Infrastructure Design Guide - with the objective of giving their elderly patients a safer and more pleasant experience.

Staff of the two polyclinics were actively involved in the planning of the new features, giving their feedback on what should be improved. Prototypes were also built on their initiative and tested for their effectiveness before they were implemented.

Key features that have been adopted by the two polyclinics included ramps and low counters at service areas for wheelchair access, handrails along main corridors, large visual guides and bigger font sizes on signages, intuitive layout and organisation of rooms, and wider door-less entry to toilets.

Refreshed polyclinics Gladys Yap, Manager of Clinic Operations at Geylang Polyclinic, who was actively involved in the redevelopment project says the refreshed polyclinic includes the addition of more glass panels to bring in natural light. As a result, the refreshed polyclinic looks brighter and more spacious. “Our patients have told us that they love the open concept,” she says. “We tried to look at every detail, even creating a green enclave to enhance the healing environment.”

Accessibility at the Tampines Polyclinic was also greatly improved. Markus Ng, Manager of Clinic Operations at the Polyclinic says, “We have created an enhanced ambience with expanded areas for patients to wait and move around the polyclinic in cool comfort. The new configuration and layout provides easier access for patients and improves operational efficiency.”

Apart from physical structures, services too underwent a revamp. Among Geylang Polyclinic’s new initiatives for the elderly is a Geriatric Centre which screens and manages age-related conditions such as osteoporosis and dementia. Patients can also participate in free workshops on ageing issues like how to prevent falls and manage their health.

Tampines Polyclinic introduced several new services, including physiotherapy, an improved diabetic foot screening service and the Health Wellness Clinic to provide care nearer to the homes of its patients, and reduce the need for them to visit the hospitals. The laboratory was also expanded to three times the size to cater to patients’ needs.

HEALTHCARE ASIA 27

Case Study : singhealth

applied to most buildings’ main entrances. The guide recommends multilingual text, black text on a light matte background, minimum font size of 36 points, and pictograms to signify key amenities such as the information counter, toilets, food court and taxi stand.

2. Specifications on inclusions in lifts in terms of minimum carriage size, lift buttons placement, appropriate lighting and use of mirrors to assist wheelchair users are also recommended for application in all public areas.

3. Sufficient space and shelter guidelines for major external walkways, particularly in Singapore’s tropical climate and a general move to encourage the elderly to be more mobile, active.

Notably, the team’s expertise is gaining recognition outside the healthcare sector. The People’s Association recently invited the team to conduct an age-friendly audit at one of its new Community Centres.

Since the book was launched in May, SingHealth has received many requests for copies of the guide. In response to this interest, copies of the book can now be purchased online, at http://www.healthxchange.com.sg/Specials/Pages/ age-friendly-infrastructure-design-guide.aspx.

28 SINGAPORE BUSINESS REVIEW | JANUARY 2014

The team’s expertise is gaining recognition outside the healthcare sector.

The age-friendly design guidelines have been implemented at: • SingHealth Polyclinics at Geylang, Tampines, Sengkang, Bukit Merah • Centre for Digestive and Liver Diseases, Singapore General Hospital • SGH Rehabilitation Centre at National Heart Centre Singapore (7th floor) • National Heart Centre Singapore SingHealth buildings which will feature age-friendly design: • SingHealth Polyclinics at Bedok, Punggol, Outram, PasirRis, Marine Parade (by 2017) • Wayfinding signage at SGH Blocks 1 to 7 for all levels (by September 2015) • Revamp external signage (eg road signs) within SGH Campus (by 2016) • Sengkang Community and General Hospitals (New buildings up by 2018) • Outram Community Hospital (New building up by 2020)

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OPINION

Suvendu & soma

Medical tourism in the Red Dot: A Peter Pan model

suvendu ganguli soma ganguli Co-Founder and COO Parkway Intl Patient Svcs Ex-staff of WHO Geneva Temaswiss

A

s the little “Red Dot” (Singapore) celebrates 50 years, it is no guarded knowledge that regionally Thailand, Singapore, India are all in a race to be preferred medical tourism hubs. Singapore almost has it all to succeed in its endeavour, yet it has the omnipresent global challenge of increasing healthcare costs.

As a tiny city-state, it has its added challenge that it cannot on one hand offer a medical ‘Disneyland’ for a wellheeled global populace and on the other hand be in any way perceived to offer a stretched de-prioritised service to its resident taxpayers. Singapore has an impressive track-record of public-private models. Its restructuring of public facilities more than two decades ago was an unparalleled success story.

What stops Singapore (if anything) from further evolving its medical tourism strategy into a successful private-public ‘Peter Pan Model’ whereby the higher-priced service to nonresidents benefits sustainable and improved public healthcare services towards taxpayers? Healthcare is a lucrative business in the private sector and the investing consortiums always go in with a long-term strategy in mind. It is with this thought in mind that we would like to float some ideas that both the public and the private healthcare groups could explore.

World MediCity Changi It has been announced that within this decade, Changi Airport will further expand with a Terminal 5 and activation of its third runway for civilian use. It is estimated that every flight into Changi will carry a minimum of five passengers on average who will either seek or are travelling expressly to seek medical attention in Singapore. That would mean about 2,300 patients in all daily; outpatient, day-care and warded.

Herein lies the idea for World MediCity Changi, a sprawling fly-in fly-out medical city, catering both to private and public sector pricing models. Equipped with specialised gate-to-bed transport facilities, multi-speciality hospitals, super-speciality clinics, therapy and convalescence facilities, hotels and facilities for accompanying families, it could be ideally located at the airport, dispensing with visa formalities.

Asia Evac-Hub Asia has its fair share of strife, war, natural calamities and even regional tourism-related accidents. Potentially coupled with the MediCity idea or even as a standalone, Singapore’s public and private sector healthcare providers could make a strategic and concerted effort to attract the emergency evacuation, surgery and warded medical services further.

30 HEALTHCARE ASIA

MediCity concept

At present, casualties from as far afield as Central Africa or middle and south Asia are often evacuated to the classic hubs of France and the United Kingdom. This is not for lack of speciality facilities or medical treatments that Singapore cannot provide.

Prosthesis Asia Contrary to prevalent layman perceptions, artificial limbs are not simply strap-on and gluing exercises. It requires an inter-disciplinary team of health-care professionals including surgeons, physical therapists, occupational therapists and psychiatrists. All the specialist fields are represented in Singapore. Incidentally, Singapore fortuitously has the added geographic advantage of being with 3-5 hours flight distance from the research and manufacturing hubs of prosthetic limbs in which India, China and Thailand are competing for market share. Singapore questionably would be able to compete on the design and manufacturing due to labour costs – yet it can expand in the related medical fields and facilities.

With the onset of 3D printing, moulding instructions and patient in Singapore, manufacturing elsewhere is feasible and is already carried out on a relatively small unconsolidated scale.

We can only emphasise that ideas will remain ideas alone unless there is a concerted publicprivate buy-in to the visions, will-power and funded efforts. The road ahead will come with its specific ‘Red Dot’ challenges: questions on population capacity, further foreign talents, and strained public resources – yet nothing that it cannot and will not overcome.

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OPINION

BARACH & skalkidis

Adopting evidence-based clinical practices in healthcare systems

P

romoting uptake and use of clinical practice guidelines at the point-of-care delivery in Asia represents a final translation hurdle to move scientific findings into practice. Evidencebased practice (EBP) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardised practice guidelines. EBP provides clinicians with a method to use critically appraised and scientifically proven evidence for delivering quality health care to a specific population. EBP practices are available for a number of conditions such as asthma, heart failure, and diabetes. It has been shown that the application of specific clinical protocols can facilitate better outcomes and clinical work, as well as optimise utilization of hospital resources. However, these practices are not always implemented across Asian healthcare systems in care delivery, and variation in practices and outcomes abound across Asia.

Traditionally, patient safety research has focussed on data analyses to identify patient safety issues and to demonstrate that a new practice will lead to improved quality and patient safety.

Much less research attention has been paid to how to implement practices. Characteristics and engagement of the intended users and context of practice in Asian healthcare systems are as important as guideline attributes for promoting adoption of CPG (clinical practice guidelines) recommendations.

Best evidence includes empirical evidence from randomised controlled trials; evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion. When enough research evidence is available, the practice should be guided by research evidence in conjunction with clinical expertise and patient values.

In some cases, however, a sufficient research base may not be available, and health decision-making is derived principally from weak research evidence sources such as expert opinion and scientific principles. As more research is done in a specific area, the research evidence must be incorporated into the EBP respecting local interest and support by the healthcare community.

Non-adherence to practice guidelines remains a major barrier across Asian healthcare delivery systems to the successful practise of evidence-based medicine. Implementing evidence-based safety practices are difficult and need strategies that address the complexity of systems of care, individual practitioners, senior leadership, and— ultimately—changing Asian health care culture to be an evidencebased practice environment.

While advocates welcome the stronger scientific foundation of such guidelines, critics fear that they will lead to “cookbook medicine.” Studies show, however, that few guidelines lead to consistent changes in provider behaviour. The hopes, fears, and mixed record of EBP are rooted in the traditional professional perspective of the clinician as sole decision-maker. Multifaceted, and multi-level implementation strategies that take the collaborative 32 HEALTHCARE ASIA

PAUL BARACH Yannis Skalkidis Clinical Professor Assistant Professor Wayne State University University of Athens

Table 1: Evidence-based guidelines and clinical practice* Review guidelines and select the highest quality best one(s) for your clinical setting.

Have providers review and discuss guidelines to develop consensus.

Customize guidelines for your organization.

Use a standardized assessment to diagnose and determine disease control and risk for complications (heart, eyes, kidneys, etc.) to guide management for all patients.

Conduct a baseline chart audit to benchmark your current practice against agreed upon guidelines.

Use flowsheets, pathways, or checklists to embed guidelines into daily practice. The guidelines include triggers for care.

Link guidelines to the information system to provide prompts.

Review and update guidelines for care regularly (at least yearly). * See IHI.org

nature and organisational context of medical work into consideration promise more effective changes in clinical practice across Asian delivery systems.

This ‘systems approach’ draws attention to the wider organisation, management and culture of healthcare. It is important to understand the barriers and drivers to adopting clinical guidelines as complex and enmeshed ‘constellations’ of factors found within and between care processes. This includes regulatory pressures, organisational boundaries, impact of perverse financial incentives and the shifting of professional responsibility.

For Asian healthcare systems to continuously improve they will need a robust information system that supports continuous process improvement (CPI) with three interlinked aims: a) Better outcomes (e.g. individuals, populations); b) Better system performance (e.g. quality, safety, value); and, c) Better professional development (e.g. competence, joy, pride). Thus it would be valuable to identify how CPG align with present culture and management styles and support these three intercalated goals in the Asian context of delivering high value, evidence-based care (Table 1).

Improving healthcare quality in Asia will require effective clinical guidelines that are theory- and evidence-based, and targeted at specific behavioural and environmental factors unique to local context. This should be a guiding framework for providers and policy-makers to improve EBP. Guideline developers need to structure the format, vocabulary, and content of CPGs (e.g., specific statements of evidence, the target population) to facilitate ready implementation of electronic clinical decision support by endusers in local systems. *This study was supported by a grant from the “Implementation of Electronic Clinical Protocols in University Clinics” Project (70/3/11641) of THALIS Program of the Ministry of Education, Greece, and is supported by National Foundation, Greece.

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