NGH EU 1

CROSS-BORDER CARE Is a Europe-wide health system a reality?

RE-IMAGINING THE NHS With UK Department of Health CTO Paul Jones

HOSPITALS OF THE FUTURE Inside Sweden’s Norrbotten Healthcare System www.nghealthcareeurope.com • Q2 2010

THE GREAT SWINE FLU SWINDLE Whatever happened to H1N1?

UNLOCKING

POTENTIAL

Why greater information sharing will be key to Europe’s healthcare revolution PLUS Rosanna Tarricone EHTI | Neelie Kroes EU Commission | Didier Pittet WHO Cover 2.indd 1

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FROM THE EDITOR 5

Chance to reflect Does the passing of America’s health reform bill provide an opportunity to reflect on European efforts to strengthen healthcare?

M

arch 21, 2010. Mark the date, people – it could go down as one of the most significant in US history. After nearly a year’s worth of political wrangling, the Obama Administration’s healthcare reform legislation was finally passed by the House of Representatives by a vote of 219-212. The legislation will give an additional 32 million Americans access to basic health insurance by 2019.

The news did not go unnoticed on this side of the pond, either. Indeed, as a result of events across the Atlantic we’ve hardly been able to avoid the issue of healthcare in the papers, on the blogs and over the airwaves in the last few months. And with good reason: healthcare is something that affects all of us at some point in our lives, and something that most of us have an opinion on.

The net result of this increased visibility is that it affords us in Europe an opportunity to reevaluate our own health systems and approaches to see if they are working as they should, and look at how they can be improved. For instance, the UK’s National Health Service has, in recent years,

deployed around 32,000 different systems – everything from theatre systems in hospitals through to new patient administration systems in community clinics – to help improve care delivery to patients across its many disparate healthcare settings.

Coordinating this effort has proved challenging to date, but it is a challenge that new Department of Health Chief Technology Officer Paul Jones is relishing. “To realise the true benefits of e-health we’ve got to put certain building blocks – interoperability, data standards, common identifiers – in place,” he explains in an exclusive interview on page 36. “Once you implement those building blocks, we can really set the NHS up for the future, which is what I care about.”

Certainly technology will play an important part in the development of the sector, but it will also require strong leadership and effective decision-making around the key issues to ensure the opportunities presented by the advent of healthcare IT do not go to waste. “We need to think of IT systems as a tool to support what we want to achieve,” suggests Elisabeth Holmgren, CEO for Sweden’s Norbotten Läns Landsting region with

responsibility for five large hospital systems.

“These new technologies will play a key part in how we get there, but they also mean that we have to work in ways that we haven’t before.”

As Neelie Kroes, Vice President of the European Commission and Commissioner for the Digital Agenda, explains, information and communication technologies (and the greater levels of collaboration they drive) will be key to the future of the sector – not just here in Europe, but around the world too. “There is no single actor – government, doctor, patient or manufacturer – setting the terms of e-health,” she says.

“Instead, success will only come from a truly joint effort.”

It’s advice that leaders on both sides of the Atlantic would do well to follow. n

Senior Editor Ben Thompson

“A lot of breakthrough innovations have been developed in Europe but marketed in the US – and that’s our weakness. European systems are not very friendly”

“WHO undertook an incomprehensible action, up to now not justified by any scientific evidence. It gambled away public confidence”

“To truly protect patients, it will take leadership, commitment, a range of actions, continuous assessment, experience-sharing, and time”

Rosanna Tarricone, Chairman, Director of the European Health Technology Institute (Page 82)

Dr Wolfgang Wodarg, Head of Health for the Council of Europe (Page 98)

Professor Didier Pittet, University Hospitals Geneva (Page 106)

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CONTENTS 7

48

The best system in the world?

A look at how healthcare systems measure up in Europe and the US

Closing the gap

26 Re-imagining the NHS Paul Jones, CTO for the Department of Health, outlines why the UK’s £12.7 billion National Programme for IT is still on track

98 The great swine flu swindle?

A pandemic of devastating proportions, it was to cause a global standstill as hundred of thousands of people around the world died and millions more got sick. Rebecca Goozee looks at what happened to swine flu

With high quality health services becoming an increasing priority, discussions around cross-border healthcare systems are coming to a head, just what and where is the future of cross-border healthcare in Europe?

36

CONTENTS_apr10 07/04/2010 15:51 Page 8

CONTENTS 8

94

Staying safe

106

Didier Pettit

32 A new era in e-health Neelie Kroes explains the positive impact of ICT on the healthcare sector

44 Addressing pre-operative anaemia management Christoph Springer explains the importance of patient blood management

46 Making connections The use of social media in healthcare, according to Matthew Lees

54 On the front line

ASK THE EXPERT 92 Sarah Whipp, Symantec

Why the need for integrated diagnostic and visualisation tools will drive the European PACS market

76 Healthy profits

62 A new path

To build a smarter system, healthcare solutions need to be instrumented, says IBM

Sir Ian Kennedy on the value of innovative health technologies

82 Innovation institute

66 Going digital

Rosanna Tarricone, reveals the challenges of a fragmented device industry

With Frost and Sullivan’s Nadim Daher

88 Healthcare goes mobile 72 The rise of medical imaging

Cloud services are helping to treat cancer

74 The future of private sector medical imaging

patients, thanks to an enormous effort by European researchers

The vital role of the hospital in healthcare

60 Cloud technology to combat cancer

110

Miracle cure

Martin Törnvik talks about the improvements currently going on in the world of medical imaging

Akanksha Joshi explains why an ageing demographic is boosting the uptake of wireless patient monitoring devices

CONTENTS_apr10 07/04/2010 15:51 Page 9

CONTENTS 9

90 A wireless world

IN THE BACK

Sarah Morris looks at Wi-Fi in the hospital setting

94 Staying safe James Koenig on the role of single sign-on in identity access management

106 Save lives: clean your hands A call to action from Professor Didier Pittet

108 The importance of hand washing Richard J. Verdiramo reveals why HCAI rates are decreasing

Moscow

114 Comprehensive diagnostics Guus Simons reveals where the molecular diagnostics sector in Europe is heading

110 Miracle cure Can the emerging field of pharmacogenomics provide a lifeline to the industry?

122 Design: Hospital 2.0 124 Regional focus: Fighting a new Cold War 126 On the shelf: Book reviews 144 Final word: Photo ďŹ nish

economy is driving the sector to a new model of payment by results

118 And the winner is...

116 The new healthcare model Healthcare may be buoyant now but a zombie

A look at the impact of healthcare reform in the UK

54

On the front line

32

A new era in e-health

And the winner is...

118

Grand Hotel Huis ter Duin, The Netherlands 12-14th October 2010

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UPFRONT 12

A BLOW FOR BIOTECH? Over in the US a federal judge has overturned the patents on two genes linked to breast and ovarian cancer on the grounds that they’re not man-made or an invention, but products of nature. Myriad Genetics had patented the BRCA1 and 2 genes and charged women more than US$3000 to test for genetic mutations. The American Civil Liberties Union and individual breast cancer patients took the case to the federal court arguing that the patent stifled medical research.

The company that owned the patent, Australian-based Genetic Technologies, initially demanded that other laboratories stop testing the genes, but under heavy pressure, agreed The American to offer the tests for ruling could have free. However, the implications for American ruling could another have implications for another 40,000 patents patents on an estimated 2000 human genes globally.

Courts have long backed the idea of gene patents, however rapid advances in technology are prompting scientists and many intellectualproperty experts to rethink their support for them. Modern gene-sequencers for example have made the task of identifying genes and figuring out their function much easier than before.

Despite this, many biotechnology stocks fell after the ruling as investors struggled to understand the impact of a ruling that threw into question thousands of gene patents.

Biotech companies spend billions every year trying to develop new tests and treatments based partly on genes that have isolated and patented. Anticipating a negative reaction

40,000

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:57 Page 13

UPFRONT 13 from the industry the Judge ininvestment and remove incencluded a footnote in his 152tives to develop tests, slowing page ruling, dismissing fears the move towards so-called perthat invalidating such patents sonalised medicine, in which gewould decimate the industry. netic tests are used to determine The decision invalidating the drugs that are best for indithe gene patents stunned many vidual patients. lawyers, who predicted the ruling But while industry watchers to have a far-reaching efwere taken aback by the fect. “It’s really quite a ruling, some groups The dramatic holding were more positive. invalidation of genetic patents that would have Chris Hansen, a would have the the effect of invalstaff attorney with biggest idating, many the ACLU First patents on which Amendment on diagnostic the biotechnology Working Group companies industry has invested said: “The ruling is a considerable money,” victory for the free flow of Rebecca S. Eisenberg, a law proideas in scientific research. The fessor at the University of human genome, like the strucMichigan, told the New York ture of blood, air or water, was Times. discovered, not created. There is The ruling is currently on an endless amount of informaappeal, but eventually – if the tion on genes that begs for furjudge’s reasoning is upheld the ther discovery and gene patents invalidation of genetic patents put up an unacceptable barrier would have the biggest impact to the free exchange of ideas.” on diagnostic companies like Professor Ian Olver, Chief Myriad that offers diagnostic Executive of Cancer Council of tests based on genes. However, Australia, said the ruling was a major breakthrough. “For a court in the US – where many of the world’s gene patents are held – to reach such a determination is a major breakthrough towards protecting the public interest from commercial monopolisation of genetic material.”

Indeed, the ruling adds weight to the argument by some geneticists that companies and institutions shouldn’t be allowed to patent basic geit would also be felt by agriculnetic information that makes tural biotechnology companies people human. And it appears and perhaps even traditional that this decision could ultidrug makers. mately be a boon for genetic Some biotechnology inresearch and public health. vestors and executives argue Still, the battle’s not over just that the lack of patent protecyet: big pharma won’t take this tion for DNA could diminish lying down.

impact

“The ruling is a victory for the free flow of ideas in scientific research.

The human genome, like the structure of blood, air or water, was discovered, not created”

NEWS IN PICTURES

US President Barack Obama signs the healthcare reform bill at the White House in Washington DC on March 23. The sweeping healthcare reform bill passed the House of Representatives and is on track to bring the most profound changes to the nation’s social security system in more than four decades.

Dozens of demonstrators participate in a waiting line in front of the oldest public toilets in Paris. ‘Living without toilets' constitutes a 'mortal risk' according to Action Against Hunger (ACF), who organised a flashmob to attract attention to the lack of toilets in the world, causing unsanitary environments for over 2.5 billion people, on the eve of the World Water Day March 22, 2010.

An installation titled the Death Clock, counts the number of tobaccorelated deaths since negotiations began on the WHO Framework Convention on Tobacco Control on October 25, 1999. WHO estimates tobacco-related deaths at 5.4 million per year; one every 5.84 seconds.

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:57 Page 14

UPFRONT 14

1

TOP 10 HOSPITALS IN EUROPE According to the Cybermetrics Lab, a research group belonging to the Consejo Superior de Investigaciones Cientificas (CSIC), the largest public research body in Spain, the top performing hospital in Europe is found in Sweden, while Germany features in five of the top 10 places.

Centre Hospitalier Universitaire Vaudois Lausanne (Sweden)

2 3 4 5

The Institute of Cancer Research Royal Cancer Hospital (UK)

Universitätsklinikum Gießen und Marburg (Germany)

Centre Hospitalier Universitaire de Lyon Hopitaux de Lyon (France) Universitätsklinikum Medizinische Fakultät der MartinLuther-Universität Halle-Wittenberg (Germany)

6

Universitätsklinikum und Medizinische Fakultät Tübingen (Germany)

7 8 9 10 THE COST OF A LONG LIFE

Landstinget I Östergötland (Sweden)

Universitätsklinikum Heidelberg (Germany)

Hopitaux Universitaires de Genève (Switzerland)

Universitätsklinikum Freiburg (Germany)

Life Expectancy United States

Per Capita Spending (International Dollars)

82.0

5000 4500

Average Life Expectancy

81.0 4000 80.0 3500 79.0

3000

78.0

2500 2000

77.0 1500 76.0 1000 75.0

500 0

74.0

Portugal

Cyprus

Ireland

Cuba

Denmark

United States

Finland

United Kingdom

Belgium

Malta

Greece

Netherlands

Germany

Luxenbourg

New Zealand

Singapore

Israel

Norway

Austria

Spain

France

Italy

Andorra

Canada

Iceland

Australia

Sweden

Monaco

Switerland

Japan

San Marino

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:57 Page 15

UPFRONT 15

AROUND THE WORLD IN 80 DAYS

HOSPITAL BEDS Japan 16.4

Switzerland 18.3*

Norway 14.4

US 3.6

France 8.4

Our guide to the last quarter’s global events – and their impact on your business.

Poland 5.1 Germany 9.2

UK 4.1 Sweden 3.7

Austria 8.8

Netherlands 11.1

*Per 1000 people

Source: nationmaster.com

NETHERLANDS TOP CHART EURO HEALTH CONSUMER INDEX The fifth annual edition of the Euro Health Consumer Index offers a user-focused performance-related comparison of 33 national healthcare systems across Europe. The report’s most remarkable outcome according to the authors is the outstanding position of Dutch healthcare, indicating that the ongoing healthcare reform is paying off. The index is compiled by 12 basic indicators concerning the design of systems policy, consumer choice, service level and access to information.

NETHERLANDS

863

DENMARK

819

ICELAND

811

AUSTRIA

FLU THREAT

Researchers have announced that China is set to face a diabetes epidemic, with almost one in 10 adults having the disease with most cases remaining undiagnosed. New tests suggest that more than 92 million Chinese adults had diabetes, representing a major public health problem as it is a factor in heart disease, stroke and kidney disease.

NGHEU impact rating: ****

Bird flu outbreaks have killed seven people across several countries so far this year, demonstrating that the virus remains a continuous threat to human health, suggests the WHO, with a major concern being the mutation of the disease. While numbers are still low, the fatality rate for humans infected with bird flu remains high at 59 percent.

NGHEU impact rating: ***

CARESHORTAGE

HEALTH PROPOSAL?

Primary care doctors in the US are concerned with how to care for 32 million newly-insured Americans since the healthcare reforms have been announced. Family physicians and nurses are already in short supply and the American Academy of Family Physicians predicts a shortfall of 40,000 care providers.

NGHEU impact rating: ****

JohnBrumby,PremierofVictoria,has asked Australian Prime Minister to rethink its AUS$50 billion hospitals plan and asked for more details about the preventive health plan proposed by the commonwealth, that is supposed to help put the commonwealth-state blame game to an end. This could all spark much-needed debate.

NGHEU impact rating: ***

COSTSRISING

JUNK FOOD ADDICTION

Elderly care in Scotland could rise to UK£8 billion from UK£4.5 billion in just over two decades, claims the country’s public health minister Shona Robison. While the commitment to providing free personal care to the elderly is set to continue, Robsion believes that streamlining needs to start now if they are to cut costs.

NGHEU impact rating: **

A report from scientistsat Scripps Research Institute in Florida found that bingeing on junk food is as addictive as smoking or taking drugs and could cause compulsive eating and obesity, presenting compelling evidence that drug addiction and obesity are based on the same underlying neurobiological mechanisms.

NGHEU impact rating: ****

795

GERMANY

787

FRANCE

778

UK

682

ITALY

671

PORTUGAL

632

SPAIN

630

POLAND

565

ROMANIA BULGARIA

DIABETES EPIDEMIC?

489 488

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:57 Page 16

UPFRONT 16

KICK IT OUT Ghanaian campaign group United Against Malaria has plans to use this year’s World Cup in South Africa to boost awareness of malaria prevention, which kills one million Africans each year – 85 percent of which are children under five years old. Nine football teams are already involved in the campaign that hopes to use the excitement surrounding the World Cup as a catalyst for highlighting the importance of public health and the eradication of malaria, which is both treatable and completely preventable.

With the slogan of “victory is in the net”, the group have already broadcast on Ghanaian radio, reminding pregnant women to take their anti-malarial drugs and for all families to sleep under the treated bed-nets provided. In addition, they have also awarded Ghana FA President Kwesi Nyantakiyi his own ‘golden boot’ for his contribution to fighting the disease.

SOUND MEMORIES A 12-week programme at Artsdepot, an arts venue in London, UK, is harnessing memories to powerful effect by using theatre and stage to reignite the lost memories of dementia sufferers. The project, In The Limelight, has witnessed small glimmers of hope by bringing out people’s personal stories through their re-inactment on the stage, with especially vivid images being termed the “reminiscence bump” by David Rubin, Professor of psychology at Duke University in North Carolina.

With long-term memory remaining intact in dementia sufferers years after their short-term memory recall has disintegrated completely, it has also been found that the recollection of music can often remain unimpaired for even longer. Combining these factors, the programme hopes to re-unite families, albeit only for a few hours a week, with the person they once knew – free from the anxiety and stress that overshadows the disease.

SAFE WATER Reports from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) says the world is on track to meet or even exceed the drinking-water target of the Millennium Development Goals, which aims to halve the number of people who don’t have access to healthy drinking water. However, the report notes that while approximately 5.9 billion people use safe drinkingwater sources, a staggering 2.6 billion people don’t use improved sanitation.

Moreover, 4000 deaths per day occur as a result of unsafe water and poor sanitation. WHO and UNICEF report that a lack of access to water, sanitation and hygiene affects the health, security and quality of life for children.

Evidence also suggests that girls and women are more affected than men and boys, as unfortunately they tend to be the ones burdened with collecting drinking water.

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:57 Page 17

UPFRONT 17

BEAUTY TEENS The Physician’s Coalition for Injectable Safety has sent out a worldwide warning against “Teen Toxing” – the administration of Botox and other injectable products to individuals under the age of 18 for cosmetic reasons. It follows after a story in which a UK mother was criticised for administering Botox injections to her 15year-old daughter. The Coalition believes that this disturbing report may be an indicator of other questionable procedures, and is keen to highlight the potential complications and risks of injecting at such a young age; especially as Botox doesn’t actually prevent natural ageing – so the adage of “preventing wrinkles” lacks credibility. To counteract this growing trend, the Coalition is raising the question of responsibility and strongly advising that all medical procedures for teens, plastic surgery or otherwise, should be reviewed with a board-certified physician.

TRAVEL CHOICE A Polish pro-abortion feminist group, known only by the acronym SROM, has caused a recent uproar by launching an ad campaign promoting the travel of women over to the UK in order to take advantage of the free abortion clinics offered by the NHS. The poster ad, featuring a spin on the classic Mastercard campaign, ends with the strapline “For everything else, you pay less than an underground abortion in Poland.”

Under EU regulations, Britain has a reciprocal agreement with Poland to provide free medical care for anyone needing treatment. However, a spokeswoman for the UK Department of Health declared that there is no provision for Polish women to travel to the UK for abortions. With one of the strictest abortion laws in Europe, Poland views abortion as illegal unless the woman’s life or health is at risk, or the pregnancy is the result of a criminal act.

BACK TO WORK The British Medical Journal website has just published a study delivering evidence that a programme of integrated care, directed at both the patient and the workplace, can help people with chronic low back pain return to work, on average, four months earlier than those receiving the usual standards of care. Researchers based in the Netherlands and Canada evaluated the effectiveness of an integrated care programme in 134 patients with chronic low back pain. The patients were split into integrated care, consisting of adjustments to the workplace and a graded exercise programme to teach patients how to move safely while increasing activity levels; and ‘usual care’, which was built on normal pain treatment and little to no workplace involvement.

Over the 12-month study period, patients on the integrated care programme returned to sustainable work after an average of 88 days, compared with 208 days for the ‘usual care’ patients.

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:57 Page 18

UPFRONT

UNDER PRESSURE

18

A joint study by the UK and Germany has shown that blood pressure drugs can reduce the ability of breast cancer to spread to other parts of the body. The study on patients taking betablocker drugs, showed that the medication reduced the risk of death from breast cancer significantly. The women were 71 percent less likely to die from breast cancer and less likely to have their breast cancer come back in the same place. It is believed that the drugs may block the production of hormones that would otherwise trigger the spread of cancer.

Earlier studies have shown that the ability of cancer cells to increase in number and then spread can be boosted by stress hormones. Beta-blockers have the power to reduce stress hormones’ ability to stimulate the cancer cell and trigger the spread of the disease. However, the study has yet to be published so it is hard to assess it’s reliability.

FAST FACT

OBESITY ADMISSIONS RISEN EIGHTFOLD IN UK Hospital admissions due to obesity have risen eightfold over the last decade, say figures released by the NHS Information Centre, which said that the nation’s growing weight problem was having a detrimental effect on the health service.

With one in four adults in Britain now obese, latest statistics show that the number of weight loss operations, which include procedures such as stomach stapling, performed on the NHS have doubled in two years. Tim Straughan, Chief Executive of the NHS Information Centre, said: “This report highlights the impact of obesity not just on society, but on the NHS. The figures show a clear rise in hospital admissions, surgical procedures and drug therapies to help people tackle their obesity.”

FLAWED BENEFIT SYSTEM

ity of them with concerns about the work caA Citizens Advice report has found that seri- pability assessment – the new system deously ill people in the UK are being registered signed to appraise someone’s potential to ‘ready to work’ because of a poorly-devised work. Advisers working for Citizens Advice assessment. According to the report, people have expressed “grave concern” about the number of people unexpectedly with advanced Parkinson’s disease, being found fit for work.

Multiple Sclerosis, severe mental Between The charity is calling illness or awaiting open heart last October and for a full review of the syssurgery have been registered December tem, a rethink that would as fit to work by the reassess who should be elEmployment and Support people consulted igible for the benefit, and Allowance (ESA), brought in Citizens Advice offices study the accuracy of the in 2008 to replace Incapacity about the ESA medical assessments.

Benefit. The reformed system Responding to the report, the was brought in to give greater supDepartment for Work and Pensions said the port to those deemed able to return to some medical assessment system was being adaptform of work and a revised fitness for work ed and changes would soon be announced test was introduced at the same time. that would make it more sensitive to the However, Citizens Advice has found the needs of cancer sufferers, people with learnassessment often inaccurate and not suffiing disabilities and autism, and those with ciently sensitive. Between last October and fluctuating conditions.

December, 22,618 people consulted Citizens

22,618

1 in 4 adults in Britain are obese

Advice offices about the ESA, the vast major-

Source: guardian.co.uk

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:57 Page 19

UPFRONT 19

STUDY HIGHLIGHTS RISKS Twenty percent of companies that provided treatment and doesn’t pay send employees abroad for pro- for emergency evacuation or repatrilonged periods fail to provide them ation – without an international with international health insurance, a health insurance policy, this could study has revealed. Conducted by cost several thousand pounds.”

PMI Global – a pioneering Moreover, the study new service offering an found that one in five integrated package employers may be of insurance and leaving themof companies rely healthcare supselves exposed to on individual port for employsignificant liabilEuropean Health Insurance Card’s for ees abroad – the ity costs abroad. their employees’ research has highTwenty percent of health cover lighted the need for a those surveyed were greater duty of care unaware that their emamongst many employers that ployers liability insurance may assign staff overseas. not always cover staff working overThe study also indicated that for seas and that country-specific polithose staffed within the EU, as many cies may be required. The research as 36 percent of companies rely on in- also revealed that 48 percent of dividual European Health Insurance companies neglect to conduct full Card’s (EHIC) for their employees’ health assessments of the destinahealth cover. “It’s encouraging that a tions they send staff to, while 44 perlarge number of UK businesses are cent don’t organise vaccinations for well equipped for sending employees their employees where required. Of abroad but the financial implications equal concern is the finding that 32 for those that fail to provide employ- percent of companies surveyed fail ees with suitable health insurance can to make regular contact with staff be considerable,” says Rachael Floyd, working abroad and that one in 10 Operations Director, PMI Global. companies leave their expat em“While the EHIC entitles any ployees totally in the dark over resident in the UK to receive emer- where to turn to for health gency healthcare treatment while advice. A further 24 percent do not travelling in the European Economic provide Employee Assistance Area (EEA) and Switzerland, restric- Programmes (EAP) for psychologitions mean it isn’t a substitute for cal support while workstandalone international health ining overseas. surance. For instance, an EHIC will only provide access to emergency, state-

36%

FAST FACT

7990 patients were admitted to hospital because of obesity in 2009

GATES PLEDGES US$10 BILLION FOR VACCINES At the reccent World Economic Forum in Davos, Switzerland, revered business tycoon and founder of computer software giant Microsoft, Bill Gates, announced with his wife that they will commit US$10 billion over the next decade to help research, develop and deliver vaccines for the world’s poorest countries.

According to Mrs. Gates, who announced the initiative last Friday, the vaccines are now the “number one priority” of the Gates Foundation because of the “incredible impact” they have on children’s lives. Bill Gates added that the next 10 years must be

defined as “the decade of vaccines”.

The boost comes after a model used by the Foundation and developed by a consortium led by the Institute of International Programs at the Johns Hopkins Bloomberg School of Public Health stated that significantly scaling up the delivery of vaccines in developing countries could prevent the deaths of some 7.6 million children.

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:58 Page 20

UPFRONT 20 A FULL AGENDA Incoming European Commissioner responsible for health and consumer policy, JOHN DALLI, outlines how he sees the synergies between health and the environment in Europe.

Health and environmental matters often take a back seat when obscured by headline-grabbing issues of the day – in particular the economic crisis, growing public debts and rises in unemployment. But in reality, health and environment are key factors, which underpin, in addition to the well-being of our citizens, economic performance, recovery and success.

There can be no sustained economic recovery without a healthy population, and without high environmental and health standards. It is therefore crucial to understand how environmental factors affect the health of our citizens and of society as a whole.

The incidence of asthma and allergy is on the rise in Europe. One in every five children suffers from a chronic respiratory condition or allergy. This means a lower quality of life for those children and more need for healthcare.

There is a pressing need to address air quality and in particular in indoor environments – we need to do more to tackle the effect on people's health.

Climate change is, of course, another significant factor with massive implications for us all. We are seeing more and more extreme weather events – such as floods, windstorms, heat waves and cold snaps. Changing climate patterns trigger changes in the transmission and spread of certain diseases.

Air quality presents problems in the event of heat waves as there is little or no dispersion of pollutants. And excessive heat, and excessive cold, leads to additional deaths.

The European Commission and the EU Member States have made reducing the social impact of the financial crisis – and thereby reducing its health impact – a key priority. The Commission has already put forward a Communication on ‘solidarity in health’ last year, to help member states tackle inequalities in health between and within EU countries. This is also a key priority of the current Spanish EU Presidency. In addition, addressing health inequalities is also part of the new European Strategy for smart, sustainable and inclusive growth (known as EU 2020), which the commission put forward last week, and which will guide all EU policies.

The main achievement of the action plan has been the integration of the key policy areas of environment, health and research at European level. The time has now come to build on progress made and do better and do more.

I am confident that we can find a way to further strengthen our cooperation for the years ahead. We can give greater political impetus to this process and keep the momentum between the high level conferences that go on. Naturally, it is important that international cooperation is translated to national level, and focused on helping member states effectively implement actions.

Source: Speech at the WHO Fifth Ministerial Conference on Environment and Health

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:58 Page 21

UPFRONT 21

BILLION SPENT ON FAKE MEDICINES Western Europeans spend an esti- Outgoing European Union industry mated €10.5 billion a year on illicit- commissioner Guenter Verheugen ly sourced medicines, many of them said in December he was “extremely counterfeit, according to a Pfizer- worried” about counterfeit medisponsored survey published in cines after 34 million fake tablets March. Germans and Italians buy were seized at EU custom points in the most prescription-only drugs just two months.

Jim Thomson, chairman of without a prescription, either over the internet or on overseas trips, in the European Alliance for Access to Safe Medicines, which receives nightclubs, in shops and via friends. funding from the drug Counterfeit mediindustry, said tests cines often contain by his group had the wrong or shown that 62 even toxic ingreof 14,000people percent of meddients and are a surveyed in 14 countries said they icines purgrowing health had bought chased online threat worldmedicines illicitly were fake or subwide, especially in standard. “Does inpoor countries, acdustry have a vested cording to the WHO. They are also a thorn in the side of com- interest in this? Absolutely. But I panies like Pfizer, the world's biggest think society should have an even drugmaker, whose impotence pill bigger interest in getting this Viagra and cholesterol drug Lipitor stopped,” he told Reuters. are two of the favourite targets for il- “Counterfeit medicine is costing the industry a huge amount of legal counterfeiters.

Critics argue that the industry money but it's costing healthcare is keen to play up the issue in order providers a lot more.”

Overall, 21 percent of 14,000 to back its demands for tighter controls on medicine supply and pack- people surveyed in 14 countries said aging, thereby protecting its brands. they had bought medicines illicitly, But the problem is being taken with the rate ranging from 38 and 37 seriously by European percent in Germany and Italy, respectively, to 12 and 10 percent in officials.

Britain and the Netherlands.

Weight-loss medicines accounted for nearly half of all online purchases, followed by prescription treatments for flu, such as Roche's Tamiflu; pills for erectile dysfunction; quitsmoking drugs; and pain-killers.

FAST FACT Over the course of a day, the brain uses the same amount of energy contained in

2 large bananas – just 12 watts of power

21%

Source: Reuters

A NEGATIVE DIAGNOSIS UK health bosses are failing to Kevin Barron, who is keep a proper eye on the hospiChairman of the health committals under their authority. That’s tee told the BBC: “The governthe verdict of a group of MPs ment must make a bold decision who have raised concerns over – if improvements fail to materithe conduct of primary care alise, it could be time to blow the trust chiefs, who are responsible final whistle.” Meanwhile the for 80 percent of the UK£100 NHS Confederation, the body billion NHS budget. The MPs, which represents PCT manwho are members of agers, has retaliated by the House of claiming the reThe number Commons health port does not of managers committee, said accurately rewithin the NHS has the PCT manflect the perrocketed by agers often formance of lacked the skills its members. within the past or knowledge Steve Barnett, decade needed to encourCEO of the age the delivery of the Confederation, told the most cost effective care. They BBC: “We continue to believe also criticised them for failing to that the current system deensure hospitals use the most up signed to achieve value for to date drugs and treatments for money and hold organisations patients. It blamed some of to account has been beneficial these shortcomings on the confor NHS patients.” stant reorganisation and high The report follows the restaff turnover within hospitals lease of figures showing the and urged the government to number of managers within the provide more support for the NHS has rocketed by 80 percent managers of PCTs. within the past decade.

80%

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:58 Page 22

UPFRONT 22 A NATION’S DOCTOR In December 2009, SIR LIAM DONALDSON informed the UK government that he intended to step down from his role as Chief Medical Officer in the summer of 2010. NGH takes a look at what he has achieved in the 12 years he has held the post.

Much has changed over the 150-year history of the post of Chief Medical Officer. Infections killed people early in the Victorian era and poverty, squalor and a lack of clean water boosted their impact. And since then, while vast improvements have been made, priorities have been moved to the disease, disability and early detection, due to conditions including heart disease, stroke, diabetes, cancers and chronic lung disease. The post has been taken by a series of exceptional individuals, from Sir John Simon who inisited on publishing independent annual reports on all subjects related to public health, to Sir Wilson Jameson, who managed to sustain medical care during the blitz.

Most observers would also put Sir Liam Donaldson in this category. Appointed in 1998, Donaldson has provided a wide range of policy recommendations to the government, such as smoke-free public places, embryonic stem cell research and consent for organ and tissue retention. He has played a major role in campaigns that are now playing a crucial part in improving the health of the nation. The ban on public smoking – perhaps his greatest achievement – owed much to his support against government opposition. In March 2009, he also started an important new drive in the fight against alcohol by demanding a minimum unit price, which while currently dismissed by Gordon Brown, will certainly remain a key issue in the days ahead.

Nevertheless despite his achievements, Donaldson has faced some criticism, mainly for over-reacting to the potential swine flu threat, although it’s argued that at least Britain was prepared for what may well have been a lethal epidemic. He has also involved in decisions regarding the Modernising Medical Careers (MMC) systems and the Medical Training Application Service (MTAS), which it claims champions competence rather than excellence and substantially reduces the length of the training programme required to become a consultant. However, both been systems have been controversial since inception and in an unprecedented demonstration against it, around 12,000 junior doctors marched against MMC and the associated MTAS in March 2007.

Despite some failures it is clear that Donaldson has also achieved much over the past 12 years and there is no doubt that his successor has a lot to live up to to ensure that they match his independence and imagination.

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:58 Page 23

UPFRONT 23

A WORLD FIRST

2000, guaranteeing the spectators visual quality. The transmission For the first time an operation of of the images and the sound was neurosurgery has been captured performed using a set of optical and retransmitted live, in 3D fibres capable of 1 GB. This comstereo and in full HD. pany had to complete its Professor Jacques G. network over 300 Verly and his An operation metres right in the of neurosurgery team from the centre of the city has been captured Laboratory for to bring the fiand retransmitted Signal and bres to the cinelive, in Image ma. The fibres Exploitation were entirely dedand in full HD (INTELSIG) of icated to the project the Department of and had to be fusionElectrical Engineering and spliced to provide a continuous Computer Science (Institut glass conduit over the 16 km beMontefiore) of the University of tween the CHU and the cinema.

Liège (ULg) designed the architecAt the far end of the chain, ture of the entire chain of capture, the 3D-stereo visualisation system transmission, and projection, and consisted of DP2000 projector and provided the technical manage3D glasses. ment of this 3D event.

The ULg-INTELSIG team also developed, in collaboration with IntoPIX, a solution for 3D-stereo fullHD retransmission in JPEG

3D stereo

In this quarter’s issue of EHM, NGH’s sister publication focused on the US healthcare sector, TERRY MASON, Commissioner for the Chicago Department of Public Health, explains the importance of effective IT for a Lean organisation and reveals how technology can help manage both the day-to-day operations and drive the collection of data for performance metrics.

To read this, or any other article from EHM, go to the website www.executivehm.com and click on ‘current issue’

€56 BILLION LOST TO FRAUD

FAST FACT The UK’s NHS budget is predicted to reach

UK£110 billion by 2011

The European Healthcare Fraud and Corruption Network (EHFCN) has launched its awareness campaign highlighting that more the €56 billion is lost each year to healthcare fraud and corruption across European Union countries.

The EHFCN awareness campaign wants to stress that the money lost to healthcare fraud and corruption could be used for purposes such as improving healthcare infrastructure, healthcare education, technology and other health services, for the benefit of every European citizen.

In fact €56 billion would represent the funding necessary to pay for over 2.5 million more nurses across Europe every year; for over 3500 new healthcare clinics in Europe every year; or for over 1.7 million incubators in Europe every year. Conversely, every cent lost undermines healthcare systems’ capacity to provide essential treatment and will ultimately lead to lower quality of care, and a reduced availability of services, treatments and care.

Source: www.european-hospital.com

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UPFRONT 24

INTEGRATION IN SPAIN

RECESSION BACKLASH The effects of the recession are having a detrimental effect on the nation’s workforce according to experts at HeartMath, a recognised authority on stress-reducing and resilience-building solutions. The economic downturn forced many companies to cut back their workforce in order to survive the recession and since then cases of stress and absenteeism have been on the rise amongst the remaining workforce, causing healthcare costs to increase. Those who managed to avoid recessionrelated layoffs have been burdened with heavier workloads and longer

The Spanish Minister of Health has announced that all autonomous communities will be integrated into a single digital health system by the end of 2010. The network will allow for all Spanish citizens to receive care in any health establishment, as well as allow physicians to access patient information. The end-of-year deployment deadline was announced at the World of Health IT Conference in Barcelona.

Not all information will be shared, only the primary history, such as hospitals visits and medications used; furthermore, the patient will have the right to block more intimate medical details. All citizens will be assigned an identity code generated by a database of the National Health System. Minister of Health Trinidad Jimenez, who announced the deadline, added that Spain has become a leader in e-health with already 98 percent of primary care physicians using digital technologies, such as electronic health record systems.

The rest of Europe is close behind. It is expected by 2015 the entire European community will have a unique system of electronic health.

Source: hitm.eu

CHILD’S PLAY A third of children globally are not getting enough exercise, according to a study by the World Health Organisation. The study led by WHO member Regina Guthold found that a third of children spend three hours a day or more watching TV or on computers. The study researched the lifestyles of 70,000 teenagers in 34 countries between 2003 and 2007 and the results were published this year in the Journal of Paediatrics. It defined adequate physical exercise as being at least one hour spent doing exercise, outside of school gym classes, five days a week. Those children who spend three or more hours a day watching TV, playing computer games or chatting with friends, were categorised as having a sedentary lifestyle.

The survey found that only a quarter of boys and 30 percent of girls were getting adequate exercise. The highest percentage of active boys, at 42 percent, lived in Uruguay. Meanwhile Zambia had the lowest number at just eight percent. The most ac-

hours, forcing increasing numbers of employees to turn to employee assistance programmes for help. A worldwide benefits consulting firm surveyed 282 large companies and found that 22 percent reported an increase in unplanned absences, and 78 percent of employers cited “excessive work hours” as a leading cause of employee stress.

Towers Perrin also conducted a survey of 321 companies and found that the 2009 average annual healthcare cost per employee is US$9660 – an increase of six percent over their 2008 figures.

tive girls were in India with 37 percent doing enough exercise while Egypt had the least number at just four percent. The least sedentary children hailed from Myanmar with just 13 percent of boys and eight percent of boys classified as sedentary.

In the study Guthold didn’t explain the reasons behind the inactivity of children, but told Reuters she believed urbanisation to be a major contributor, as well as easy access to cars and TVs. “I guess it’s pretty safe to say we have a huge problem with physical inactivity among school children around the globe and we should take action,” she said.

UPFRONT NGH EU1 NEW_25 June 07/04/2010 16:37 Page 25

UPFRONT 25

FAST FACT According to the WHO,

DON’T MISS...

4000 people die every day around the world as a result of unsafe water and poor sanitation INNOVATION INSTITUTE With EHTI’s Executive Director Rosanna Tarricone P82

COMPANY INDEX Q2 2010 Companies in this issue are indexed to the first page of the article in which each is mentioned.

MIRACLE CURE

Aerometrix 117

GE Healthcare 53

Excellence (NICE) 62

Verizon 92

A look at the potential of pharmacogenomics

AGFA 71

Gremed Inc 101

NHS 36, 112

Vifor Pharma 4, 44, 45

P110

Visage Imaging 69

Allmed Medical 59

HandGiene Corp 6, 108, 109

NNIT 2

Bracco IFC

Health Care Strategy

Norrbottens Läns Landsting 54 Vital Images 79

Centers for Disease Control

International 26

Organisation for Economic

Wi-Fi Alliance 90

(CDC) 98

healthCare cybernetics 26

Co-operation and

World Health Organisation

Circle 112

Hermes Medical Imaging 75 Development 48

(WHO) 48, 98, 106 Ziehm Imaging 72, 73, OBC

European Commission 26, 32 Hôpitaux Universitaires de

PA Consulting Group 116

European Health Technology Genève 106

Parliamentary Assembly of the

Institute for Socio-Economic IBM 76

Council of Europe (PACE) 98

Research (EHTI) 82

ICT Results 60

PathoFinder 114, 115, IBC

European Parliament 26

iStategy 81

Patricia Seybold Group 46

European Vaccine

MDS Nordion 61

PricewaterhouseCoopers 94

Manufacturers 98

Meettheboss.com 47

Relay Health 87

Foster & Partners 112

National Health Service 48

Symantec 11, 92, 93

Welcome to the hospital of the future

Frost & Sullivan 66, 88

National Institute of Clinical

Ubichem 34

P122

HOSPITAL 2.0

SPECIAL REPORT

CLOSING THE GAP

26 www.nghealthcareeurope.com

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With high quality health services becoming an increasing priority, discussions around crossborder healthcare systems are coming to a head.

Will it ever be possible to find a solution that suits all? And just what and where is the future of cross-border healthcare in Europe?

NGH investigates.

O

n 2 July 2008, the EU Commission unveiled a healthcare package designed to make it easier for patients from one member state to get medical treatment elsewhere in the EU. Aimed at ensuring a clear and transparent framework for the provision of safe and high-quality cross-border healthcare within the EU, the commission issued a proposal for a directive on the application of patients’ rights in cross-border healthcare. Under the proposals, patients would not have to get their doctor’s approval for non-hospital care abroad and would be able to claim up to the amount of what their treatment would have cost in their home country.

Jo Leinen, Chairman of the European Parliament’s ENVI committee on crossborder healthcare, believes that EU health policy should give all citizens equal access to quality healthcare. He says that policies should be centred on the patients and should aim to reduce inequalities in healthcare between and in the member states. “The EU can offer added value for the member states by providing instruments for sharing good practices, knowledge and information across national borders, by supporting research and by pooling resource,” he explains, before going on to explain the potential benefits of the cross-border healthcare directive. “It aims to introduce rules for the provision of healthcare in member states different from the patient’s country of affi liation, as well as to recognise prescriptions from other member states. The rulings from the European Court of Justice (ECJ) make it clear that there is a need for legislation on patient mobility. The defi nition and set up of these policies must, however, not be left to the ECJ, but to the elected representatives of the citizens.”

Leinen believes that in a Europe without borders, freedom of movement should be applied to the healthcare sector and set up in a favourable way to patients, while at the same time ensuring that the principles of access to appropriate healthcare in a geographical proximity is taken into account. He says that the field can become a prime example of how the EU is working to improve the quality of life, and in particular the healthcare conditions, of its citizens. “Already a citizen of one member state is entitled to healthcare in any other member state when the purpose of the stay was not medical treatment – for example, in the case of accidents or sudden illnesses the costs of the treatment will be covered by the public health insurance system of the home country. Furthermore, planned healthcare in another member state is possible, if the treatment cannot be provided in the home country. However, problems with implementing the underlying EU regulation on the coordination of social security schemes remain and must be addressed in the EU legislation.”

Currently, with a lack of legal certainty regarding the entitlements of patients to seek healthcare in other member states – and more specifically, the limits that member states can impose on such healthcare abroad and the level of financial cov-

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erage – patients are left in a state of legal uncertainty, claims Leinen. “The technocrats, with incomplete understanding and appreciation of how EU is now seeking to clarify this situation with the goal to improve the healthcare delivery and consumption works, felt that this would allow for mobility of patients. In particular, the issue of pre-authorisation of treatthe more efficient distribution of care provision. For example, they cited ment in other member states needs to be clarified again, in order to ensure the possibility of an EU as opposed to a national waiting list system. This that the financial liability of national healthcare systems remains intact, could alleviate congestion at some hospitals whilst providing work and and that they are still able to function properly.” revenue for hospitals with spare capacity, but is not necessarily practical.”

Last April, in the first reading of the directive, the European ParliaIn January 2010, a group of ‘global health experts’ at the London School ment made it clear that the proposal was not about the free movement of Hygiene and Tropical Medicine and the Indian Institute of Management of health service providers but about patient mobility, and underlined in Bangalore suggested flying British NHS patients to India, where there that the autonomy of the health systems in member states should remain were no waiting lists and costs were considerably lower. The government untouched. The parliament also voted in ruled it out, probably for political reasons, but also favour of the proposal to establish a Europossibly on practical grounds – shunting patients pean Reference Network of highly speciabetween countries, even if it is to ‘near-abroad’ (less lised centres that will provide high quality than a three-hour flight) destinations, is not feasible, care to patients to receive information and says Constantinides. “At the International TEMOAS to share their experiences. The network Conference in Cologne in November last year, my could also help maximise the cost effective presentation looked at the concept of distributed use of resources, as well as develop stanhealthcare delivery, where the different elements of dards and benchmarks. the care cycle could be provided at different locaSince the original proposal for a ditions and by different providers – the opposite of a rective in 2008, little progress has been one-stop shop. I had to conclude that this, though made towards it. In fact in December 2009, technically possible, would be a compromise solualmost 18 months on, 11 out of 27 countion as opposed to a choice solution, and definitely tries, including Spain, Greece, Poland and not in the best interests of the patient.”

Dr Constantine Constantinides Lithuania, blocked the ratification of the And it’s not just continuity of care that is an draft European directive on cross-border important consideration in the directive; Constanhealthcare. So why is there such opposition tinides believes that the first big challenge to the to a directive that is looking to improve successful implementation of the directive refers to healthcare systems across Europe? the provision of ‘legal certainty’, the definition of which is currently still Dr Constantine Constantinides, CEO of healthCare cybernetics, missing from the proposal. “Countries are opposing the directive for very based in Greece, one of the countries opposing the directive, believes that simple economic and logistical reasons – they feel that as it stands the dithe impact on healthcare and its delivery will be negligible. He says that rective will make them victims rather than beneficiaries.” while the directive may lead to a ‘forced’ improvement of the quality of He also reveals a number of other technical stumbling blocks that he care and increased efficiency at home, as people are discouraged from believes mean that the proposal is currently unworkable, including the seeking treatment abroad, it will create a logistical headache. “Some feel direction of patient flow, problems around financial responsibility and that the directive will lead to the emergence of new centres of excellence – reimbursement, patient safety and non-implementation of e-health. In facilities specialising in certain conditions – and that certain locations will terms of direction of flow, some countries fear they would be inundated by become good at this because of the experience and knowledge associated foreign patients, whilst others fear the financial and political implication with treating large number of ‘same condition’ patients,” he says. “Certain of their citizens fleeing the country for treatment abroad.

Financial responsibility and reimbursement, including issues such as costing, pricing and payment procedures, has not been resolved either, says Aims Constantinides. He believes the Disease Related Grouping System (DRG) The three stated aims of the cross-border suggested for costing and pricing services is flawed and can only work if healthcare directive are: there is a large movement of patients and a balanced flow, which will tend to cancel out any credit and debit injustices.

• To help patients exercise their rights to The third issue – responsibility for ensuring patient safety – will inaccess cross-border care volve the dispatching country taking responsibility for the safety of the • To give patients assurances about the safety patient going for treatment abroad; if nothing else, the authorities must and quality of cross-border healthcare be able to advise the patient on suitable and reliable healthcare facilities.

• To help national health systems cooperate Constantinides explains that in such a scenario, the authorities, or payers, and achieve economies of scale will need to know who they will be dealing with – for example, whether the hospital or facility has some form of accreditation or medical staff with appropriate and adequate insurance cover.

“Countries are opposing the directive for very simple economic and logistical reasons – they feel that as it stands the directive will make them victims rather than beneficiaries”

1 2 3

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The future of healthcare?

Medical tourism (also called medical travel, health tourism or global healthcare) is a term initially coined by travel agencies and the mass media to describe the rapidly growing practice of travelling across international borders to obtain healthcare. It also refers pejoratively to the practice of healthcare providers travelling internationally to deliver such care.

Services typically sought by travellers include elective procedures as well as complex specialised surgeries such as joint replacement (knee/hip), cardiac surgery, dental surgery and cosmetic surgeries. However, virtually every type of healthcare – including psychiatry, alternative treatments,

convalescent care and even burial services – is available. As a practical matter, providers and customers commonly use informal channels of communication-connection-contract, and in such cases this tends to mean less regulatory or legal oversight to assure quality and less formal recourse to reimbursement or redress, if needed.

Over 50 countries have identified medical tourism as a national industry. However, accreditation and other measures of quality vary widely across the globe, and there are risks and ethical issues that make this method of accessing medical care controversial.

GERMANY is a destination for patients seeking advanced medical technology, high standards, safety and quick treatment. A high hospital density, with twice as many hospitals per capita as the US, results in shorter waitlists for treatment. Costs for medical treatment compete well with other developed European countries and are commonly 50 percent of those in the US.

THE PHILIPPINES has been growing as a destination for medical tourism. The US Medical Tourism Association magazine reported that this services sub-sector grew eight percent in 2007. The number can be expected to grow as American healthcare costs rise, or if pending legislation results in an increase in patient wait times for surgical procedures.

Factoid: German medical costs are commonly 50 percent of those in the US

Factoid: The Philippines’ medical tourism sector grew eight percent in 2007

CUBA has been a popular medical tourism destination for more than 40 years. Thousands of patients travel to Cuba, particularly from Latin America and Europe, and in 2006, Cuba attracted nearly 20,000 health tourists. Medical treatments include joint replacement, cancer treatment, eye surgery, cosmetic surgery and addictions rehabilitation. Costs are about 60-80 percent less than in the US.

INDIA’s medical tourism sector is expected to experience an annual growth rate of 30 percent, and estimates of the value of medical tourism to India go as high as US$2 billion a year by 2012. Advantages for medical tourists include reduced costs, the availability of state-of-the-art medical technologies and a growing compliance with international quality standards.

Factoid: In 2006, Cuba attracted nearly 20,000 health tourists

Factoid: Indian medical tourism is set to be worth US$2 billion a year by 2012

Constantinides also highlights the important issue of e-health.

While governments of EU countries have spent millions of euros on ehealth initiatives, almost a decade later there is still no one consistent or broadly implemented system in clinical practice. Th is poses a huge challenge and he points out that the other issues of concern cannot be successfully addressed in the absence of universal e-healthcare adoption and implementation.

Constantinides believes that, unfortunately, the blocking of the directive by certain member states will change very little. He believes that during 2010 governments around Europe will have many other economic and finance related priorities. In fact, as it is, we are seeing even the best-run EU countries announcing freezing or cuts in healthcare-related spending.

“Contrary to simplistic reasoning and thinking, during the recession we have documented a sharp drop in patient mobility and medical tourism.

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Tackling challenges Dr Constantine Constantinides has a number of recommendations in regard to the challenges currently up against the directive: Direction of Patient Flow: With regards to patient flow, we recommend that a study be commissioned (which could take the form of European action) to study the direction of patient flow, the volume and economic dimensions. The findings of the study should be used to pre-emptively instigate suitable measures aimed at averting disruptive challenges to the health systems of EU-member states likely to be net recipients of patients.

Financial Responsibility/Reimbursement: As for financial responsibility/ reimbursement, we again recommend, as a first step, that an EU-wide survey be conducted to determine which healthcare facilities are DRG and eBilling compliant, and can thus participate in the scheme envisaged by the directive. Furthermore, laggards should be encouraged or helped to conform. And as I commented already, the DRG system is flawed, but this is the best we have for now.

Responsibility for ensuring patient safety: When it comes to responsibility for ensuring patient safety, we suggest that the authorities in the EUmember states involved in cross-border healthcare, collaborate to compile a (dynamic) database of assessed and approved healthcare facilities/ providers. This database should be centrally stored and accessible by all interested parties. This database could be consulted by patients, authorities and referring physicians – for the obvious reasons.

Implementation of eHealth: Finally, on the issue of implementation of e-health, we have a similar recommendation – that an EU-wide survey be conducted to determine which healthcare facilities are e-health compliant, and can thus participate in the provision of cross-border health services. Furthermore, laggards should again, be encouraged or helped to conform. And of course, we will need to establish a new profession, that of Professional Medical Coder. In this regard, healthCare cybernetics has taken the initiative of developing a Medical Coder Course and plans to soon offer seminars on the subject.

Cross border health.indd 30

During a recession, the associated uncertainty about jobs and personal financial viability, means people are put off going abroad for care – unless it is absolutely necessary of course.”

Unlike Constantinides who foresees a logistical headache in the formation and implementation of the directive, Dr Uwe Klein, CEO of Germany-based Health Care Strategy International, believes that the healthcare system across Europe will benefit from increased quality and financial aid and sees a certain amount of innovation injected back into the industry, because countries will need to stay competitive in order to keep – and perhaps attract – patients. “The crossborder healthcare directive is important because it gives all the nationals of EU countries the right to select a healthcare provider of their choice. And undoubtedly there will now be a big stimulus for more customer orientation in the healthcare system,” he says. “As we all know, a focus on customers is not always a big issue for some medical institutions, so it seems this will become increasingly important as patients become more challenging in the types of services they demand.”

While Klein admits that the main challenge for the directive is the highly fragmented situation – for instance, there are various regulatory legislations across the region and the delivery system will need to be standardised – he says

“Patients are left in a state of legal uncertainty and the EU is now seeking to clarify this situation with the goal to improve the mobility of patients” Jo Leinen

that this not the intention of the directive; it is simply about opening up more choice for patients to select their healthcare provider. “We’re living in a democratic market and as such there are many private initiatives that are trying to ensure patients are as mobile as possible in terms of their healthcare choices. There are German insurers, for example, who are going abroad and setting up contractual networks with partner clinics. And beyond that there is a very clear jurisdiction from Brussels in the compensation of patients who have a reason to go abroad, such as long waiting lists and so on. If patients knew more about this, or if patients could get legal advice from a host country as opposed to their home country, the national health system would need to pay for it. This has occurred many times and every patient has won their case.”

Klein and Constantinides both believe that this brings a welcome opportunity for the EU to take the directive back to the drawing board and re-draft it. However, Constantinides

7/4/10 16:25:37

is quick point out that a revised draft of the directive is yet to be seen. “If there are any individuals involved in ‘back to the drawing board’ activities, they are keeping very quiet – we have not seen any signs that even a draft of a revised directive exists,” he says. “Practical and logical recommendations submitted during the original consultation, for the most part, seem to have been ignored by those drafting the directive. And it’s unlikely we will see a second consultation.

All I can say is that unless the identified issues of concern are not only addressed but also resolved, we are unlikely to see any countries having a change of heart and rushing to sign.”

Uwe believes that the current directive discussions have been frozen due to the financial crisis. “I think we will just have to wait and see,” he says. “But, it all goes back to patient mobility, which has a basis in the philosophy of human Dr rights and thus won’t go away – it’s the basic right of EU nationals to make a decision about their lifestyle and healthcare has to be part of that – it just needs to be feasible and organised so that the right systems are in place to allow this.”

Constantinides agrees that there will not be a defi nitive ratification whilst Europe remains in recession. In fact, he goes as far as saying

“God only knows” when asked about the next step for the directive.

“Even before the directive was vetoed, we started seeing the issue opportunistically included in the agenda of conferences. After the veto, we started seeing ‘topic-specific’ conferences being opportunistically staged with academic, politicians, techno-bureaucrats and some real medical tourism insiders going round in circles, inconclusively regurgitating the same old mish-mash – what comes out of these debates, presentation and deliberations can be best described as waffl ing.”

Leinen, Chairman of the European Parliament’s ENVI committee on crossborder healthcare, concludes by saying that the Spanish presidency has promised to continue working on the directive and that in the meantime, Europe will rely Uwe Klein on ECJ rulings when it comes to crossborder healthcare and treatment. “The parliament will certainly not reduce the pressure on the council to work on this proposal and come forward with solutions and it will not allow member states to abandon this important dossier.” Indeed, with the proposal at a critical turning point, the very success of the directive depends on it.

“The cross-border healthcare directive is important because it gives all the nationals of EU countries the right to select a healthcare provider of their choice”

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NeelieKroes Ed_mar10 07/04/2010 15:53 Page 32

TECHNOLOGY

A new era in e-health Neelie Kroes, Vice President of the European Commission and Commissioner for the Digital Agenda, explains the positive impact of ICT on the healthcare sector.

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s European Commissioner responsible for the Digital Agenda, I have publicly stated that one of my priorities will be to accelerate the positive impact of ICT on everyday life. In that vision, ehealth will play a key part.

There are many reasons for this. Latest research indicates that 29 percent of the EU’s population will be over 65 years old in 2050. And we are battling the deepest financial crisis in decades. These facts are not news – but combined, they tell us that great innovations will be needed to keep people healthy and comfortable in the coming decades. The grand theme of our time is the need to do more with less. Improving e-health systems is one of the best ways we can address this challenge.

At the practical level, powerful truths are lined up in support of e-health.

Chronic disease management already accounts for seven out of every 10 euros spent on healthcare. Knowing this is the area where e-health has the most potential, it would be foolish not to make the most out of it. I know all too well that it is easier to talk about these problems than it is to fix them. But the point remains that the next few years represent a huge opportunity.

The commission has promoted and co-funded research in ICT for health for more than two decades. This has translated into more than 450 collaborative projects involving partners from all over Europe, and more than €1 billion in funding. In addition to saving lives and containing costs, this has helped to build a growing industry turning over €15 billion per year. And this is the fastest growing market in the health sector.

This is good, but to truly harness this trend we must explore new avenues.

For example, I see e-health as a way to offer more control for patients on their own health. Already today, people go and look for health information on the internet – often before they even speak to their doctor. Some say we should fight this trend; I say we should make the most of it. Simply, patients must now find their doctor on the internet. And the proof that this works is in our early success with telemedicine.

I also see e-health as a means to achieving economic recovery. E-health is the fastest growing part of healthcare. And ICT is one of the main innovation factors of the pharmaceutical and medical devices industries – two industries traditionally strong in Europe. So this is also about new jobs and successful businesses, and taxpayer savings. E-health builds on two of the best assets of Europe: its health systems, and its technologies.

E-health also requires collaboration among all players in the healthcare sector. There is no single actor – government, doctor, patient or manufacturer – setting the terms of e-health. Instead, success will only come from a truly joint effort.

That last point is an important one. E-health has great potential, but we need each other to realise that potential. In my mind, the technology is more mature than the market. Yet we have already come a long way – and I value

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that. For example, our 2004 E-health Action Plan helped to test and expand our boundaries – showing that political cooperation at the European level was possible. After that, the Lead Market Initiative has helped us to understand the true potential for the growth of e-health markets. And now we are seeing that large-scale projects such as epSOS enable continuity of care across national borders. We are ready to work with and support all member states in epSOS or similar large-scale actions.

But we need to do more. Take, for example, the E-health Governance Initiative. This initiative consolidates not only new ways of working with governments across Europe, but also with stakeholders. In my view that delivers two crucial things to the field: 1) the predictability; and 2) the transparency that is so critical in enabling large groups of interests to work together.

Yet I am fully aware of just how difficult it will be to achieve this agenda. To bring about change, we will need to convince various layers

“The grand theme of our time is the need to do more with less. Improving e-health systems is one of the best ways we can address this challenge” of governments and policy areas, but also many industries and stakeholders – in particular health professionals and patients. We need to be pragmatic; I do not want to leave anyone behind. The economics of healthcare gives us all a mutual interest. In addition to better patient care, we all stand to either save or make money from the full development of e-health. This is a very powerful driver for cooperation.

Earlier in March, the commission issued its all-encompassing strategy for the years to come, Europe 2020. In April, I will unveil the ICT chapter of this strategy, the Digital Agenda for Europe. It will be our vision of how ICT can shape Europe by 2015 – and be assured that e-health will play an integral part of our ambition to make Europe a truly sustainable digital society. My intention for the Digital Agenda is to propose clear objectives and specific targets. I believe we must focus on concrete goals to mobilise and address the legal and organisational barriers that are holding back innovation in Europe. In doing so, we must also ensure we do not compromise the values we believe in – the quality of our care and the privacy any individual is entitled to.

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A key for success is to create pan-European interoperability between the various initiatives that emerge here and there. E-health is a very good example of that.

I have been inspired by examples such as the epSOS project. With 12 member states on board (and hopefully more to join soon) and 31 industry partners, epSOS shows we can set the bar high and clear it.

To me this is important because I don’t want to see us get stuck at the stage of delivering ‘only’ electronic patient records. That is, no doubt, a huge challenge in itself. But we need also to work together to deliver tools for patients that prevent health problems and personalise their healthcare. To give

just one example, wearable and portable personal health systems should be mainstreamed to become standard care. We can’t allow today’s difficulties to distract us from these long-term outcomes.

We made the right investments over 20 years to become the world leader in e-health. The investments worked because we took them early and we took them together.

Now it is time to step up another gear. Our finances demand it. Our citizens expect it. The technology is ripe. We are all rightly proud of our health systems in Europe. We have every reason to be proud to be working towards e-health for all. n

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PaulJones_NHS ED_mar10 07/04/2010 16:17 Page 36

THE BIG INTERVIEW

Re-imagining the NHS

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PaulJones_NHS ED_mar10 07/04/2010 16:17 Page 37

The UK Health Department’s UK£12.7 billion National Programme for IT – the blueprint for a technology-enabled healthcare system – has come under fire in recent years for perceived cost overruns and delays. Paul Jones, Chief Technology Officer for the Department of Health, outlines why the project is still on track.

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f there’s one thing the British public like complaining about even more than the weather, it is the state of the country’s healthcare system. Ask any cabbie in London what he thinks of the world’s most admired public health service and you’ll be met with a stream of cockney invective about how it could be improved. Quiz people in Cardiff or Edinburgh and the response will be much the same. While the accents might differ, it seems everyone from Land’s End to John O’Groats has an opinion on what is wrong with the NHS. But such grumblings shouldn’t be mistaken for antipathy, for what is also striking is the huge sense of pride most in the British Isles feel for the 62-year-old institution. The NHS is one of the largest employers in the world, along with the Chinese People’s Liberation Army, the Indian railways and the Wal-Mart supermarket chain, and employs around 1.3 million people – or approximately one in 23 of the working population. These staff members are in contact with over 1.5 million patients and their families every day, and each month more than 23 million people (more than three times the population of London) visit their GP surgery or practice nurse. In a typical week, 1.4 million people will receive help in their home from the NHS, while community pharmacies dispense around 745 million prescription items per year. No wonder the British people feel they have such a personal stake in the service.

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PaulJones_NHS ED_mar10 07/04/2010 16:17 Page 38

Hospital drives efficiencies with ITSM ITIL adoption aims to streamline IT operations and improve service to over IT 2400 users.

The Hillingdon Hospital NHS Trust – the main provider of acute healthcare to over 300,000 residents within the London Borough of Hillingdon – has selected Supportworks ITSM from Hornbill to underpin IT service management provision to 2400 nurses, doctors and administrative staff across two sites. The Trust will go live with incident and problem management initially and plans to roll out a customer self-service web interface to staff, enabling them to log their own calls in the second phase of the implementation. This is anticipated to reduce the number of calls taken by the service desk significantly from its current level of 1000 calls per week, enabling the IT team at the Trust to provide a faster, more efficient and more proactive service.

“We wanted to streamline our operations in IT and to provide a more proactive service to our customers while working to ITIL

best practice,” says Tony Anstis, IT Services Manager at The Hillingdon Hospital NHS Trust. “To do this we needed a service management platform that would enable us to keep track of the requests that we have each day, evaluate the types of calls and work more efficiently as a team. The automated workflow processes will enable us to provide a faster, more organised service while freeing up staff to work on more strategic work like bug fixes, development work and longer term projects.”

Anstis and his team evaluated several products via a tender process. “They were judged on criteria that included usability, functionality, flexibility and value for money,” he explains. “It was also important to us that the culture of the vendor fit with our own ensuring a willingness to work together. Hornbill came out top, particularly in the usability of the system.”

And it appears such affection is justified, too: in a survey of more than 10,000 primary care physicians in 11 developed countries conducted recently by leading US think tank the Commonwealth Fund, the NHS was rated top in a number of key areas – including being the only country where the majority of doctors feel the quality of healthcare is actually improving. The UK was rated top in several categories, including improvements in quality over the past three years; managing chronic conditions with specialist teams; using financial incentives to reward doctors for good patient experience; the use of patient satisfaction and experience data to improve services; and the use of comparative data to review doctors’ clinical performance. The UK was also the least likely to report long waiting times for patients referred for specialist care.

Many of these improvements have been achieved through greater use of IT, according to the Department of Health’s Chief Technology Officer Paul Jones. Since transferring to the Department’s Directorate for Informatics from his previous role as CTO of Connecting for Health (CfH),

the organisation previously charged with delivering the UK Department of Health’s flagship National Programme for IT, Jones has been influential in restructuring the IT function of the organisation to create a better balance between the needs of hospitals and facilities at the local level and the requirement to have a coherent, interoperable and collaborative national system.

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Could you give us some insight into your roles and responsibilities and where you fit into the wider IT picture of delivering IT to the NHS? I have a technology portfolio covering four main areas. The first is technology architecture assurance. So within the National Programme for IT there’s a variety of different elements, things like the London Programme for IT, PACS, Choose and Book, and many others. Each one of those has a small team of technical architects working on it to make sure that we design the systems appropriately – that the systems fit in with everything else that’s going on. Because things are never quite as easy as you’d like, and you often have to make decisions around things not being quite so ideal. What that

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Hornbill will supply Supportworks ITSM, which will sess where they are in terms of the infrastructure. The intention of that isn’t replace an existing system that Hillingdon has outgrown, just to be a scorecard, it is to help Trusts understand what they need to do next with a specialist ZENworks connector that will enable the and to help structure a plan for them. I think that we’re all guilty of doing the remote management of machines and assets and improve things we like rather than the things that we need to do. One trust might data quality. Supportworks ITSM’s powerful reporting will have a fantastic network because the guy who’s in charge loves networks. enable the Trust to easily identify trends and problem Yet some of the desktop management might not be quite at the same level areas, for instance it can provide the top 10 issues and the as the network. What the Infrastructure Maturity Model aims to do is say, top 10 callers at the click of a button. This visibility will well look, if your network’s really good and your desktop’s not so good, then enable the team to see clearly how much work is being that’s where you need to put your efforts, and here are the steps that done and will identify key strategic areas so that you need to take. What we’ve tried to do is to work with supdevelopment work can be channelled in the best pliers so that they can align their offerings with the Staff across the direction for maximum benefit.

Infrastructure Maturity toolset. So if your desktop manNHS are in contact The second phase of the implementation agement is at stage one and you need to get it to stage with more than will also include email integration so that three, suppliers should be able to say, “Here are the steps callers may email requests for assistance, and that we can help you with and here are the benefits.” So the details of their call will automatically that’s the infrastructure area. patients and populate the Supportworks system. This will As part of the National Programme for IT, I also their families save further time for the service desk agents. have responsibility for a test assurance function in the every day Gerry Sweeney, CEO of Hornbill Systems, National Integration Centre. So if you have a system that commented: “Technology is a great enabler, and as you want to plug into the spine then it’s got to go through the the whole of the public sector, including the NHS, start to National Integration Centre to make sure you’re not going to bring the see cut backs across the board, it is crucial for IT to be whole system down when you plug it in. So that’s my area. able to provide efficient services to support the organisation. Self-service portals and encouraging I guess one of the challenges for a centralised IT function is getting customers to help themselves is a quick way for service an initial picture of exactly where you are across such a huge and desks to reduce their call rates and gain extra time to wide ranging system. How do you achieve that? provide better service aligned to the business needs of I think it’s really important when you have a national function that you focus on the organisation. Supportworks has been designed not the things that it makes sense to do nationally, and don’t try to do too much – only to be easy for the service desk to use, but to provide there are 20,000 people in the NHS who do IT and they don’t all report to me! an intuitive look and feel for end customers encouraging They work very hard and there are very clear responsibilities for what they’re them to try self help before picking up the phone to the doing, and I’m not trying to tell them what to do. But there are things we can do service desk.” centrally around providing best practice, advice and guidance.

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group is charged with is making sure that when we deviate from our ideal position, it’s done in a structured way so that people know why that’s being done. There’s an agreement there as to why that deviation’s been made and ideally how we bring it back on track.

I also have a group who work on data standards across the NHS. So in the NHS we have lots of standards used on a day-to-day basis. If you go to your GP and you say, “I’ve got a cough”, he doesn’t type cough in, he types in a particular code, four or five digits called a Read Code. Those are managed by my team, as are the OPCS codes and the ICD codes which are used in hospitals for procedures and diseases. Combinations of those actually drive what’s called Payment by Results – how many acronyms can you fit into one answer!

– which is what actually drives the money for us across the NHS. So those are also managed inside the technology office.

I then have a group working on infrastructure, who are providing advice and guidance to the NHS around something called the NHS Infrastructure Maturity Model, which is part of the operating framework so Trusts can as-

We take responsibility for the nationally funded programmes; that’s where we can provide more control, more advice, more assurance and take a much more direct, hands-on position. It’s not my role to make everything in IT work exactly as I want it to work. It’s about providing advice and guidance. So right after this meeting I’m off to visit the Technology Board for Informatics, which has representatives from each of the SHAs that we consult with to establish the important priorities for us to work on nationally. There’s no point in me producing advice and guidance on how to set up a wireless network for a hospital if they’re not interested or if they’ve already done it. So the Technology Board is where we get that input from Trusts, where they can tell us what it would be useful for us to do for them centrally so that they only have to do things once rather than doing it 10 times or 100 times.

The other thing I think we can do nationally is to share the positives.

We really like to know about all the good stuff that’s being done in Trusts.

I get to travel around and see lots of different hospitals and meet lots of interesting people, and often I’ll go to two hospitals not far from each other that are trying to do two very similar things but don’t know it because they’re across a different SHA boundary, or because the communication isn’t great, or whatever. I think there’s a lot we can do centrally to just let people know what else is being done.

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So you see your role as more about facilitating collaboration between different parts of the health system?

Absolutely. In the space of about eight weeks I visited three Trusts and they were all doing work on document management, all in different phases. By simply emailing the same documents around I was able to accelerate all of their procurement cycles because they could reuse parts of the documentation and share their experiences. We saved time, saved money, and if we could do that on a slightly more industrial scale as opposed to just stumbling across it, I think that would be a real value we could add centrally. Again, it’s looking at what can you do nationally that is very hard to do locally. So that’s very much what I’m trying to focus on.

The National Programme for IT plays directly into this. Can you tell us a bit more about this programme – its history and its current status?

How long have you got? Because there’s some myth and there’s some legend.

The National Programme for IT is a very large set of programmes and projects and – I feel like I’m putting a spin on this, but it’s true – an awful lot of that has been incredibly successful. Many of those are working, they’re finished, they’re live, they’re used every day. They’re now completely embedded in the NHS. For example, one of the things that I think is a really impressive implementation is N3 – the NHS national broadband network linking hospitals,

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medical centres and GPs in England and Scotland. So before the National Programme for IT, most hospitals weren’t actually connected to the internet – or if they were they weren’t connected by anything very substantive, and certainly weren’t connected to each other in any meaningful way. But now there’s a broadband network across the whole of the NHS that is a fantastic example of technology engineering. Frankly, if that was all we’d done it would be held up as a paragon of how to do a public sector project. We’ve saved huge amounts of money by taking a central procurement strategy. Everyone needs a network, so we might as well procure that centrally. Because when you get down to it, an individual Trust as an organisation lacks buying power, certainly in global terms. But when you group the NHS together as a whole it’s enormous, and that’s when you get the real economies of scale.

In order to drive efficiencies in the NHS going forward, one of the things

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we have to do is to be able to link medical records together. To link The National Programme for IT has come in for a fair amount of criticism medical records together you need an identifier – and if you want over project delays and cost overruns. Is this criticism justified? an identifier, you need a single place for the truth. So we’ve rolled Lots of things inside the National Programme for IT have been delivered, are out the Personal Demographic Service (PDS), which stores basic deshowing benefits, and it’s a shame that the many people and suppliers who’ve mographic information about each patient and their NHS number. worked on those projects don’t get the credit they deserve, to be quite honest. We I think last month 50 million messages hit the PDS where peodon’t do this do be seen. We do this because we care and we want things to ple were checking the NHS number was right, making be done better. So I think in terms of the National Programme for sure we’ve got the most recent address so that apIT, there’s been an awful lot of good stuff done.

The NHS pointment confirmation letters and other pieces of corWhere we’ve had challenges – and we’ve admitted to employs around respondence don’t get lost, etc. That has a huge benefit them and we’re not trying to hide from them in any way in terms of being able to drive interoperability for– is dealing with the acute sector. The acute sector is big, ward, but also to do simple things like reduce the it’s difficult, it is challenging. So one of the things we are people. This is number of letters sent out to the wrong address, which focused on right now is looking at the changes we need approximately one in in turn reduces the number of ‘does not attends’ that to make to be able to have a plan of delivery for the acute 23 of the working really adds to the costs for the NHS. sector that’s affordable, that ties with our current strategy population So those things have been delivered and work. Choose priorities and that suppliers are able to deliver. How do we and Book is another good example – my wife is currently dealbring all that together? ing with the NHS so her GP had to make an appointment at the hosThere is a myth out there that the cost of the National Programme pital, and through the Choose and Book system she was able to plan her has run way over, but that is not the case. The budget is UK£12.7 billion, and beappointment so she could drop the kids at school, get to the hospital, get fore Christmas it was announced that this would be trimmed by a further back to pick the kids up, etc. That kind of stuff really helps patients in a UK£600 million. To date we’ve spent less than 50 percent of that, and that’s bemeaningful way, and it is certainly cheaper for the NHS in terms of reduccause we don’t pay suppliers until they’ve delivered. So it’s about protecting taxing the whole paper trail. payer’s money.

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I think that touches upon an important point, which is that technology is really only an enabler, and it shouldn’t interfere with getting the job done. Do you agree?

Absolutely. I was at a patient conference last month and was asked whether my target was to make everything in the NHS electronic. I don't think in those terms, and that’s not a target I hold. My intention is that where there are clear benefits to patients, clinicians and the NHS from enabling processes or systems through the use of technology, then we’ll enable them. It’s about what can be made better, not putting in technology for technology’s sake. We’ve never done that.

How do you balance the needs of healthcare professionals at the local level with the need for a comprehensive view of the use of IT systems nationally? Are there conflicting interests there?

I don’t think there are conflicts of interest. You may get misunderstandings, you may get people being too dogmatic about certain things, but I don’t think we’ve ever had conflicts of interest between technologists at the central and local level. What’s important for me in a national service is that people feel that they can contact us and tell us what they’re planning to do just in case we can help. And even if we can’t help in that particular instance, then at least the next time someone tells us they are doing something similar we can provide them with advice and guidance based on the outcomes from that first instance, and put them in contact with people who might have had similar or useful experiences in the past. So I don’t see a conflict of interest really. I do think our responsibility is to The overall cost try and provide the glue to try and bring some of this of the National together. We have national services I would like to see Programme for IT is used and if there are challenges that stop those services from being used, then I need to know about them so that we can fix them together.

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So it is more like a roadmap than a single initiative?

It’s made up of lots of individual programmes. I think across the NHS we’ve deployed something like 32,000 different systems, everything from theatre systems in hospitals through to new patient administration systems in community clinics. And the successes of those small-scale rollouts have led us to reexamine our strategy around system deployments.

A few years ago I visited a small community hospital in the Manchester area and they’d installed a relatively simple administration system that was helping drive some fantastic results. For instance, they’d managed to shorten their waiting times for appointments from around six months down to about three weeks, and it wasn’t the technology that had done that, it was the fact that they now had a standardised process for managing appointments that everyone bought into and supported. Under the old model we’d probably have said, “Okay, that works for now, but at some point in the future we’ll replace it with this big strategic solution.” But if you look at it, the existing system is incredibly valuable to them and working well; does a small community hospital need an awful lot more than that? Is the pain and effort of doing another system replacement worthwhile for them? Is there a patient or a clinical benefit? If there is then that’s great, but let’s look at that decision rationally rather than just saying we’re going to replace it for the sake of replacing it.

So where things have been deployed and are successful and there isn’t a case to make a change, we’re not going to force it through just because of an ideological need. Let’s be sensible about it instead.

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One of the items that has been much in the news recently is the idea of electronic patient health records. So what are the challenges and opportunities presented by implementing a system of electronic health records?

In the UK I think we’re years ahead of most other countries, particularly in terms of primary care. Most GPs are using electronic systems and are paperfree in many cases. So regarding the benefits, go ask a GP – many of them are reporting clear benefits both in terms of the security of the electronic record and the ability to retrieve it and share it. Many of the most significant challenges in health happen because the right information’s not available at the right time and in the right place. When a certain piece of information is held in a filing cabinet in a clinic or in a records management department in the basement of a hospital, then there are challenges with regards to sharing that piece of information with the next care setting that requires it. And digitising that data is only part of the solution. For example, in Lincolnshire two summers ago we had horrendous flooding, and some of the places that were affected were GP surgeries. In that case, even if you had electronic records, if they were on your PC on your desk, they were about as much use as the paper records that were floating around the office as well.

What we’re trying to do in the National Programme for IT is to say it’s not just about things being electronic, it’s about things being treated in a

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professional way. If you go into your bank and you ask them for the balance, they don’t have a computer on the desk with your bank details on it; your information is held in a secure datacentre and that datacentre has another datacentre about 30 miles away with dark cabling in between that keeps the information backed up and synchronised. That’s how we should look after patient records and that’s what we aim to do with the National Programme for IT: build out multiple datacentres. If you were to visit the datacentre that holds the NHS spine, it’s very secure: it’s filled with security guards, and if there’s a power cut they’ve got three generators and weeks of fuel in there.

I think of patient records as being precious. And if something’s precious there’re two things you need to do: you need to keep it secure and you need to be able to find it. I actually visited a records department where the lift had got jammed because there were so many records falling down the lift shaft. It was a real horror story. And while those medical records were very, very safe – no one was going to be able to read your medical details – they weren’t being treated as precious. We need to treat medical records as precious, meaning you have them in secure datacentres, and you have them backed up at other datacentres. Then, in the case of severe flooding as in Lincolnshire a few years back, you could just move to a different location, we could give you a new network and you’d be up and running with all your patient data safe, secure and available. That’s a huge benefit. And that’s not just about it being electronic, that’s about it being electronic and treated properly.

And so finally Paul, what are your technology priorities over the coming 12-18 months?

I think we have some challenges around interoperability. So for me there’s work to be done on our standards, there’s work to be done around working with suppliers. That’s really key for me, but I don't see there being an instant interoperability fix; I’ve learned that health doesn’t work that quickly. But if we can change people’s mindset about how the relationship between the suppliers and the NHS is supposed to work, I think it would be a fantastic achievement.

I think we also need to put some effort over the next year into making sure that people know that the demographic service is out there and it can be used. Millions of messages are being sent every day so we must be able to communicate that to the organisations that aren’t currently using it for whatever reason. Because if we don’t have a unique identifier on a patient’s electronic records, then we can’t start sharing the data in any kind of safe way.

To realise the true benefits of e-health we’ve got to put these building blocks – interoperability, data standards, common identifiers – in place.

Once you implement those things, everything becomes much easier and we’ll start to see the benefits of that. I think by focusing on some of those building blocks we can really set the NHS up for the future, which is what I care about.

I guess that’s part of your role really, isn’t it? Taking the longer view that the Trusts aren’t able to do because they’re mired in the day-today operations…

Yes. But I hope we take that longer view with the Trusts rather than trying to fight against them; that we take those steps in a pragmatic way. I don’t want to live in an ivory tower. That’s not a comfortable place to be. ■

Myth-busting Since its inception, the National Programme for IT has evoked a huge amount of interest, debate and controversy – much of it unjustified.

• The technical architecture is flawed The National Programme for IT is a platform that will ensure that all systems within the NHS can work together. It is not one enormous IT system. There is a robust technical architecture designed to cope with enormous volumes of traffic, while the new applications are being delivered gradually – there will be no ‘big bang’ – which will ensure that the new systems continually evolve and there is a resolution of any problems that arise.

• The cost is spiralling The overall cost of the National Programme for IT is UK£12.7 billion over 10 years, and the National Audit Office’s report in June 2006 confirmed that the National Programme for IT in the NHS is much-needed, wellmanaged and on budget. Independent analysts Ovum have estimated that UK£4.4 billion is being saved through central procurement of IT systems by the NHS compared with what could have been achieved by individual NHS organisations purchasing the same systems separately.

• The project is plagued with delays The Summary Care Record, which will provide an electronic summary of a patient’s medical details wherever they are needed in England, is behind schedule. This is because the new software is challenging and there is a debate in the medical profession about what information should go in the records. But substantial progress is being made on other parts of the National Programme for IT. The work is about delivering benefits’ it is better to get the tasks right rather than sticking to a rigid timetable.

• Electronic patient records risk patient confidentiality Strict and robust safeguards will be in place to protect the security and confidentiality of every patient’s healthcare records. Access to records will be controlled by the use of smartcards that use chip-and-pin technology and have to be inserted into a card reader attached to a computer before the user is allowed access to patient records. How much they can see of the records will depend on their role in the NHS organisation. Smartcards are issued only after stringent identity checks.

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EXECUTIVE INTERVIEW

Addressing pre-operative anaemia management Christoph Springer explains the importance of patient blood management.

How has Vifor Pharma’s expertise in providing treatments for iron deficiency helped patients?

Christoph Springer. Vifor Pharma is a leading company in iron therapy and the management and treatment of anaemia and iron deficiency. One of Vifor’s leading products is Ferinject (ferric carboxymaltose), a novel formulation of intravenous iron indicated for the treatment of iron deficiency when oral iron preparations are ineffective or cannot be used, and has been shown to rapidly improve haemoglobin levels. Ferinject can be administered by a healthcare professional, and provides a choice of fast administration methods: high single dose drip infusions of up to 1000 mg iron, but not exceeding 15 mg iron/kg body weight, in 15 minutes only, or bolus injections of 200 mg iron. Th is gives Ferinject a dosing flexibility enabling iron replenishment to be adapted to individual needs. Importantly, no test dose is required before the administration of Ferinject.

Vifor Pharma’s expertise in iron therapy enables it to work with clinicians to develop patient blood management strategies, which identify patients at risk of transfusion and provide a management plan to reduce or even avoid peri-operative transfusions. Patient blood management comprises three elements: the correction of a low pre-operative erythrocyte mass or anaemia; minimising peri-operative erythrocyte loss; and using minimal haemoglobin-based transfusion triggers. Thus, patient blood management can potentially improve patient outcomes and may lead to considerable fi nancial savings as transfusions can be costly due to high blood acquisition and administration costs.

Why is patient blood management important?

CS. Patient blood management has been adopted worldwide by a number of hospitals and health networks, and its success has led to many others considering implementing

this strategy. An expert-panel review of the medical literature on blood transfusions at the International Consensus Conference on Transfusion and Outcomes (ICCTO) concluded that the majority of studies show an association between red blood cell transfusions and higher rates of complications such as heart attack, stroke, lung injury, infection, kidney failure and death. Additionally, blood is a precious resource with an ever-limiting supply due to an ageing population.

The treatment of pre-operative anaemia is integral to patient blood management. Preoperative anaemia is common: over a third (35 percent) of adults scheduled to undergo elective orthopaedic surgery were found to be anaemic at pre-admission testing. Thus, it is recommended that all patients should have their haemoglobin levels assessed at least 30 days before scheduled surgery, and if necessary, should be treated pre-operatively.

“The treatment of preoperative anaemia is integral to patient blood management"

Christoph Springer is Global Head of Anaemia TA Marketing at Vifor Pharma, the pharma business sector of the Galenica Group, which researches, develops, manufactures and markets pharmaceutical products, with focus on the treatment of iron deficiency. The Swiss-based company is a world leader in this particular field.

Springer is proud of Vifor Pharma’s growing reputation for developing novel medicines that treat unmet needs especially in anaemia.

bidity and an increased requirement for blood transfusion (and its own associated risks).

Treatment options for anaemia linked to iron deficiency are oral or intravenous iron.

Have any healthcare systems already adopted patient blood management?

CS. The Western Australian government’s

Why is it important to treat pre-operative anaemia?

CS. Patients with iron deficiency anaemia prior to surgery are at high risk of receiving a blood transfusion. An Austrian study of 3622 patients undergoing total hip replacement, knee replacement, hemicolectomy or coronary artery bypass graft surgery in 18 hospitals found that 62 percent of anaemic patients needed a blood transfusion compared with 32 percent of non-anaemic patients.

Patients with anaemia who undergo surgery face increased risk of mortality and mor-

Department of Health is implementing patient blood management as a standard of care state-wide. The reasons for this include the true cost of blood transfusions, which are estimated to be up to five percent of the Western Australia’s public healthcare budget; expected blood shortages because of an ageing population; patients being able to give informed consent for patient blood management; and growing knowledge of the limitations and adverse outcomes with transfusion.

References available on request

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SOCIAL MEDIA

Making connections NGH talks to Matthew Lees, Consultant and Vice President at the Patricia Seybold Group, about the opportunities that the use of social media can bring to the healthcare sector.

What are the benefits of implementing a customer-centric approach and social media within the healthcare industry?

Matthew Lees. Healthcare tends to have particular challenges around privacy and the seriousness of the conversations. In healthcare, if you are creating an environment for people to communicate and share their stories with each other – things that have worked for them, things that haven’t worked for them, ways of getting information you need or getting results that you need – whoever is sponsoring those conversations needs to be particularly careful.

Part of it is ensuring a safe environment. It’s part moderation and policing to make sure it’s a comfortable environment and that the community is a friendly and productive place.

Are there any approaches that have worked particularly well in the healthcare sector regarding for the implementation of social media or social networking in a community-centred task?

ML. An example that’s often given, from the physician perspective, is the Sermo site, where physicians can communicate with each other. It’s password protected and anybody can join, though you need to be a physician to do so.

The site uses a lot of social and engagement approaches to helping physicians, not only with medical work, diagnostic work and reading between the lines on different products and medications and drugs, but also on the processes that physicians have to deal with.

From a patient perspective, what many people find helpful is sharing their stories and reading the stories of others, people who have been in similar situations and are dealing with the issues, whether it’s helping support an elderly parent or children with medical conditions.

Regulation must be a key challenge for any healthcare organisation looking to get started on a crowd sourcing social media type initiative. What challenges do healthcare institutions face in terms of regulation around things like HIPAA? ML. HIPAA underscores the importance of involving your legal team in the early stages in the design of whatever customer-facing programme you’re setting up. There’s not a lot of case law around online communities and legal aspects, whether it’s intellectual property or privacy of information.

There haven’t been that many cases, and so there’s always some uncertainty there. But for any of these kinds of programmes, you want to make sure that your organisation is receptive to what you’re hearing and that you determine your business goals and your success. What would constitute success of the program ahead of time?

You figure out what technology resources you’ll need, what people resources you’ll need, and you need to think about risk. And you’ll want to involve your corporate communications and your legal team in those conversations early on.

You mentioned technology requirements. What kind of considerations should healthcare organisations keep in mind when selecting a technology solution for their social networking initiative?

ML. One requirement relates to security and HIPAA. There’s a huge trend towards soft ware-as-a-service and putting technology in the cloud. So one question to be asked early on is, are we going to host the data? Are we going to host the community, the crowd-sourcing programme?

Is that going to be done internally on our own servers in our own datacenter, or are we using a vendor, a provider that hosts everything in the cloud?

There are soft ware-as-a-service companies that run stuff out of their own servers, which can meet any security constraints that there are. At first, healthcare wasn’t using these companies so much. They wanted to run them themselves, but as these datacenters improve their security and their compliance, these are stronger options.

Integration and extensibility are becoming important these days, and these applications, less and less, are living by themselves as islands.

Everything is starting to connect with everything else. For example, there’s the social web: maybe there’s a crowd-sourcing application or a community that you’re running on a platform, but other people in the community are also on Facebook. Maybe some people are using Twitter.

It’s becoming an incresingly important technology requirement that these applications can integrate with other systems such as Facebook, such as Twitter, such as a CRM system with customer information. You want these applications to be able to talk to each other.

Matthew Lees is a Consultant and Vice President at the Patricia Seybold Group.

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COUNTRY FOCUS

The

best in the

system

world?

Healthcare reform is a highly emotive issue on both sides of the Atlantic.

NGH takes a look at how health systems in Europe and the US measure up.

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A

s the battle to reform the US healthcare system continues, those of us in Europe look on with interest, and sometimes, frankly, puzzlement. Why do the Americans seem to prefer to risk bankruptcy in the face of a particularly debilitating illness rather than ensure that all citizens have health insurance? Why, in the face of overwhelming evidence to the contrary, do many of them proclaim their health system to be the best in the world?

According to figures compiled by the Organisation for Economic Co-operation and Development and the World Health Organisation, prior to the reforms being passed, the US spent US$7290 per capita on healthcare (16 percent of GDP). Infant mortality in the country stood at 6.7 per 1000 live births in 2009, and life expectancy at birth was 78.1 years.

Compare these numbers to two European countries with more universal access to care, France and the UK. In 2009, France’s healthcare spending was US$3601 per capita (11 percent of GDP) and the UK’s was US$2992 (8.4 percent of GDP). Infant mortality was 3.8 per 1000 live births in France and in the UK 4.8.

French citizens could expect to live on average 81 years, and UK citizens 79.1.

Even a cursory glance at these numbers shows that something doesn’t add up. The US spent more than twice as much on healthcare as France and the UK, and yet its life expectancy is lower and – perhaps even more shocking for a country widely considered to be the most advanced and most powerful on earth – its infant mortality rate is decidedly higher.

With these facts in mind, NGH decided to have a closer look at how health systems on both sides of the Atlantic developed into the ones we know and love – or not – today.

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The birth of public health

to cover wage earners. The country’s experiences during German occupaOtto von Bismarck is credited with establishing the world’s first univertion led to the post-war adoption of the Securite Sociale, a programme of sal healthcare system, when he introduced a health insurance bill in Germany healthcare and pension benefits that remains the basis of French healthcare in 1883. However, most current systems providing universal coverage were to this day. established after the end of World War II, following the signing of the Like its American counterpart, the system was initially funded Universal Declaration of Human Rights in 1948. The related International through payroll deductions: a 16 percent deduction from wages, with 10 Covenant on Economic, Social and Cultural Rights, adopted by the UN percent paid by the employer and six percent by the employee. However, General Assembly in 1966, contains an article that recognises the right of in contrast to the US, the French government provided 80 percent of payeveryone to “the enjoyment of the highest attainable standard of physical and ment, while private insurance companies covered the rest. The Securite mental health”. The US has not yet ratified the sections of the covenant dealSociale now provides healthcare coverage to 99 percent of the country’s ing with social and economic rights, including healthcare. population.

One example of a universal system, the UK’s National Health Service (NHS), was founded on July 5, 1948 by then Early advances Currently as Minister of Health Aneurin Bevan. Bevan’s aim was to Healthcare in Germany also has a long history, beginmany as provide good healthcare for all, financed entirely ning with von Bismarck’s landmark bill in 1883. As early through taxation. For the first time, hospitals, doctors, as 1885, statutory health insurance, known as GKV, proAmericans (15.3 % nurses, pharmacists and others directly involved in vided access to quality healthcare for 26 percent of those of population) do healthcare were brought together under one umbrella earning low wages, or 10 percent of the population. This not have health organisation. was gradually extended by raising the income level below insurance Bevan wanted the new system to be democratically acwhich people were required to contribute. In 1918, coverage countable to the people through Parliament, giving the Health was extended to the unemployed; to seamen in 1927; and in Secretary a lot of power over the funding and how the money was 1930 to all dependents. used. The Health Secretary is in charge of the Department of Health, which is In 1941, the German government extended coverage to retirees, and ultimately responsible for running the NHS. The department sets priorities, passed legislation allowing those whose incomes had risen above the ceiling allocates money and oversees the management of the service. Below this, the to continue with voluntary contributions. In later years, agricultural workers, system is divided up into Strategic Health Authorities, and below that again students and the disabled also gained coverage. When Germany split in two it is split into Primary Care Trusts and NHS Trusts. after World War II, East Germany set up a centralised state-run system, with Across the channel from the UK, the case of the French health system is doctors becoming state employees, while West Germany re-established the particularly interesting. Although the French system has existed in some form prewar system. for 100 years, before World War II, people bought health insurance from fraHealth services in Scandinavian countries are also financed through ternal associations, much as the Americans once did. In the 1930s, the gova combination of government funds and private insurance programmes. ernment brought in a mandatory system similar to the American Medicare In Denmark, most treatment is given by individual physicians, while in

47.5 MILLION

HEALTH SYSTEMS COMPARED

France France boasts a national social insurance system with elements of tax-based financing and voluntary health insurance. The state regulates the health system and the statutory health insurance funds. It sets the limit for health insurance spending, approves a report on health and social security trends and amends benefits and regulation.

The statutory health insurance system is divided into three schemes. The general scheme covers about 84 percent of the population, including employees in business and industry and their families; the agricultural scheme covers farmers and their families (7.2 percent of the population); the scheme for self-employed people covers five percent of the population. In 1999, the government brought in universal health insurance coverage on the basis of residence in France (99.9 percent coverage); and in 2004 an insurance fund for dependent older people was established.

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“As the populations of Western countries continue to age and healthcare requirements increase, reformers must stress the message that the system in place in any given country is not necessarily the best one to meet its citizens’ changing health needs”

Norway, Iceland, Sweden, Finland and Iceland, it takes place at public health centres.

In Sweden, the central government is responsible for hospitals and health services, through the National Board of Health and Welfare. Services under the 23 county councils are divided into the regional hospital service, the provincial hospital service and the primary health service.

Each of the six Swedish regional hospitals is associated with a university; the universities are run by the central government, while the hospitals are re-

gional. Private healthcare does exist, but on a limited scale: approximately 15 percent of all medical consultations are given by private practitioners.

While several European countries brought in legislation to deliberately establish their universal healthcare programmes, the origin of the current health system in the US was more haphazard. Up to the early 1920s, Americans spent an average of US$5 a year on medical care (US$100 in today’s money), mostly only ‘cure-all’ potions from dubious sources. Hospitals at this time were primarily places where the destitute went to die.

Germany

Sweden

The German system is based on social health insurance and also consists of three schemes. About 87 percent of the population are covered. Mandatory membership applies to about 77 percent (based on income) and is voluntary for 10 percent.

Ten percent of the population are covered by private health insurance; two percent by governmental schemes and 0.2 percent are not covered by any third-party scheme.

Coverage is fully portable, with eligibility and benefits independent of any local reinterpretations by insurers, politicians, administrators, or healthcare providers. Universal coverage is honoured by all medical centres and hospitals.

Sweden has a compulsory healthcare system that is predominantly tax-based, providing coverage for every resident of the country, although there is some voluntary insurance that gives supplementary coverage. The system is regionally based and publicly operated, organised on the national, regional (23 counties) and local (290 municipalities) levels.

The Ministry of Health and Social Affairs ensures the efficient operation of the system at a national level. The National Board of Health and Welfare is the central advisory and supervisory agency for health and social services, and there are several associated national institutions, such as the National Social Insurance Board, which guarantees uniformity and quality in the processing of insurance and benefits.

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With the advent of modern medicine – particularly antibiotics – hospitals began to promote themselves as somewhere to go to be made better. Still, people only paid for care if they were desperately ill, and hospitals began to look for ways to increase their patient numbers. Baylor University Hospital in Dallas decided to offer a deal to a group of local teachers: they would pay 50 cents a month and the hospital would cover the bills for any hospital visits. When the Depression hit, the scheme’s popularity soared, and it eventually became known as Blue Cross.

During World War II, factory owners used health in“The NHS is one surance benefits to attract workers. In 1943, the IRS of the largest made employer-based healthcare tax-free, and a secemployers in the world, ond law passed in 1954 bumped up the tax advantages along with the even more, paving the way for the existing multiChinese People’s Liberation Army, the payer system.

Indian railways and What lessons can President Obama and his healthcare Wal-Mart” reform team draw from the history of those systems providing more universal coverage? It is clear that the growth of a country’s health system is largely a result of accidents of history. In a few cases, such as the UK and Germany, universal care was established through legislation; but in other instances, most notably the US, one thing literally led to another. This is somewhat ironic, given that people often become irrationally attached to their current system and put up strong resistance to change.

As the populations of Western countries continue to age and healthcare requirements increase, reformers must stress the message that the system in place in any given country is not necessarily the best one to meet its citizens’ changing health needs. As the figures on the current American system show, just because it worked in 1943 doesn’t mean it does now. n

UK

US

The countries that make up the United Kingdom – England, Northern Ireland, Scotland and Wales – are individually responsible for their own healthcare. They fund healthcare mainly through national systems of taxation, with services being delivered through public providers. Purchasing responsibilities have been devolved to local bodies (Primary Care Trusts in England, Health Boards in Scotland, Local Health Boards in Wales and Primary Care Partnerships in Northern Ireland).

Coverage is available to all legal residents of the UK, residents of the European Economic Community and citizens of other countries with which the UK has reciprocal agreements. Private medical insurance does exist, but has quite a low uptake – about 11.5 percent of the population.

Although now on the brink of reform, for many years the US health system has been funded mainly by the private sector, through insurance available from employers or other private schemes.

Currently as many as 45.7 million people (15.3 percent of population) do not have health insurance.

The federal government is involved in two main schemes, Medicaid and Medicare, each covering about 13 percent of population. Medicaid is funded jointly by the federal and state governments and covers low-income or otherwise needy groups such as the disabled or children from impoverished families.

Medicare covers people 65 or older, some younger people with disabilities and those on dialysis or undergoing a kidney transplant.

Most doctors practice privately and are paid through discounted fees paid by private health plans, public programmes and direct charges to patients. Public and private hospitals provide inpatient care, with hospitals paid through a combination of charges per admission and capitation.

Sources: www.euro.who.int/observatory, news.bbc.co.uk/

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INSIDE STORY

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On The

Front Line Ensuring safety, improving efficiency, modernising IT strategies, developing staff training: no doubt about it, hospitals across Europe have a balancing act on their hands. At Sweden’s Norrbottens Läns Landsting CEO Elisabeth Holmgren reveals why a focus on quality and efficiency is imperative to improving hospital operations.

P

laying a central role in healthcare delivery the hospital is often ignored in healthcare policy and by academics alike. But hospitals shouldn’t be underestimated. Firstly, they account for a substantial portion of the healthcare that patients experience – around 50-80 percent – and secondly, their position means that the policies the hospital adopts, which determines access to specialist service, has a major impact on overall healthcare. Also, technological development – as well as more attention to evidence-based healthcare – means the services that hospitals provide have the potential to significantly affect population health. Numerous research studies have proven that significant improvements can be made within limited resources if hospitals recognise what can be achieved, set standards and invest in the relevant design expertise. Needless to say if hospitals are ineffectively organised the potentially positive impact can be reduced or even negative.

An extremely stressful place for patients, families and staff, the hospital environment is critical. However, for the most part, hospitals can be noisy, have a complicated layout, inadequate ventilation and air quality with poor positive distractions, or suffer from all of these to name just a few. These environments are understood to contribute to medical errors, as well as lack of sleep and increased anxiety, which at the very least can slow down the healing process and may even result in serious injury or death.

And it’s not just daylight and space that can make a huge difference between a well performing hospital and one that isn’t quite up to scratch: the role of information technology in providing high quality healthcare is rapidly growing. Traditionally healthcare has seen lower levels of investment in IT than other service industries, which has resulted in a number of problems for healthcare providers with systems in desperate need of modernisation to overcome the challenges that have arisen over the years, including a disparate mix of soft ware systems that struggle to share information.

However, IT is changing and today’s models are enabling providers to improve the quality of patient care by fully exploiting the new tools and information that systems can provide. Soft ware supports core medical processes while hardware allows east access to information at the point of care.

And, while European national policy makers broadly agree on the critical objectives of a universal healthcare system – the list is surprisingly straightforward – including universal access for all citizens, effective and responsive care and efficient

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HEALTHCARE IN SWEDEN Costs for health and medical care in Sweden amount to approximately nine percent of Sweden’s GDP, a figure that has remained stable since the 1980s. 71 percent of health care is funded through local taxation, and county councils have the right to collect income tax. The state finances the bulk of health care costs, with the patient paying a small nominal fee for examination. The state pays for approximately 98 percent of medical costs.

use of resources, actually implementing this list has proved difficult to implement, particularly at hospital level.

A constantly changing – and improving – industry means that better treatment methods and more effective drugs are being developed all the time, and with patients demanding increasingly better service there is a huge demand on the healthcare system to defi ne and improve the role of the hospital to be able to deal with these ever mounting challenges.

In fact, now more than ever before, hospitals are challenged with ensuring safety while improving efficiency and increasing survival rates, as well as taking on board new initiatives contributing to a more universal healthcare system. Regularly fi nding itself top of worldwide healthcare systems, Sweden’s healthcare is the envy of many other countries around Europe. But what is it that makes this system so successful? Well, fi rstly, the entire population has equal access to a healthcare service that is governmentfunded and heavily decentralised. And while the role of central government is to establish principles and guidelines for care and to set the political agenda for health and medical care, ultimately the way care is managed falls to one of the 21 county councils in the country.

Quality care CEO for Norbotten Läns Landsting county council, Elisabeth Holmgren is typically found in a meeting with her top management team. Responsible for the entire organisation, including five hospitals (Sunderby Hospital, Piteå Älvdal Hospital, Kalix Hospital, Gällivare Hospital and Kiruna Hospital), she claims that the most important issues for her are good communication with the management team in order to do the most efficient job possible and promoting top quality healthcare. “Outlining my leadership system is an infrastructure in which we have regular meetings and discuss certain key aspects of healthcare and how to make decisions around improving these areas. We also have tools that we are working on to support our staff in order to help them achieve their goals. For instance, one of our focus areas is around access to healthcare, which has traditionally been a problem in Sweden, however, we have very good access to healthcare here and continue to work to ensure this remains the case.”

Ultimately the key for Holmgren is to have enough knowledge to know which tool to use and when. “No tool by itself could solve any focus area if we hadn’t decided – via the management team – what we wanted

Norrbotten has reduced HAI’s by

50%

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Kalix: to achieve. And when we made that decision we chose the right tool to support what we are going to achieve, and that’s a knowledge all by itself.”

One of the tools that Holgren places a great deal of importance on is IT. She believes that it should be at the heart of what the hospitals are hoping to achieve and a key Kiruna: factor in how to actually achieve it. “No doubt about it, we Rheumatology is need to think of IT systems as a tool to support what we want to achieve integrated with the is extremely important – and these new technologies coming through countywide function at really need to support what we want to achieve and will play a key part Sunderby Hospital, and in how we get there.” dialysis with Gällivare With IT a huge aspect within the functioning of any hospital, ensurHospital. ing that a system that supports the entire County Council of Norbotten has been a huge challenge for Holmgren. She explains that one of the Piteå: IT systems in place has been around for two decades now and includes medical records as well as everyday activity that is connected to the care Planned activities of patients, which is unique for Sweden. Today, while other county in orthopaedics as councils around Sweden are still struggling to implement infrastrucwell as polyclinic ture that allows communication between hospitals and primary gynaecology. healthcare, Norbotten Läns Landsting has none of these issues.

However, the situation has changed recently regarding ehealth in the country. Th ree years ago there was a decision at Gällivar: a national level that meant Sweden was intending to build a Functions as a medical centre national e-health strategy and an infrastructure that would for the Orefields district and make it possible to communicate between different IT sysis responsible for major and tems in various regions in order to access medical records resource-demanding surgery around the country. “There has been great deal of money put in the northernmost part of into the infrastructure from both the government and the the county. different county councils,” explains Holmgren. “We have come quite a way on this and have the infrastructure all over the country which means that it is now possible to communicate between the various county councils in Sweden.”

HEALTHCARE IN NORRBOTTEN COUNTY As Norrbotten already had the one system in place it was easy on a Each district hospital has its own area of specialisation: local level to ensure that all five hospitals in the region were integrated, but now Holmgren is looking at spending money on this local system to bring it more up to date and look to support a system where, for instance, Primary care is the core activity in Sweden and it will be possible to do long-distance consultations, or support doctors many clinics in locations far from hospitals function as mini-hospitals. Alongside the clinics are a regional hoswho are in surgery. “So far, it’s certainly a very worthwhile investment pital and four county hospitals with different areas of and it will certainly be a key feature of the system in the future and will specialisation in addition to basic care. allow us to continue to develop ways to work in a smart and efficient way.

The five hospitals complement each other in terms It’s both a question of quality in the IT systems that are used and ensurof expertise and equipment. Sunderby Hospital is the ing that they are safe enough, as well as understanding improvements in regional hospital for the entire county and functions new techniques that enable us to continue working in a smart way. as a centre of excellence for health care in Norrbotten.

“It also means, of course, that we have to work in ways that we haven’t It more than 400 care places and 17 operating theatres before, because as a doctor or nurse, for example you have to prepare as well as a 40-room hotel for patients who do not reyourself and the patient to communicate in way that you haven’t before, quire round-the-clock care. The hospital is designed and so you may not be sitting in the same place for example.” equipped to enable a new approach to care. Care work is Rising costs organised in various functional areas whereby personAnd with increasing investments in modernising IT systems the nel work together, for example there are heart teams cost of healthcare continues to escalate across Europe and the rest of the and diabetes.

Cardiovascular care, neurology and planned activities in orthopaedics as well as polyclinic gynaecology.

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world. In fact rising healthcare costs are a major concern for the industry, particularly on the back of the worldwide economic recession in 2009. Being increasingly efficient is of course vital in keeping costs down and Holmgren’s focus on providing a quality service has been critical in this area. “A systematic improvement in quality is what we are continuing to focus on and is proving critical in keeping costs down.

And this is our main strategy at present, which is all about ensuring that, firstly, the structure is efficient enough to support this in the right way.”

One way in which this quality care continues to improve at Norbotten Läns Landsting hospitals, particularly in regards to the tricky issue of healthcare-acquired infections (HAI), is by using the World Health Organization’s (WHO) checklist. For several years Holmgren has been focusing on the vital issues of patient safety and infection, these issues are at the centre of everything, she says going on to explain about the national programme that started back in 2008.

“The goal two years ago was to reduce healthcare-acquired infections by 50 percent and while this was a huge challenge – that to be honest, we didn’t think was realistic – we realised that if we wanted to reach those tough goals you have to have to face the challenges alongside it. On the whole, Sweden achieved extremely good results and in the Country Council in Norrbotten we reduced our healthcare-acquired infection rate by over 50 percent, so we exceeded the target and turned out to be one of the top performing areas in the country, which was absolutely fantastic.

“And we’ve actually implemented many more strategies too, both to do with patient safety and culture and things like that, but also so that our healthcare staff have the right clothes when they are working and the right products with which to wash their hands, for example.”

The Infection Prevention Act makes each county council responsible for taking measures to prevent infection, explains Holmgren. An infection prevention officer plans, organises and manages the county’s infection prevention programme so as to minimise the spread of diseases classified as constituting a public danger as well as other infectious diseases. The officer also provides public information and advice on the prevention of infection.

“Hardly any function of society is as creative and as constantly changing as healthcare” Holmgren goes on to reveal that her staff have been very enthusiastic in regards to the targets they have been set and admits that it is inspiring to be driving an organisation where her colleagues are so interested and serious about what they are trying to achieve. She goes on to explain that, in terms of human resources, there are a number of different programmes going on to support and improve the skills of employees

across the organisation. “We have various training to support doctors, nurses and other people in our healthcare system, which are very much connected to the improvements that we want to make and offer the opportunity to learn new methods and support the improvements we want to make across the board,” confirms Holmgren.

“We also have a leadership training programme in place, and personally I believe it is important so that leaders at all levels have enough knowledge to know how to properly support staff and to organise the workload and get the right results – the results that we are working together to achieve that support the goals for the entire system.”

Looking to a number of her future goals, Holmgren reveals why she believes the role of the hospital is so important: “Hardly any function of society is as creative and as constantly changing as healthcare. Better treatment methods and new, more effective drugs are being developed all the time. At the same time people have a need for security and continuity. They need to come back to a familiar place and they need to be able to see the district nurse and the doctor they know and trust.”

And it is exactly this that Holmgren will be continuing to focus on in the coming 12 months as she looks to continue improve the hospitals in her care.

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TECHNOLOGY

Cloud technology to combat cancer Cloud services provided over grid technology are helping to treat cancer patients, thanks to an enormous effort by European researchers working closely with industry.

C

ancer is Europe’s second largest killer and one of the most difficult diseases to treat. There are dozens of therapeutic protocols designed to respond to the vast diversity of cases that confront doctors. Radiotherapy has proven a particularly effective treatment. Here a linear accelerator, or Linacs in the jargon, attacks the cancer directly by delivering radiation from several directions. But treatment is complex. The direction, size and duration of dosages are all tailored to each case, and must be recalculated every time via simulation.

It is a phenomenally complicated computation, requiring lengthy processing time – so much so that it can mean delays and this has the knock-on impact of lowering the number of patients who can be treated by each Linacs machine. Faster diagnoses would help, but the required computing power is expensive, dramatically increasing the Linacs installation and operation costs. It is a critical bottleneck.

Cloudy strategy clears bottleneck But not for long. A cloud computing solution for radiotherapy developed by the BEinGRID project uses a computer grid. This type of infrastructure can share out resources like processors, storage, networking and software, wherever they are and on whatever platform. Grids can deliver on-demand hardware and software, and because they are combined into a super system, they offer much more power at lower cost. The individual elements of the system are hidden in the cloud, invisible to the user.

The new RadiotherapyGrid delivers two services: treatment plan verification and search. The search function is optimised to provide alternative treatment plans based on the patient scan, treatment prescriptions and other constraints. Both services can run in the background. The doctor simply enters the details in a browser window, and is alerted by email when the results are ready. Security and Service Level Agreements (SSLAs) are a particular focus of the RadiotherapyGrid.

Grids excel at delivering these kinds of benefits, because they ensure that resources are used to the maximum of their capacity. Security can be guaranteed because the computers on the grid behave like a single supercomputer.

Better and cheaper The upshot is that doctors can call on enormous computing resources without paying the full costs. It offers better performance, delivering faster results, and only when the service is required. Hospitals do not have to pay when the machines are idle. “The system can also be extended and adapted, to use new algorithms when new techniques and protocols are developed,” reveals Andrés Gómez Tato, a BEinGRID Business Experiment manager from CESGA, one of BEinGRID’s partner.

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Cloud computing in healthcare The Data Management Healthcheck 2010 survey, carried out

by BridgeHead Software, found only 6.5 percent of healthcare respondents said cloud storage is currently part of their strategy for storage of archived data. Not only that, but only 33 percent of healthcare organisations said they planned to adopt a cloud storage strategy for any data over the next 12-24 months.

“While preliminary, these results are highly indicative of the industry’s concern about the security of confidential and sensitive material,” says Tony Cotterill, CEO of BridgeHead Software. “Second to delivering excellent care, healthcare leaders are committed to protecting any and all information pertaining to patients.”

A major challenge for cloud computing is security of patient records and the need to audit all the processes and systems because of potential breaches in confidentiality laws. At the moment, there are no clearly defined laws for sharing patient data across those clouds.

Nonetheless, a report by the European Network and Information Security Agency (ENISA) entitled Benefits, Risks for Information Security stated that cloud computing is set to see massive global investment in many sectors. The report, conducted in 2009, estimated that around the world in 2013, €32.5 billion will be spent on the technology, with €6 billion being spent in the European market.

The BEinGRID partners in the radiotherapy application are now looking to exploit the service commercially, and they believe the market is very promising. Initially, the RadiotherapyGrid will be primarily marketed as a ‘software-as-a-service’ platform at these institutions, but ultimately it may also come with hardware. Moreover, the RadiotherapyGrid could be applied to other treatment modalities, like the Image Guided Radiotherapy (IGRT), hadrontherapy or brachiatherapy.

So far healthcare organisations have been slow to benefit from the power of cloud computing. The BEinGRID project, however, proves that clouds are more than a just a cancer killer, they are a killer app. n Article provided courtesy of ICT Results. For more information, please visit cordis.europa.eu/ictresults

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TECHNOLOGY

A NEW PATH Sir Ian Kennedy talks about his report on the value of new innovative health technologies and what he recommends for the National Institute of Clinical Excellence.

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n January 2009, as part of its process of constantly updating and improving the methods it uses to evaluate new health technologies, the National Institute of Clinical Excellence (NICE) commissioned Professor Sir Ian Kennedy to carry out an independent study into how NICE values innovation in its appraisals of health technologies. The study involved evidence submissions and the use of a series of workshops involving the healthcare industries, patients and the wider public, together with representatives of the NHS to explore this issue.

Professor Sir Ian Kennedy, emeritus professor of health law, ethics and policy at University College London led the study.

“The study arose because there was a report by Sir David Cooksey who advises the government and treasury,” says Kennedy explaining the key aims of the study. “He was concerned about industry generally – pharmaceutical, bio-engineering and bio-science – and the need for that industry to receive incentives because it was an important part of the UK economy. The view was expressed to him and to a degree he endorsed it.”

Cooksey suggested that there be a complete study of the role that NICE plays in the architecture of healthcare, followed by a more particular and in-

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depth study of how NICE deals with the notion of innovation and whether it encourages it sufficiently. While the government rejected the larger architecture study, Sir Michael Rawlins, Chairman of NICE, asked Kennedy to conduct the study into how NICE responds, deals with and incorporates innovation in to the organisation. A huge subject to tackle, Kennedy initially resorted to getting the primary thoughts from the industry academics and patient groups.

“Getting all those themes together we then organised some workshops where we had fairly heated and very interesting exchanges on various themes we’d picked out and then that added to my understanding. Then there was a meeting with the Patient Involvement Network (PIN) group where I attended their meeting and they gave me some views and put in a submission and there was a meeting of the Citizens Council where the sort of questions that I was dealing with were answered and I was able to hear their responses after two days. That was helpful – and then I went away and worked at it,” says Kennedy.

“The size of the project was in part a function of what I quickly came to see as the need to expand the terms of reference somewhat, not just to talk

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about innovation but to talk a little bit about the background of how NICE is seen by the pharmaceutical industry and others as well as how it sees itself.”

Kennedy also looked at the benefits that the pharma industry was anxious to put on the table in addition to the innovation payback – the industry didn’t believe NICE took account of these benefits, which were undoubtedly important for patients.

Kennedy explains that this required him to operate at a series of levels: “The most abstract level being a kind of political philosophy of NICE, established by government to do a specific job – namely to allocate resources against the background of a fixed budget – and pharma, to a degree driven by American models of healthcare, seeing the consumer as king, and if a patient wants something then it ought to be made available. The clash between two political philosophies was a thread running through, as was the tension between the idea of UK Plc needing a vibrant, effective, pharmaceutical industry for the sake of the economy and NICE being really not part of that UK economic philosophy, but rather a mechanism to allocate scarce resources.”

The report saw a number of findings, particularly between NICE and the pharmaceutical industry. Kennedy believed that NICE was often behind in explaining it’s role and it’s impact on society. He says that it was ineffective in explaining what it did and ineffective in it’s appraisals. The pharmaceutical industry on the other hand had to break away from American thinking and play by the British rules.

“Having set the scene, I then said ok, are there certain benefits that NICE doesn’t take account of which are important or which could be called health gains,” says Kennedy. “I took the view that there were gains and that they ought to be taken account of in the cost effectiveness analysis to which of course people inside NICE say ‘we always do that’, to which I say, ‘but you do it in a way that isn’t clear enough and isn’t transparent enough, so you’ve got

to make the process transparent so that everybody can see that you are taking account of these. You may actually have to take account of rather more things than you currently do as we guard the wider issues that some people making submissions argued for – namely the importance of a product to enable people to work or a productivity increase or people will be liberated to enter the workforce – the so-called social values.”

“The clash between two political philosophies was a thread running through, as was the tension between the idea of UK Plc needing a vibrant, effective, pharmaceutical industry for the sake of the economy and NICE being really not part of that UK economic philosophy” Supply and demand Kennedy argues that these should not be included in NICE’s appraisal because of the difficulty of calculating them in themselves and also setting them off against other aspects of the public purse to work out what’s wining and what’s not. He did however suggest that further work should be carried out if it is possible to formulate a model that is able to take account of those benefits.

With regards to innovation he took the view that there was an opportunity for NICE to provide incentives to the pharmaceutical industry and others in return for a focus on innovation. Kennedy defined innovation as something that everyone talks about and is in favour of, yet nobody identifies what they mean, instead seeing it as being to do with a step change involving

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a product that meets a current unmet need and is effective to a degree of around 70 percent. “Something innovative may have gone through a stratification process so that we know the population is going respond to it.

Currently it only works on 30 percent of the population, but we don’t know which 30 percent, so you buy it and you waste money if it isn’t used by the right person. If all those criteria I suggested are met there might be an incentive for pharma to concentrate on that rather than other things – you might allow it to bust the threshold a little bit and you might allow it to do that for a limited period, let’s say three years and then fall back in. So pharma’s got an incentive to focus on.”

Another innovation criteria could mean that the product meets the needs required as declared by the NHS and Ministers so that they’re focusing on incentives, but it must be real innovation now, adds Kennedy.

“As regards to the innovation which is being promised, the pharma industry needs to be encouraged to do this now, I rejected the argument of special privilege for that on the grounds that we don’t know whether it currently will be an innovation and a significant development. Currently we’re not very good at conducting research and collecting data and pharma’s got no incentive to collect that data because it might prove that it wasn’t promising so we need to find creative ways of allowing further research

Sir Ian Kennedy is a British academic lawyer who has specialised in the law and ethics of health. He has been a member of numerous committees and enquiries. For nine years he was a member of the General Medical Council and in 1978, he founded the Centre of Laws and Ethics, of which he later became President. He has also been a member of the Medicines Commission and the Department of Health advisory group on Aids.

Innovative devices and diagnostics In November 2009, NICE launched a programme focusing specifically on the evaluation of innovative medical technologies, including devices and diagnostics. The new programme will both complement and operate in conjunction with NICE’s existing technology appraisal capacity. Professor Bruce Campbell has been appointed to chair of the new Medical Technology Advisory Committee. As a Consultant Vascular Surgeon and Chair of NICE’s Interventional Procedures Advisory Committee since 2002, Campbell has extensive experience of NICE’s evaluation processes and guidance production.

What has caused the problems with medical technologies in the past and how is the new Medical Technologies Advisory Committee going to bring about change?

Professor Bruce Campbell. There’s been no really organised way of introducing medical technologies and

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there’s been no mechanism to recognise and foster those new devices and diagnostics, which are likely to really make a difference. The new Medical Technologies Advisory Committee is going to be a very collaborative venture with the industry, because the devices and diagnostics that we will evaluate I think we will be notified, largely by the manufacturers, and the system will involve a manufacturer notifying us of a device or diagnostic, which they think has some major advantage over what goes on in the NHS. This will be evaluated against a clear set of criteria to see whether it fits with the programme, and at that stage will be considered by the committee, which will do two things: first of all, it will take a closer look at each technology to see whether it really does seem worthwhile; and then it will be routed into one or another NICE programme.

What is this going to mean for the NHS? BC. Well, for patients, we are hoping that many of the devices and diagnostics will have very obvious benefits,

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and collection of data between NICE and the pharma industry or universities. I also believe that all of this is to concentrate on what is called the demand side; the side of the people who are, as it were, representing the purchaser or the user. However, the attention of pharma and the government should not solely be concentrating on the demand side, it should consider the supply side too – there’s a limit to what NICE can do on the demand side and it can’t do anything about the supply side, however, it needs to be addressed and fortuitously.”

Kennedy explains that if financial incentives are used then NICE, the government and the NHS must realise that that will come at a price. “In too many cases the cost effectiveness will destabilise the system at precisely the moment that public finances go over a cliff,” he says. “So the NHS will not have the same amount of money or will have the same amount of money but inflation will increase, and in those circumstances pharma, the government and the office of life sciences may have to comes to terms with the fact that to have an increased threshold for some.”

Whether the report will have any wider implications it is hard to say.

Kennedy believes that it is part of the jigsaw about how the architecture of the NHS is managed, its budget and the response to the changing nature of demographic circumstances and people’s illnesses. The Office of Life Sciences report emerged at around the same time as Kennedy’s report on NICE, concerning bigger issues than simply the institute, but rather the entire industry of life sciences, identified by the Prime Minister as one of the important parts of the UK economy. “NICE is a bit player. But that said, there is a proposition about the development of something called an innovation pass whereby the need for NICE appraisal and approval is bypassed,’ says Kennedy.

“The attention of pharma and the government should not solely be concentrating on the demand side, it should consider the supply side too”

Moving forward Reflecting on his report, Kennedy hopes that it will be of assistance in clarifying the role of the organisation and the way it works in the future.

“Clearly there are those who are not entirely content with what NICE does, either because NICE exists, or the methods that NICE uses are not to their liking because they’re frustrated or disappointed in certain circumstances.

That being the case, I think it’s entirely appropriate for NICE to bring in someone who as an outsider – with no axe to grind – and say what do you think of the picture and then look at that, so that’s part of NICE’s constant attempt to engage with the wider world and to examine what it does and I think that’s welcome.”

in terms of being comfortable, being less painful, resulting in less hospital visits. For the NHS, if procedures are being done as an out-patient rather than an in-patient it might produce some cost savings. Or it might be that a technology requires less staff.

There’s a large number of medical technologies around – how will you decide which ones to evaluate, and what will be the proves for how you work?

BC. I think that may evolve to an extent. Getting good research done on devices and diagnostics has been historically quite difficult. One of the aims of this pathway is to identify the gaps in research that we need to fill in order to say that a technology really should be used. And we will be doing that by producing research guidance and hopefully by influencing the way in which collaborative research is set up between manufacturers and the NHS. And we hope to make that easier.

In terms of setting up this committee, who have you been working with?

“Some could say that this is the thin end of a wedge to undermine NICE. I don’t think it need be, particularly as it’s recommended that it be managed

by NICE. The money associated with the products that have the pass, shouldn’t come from the NHS, but an earmarked ring-fenced fund, and that it be piloted for only a year and then reviewed. It’s kind of a toe in the water way of determining how you can provide incentives to get drugs to patients that are cutting edge. I certainly derive some comfort from the Office of Life Sciences saying in their report that they are committed to the notion that the NHS requires products that are cost effective. That’s what NICE does.” n

BC. The committee has been set up by negotiations between NICE and the Department of Health, and a lot of internal work within NICE, but with very strong collaboration with industry, representatives from industry have been on the project board and have been helping all along the way in the development. There have also been a number of working groups, comprising a great variety of interested parties, from industry, through members of the Department of Health, through commissioners of healthcare, to providers in hospitals, and specialists in relevant disciplines. It has been a very complex process. And that’s one of the reasons it is, as yet, unfinished, even at the time of launch. And even beyond the launch, I have no doubt that this system, this pathway, will evolve as we gain experience of the notifying procedures, having to work with them, collaborating with industry, I think there are many aspects of this which will evolve as we gain experience.

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DIGITAL IMAGING

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With the requirement for digital data to be archived for up to seven years, the need for efficient picture archiving and communications systems has never been greater. Frost & Sullivan’s Nadim Daher fills Marie Shields in on the current state of the PACS market.

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icture archiving and communications systems (PACS) have become important tools in a hospital’s digital data management arsenal. According to Nadim Daher, Senior Industry Analyst for Frost & Sullivan’s North American Healthcare Practice, one of the challenges is managing data throughout its lifecycle, while also minimising the incredibly high cost of using expensive storage media.

“Today PACS is also a lot about the distribution of images to other stakeholders in the imaging enterprise,” he says. “This is often spread outside the radiology reading room and into certain physicians’ office spaces and sometimes to other hospitals or to the electronic library of patient records.”

Daher explains that the advantages of PACS are those of a digital environment when it’s working well. There are challenges pertaining to the transition to digital, which has been going on in radiology for about two decades in the more advanced countries. This has taken place progressively, but Daher says there are still many places that are lagging behind and still largely printing out films.

“There is also a challenge regarding the investment that needs to be made into it,” he continues, “both from a clinical standpoint where you get a high resistance to change, especially among the older generation of radiologists and other users, and also financially. You have an important financial investment in those systems, which have typically been acquired as a capital purchase. For an average 200- or 300-bed hospital with an average volume of 100,000 procedures annually, it can easily cost up to US$1 million to install PACS. “Because PACS has an important hardware component, it requires a lot of equipment in the IT room, from servers and storage and networking, as well as probably the most expensive element, the software license.

Then you have all the services, both to put it in and to support it, because most of these systems are supported through maintenance contracts, typically over five years, and usually throughout the lifecycle of the systems.”

Investment One of the first considerations for hospitals considering a major capital outlay is return on investment. As Daher points out, for those facilities that have never used PACS before, the ROI model is pretty straightforward, because they’re going to be replacing film, which costs about a few dollars per sheet, with digital. “Once they have the system in place it’s going to cost less per procedure to manage study data,” he says, “unlike the film-based model where every study is going to cost tens of dollars for printouts on high quality silver-plated film.

“Various case studies that shown that PACS pays for itself in anywhere from two or three years to six or seven years, depending on the case. But, replacing film would be the main ROI item for first-time PACS users.”

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PACS: a definition In medical imaging, a picture archiving and communication systems (PACS) is a combination of hardware and software dedicated to the short and long term storage, retrieval, management, distribution and presentation of images. Electronic images and reports are transmitted digitally via PACS; this eliminates the need to manually file, retrieve or transport film jackets.

PACS consists of four major components: the imaging modalities such as CT and MRI, a secured network for the transmission of patient information, workstations for interpreting and reviewing images, and archives for the storage and retrieval of images and reports.

Combined with available and emerging web technology, PACS has the ability to deliver timely and efficient access to images, interpretations and related data. PACS breaks down the physical and time barriers associated with traditional film-based image retrieval, distribution and display.

However, market penetration is already high, with the majority of US hospitals – as many as 60 or 70 percent – already having PACS in place. Daher believes the bigger question today centres on the users of first-generation PACS who are looking to replace their systems. “The replacement PACS market is what’s attracting the attention of the entire PACS industry,” he explains. “This tends to leave the few remaining first PACS opportunities out there to the smaller companies, who are happy to take on a contract for a 60-bed hospital or a rural community hospital that doesn’t have PACS. That represents a small contract value.

“The big players are all focused on the replacement PACS market and on being selected as a replacement vendor to put the next generation system in place and get that new US$2 million or US$3 million deal for the large hospitals and hospital chains.”

With the next generation of PACS, the return on investment on all models is much less certain. There are a number of benefits, but according to Daher they’re not easily quantifiable the way replacing film is: “They are not very quantifiable because they would be something like reducing the turnaround time from study to report from two hours with the current PACS, to 1.6 hours with the new PACS, for instance. While a business case can be made for that 0.4 hours when you look at the productivity of the radiologists, what they’re being paid and what they could be doing if they saved time on their current workload, it’s not as obvious as that for installing a first PACS.”

A hospital organisation that has two or three hospitals in different locations, with imaging centres at each, can bring together these geographically dispersed locations through an enterprise PACS system.

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Nevertheless, Daher believes there is a place for the next generation of PACS, to help improve workflow, make the imaging enterprise more productive and open up better communication with referring physicians. “At the end of the day, as an imaging enterprise, your customers are those referring physicians who send you patients to get images done. It’s important to have efficient IT solutions and to make it work better for them.

“On the clinical side, a better PACS infrastructure can help physicians make better decisions, because they have greater access to imaging over time, comparing priors to new, comparing with other patients, when you start doing things like data mining. It’s mainly clinical benefits, but also with a strong business component.”

PACS has been around for 10 or 15 years, so the first few academic cenres that implemented the digital PACS that we know today are now at their third generation of the technology. Another large chunk of the marketplace is coming up to its second generation PACS, and Daher’s view is that this is probably the main thing that’s still driving the market forward.

“Although the uptake has slowed down in the last two years, it’s a continual process. Technology has to be upgraded at some point. You can’t keep 10-year-old servers running in your IT department.”

External pressures have also exerted an influence, resulting in the last twoand-a-half years being very challenging for the American PACS market. “The macro-economic pressures that occurred in 2008 did not spare the PACS market,” Daher says. “Traditionally it has been more immune to outside market conditions, but this time it was hit pretty badly. The IT projects hospitals were doing were put on hold, if they weren’t cancelled.

“The fact that the reimbursement pressure is so heavy on imaging in general makes the ROI model for PACS less and less solid, because individual procedures are getting left without reimbursement. Some of it is offset by the fact that procedure volumes continue to grow at a single digit of five or six percent a year.

When you have to do more for the same amount of money, IT is a solution for that, but at the same time you can’t spend the required money on it. That has been the deadlock for the PACS market during the last two years.”

International Comparing the US market to parts of the world like Canada, the UK and Scandinavia, Daher sees the major difference being that the US has a mostly privately operated healthcare system, and Canada, the UK and Scandinavia have a publicly managed system.

This has had a direct impact on the way that technology has been implemented throughout the years. It has been more of a grass roots movement in the US, of individual hospitals getting PACS and wanting to be competitive with respect to the technology and the neighbouring facilities. On the other hand, in Canada, the UK and Scandinavia, PACS adoption has been planned more from the top down; province-wide or state-wide agencies have planned, to put on PACS in several hundred facilities at once.

“Places like Scandinavia,” Daher says, “have been able to reach 100-percent penetration. They’ve been able to do it much more cost-effectively than in the US. The national programme for IT in the UK was also one of those top-down forces that has planned for PACS. They have had some

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big failures and some important challenges, but they have been able to put in more PACS technology in more remote places and do it more cost-effectively than in the US. “They’re also able to get the systems to better talk to one another, because the first phase when you look at it over a long period of time is to have digital data everywhere. And the next phase, which is the major debate in US healthcare IT today, is interconnecting all of these individual healthcare facilities into something more widespread, so you can track diseases, track trends, track everything nationwide.”

Daher underlines that in the US, vendors have not been forced to comply to industry standards and have not been prevented from using proprietary technology, which has created a very challenging situation. “It’s very hard to get the legacy systems to talk with each other. In the legacy systems there is a lot of proprietary technology; it’s almost like secret recipes the vendors are using, and when it comes to replacing the system, providers find that they’re not able to read them.

“You don’t see this kind of thing much in the other countries I mentioned, where the vendors are more forced to align themselves and the way they do things. There was more put in the long-term planning so that one day these systems will talk to each other, we will interconnect them. And you’re starting to see that in Canada, Scandinavia and the UK.”

“When you have to do more for the same amount of money, IT is a solution for that, but at the same time you can’t spend the required money on it. That has been the deadlock for the PACS market during the last two years”

Looking ahead Looking to the future, Daher says systems will be better integrated with each other and there will also be better integration with electronic medical records, where PACS will become the imaging element of the EMR. “The EMR has a lot of components, an important one of which is images, and PACS is likely to be the underlying system that handles this component.

“Also, we have what we call enterprise PACS, and there are two sides to this. One is enterprise, meaning multi-departmental, so going beyond radiology and having a single system, or again, multiple systems, but that talk nicely to each other; one for radiology, one for cardiology, for orthopedics. All the imaging is done in the departments outside radiology that are also producers or users of images, so that you can have an effective way of managing those images throughout the multiple departments.

“And the other side of it is by enterprise, which can mean also multi-site.

When you have a hospital organisation that has two or three hospitals in different locations, with imaging centres at each, they can bring together these geographically dispersed locations through an enterprise PACS system. That’s probably the biggest market shift in those larger scale systems.”n Nadim Daher is Senior Industry Analyst for Frost & Sullivan’s North American Healthcare Practice.

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EXECUTIVE INTERVIEW

The rise of medical imaging Martin Törnvik talks about the innovations and improvements currently going on in the world of medical imaging.

Medical imaging has the potential to play a central role in the global healthcare system as research increases and improves. What role does research and innovation play at Ziehm Imaging?

Martin Törnvik. Research and development plays an extremely important and central role in our company. We invest more than 10 percent of our company turnover in R&D each year. We have a core competence in developing X-ray generators, imaging systems and software for image processing and these are the key components for us to provide mobile interven-

since minimal invasive surgery techniques means the demand of high-level imaging support in real-time is increasing tremendously.

The surgeon needs more accurate image-guidance tools when performing minimal invasive surgery to be able to be safe and more accurate. The need for intraoperative, high-level subtraction angiography solutions, as well as, in many cases the need for 3D or multiplanar reconstruction (MPR) imaging, especially in spinal surgery application, will increasingly drive new flexible solutions, which is positive in the view of investments to the hospitals.

“The surgeon needs more accurate image-guidance tools when performing minimal invasive surgery to be able to be safe and more accurate”

tional imaging systems today and tomorrow.

We are focused and devoted to mobile C-arm solutions for many different applications in interventional imaging. As these are our only products and we need to stay ahead of our competitors we are working to differentiate our products and provide better solutions.

There is no doubt that clinical applications are continuing to dominate the healthcare industry. In your opinion, which clinical application offers the biggest growth opportunity and why?

MT. I would say that one of the biggest growth opportunities in the healthcare industry will be the increase of minimal invasive surgery procedures. Th is is focused on the patient being in the hospital for as short a time as possible and taking care of the patient without the need for big surgical intervention. Th is generates many positive effects in healthcare and industry overall. It impacts us specifically

Last year’s economic recession impacted industries around the world. What influence did it have on Ziehm Imaging and how did you go about tackling the associated challenges?

MT. We saw the impact from the recession in healthcare last year of course and undoubtedly some countries were effected more than some others, but in general business for us developed quite well and we had a reasonable growth of five percent last year. Crucial to that was that we were able to stay focused and work closely with our partners and distributors around the world, looking at each deal and what we could do to support and help out to get the purchase order. We had to be much more flexible in order to fi nd solutions and of course great teamwork in the company is essential for accomplishing that. Employees in all departments across the company pulled together and worked hard last year and I am very proud about that.

Where do you expect to see innovations in mobile imaging over the next five years and beyond? Can you give some examples?

MT. I see highly increased improvements of image quality in the image guidance procedure and the possibility of using mobile interventional imaging to very high demanding procedures, which are today fi xed installed systems. I believe that the radiation dose will be reduced dramatically with more advanced image processing and digital technology.

Further innovations in improving workflow, ergonomics and user-interface will also be in big focus the next few years. We need to take better care of the user that needs to handle the intraoperative imaging solution in critical situations where everything has to work easily and simply with excellent results.

Martin Törnvik, Vice President Global Sales & Marketing of Ziehm Imaging GmbH, joined the company in 2003 as a Product Manager. He has 20 years of experience in the healthcare business. He has held various responsibilities in the position of Service Engineer, Sales Engineer, Sales Director and Business Manager.

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IMAGING FOCUS

The future of private sector medical imaging The need for integrated diagnostic and visualisation tools for non-radiology departments such as orthopaedics, cardiology, oncology and mammography will drive technological innovation in the European PACS market, argues Jodie Humphries.

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edical imaging has been pegged as one of the industry’s largest growth markets for many years, but it is expected that over the next year it will grow by an impressive six to eight percent. And with year-on-year growth expected to happen for the next five years, Europe’s picture archiving and communication systems (PACS) market is drawing more and more opportunities within the sector.

Combined with available and emerging web technology, PACS has the ability to deliver timely and efficient access to images, interpretations and related data, breaking down the physical and time barriers associated with traditional film-based image retrieval, distribution and display. A number of technological advancements in both clinical applications and work-flow management tools are being introduced that have transformed the functionality of PACS from a viewing and storage solution for images, to a crucial decision-support system. There is growing evidence of workflow efficiencies, improved quality of care and cost savings being realised in a number of hospitals, which in turn, has generated interest in the adoption of PACS among general physicians and private practitioners.

For example, PACS has become indispensable in a digital radiology environment today, in spite of the many hurdles faced during its implementation. According to London-based market research company Global Data, the European radiology market contributed 67 percent to total PACS sales in 2008, when it was valued at US$384 million. The radiology segment is projected to grow at 5.5 percent for the next seven years to reach US$557 million in 2015. Meanwhile, the cardio PACS market will be the fastest growing segment in Europe at nearly nine percent compound annual growth rate between 2008-2015 to reach US$93 million in 2015. Other PACS, which include mammography PACS and orthopedics PACS, are expected to grow at around six percent, to reach US$198 million in 2015.

The overall market will be driven by the late adoption of PACS in countries such as Spain, Italy, Wales and Northern Ireland due to regional government initiatives, increased adoption amongst private practitioners, and the replacement market. Non-radiology PACS segments such as cardio PACS are expected to be driven by the integration of computer-aided diagnosis/detection (CAD) with PACS. A number of regional PACS projects, such as the Hospital District of Helsinki and Uusimaa regional PACS project (HUSpacs) in Finland, have shown that when implemented correctly PACS can be instrumental in not

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PACS in numbers • The European PACS market will reach US$848 million by 2015 • The radiology segment is predicted to grow 5.5 percent for the next seven years, to reach US$557 million in 2015 • The European radiology market contributed 67 percent to total PACS sales in 2008 • The cardio sector will be the fastest growing segment in Europe, reaching a nearly nine percent compound annual growth rate

only providing superior quality of care, but also in reducing costs and improving efficiencies. Indeed, the challenge of convincing private practitioners to invest in a good PACS is being met by vendors through customisation, innovative pricing models and by providing technical support for maintenance.

While PACS represents an opportunity to reduce many costs, it requires a substantial investment of time, personnel and financial resources and therefore decisions about whether to go digital must not only meet local requirements but also incorporate an awareness of regional, national, and even continental efforts to establish networks and data standards. n

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TECHNOLOGY

To build a smarter system, healthcare solutions need to be instrumented, interconnected and intelligent. IBM believes it has the answer.

By Ben Thompson 76 www.nghealthcareeurope.com

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W

e live in an unpredictable world.

You know it when you get caught in an unforecast storm on a sunny summer’s day; you know it when the stock market tanks and your previously rock-solid investments are reduced to worthless junk; you know it when you hit unexpected gridlock on the way to that all-important business meeting. What you don’t always know are the hows, whys and wherefores – the myriad combination of variables that fell into place in order for those events to unfold.

But what if you did? Given better intelligence, is it possible to predict how such permutations might play out in future – thus avoiding the storm, selling high and dodging the worst of the traffic? Can a better understanding of the way systems work help solve some of the challenges we face as a global society? And what implications could this have for that most complex system of all: human health?

IBM Chief Executive Sam Palmisano doesn’t claim to have the all the answers – but he’s working on it. From fi nancial crises to climate disruption, energy geopolitics to food supply hazards,

“If we are going to address the issues of access, cost and healthcare quality, we have to have better information technology to support that” Palmisano believes solving the global challenges of today and tomorrow will be about the smarter use of information, and has spent over US$50 billion on acquisitions and R&D in preparation for the seismic shift in thinking such a move will require.

“The first decade of the 21st century has been a series of wake-up calls with a single subject: the reality of global integration,” he explains. “In business, global integration has changed the corporate model and the nature of work itself. In the last few years, our eyes have been opened to global climate change, and to the environmental and geopolitical issues surrounding energy. We have been made aware of the vulnerabilities of global supply chains for food and medicine. We entered the new century with the shock to our sense of security delivered by the attacks on 9/11. And, of course, we are now in the midst of a global fi nancial crisis. These collective realisations have reminded us that we are all now connected – economically, technically and socially.”

And as the world continues to get flatter, smaller and more interconnected, IBM is banking on something happening that holds

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Case study: Integrating health systems Servicio Extremeño de Salud (SES) is the public healthcare service for the regional Ministry of Health (Consejería de Salud) in Spain. The Mérida-based organisation delivers healthcare services to more than one million people in the Extremadura region in the western interior of Spain through approximately 13,000 professionals.

Challenge Each hospital in the regional healthcare system had its own IT solutions, and only a few medical care centres received any application support. In addition, each facility had its own patient records system, and the data was not accessible regionally. SES realised that it needed to integrate both patient-related and administrative processes to serve patients better. This transformation required local solutions to be replaced with one integrated system, and extending access and application support to create a more cohesive regional healthcare unit.

Solution SES selected IBM Global Business Services to design and deploy an SAP R/3 based integrated healthcare information management system that supports and manages all business processes at SES, including patient-related records management and administrative processes. This Linux-based solution leverages a single integrated data repository that stores medical and administrative data in a central location, making it available region-wide.

Results As a result of the IBM solution, up-to-date patient information is available throughout the region to all hospitals, medical care centres and administrative offices, enhancing the ability of doctors, nurses and other healthcare professionals to provide the best service to their patients. The new solution connects almost 13,000 professionals, with the scheduling system managing nine million outpatient visits each year, while SES has seen reduced costs of paper and other media, and improvements in clinical and administrative efficiency.

even greater potential: the prospect of our planet becoming smarter. “Th is isn’t just a metaphor,” asserts Palmisano.

“New intelligence is being infused into the way the world literally works – the systems and processes that enable physical goods to be developed, manufactured, bought and sold; services to be delivered; everything from people and money to oil, water and electrons to move; and billions of people to work and live. The future now beckoning us is one of enormous promise.”

His confidence is based on three key developments. Firstly, the world is becoming instrumented. IBM claims that by 2010 there will be a billion transistors per human, each one costing one ten-millionth of a cent, while sensors are being embedded into everything from cars, appliances, cameras, roads and pipelines to medicine and livestock. Secondly, with over a trillion networked devices, the world is also becoming more interconnected, producing rising volumes of data each year. Finally, things are becoming more intelligent.

Algorithms and powerful systems can analyse and turn those mountains of data into actual decisions and actions that make the world work better. Real insight, in realtime, is now a real possibility.

“With so much technology and networking available at such low cost, what wouldn’t you enhance?” he asks. “What wouldn’t you connect? What information wouldn’t you mine for insight? What service wouldn’t you provide a customer, a citizen, a student or a patient?”

Healthcare is one such sector set to benefit. “Our current approach to healthcare is just not sustainable,” says Sean Hogan, IBM’s VP for Healthcare Delivery Systems. “However, the fi nancial crisis has highlighted the burden that healthcare costs are placing on our society, and as such is prompting a very engaging debate about what to do about it. And the conclusion is that if we are going to address the issues of access, cost and healthcare quality, we have to have better information technology to support that.”

Rising costs, limited access, high error rates, lack of coverage, poor response to chronic disease and the lengthy develop-

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ment cycle for new medicines – Hogan explains how most of these could be improved if we could link diagnosis to drug discovery to healthcare providers to insurers to employers to patients and communities. Today, these components, processes and participants that comprise the vast healthcare system aren’t connected. Duplication and handoffs are rampant. Deep wells of lifesaving information are inaccessible.

IBM believes that a smarter healthcare system starts with better connections, better data, and faster and more detailed analysis. It means integrating data and centering it on the patient, so each person ‘owns’ his or her information and has access to a networked team of collaborative care. It means moving away from paper records, in order to reduce medical errors and improve efficiencies. And it means applying advanced analytics to vast amounts of data, to improve outcomes.

“If you had a map of all industries and plotted the sophistication of the use of information technology within those industries, healthcare would be on the lower end of the spectrum – despite the fact that it is a very technology intensive and information intensive sector,” says Hogan.

“But IT can help make the administrative process smarter and more efficient; it can enable health information to be shared between care providers and eliminate redundant procedures; and it can better support the process of care so that physicians have the right information available to support the decisions they need to make.”

For instance, Sainte-Justine, a research hospital in Quebec, is automating the gathering, managing and updating of critical research data, which is often spread across different departments. With the help of IBM technology, the centre is applying analytics to speed childhood cancer research and improve patient care while drastically lowering the cost

of data acquisition and enhancing data quality. Another example is Geisinger Health Systems, which is integrating clinical, fi nancial, operational, claims, genomic and other information into an integrated environment of medical intelligence that helps doctors deliver more personalised care. Th is enables them to make smarter decisions and deliver higher quality care, all because they can easily turn information into actionable knowledge.

And true to the premise of Smarter Planet, healthcare systems like these hold promise beyond their particular communities, patients and diseases. “The smart ideas from one can be replicated across an increasingly efficient, interconnected and intelligent system,” says Hogan.

“Th is should result in lower costs, betterquality care and healthier people and communities. In other words, we’ll have a true healthcare system with the focus where it belongs – on the patient.”

In fact, much of smarter healthcare is not focused on the next big breakthrough in medical research. Smarter healthcare solutions start with the individual. Take the Medical Home model, for example, where primary care physicians act as ‘coaches’, leading a team that manages a patient’s wellness, preventive and chronic care needs. The doctor spends more time with each person, is available via e-mail and phone for consultation, offers expanded hours and coordinates care across the individual’s entire care team. Interest in the Medical Home is building in the United States and has caught on globally as well. Physicians, healthcare leaders, insurers, legislators, large companies and other stakeholders are focused on the fact that the Medical Home model of care improves quality and patient satisfaction and contributes to lower overall healthcare costs.

But while medical homes can be a cornerstone of transformation, they are not what Hogan calls “a silver bullet”. They hold a great deal of promise, but many more supportive measures need to be undertaken to fully realise the benefits. For example, steps needed for full implementation include improved access to patient information and clinical knowledge to improve prevention, diagnosis and treatment; changes on the part of other stakeholders (consumers, other physicians, hospitals, health plans, employers, governments and such life sciences as pharmaceuticals); and a robust infrastructure to support comprehensive, coordinated care.

Nevertheless, he believes the strides being made by IBM in terms of harnessing the power of technology for better healthcare solutions are significant. “We are taking advantage of the fact that our society is much more instrumented, connecting that information and using intelligence to take actions that create benefits,” he concludes. “It’s a very exciting area.”

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iStrategy Europe 5th-6th October 2010 The Millenium Gloucester Hotel, London, UK Transforming the Enterprise with Digital Expertise

Participation in Social Media and Interactive Marketing is no longer revolutionary.

it’s crucial.

In 2009, companies with dedicated social media activity boosted sales by over 18%, while those with minimal or no presence saw a 6% decrease.

As 2010 marks a shift in consumer mentality from recession to recovery, companies must adjust their strategies according to how customers make purchasing decisions. Brand differentiation will be key, and companies must be at the forefront in areas like social web, mobile apps and SEO in order to create a distinguished customer experience. iStrategy October 2010 marks the next step in your marketing strategy. Here, you will learn: • The biggest trends in consumer spending online • Innovative technologies for communicating with customers and how to best implement them

• The top 10 most important factors in your social media strategy • How to measure your social capital and monetize your efforts • Hot buttons to bring people to your web store front • How to find your best fit in integrating email and social media • How to deliver a response-driven, relevant message The simple truth is that there is no magic one-sizefits-all marketing mix. iStrategy will arm you with the deep understanding of aligning social media and digital strategy according to your organization’s processes and operations to achieve the objectives you’re after. Join us in October to network, share ideas, and most importantly find out how to build your marketing strategy to its fullest potential.

For More Information, Please Call: Max Ford, Global Event Director. Tel: +44 (0) 117 915 4753. Mobile: + 44 (0) 7798 820 711

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TECHNOLOGY

Innovation institute 82 www.nghealthcareeurope.com

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In an exclusive interview Executive Director of the European Health Technology Institute, Rosanna Tarricone, reveals the challenges of a fragmented device industry and the impact this will have on innovation.

By Rebecca Goozee

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s an independent research organisation the European Health Technology Institute for Socio-Economic Research (EHTI) is invaluable in developing data and evidence on the social and economic value of medical technology and its impact on the economy and welfare of European countries. Executive Director, Rosanna Tarricone has been at the helm of the research institute since its inception in 2007. The institute was created three years ago to stem the lack of scientific and economic evidence on medical devices, and has been working towards providing a systematic review and analysis of the major reimbursement and security systems in Europe, so as to have a deep and detailed understanding of how medical technology is currently procured and reimbursed, as well as who benefits from investment in medical technology.

“Th is is something that, until some years ago, many people were not aware of – even at the policy level – because the sector is so diverse that reimbursement and procurement positions are decentralised throughout Europe, and even within countries themselves, decision makers were not aware of how the system was whole was working,” explains Tarricone.

Th is vital fi rst step in understanding the current system was crucial and has laid a foundation for where the institute currently fi nds itself – attempting to recognise how healthcare policies implemented by different countries in Europe are actually effecting the consumption of medical devices in the same countries. Indeed, Tarricone stresses that the main improvement the EHTI has brought to the industry has been in terms of knowledge: “We have led a huge improvement in progressing research and building up scientific knowledge in this specific field, fi rstly for academics and secondly for policy makers themselves.”

The industry today is undoubtedly much more aware of how systems are implemented throughout Europe, such as the major differences between various countries and whether they have an impact on the diffusion and uptake of medical technology across the continent. So while the improvement is not something tangible there has been progression.

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Indeed, Tarricone asserts that the last three years have secured a good foundation of knowledge from which to continue the institute’s mission.

Rosanna Tarricone

Innovation As a cornerstone of the health systems in Europe, innovation is key to understanding more. Tarricone believes that she sees the benefits of innovation on several levels, including the patient, the hospital, the clinicians and the industry itself. “Even within the basic technology side, today we are able to deliver surgical intervention in many invasive ways, that were impossible just a few years ago,” she says, before adding, “Instead of opening the chest, for example, we can make a small hole in the chest and insert a medical device that means the patient can go back home and recover much more quickly. We are benefiting the healthcare system and hospitals in that the costs are lower because we are using less intensive equipment and less time is spent in the operating theatre, but we are also providing a better quality of life to the patient as they are less exposed to the risks of major cardiac intervention and anaesthetics.”

Tarricone goes on to explain that innovation is benefiting the entire economic system as technologies, approaches and procedures improve and allow increasing opportunities for patients to get back home earlier and get back to their job faster. However, despite technological innovation being crucial to a speedier recovery for patients, there is no doubt that it has recently been tainted with a bad reputation: innovation has been deemed to be at the root of the recent escalation in healthcare costs.

Tarricone, however, completely disagrees that innovation is behind rising fi nances. She points to three studies that were published last year that prove that the rise in healthcare expenditure is due to personnel and other costs as opposed to innovation.

Recent data from Bocconi University that is yet to be published, for example, states that of all the expenditure in Italian hospitals over the last decade – the costs for medical technology and for innovation in general in the field of medical technology – has actually decreased while other cost components such as pharmaceuticals and other healthcare services have increased. “I would like to see the evidence demonstrating that technological innovation is at the root of escalating costs,” says Tarricone. “Of course this doesn’t mean that innovation hasn’t contributed at all to the increase in costs, simply that it is not the most important factor.

Obviously technological innovation contributes to higher expenditures, but today – simply because we have the opportunity of treating and making a better diagnosis than in the past. Th ink of the screening programmes, for vaccinations or genetic tests that weren’t available 10-15 years ago. We didn’t have the opportunity to make genetic tests help clinicians target their medication in such a precise way.”

Going on to give an example, Tarricone explains that until 2007, the only way to treat patients with severe cardiac problems was by implanting heart valves, which actually translated into a high percentage unable to go through with the procedure because it was too risky. Over the last two years several medical device companies have developed innovative ways to treat these patients and the risk of surgical intervention has been decreased dramatically translating into more

eligible patients who go on to survive at least five years longer than in the past. “Surely cost shouldn’t even come into this – we are not delivering these new systems or procedures because they are more costly than in the past – although obviously they are – but for the benefits they bring. There are incremental costs, but we should compare these against the incremental benefits in terms of a longer and healthier life for patients,” says Tarricone.

Overall savings from telemonitoring range from $430 to $821

Challenges

And potential cost increases are not the only challenge facing the medical devices sector, the biggest challenge, claims Tarricone, is the very deep lack of knowledge and understanding of the differences between the devices and other technologies, particularly pharmaceuticals. Over the last decade pharmaceuticals have come under heavy regulation from both local governments and international organisations, such as the European Commission. A similar trend has developed as those organisations attempt to regulate the medical devices sector. However, the challenge is that the same individuals who are used to regulating, managing and controlling access to the pharmaceutical industry are looking to use the same principles and methods to regulate

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Economic evaluation Along with Michael Drummond at the Centre for Health Economics and Adrian Griffin, Vice President of Strategic Affairs at LifeScan EMEA, Rosanna Tarricone recently released a report, Economic Evaluation For Devices and Drugs, arguing that the economic evaluation of devices raises additional challenges that international guidelines, written with pharmaceuticals in mind, frequently overlook. In the report the authors stress the six reasons why devices are different: “The first reason is the rather obvious one that many devices are diagnostic. This raises two challenges, the first being that the value of improved diagnosis cannot be separated from the value of the improvement in patient outcome resulting from the subsequent treatment. This problem is not insurmountable, but makes the economic evaluation of some devices much more complicated.

“The second way in which devices are different is in the difficulties in undertaking randomised controlled trials (RCTs). By the time a drug reaches Phase III of clinical development, its dosage and route of administration will typically be set. Therefore, whilst it is well known that the efficacy demonstrated in RCTs does not always translate into practice, the results from trials provide a reasonable basis for conducting an economic evaluation.

“The third reason why devices are different is that the efficacy of a device depends not only on the device itself, but how it is used. Again, this is particularly true for devices used in surgery, as the clinical outcome can depend on the skill or experience of the surgeon. On the other hand, drugs are a classic case of an ‘embodied technology’. That is, as long as the drug is given in the right dose, the efficacy relates solely to the drug itself, not the person administering it.

“The need to adjust for user characteristics further complicates the design of RCTs and user performance is a potential confounder in the analysis of observational data on the efficacy of devices. Indeed it might be preferable to undertake more multicentre studies than is typical for all but the large Phase III studies of drugs. Whether these studies are randomised or not, the statistical analysis would be more complicated, since it would need to allow for treatment center effects. Taken in conjunction with the points made above, it is clear that the design and analysis of clinical studies of devices can be more challenging than comparable studies of drugs.

“The fourth way in which devices are different from drugs is that implementation of a new therapy involving a device can have wider economic implications. For example, there may be a need for training, or more fundamentally, the local organisational context

may be important for harnessing the improved cost-effectiveness of a device.

“The fifth way in which devices are different from drugs is that equivalent clinical evidence may not be available for all products, making comparisons difficult. Those undertaking economic evaluations are often quick to ‘genericise’ their recommendations, unless there is specific evidence to differentiate products. This position is possibly driven from experience with pharmaceuticals, where there is clinical evidence on each product and where assumptions about class effects are common, unless there is specific head-to-head trial evidence to the contrary. In addition, there are now acceptable methods for making indirect, or mixed treatment comparisons, providing sufficient clinical data is available (Ades et al., 2006).

“The sixth way in which devices are different from drugs is that prices are much more likely to change over time, because of the market entry of new products, or because of the ways in which procurement takes place in many healthcare systems. On the other hand, in many countries, once the price of a drug is negotiated, it is more likely to stay at or near that level until the patent expires.”

Extract from: Economic Evaluation For Devices and Drugs by Michael Drummond, Adrian Griffin and Rosanna Tarricone.

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access to medical devices. “I can envisage a huge danger in this,” warns Tarricone, “there are deep differences in the way medical devices are developed compared to the pharmaceutical industry is managed.”

She goes on to explain that the medical device industry is extremely fragmented with around 80 percent of the companies operating in it being SMBs, compared to the pharmaceutical industry, which has a high concentration of super companies used to operating around the world.

“There are huge differences in terms of R&D, competitiveness and the lifecycle of medical devices in the two industries,” explains Tarricone.

“When you have a new molecule for example, normally it will be present for at least 15-20 years until a new one replaces it. A medical device will usually be obsolete after around 18 months.”

If policy makers at all levels still fail to understand the key differences between these two industries, there is a risk that the medical devices sector will be regulated with pharmaceutical rules, killing the competitiveness and innovativeness of the sector, says Tarricone. “Th is translates into a huge responsibility for the EHTI – we need to unveil these differences from a scientific perspective through evidence demonstrating the differences and arguing the case for alternative policies and regulations to the policy makers.”

And while policy decisions will continue to impact the medical devices industry for some time, there is another challenge on the horizon, namely the aftershocks of the economic downturn. While the medical technology sector has not been directly or heavily affected by the worldwide recession, there has been an impact on other sectors of the industry, such as for instance, diagnostics and preventive medicine. Tarricone says that screening programmes for breast cancer, for example, have experienced a heavier impact as patients have started delaying the services because in many countries these services require co-payment from the patient. It seems that patients have started thinking twice of the necessity of performing some diagnostic tests and we have the data proving this.”

Tarricone goes on to explain that the economic downturn will probably have a bigger influence in the long run, as the impact is felt by the companies producing these devices. The risk here, of course, is that long-term this downturn has the potential to kill the most dynamic sectors of these companies, which are the R&D sectors. Th is is unfortunate considering that Tarricone believes the big potential for the medical technology industry in Europe is all about R&D and the emergence of breakthrough innovations. “You have to consider that a lot of breakthrough innovations have been developed in Europe but marketed in the US – and that’s our weakness. European systems are not very friendly in terms of facilitating, stimulating and welcoming innovativeness in companies within Europe,” she says, going on to explain that Europe is wasting a lot of potential in terms of economic return on investment and positioning the region on a higher competitive level with the US and Asia. “I really would like to see many countries, including Italy, become more aware of what they are missing in terms of

Device analysis An analysis performed by Dr Christian Elsner, Center for Healthcare Management, Leipzig Graduate School of Management on behalf of Eucomed CRM Telemonitoring WG found the following: • Overall, the decrease in physician’s time ranged from 40 percent to 70 percent from the use of telemonitoring, depending on the perspective (e.g. payer’s perspective-only or societal perspective) • Costs per visit ranged between $94 (France) and €281 (Germany). Transportation costs per visit ranged between $121 (France) and €43,5 (Germany) • Overall savings from telemonitoring per year ranged between $430 (France, a saving of 30.1 percent) and €821 (Germany, a saving of 60.9 percent).

opportunities and understand the advantages that could be delivered in keeping investment in Europe.”

Focusing on opportunity, Tarricone believes that the next three years will be important for the EHTI’s research agenda, fi rstly to understand the impact of healthcare policies onto healthcare systems and the uptake diff usion of medical devices in different European countries, and ultimately to understand whether the different diff usion of medical devices in European countries is affecting the equitable access of patients. Tarricone goes on to stress her previous point that while researchers have always been asked to provide evidence of their fi ndings, policymakers have never been asked to supply the evidence of their work. “Policymakers are struggling with healthcare expenditures and while they are right to understand and try and implement different types of cost containment policies – from procurement to reimbursement – none of them have been called to prove the impact of these policies on the efficiency of the systems, the effectiveness of the systems and, more importantly, the equity of the systems.

“In modern-based societies health policies must be evidence-based.

We are the fi rst European institute that is dealing with this specific field of research in a very structured way, specifically on medical devices, and I think that the output of all this research will be interesting, and in many cases surprising, for many stakeholders.” And with Tarricone so determined in her mission to improve these systems I have no doubt that she will succeed.

“There are incremental costs, but we should compare these against the incremental benefits in terms of a longer and healthier life for patients”

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ANALYST VIEWPOINT

As digital becomes an increasingly important function of healthcare IT, Frost & Sullivan analyst Akanksha Joshi reveals why an ageing demographic is boosting the uptake of wireless patient monitoring devices.

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s healthcare across Europe becomes increasingly digitised, there is a growing need to develop equally sophisticated information systems.

Indeed the popularity of wireless and handheld devices in the healthcare area is poised to grow significantly as the benefits of mobility and flexibility become progressively more important to both physicians and patients – particularly in the European wireless patient monitoring devices market. New analysis from Frost & Sullivan, European Market for Wireless Patient Monitoring Devices, finds that the market earned revenues of €131.2 million in 2008 with estimates reaching €66.7 million in 2015.

Akanksha Joshi, Research Analyst for Frost & Sullivan, believes that the most important drivers in the growing market is the rise in elderly population plus the increasing preference of this population to age at home. “Not only is the number of people over the age of 65 increasing, but there’s a preference for people to have a comfortable life at home and this is becoming a very important factor, which is accompanied of course by an awareness about the need to provide a better standard of living to them,” she explains. “The importance of providing rapid, real-time diagnoses is being realised due to the focus on home-based, wireless enabled patient monitoring devices.”

Alongside the desire to provide better patient care in a more comfortable environment – namely, the home – the healthcare industry

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because it is the most cost-friendly solution that they can come up with in terms of basic patient monitoring,” she confi rms.

Joshi also believes that the technology grid in Europe needs to be improved before the chance of further development in the field. Better network and standardisation from the service providers would reduce the cost to patient. She also suggests that the manufacturer develops more of a relationship with the end user in order to get a better feel for what products are needed. “Initial testing of the system will ease up the process and I also believe that the manufacturer should do more to understand the end user, especially in terms of the user requirements that are bound to be different from country to country. Th is will enable the manufacturer to adapt their product to both a specific end user from a specific country as well as enable a better line of communication.”

Joshi indicates that the main regions that will see growth are the UK and Scandinavia, as these are the two markets with a greater awareness among patients as well as government organisations who are looking to cut costs and provide a better service for their citizens. Still in it’s initial growth stage, Joshi says that the market could grow explosively across the whole Europe region. “Specifically in the assisted devices region,” she says, “Basically those devices that fall into the sub-segment category, such as movement detectors.”

With the number of elderly rising across Europe, without doubt there is a considerable growth potential for wireless patient monitoring devices across the region.

Akanksha Joshi is a Research Analyst for Frost & Sullivan.

Wireless Patient Monitoring Devices Market: Revenue Share By Country, 2008

Germany: 28% France: 13% in Europe is also focusing on reducing hospital costs. “Part of those reduced costs is down to a diminished change of spreading an infection,” says Joshi. “With vital signs easily and comfortably measured in a user-friendly way at home, wireless patient monitoring is becoming more popular as well as reducing costs. Assisted living devices and vital signs devices with a wireless option are certainly in demand.”

However, one of the challenges facing the industry is around the lack of clearly defi ned reimbursement. Joshi also says that there is an element of price sensitivity in the market: “If we are talking only about telecare devices and the sensors the price is not all that high, but if you include the service providers, which constitutes about 60 percent of the total cost of the treatment, obviously you are looking at increased costs.”

While the economic recession has aggravated price sensitivity in the healthcare market, Johsi believes that due to the wireless monitoring sector being in its infancy the sector has avoided any major impact.

“People – both physicians and patients are moving towards homecare

Benelux : 6%

UK: 27%

Italy: 11%

Scandinavia: 9%

Spain: 8%

Source: Frost & Sullivan

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WIRELESS NETWORKING

A wireless world The Wi-Fi Alliance’s Sarah Morris looks at the expanding use of Wi-Fi in the hospital setting.

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10-year-old trade association, the Wi-Fi Alliance has 350 member companies that span the whole ecosystem from service providers to equipment makers, chip, silicon IC vendors and software.

Its goal is to ensure that Wi-Fi has full access to markets. Much of this is achieved through members coming together to design certification programmes around the needs of particular markets.

As Sarah Morris, Senior Marketing Manger for the Wi-Fi Alliance, explains, most people associate Wi-Fi with wireless area networks (WLANs), but the diversity of uses for Wi-Fi has grown exponentially in the past few years. “In a traditional wired setting, a local-area network is a series of devices that are interconnected so that they are networked together,” Morris

explains. “So from a wireless standpoint, obviously that connection could be happening over Wi-Fi. “And then there are the broader places that Wi-Fi is being embedded into; a lot more electronics devices as well as into mobile handsets, and smartphones in particular, are integrating Wi-Fi. What it then becomes is something a bit more pervasive where a single device may be using several different kinds of connections. But from the end-user’s standpoint, you’re just connected.

“It’s still pretty common for people to associate Wi-Fi with internet connections, that’s one of the kind of core uses of Wi-Fi. But again, Wi-Fi is certainly broader than that. There are Wi-Fi technologies that are about wide-area networking, otherwise known as mesh networking, that are used for public-area networks and municipal networking.

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“When we talk about Wi-Fi security, we’re talking about two things: authenticating devices that connect to the network, guaranteeing that appropriate devices connect; and encrypting the transmission from that device to the access point.

“In those two regards, Wi-Fi is top notch. The Wi-Fi Alliance has a programme called WPA2, Wi-Fi Protected Access 2, and it has a sophistiHospitals cated and robust security that includes government grade encryption.

Within the hospital setting, Wi-Fi is very well established as a com“Questions about network security shouldn’t make anyone munication tool for a wide range of data functions. Voice over IP conhesitate to install Wi-Fi. That’s not to say that IT managnections, for example, are a big deployment practice forr Wi-Fi, ers don’t as are mobile computing carts. This appears to be borne out do have other layers of security concerns, but the Wi-Fi by an estimate from ABI Research that Wi-Fi revenue forr Wi- piece certainly is a strong player. I wouldn’t say anything other than a thumbs-up on that.” healthcare in 2013 will equal US$5 billion. an It is estimated that Wi-Fi can also look forward to a strong future Morris says uptake of wireless among hospitals Wi-Fi revenue for in varies geographically in terms of what infrastruci the healthcare sector. Morris sees a lot of mohealthcare in 2013 mentum, with hospitals seeing the benefits of a ture is already in place and where it makes sense. “If m robust, secure, wireless connection for their data you look at hospitals as similar to typical enterprise will equal applications.

“That’s happening right now, and it networks, it’s as if you have an existing building and a US$5 billion will wi continue to be the case, and penetrate further your alternative is putting in Wi-Fi access points versus and further into that market. running new cabling,” she explains.

“The next growing edge, the next opportunity for IT “It also lets you be flexible as you grow. You don’t have managers and pacity to a hospital administrators, will be where Wi-Fi to pre-wire everything at the start, and you can add capacity can add value in the monitoring, and into patient services, for home the network as it goes on. It’s very flexible and cost-efficient in that way. healthcare as well as hospitals. They’re distinct needs, but they’re both Depending on the individual circumstances, I think Wi-Fi is becoming a places where Wi-Fi can be a real valuable part of the solution. no-brainer choice for a lot of applications. And hospitals are in a similar “The key is for hospital administrators to be thoughtful about what place with regard to data.” their needs are. Remote monitoring and dispensing is one example. We have members who are active in that area, where they are developing devices that might be a wireless blood pressure cuff, or something that could take vital information and report it over the network.

“That’s the early edge, and there are more developments to be made, but we certainly have members who are active and successful in those markets.”

“There’s also a move within Wi-Fi right now to connect individual devices together without an access point. That’s a technology that was developed in the Wi-Fi Alliance, called Wi-Fi peer-to-peer. It will be coming out under the tradename Wi-Fi Direct.”

“Questions about network security shouldn’t make anyone hesitate to install Wi-Fi”

Morris points out that when we talk about hospitals as a single entity, IT managers are comfortable and familiar with Wi-Fi and data networking and the voice applications, and the next horizon that they have in terms of understanding, is not so much Wi-Fi’s limitations as the particular needs they have.

However, as these needs begin to encompass things like medical sensing applications, which are more about data and the monitoring of patients, it will become even more important for IT administrators to understand the needs they have in their specific environments.

“Wi-Fi is a robust, proven, reliable technology,” Morris says. “The focus for a successful deployment for IT managers is to understand the environment they’re in as well as the requirements they have for the network.”

Security There are always security concerns around any kind of patient data, and perhaps even more so when it comes to electronic storage and transmission. Morris underlines the importance of putting Wi-Fi security in the context of the security of the whole network.

The Wi-Fi Alliance’s mission is to: • Deliver the best user experience by certifying products enabled with Wi-Fi technology • Grow the Wi-Fi market across market segments and geographies, on a variety of devices • Develop market-enabling programmes • Support industry-agreed standards and specifications

What is Wi-Fi? Wireless fidelity (Wi-Fi) is a trademark of the Wi-Fi Alliance that may be used with certified products that belong to a class of wireless local area network (WLAN) devices based on the IEEE 802.11 standards. Because of the close relationship with its underlying standard, the term Wi-Fi is often used as a synonym for IEEE 802.11 technology

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ASK THE EXPERT

The anatomy of a data breach

Sarah Whipp on why breaches happen and how to prevent them occurring.

I

n a world where data is everywhere, why they occur. Th ird-party research into the it has become harder than ever for root causes of data breaches, including data healthcare organisations to profrom the Verizon Business Risk Team and the tect confidential information. In Open Security Foundation, reveals three main fact, more electronic records were types: well-meaning insiders, targeted attacks breached in and malicious insiders.

2008 than in the previWell-meaning insiders ous four years combined, who inadvertently violate data according to Verizon’s security policies continue to 2009 Data Breach Inrepresent a major factor in ocvestigations Report. Aucurrence of data breaches. In a tomation of electronic 2008 survey of 43 organisations medical records, clinical that had experienced a data systems and medical imbreach, the Ponemon Institute aging poses increasing found that over 88 percent of all challenges to safeguardcases involved incidents resulting the privacy of patient ing from negligence. data and securing the IT In today’s connected world, infrastructure housing where data is everywhere and Sarah Whipp is VP of marketing an organisation’s most the perimeter can be anywhere, for EMEA at Symantec. She joined Symantec in July 2009 sensitive information. protecting information assets after nine years at McAfee, most recently as VP of EMEA While the continufrom sophisticated hacking Marketing. Symantec is the ing onslaught of data techniques is an extremely difworld’s fourth-largest software company and a global leader in breaches is well-docuficult challenge. Driven by the providing security, storage and systems management solutions. mented, what is far less rising tide of organised cyberunderstood is why data crime, targeted attacks are breaches happen and what can be done to increasingly aimed at stealing information prevent them. In order to get ahead of the data for the purpose of identity theft. More than 90 breach challenge, it is essential to understand percent of records breached in 2008 involved

groups identified by law enforcement as organised crime. Such attacks are often automated using malicious code that can penetrate into an organisation undetected and export data to hacker sites.

Malicious insiders constitute a growing segment of breach drivers, and a proportionately greater portion of the cost to business of data breaches. The Ponemon study found that data breaches involving negligence cost €138 per record while those caused by malicious acts cost €156 per record.

With the regularity of data breaches making news headlines, it might seem reasonable to regard data breaches as an inevitable by-product of our connected world, a cost of doing business that we must simply learn to live with. A closer view of the facts, however, suggests that this is not necessarily the case.

Symantec’s security expertise, global intelligence network and real-world experience with customers combine to inform a more confident perspective.

How to stop breaches By following a risk-based and contentaware information security strategy that incorporates multiple solutions working together in concert, data breaches are preventable. The six steps that any organisation can take to significantly reduce the risk of a data breach using proven solutions are to proactively protect information with a unified data loss prevention solution, automate the review of entitlements to sensitive data, identify threats by correlating real-time alerts with global security intelligence, deploy a multi-layered combination of security solutions to stop incursion by targeted attacks, establish network defences to detect and block data exfi ltration and to integrate prevention and response strategies into security operations.

Getting started For many organisations, the process begins with a data breach workshop. The Symantec Data Breach Workshop helps organisations quickly identify their confidential information and accurately identify and quantify their risk of a data breach.

To schedule a Data Breach Workshop or to see a full copy of the Anatomy of a Data Breach whitepaper, contact Symantec at http://go.symantec.com/one-breach

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DATA SECURITY

Staying safe James Koenig tells Marie Shields about the role played by single sign-on in identity access management for healthcare IT.

T

here are challenges within the hospital IT environment: legacy applications may not support modern authentication controls; there is a need to share access to equipment and patient care areas across multiple users who require access to medication records; the open nature of hospital floors causes problems of physical security; and regulatory compliance requirements are increasing.

If that’s not bad enough, there is the additional, often underestimated, risk of improper access and even medical identity theft by knowledgeable insiders James Koenig, Practice Leader, Privacy & Identity Theft, and Practice Leader, HIT Privacy & Security for PricewaterhouseCoopers, explains: “Knowledgeable insiders have surpassed outsiders and hackers as the leading cause for identity theft within companies. Within hospitals, the main areas that have been vulnerable have been within collections, within patient enrolment, with physical security, with IT and even the janitorial crew. There are a lot of risks within the environment to electronic health records.

“There are many reasons for which information is improperly accessed. Some of the more notable ones have been when healthcare providers and staff have accessed the medical records of celebrities; that’s one type of improper access that is still relatively common. The other type is for gaining information that can be used for medical identity theft , to get a health insurance ID number or other information that could allow someone else to access medical care, or to even obtain prescription drugs that are commodities that can be used on the street.

“That’s one of the new major underestimated risks within an environment, and within hospitals you have so much change, so much vulnerability, so many people, that this is naturally starting to grow.”

In the US, hospital IT departments are also now faced with the challenges of complying with the requirements of HITECH, which has expanded on those originally set out by HIPPA. Koenig recommends that healthcare providers there focus on the changes to HIPPA under HITECH, specifically on the protected health information breach notification requirement.

“The return on investment depends on the profile of your workforce and how many logins they average in a given day”

A number of requirements were added under HITECH, which was part of the stimulus bill. One of these is to create in the US a federal breach notification provision if protected health information becomes improperly accessed or compromised. Hospitals must notify the individual whose information has been compromised, whether the information is in electronic form or paper form. They must also notify Health and Human Services, who will list the breaches on a website; the state attorney generals if there are more than 500 people in a particular state that have been compromised; and the local media.

“Th is new notification provision is stronger than any state requirement,” Koenig points out. “Providers are quickly focusing on this for three reasons. One, most of the state breach notification laws that existed before didn’t include health information; now health information under HITECH is included.

“Second, providers had a strong programme around HIPPA but HIPPA security only applied to electronic protected health information.

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Single sign-on Despite the rising concerns about security and the need to comply with increased regulatory requirements, the adoption of single sign-on in healthcare has been slower versus other industries, often due to the inability of older specialised medical equipment to talk and to accommodate some of the new identity management and single sign-on tools.

According to Koenig, this is becoming less of an issue as technology matures and hospitals continue to upgrade their systems, especially around electronic health records. “Vendor consolidation has reduced the number of tools in the market,’” he says. “It has also consolidated some of the developer talent, and the remaining tools tend to be a little more consistent so that there’s no longer a reducing number of platforms and standards and options that healthcare can focus around. It’s probably behind other industries, but it’s maturing and getting better.”

The use of single sign-on does confer a number of benefits, including fewer passwords to remember, lower support costs, more ability to push secure authentication standards and controls across the enterprise, at one time, centralised support, centralised logging and monitoring, and fewer accounts to maintain each year.

In general, Koenig says, organisations using single sign-on will spend less time looking into many different types of applications; instead, they can track it across the single sign-on. “The return on investment depends on the profi le of your workforce and how many log-ins they average in a given day, and with this reduced time and cost of the people entering in passwords repetitively it allows more time to focus on healthcare delivery.

“Resetting of passwords will fall if you have fewer passwords to remember. You will also fi nd people writing them down less, and writing passwords down is what makes them insecure; this is how some of the security incidents at hospitals have occurred. Also, because of the new technology, many payers in HITECH now includes paper-based prothe US are upgrading their electronic health tected health information, which providrecords and related systems and architecture James Koenig is Practice Leader, ers may not have focused on before. in preparation for certification to get stimuPrivacy & Identity Theft, and Practice “And third, HITECH now requires lus funds for the meaningful use of electronic Leader, HIT Privacy & Security, for that all business associates comply health records.”

PricewaterhouseCoopers. completely with the HIPPA privacy and As part of this overall update of the syssecurity rules. Previously they only had tems and investment in the infrastructure at to agree to provide adequate safeguards in a contract. Now, when enhospitals, single sign-on will also be accompanied by self-service resets trusting protected health information to a third party – which could be as opposed to a manual call to a help desk. These new systems often have a lab or another vendor – the focus around protected health information features that allow users to go to an intranet site and through self-service is growing.” and answering challenge questions, they can reset the password themKoenig says that the types of information that can be compromised, selves. not just healthcare information, but employee information and the The benefits can be summarised as: reduced cost for the enterprise, requirements under other privacy laws, including the state breach noquicker response time for people who need to get their passwords, fewer tification laws, have changed the environment and made it much more instances of passwords being forgotten because people remember a single complicated for healthcare providers to comply. sign-on better, and less need to write passwords down.

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Glossary Single sign-on (SSO) is a property of access control of multiple, related, but independent software systems.

With this property, a user logs in once and gains access to all systems without being prompted to log in again at each of them.

Identity access management (IAM) encapsulates people, processes and products to identify and manage the data used in an information system to authenticate users and grant or deny access rights to data and system resources. The goal of IAM is to provide appropriate access to enterprise resources.

Strong authentication centres around the strength of the information needed to access a system, such as the type of password and how difficult it is to crack.

Multi-factor authentication brings other information into the equation, based on questions related to ‘something you have’ or ‘something you are’. Federal Financial Institutions Examination Council guidelines state that true multi-factor authentication requires the use of solutions from two or more of the three categories of factors.

Implementation As with any new technology implementation, there are challenges involved in bringing single sign-on into a hospital or healthcare setting.

Koenig believes the main challenge is cost. “Return on investment is based upon building a core framework and then adding additional applications over time. Part of the challenge is adding that to our legacy applications that aren’t quickly compatible. You can always build them in, you can always address it, but the question is, at what cost?

“The second challenge is that by having a single sign-on, people will potentially have access to a wider group of systems, applications and information with each sign-on across this system of single sign-on applications.

“Th is means it will be more difficult for providers to make sure that access control rights and authorisations given to employees, doctors and staff are limited to the areas that they need for legitimate business and healthcare purposes.

“For example, there may be a staff person who used to have a log-on for the practice management application, which would do scheduling and billing for patients. There was another application for the electronic health records that needed a different sign-on. There’s another sign-on for the laboratory, and for the blood work. There’s another sign-on for radiology data.

“Four different sign-ons, just in this one example. If they’re all part of a single sign-on, hospitals have the challenge to make sure that the right person can only go into where they need to. If there’s a staff member who doesn’t need radiology data, maybe they’re improperly looking at a patient’s data or multiple patients’ data in radiology.”

Koenig says the challenge will be to limit controls and adjust them when people get promoted or terminated, or at a minimum review them each year. “With single sign-on, you can do a lot more and seamlessly move across areas. That’s great unless you haven’t checked to make sure that the areas are appropriate.

“Right now the management is done because there isn’t single signon, it’s all manual. When somebody says, ‘I need another sign-on,’ you ask, ‘Is it appropriate for that person?’ Now, when you’ve seen them all together someone may have too much access to information that they don’t need.”

Authentication Another method of ensuring only the right people are allowed access to the correct areas is authentication. Strong authentication centre around one type of authentication, such as a password: how many characters are there, are they letters and numbers? Do you need a special character like an asterisk or an exclamation point? How hard is the password to crack?

Multi-factor authentication involves the number of questions you need to answer to get in. For example, single-factor authentication could be just a user ID. If someone had a user ID 123, and someone else knew that ID number, they would be able to access that system.

Two-factor or multi-factor authentication adds other information to the equation, related to ‘something you have’ or ‘something you are’.

“When you’re logging in to your bank or calling up, they may ask you challenge questions about your mother’s maiden name or other things, that’s multi-factor,” says Koenig. “It goes beyond the simple stuff.

“How does single sign-on work with two-factor authentication?

Strong authentication or strong passwords should always be part of the equation. Two-factor authentication, using a name plus a password, is currently industry common practice. The fi nancial services industry addressed this issue several years ago, requiring it for online fi nancial information.

“Since then, fi nancial institutions and frankly most large and medium-sized organisations have used two-factor authentication to allow access to any system. That would be a sub-requirement for a single signon. Sometimes, for example, if you’re going from a simple access into the radiology system, where a limited number of people have access, you might just have someone’s user ID number and not necessarily a password, and maybe the password requirements aren’t that hard.

“But when you’re going to a single sign-on environment, you want to make sure that the person who is entering, who now has access to a lot more information, actually is that person. It’s very common, when you’re moving from a smaller environment that may not have these controls to single sign-on, that people will need to have more complex passwords in addition to what might previously have just been a user ID. “Part of that goes to the success of the single sign-on. People need to be trained and they need to get used to the fact that instead of having multiple IDs to remember, they may now have only one, but a more complicated one that would truly make sure that it’s them.”

Identity management Koenig points out that typically, single sign-on is part of an organisation’s identity management programme, or it could be thought of as

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a component or a benefit of some of these identity management tools.

Organisations’ websites will very often already have single sign-on and some of these identity management access control solutions built in, but other areas are not so secure.

“Very often it’s the internal intranet connections between the laboratory, radiology, billing and the practice management system’s electronic health records that aren’t connected,” Koenig says. “That’s the area where there needs to be work and often a separate investment focusing on extending what might be an existing identity management approach, which covers certain applications to some of these older legacy systems and applications.

“For example, many organisations have a wide variety of applications that leverage what’s called an active directory, which is like a single vault of ID. Every time someone enters the system, they check against this active directory. But typically right now, it’s only covering email and a couple of other applications. It doesn’t always get out to those separate ancillary, important healthcare delivery applications. Extending identity management beyond the existing areas that are covered – email, web and some basic applications – will take a separate investment.

“It’s part of regular authentication of controls, but when people buy these systems in these different departments, they don’t always integrate them with the existing identity management controls and functionality that already exists elsewhere. Th at’s the connection that needs to be done now.”

Koenig’s forecast for the use of SSO and identity access management tools in the healthcare sector is bright: continued deployment in the industry will occur as US providers mature their systems and applications to prepare for certification to get the stimulus funds for the meaningful use. There will be increased purchasing and use of some of these single sign-on and identity management tools to help grow secure access from beyond the areas in which it now exists.

“Return on investment is based upon building a core framework and then adding additional applications over time” “A big stimulus or driver for that will be the stimulus funds and the meaningful use of certifications over the next couple of years,” he concludes. “It’s a great opportunity to use those funds and those existing efforts around enhancing your technology, plus the need to certify around privacy and security when you apply for the meaningful use funds. That’s an important part that a lot of people who are just focusing on the technology are potentially missing.”

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Swine flu swindle_mar10 07/04/2010 15:55 Page 98

SPECIAL REPORT

The great

swine flu

swindle?

Billed as a pandemic of devastating proportions, it was predicted to cause a global standstill as hundreds of thousands of people around the world died and millions more got sick. So what happened to swine flu?

By Rebecca Goozee

I

t was almost exactly a year ago that an outbreak of H1N1, or swine flu, began in the state of Veracruz in Mexico. There was evidence that there had been an ongoing epidemic for months before it was officially recognised as such and the Mexican government closed most of Mexico City’s public and private facilities in an attempt to contain the spread of the virus. Unfortunately, it spread globally as clinics became overwhelmed with infected patients. In fact, the World Health Organisation (WHO) and the US Centers for Disease Control (CDC) stopped counting cases over the coming months and in June 2009 declared the outbreak a pandemic.

The news sparked near-constant media focus on the condition as death on a mass scale was expected. Over one billion people around the world were expected to fall victim to the disease with millions more getting sick as parallels were drawn with the Spanish Influenza of 1918, in which 40 million people died in just 18 months. In Britain alone health authorities worst-case scenarios predicted as many as 65,000 people could die over the winter season, while Germany ordered 50 million doses of a swine flu vaccine and the Netherlands 34 million. Meanwhile France and Portugal announced major orders for vaccines against the virus, soon after Latin American countries expressed concern that their poorer region could miss out.

The Outbreak March 2009

April 17, 2009

April 27, 2009

April 30, 2009

First swine flu infection

A high-tech laboratory at the Centers for Disease Control identifies a new influenza virus

The WHO raises its pandemic warning to phase 4, meaning it has discovered human-tohuman transmission of the virus in at least one country

Egypt begins killing all domestic pigs in the country, despite protests from animal rights activist and French actress Brigette Bardot to stop the mass slaughter

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June 11, 2009

July 24, 2009

November 2009

February 11, 2010

The WHO declares a swine flu pandemic

German states order 50 million vials of swine flu vaccine

Poland decides not to buy any vaccine

The National Pandemic Flu Service in England is closed

August 2009 By the end of the southern winter, fewer people than usual have died for an average flu season

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Swine flu deaths in europe

A cautionary tale Scientists claim that while the virus is mild, it can still kill – and in fact is still responsible for deaths and that the low fatalities are down to the fast-acting response to official advice. Fred Hayden, influenza research coordinator at the Wellcome Trust 50 deaths and a former WHO expert, told Reuters back in November 2009 that early planning paid off because the original predictions had been revised. “I wouldn’t characterise this as a ‘mild’ pandemic Below 100 Above 100 at all,” he said. “We are seeing some very unfortunate loss of life.

I think it’s a bit early to make that judgement.”

But five months later and after the dreaded flu season in Europe has passed, it seems Hayden could be wrong in his evaluation and that the pandemic is indeed ‘mild’ – particularly as it has been used so frequently to describe a patient’s condition.

Accusations of overreaction were flying as early as October and November last year when both British and French media suggested that the pandemic had been ‘hyped’. Sceptics across the continent are asking what are the hype was all about – in November for example, France’s Le Parisien newspaper ran the headline ‘Swine A-Z List of countries and total number of swine flu deaths flu: why the French distrust the vaccine’, and remarked upon the “dangerous liaisons between certain experts, the labs and the gov6 Albania 41 Finland 3 Luxemborg 15 Slovenia 271 Spain 24 Austria 258 France 13 Macedonia ernment, with the obscurity of the contracts between the state and 35 Moldova 16 Switzerland 20 Belarus 178 Germany 54 Netherlands 25 Sweden 17 Belgium 21 Georgia the pharma firms adding to the doubt.”

93 Greece 29 Norway 415 Turkey 10 Bosnia 57 Hungary 138 Poland 202 Ukraine 35 Bulgaria Scientists claim they are stuck in the middle and can’t win; that 26 Croatia 2 Iceland 83 Portugal 362 United Kingdom 77 Czech Republic 210 Italy 107 Romania they were unable to avoid the advice from organisations like WHO, 30 Denmark 31 Latvia 71 Serbia 13 Estonia 21 Lithuania 38 Slovakia because it would have caused public outrage and widespread panic Figures from 21 January 2010 to simply ignore the global guidelines. And it appears that the WHO has yet to learn its lesson – indeed, the organisation has been urging countries to prepare for a flu pandemic since 1997, when H5N1 Films like Danny Boyle’s 28 Days Later suddenly became a daunting re(avian flu) infected 18 people in Hong Kong and the re-emergence of the infecality as people around the world were convinced a devastating plague was on tion occurred in China and South Korea in 2003. its way: trade was predicted to slow to a crawl, economies were sure to crumMike Fumento, a writer and blogger based in the US, believes that the hype ble, schools would be empty, food supplies would dwindle and power supplies is all down to the way WHO has dealt with the situation, particularly in the were going down. way it dealt with changing the definition of ‘pandemic’, which occurred just But by March 2010, swine flu had claimed just 16,713 lives – nowhere before swine flu was announced as such. “The definition previously required near the millions suggested – which barely registers on the annual death toll ‘enormous numbers of deaths’, but the agency desperately wanted a pandemic from seasonal flu, estimated at between 250,000-500,000. So just what hapand with swine flu vastly milder than ordinary flu, it clearly didn’t fit. So they pened to swine flu? simply penned a new definition to match swine flu, making deaths irrelevant

Spot the difference Original definition of a pandemic, according to the WHO: An influenza pandemic is a worldwide epidemic caused by a new strain of virus which leads to infection rates and mortality rates which exceed seasonal but similarly heavy waves of influenza by several orders of magnitude. A precondition for an influenza pandemic is the appearance of a viral subtype which had not yet circulated amongst the human population or which had occurred so long ago that no residual immunity remains amongst the population, and which is capable of provoking severe illness and of

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disseminating effectively from one human to another.

New definition of a pandemic, according to the WHO: An influenza pandemic may occur when a new influenza virus appears against which the human population has no immunity.

WHO has defined the phases of a pandemic to provide a global framework to aid countries in pandemic preparedness and response planning. Pandemics can be either mild or severe in the illness and death they cause, and the severity of a pandemic can change over the course of that pandemic.

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and explicitly declaring ‘mild’ strains would qualify,” says Fumento.

“However, the change cannot be justified medically – a flu pandemic simply has to include severity or it’s meaningless, which is unlike non-flu or other virus pandemics, because flu hits almost every single country around the globe every single year.”

Fumento goes on to explain that because the WHO described swine flu as a pandemic, the media jumped on the story focusing on the fact that this was the first pandemic in 41 years and therefore putting it in the same category as Spanish Flu and Asian Flu. Experts like John M. Barry wrote a piece for influential newspaper The Washington Post claiming that because it is a pandemic the US alone could expect between 89,000 to 279,000 deaths. And rather than look at the severity of the infection, Fumento proposes that figures were extrapolated from the last pandemic in 1957/58, which makes the data meaningless when the mildness of the infection is taken into account.

Tom Jefferson, a physician and epidemiologist who for the last 15 years has been conducting extensive reviews of seasonal influenza vaccines, believes that one of the extraordinary features of the whole influenza saga is that there are people who make predictions year after year, seeing it getting worse and worse.

“The WHO basically held a trigger for the implementation of the pandemic preparedness plans and with this high revenues for the involved producers of pandemic vaccines and some antiviral drugs” DR WODARG WOLFGANG

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“Sometimes you get the feeling that there is a whole industry almost waiting for a pandemic to occur,” says Jefferson. “The WHO and public officials, virologists and the pharmaceutical companies – they’ve built this machine around the impending pandemic. And there’s a lot of money involved, and influence and careers, and entire institutions. And all it took was one of these influenza viruses to mutate to start the machine grinding.”

Jefferson goes on to explain that influenza is a big money maker for the pharma companies, because of the vaccines and drugs that are sold to combat it. He says that the strict focus on flu is not only misguided, but extremely dangerous. Indeed, many cynics are pointing the finger at pharmaceutical companies as being the mastermind behind the swine flu pandemic. It doesn’t help matters that in the US, for example, the government has decided to make sure that the pharmaceutical companies producing vaccines are protected from legal action by any patients who suffer from adverse affects of the vaccines such as pain, suffering or death should it occur. Secretary of Health and Human Services Kathleen Sebelius signed a document back in June 2009 granting immunity to those making swine flu vaccines under the provisions of a 2006 law for public health emergencies that allows for a compensation fund if needed. Federal officials will also be immune from lawsuits, conveniently granting themselves impunity from their actions.

Unfortunately for the public, vaccines have been rushed to market before many of the tests to discover potential side effects become known, which could prove extremely dangerous. Back in February 1976, when an outbreak of swine flu struck New Jersey’s Fort Dix army base in the US, killing a 19-year-old and infecting hundreds of soldiers, President Gerald Ford – believing the US was on the brink of a devastating epidemic – ordered a

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nationwide vaccination programme at a cost of US$135 million. Within a At the same hearing back in January, Dr Keiji Fukuda, Special Advisor month, reports of Guillain-Barre syndrome – a paralysing nerve disease – on Pandemic Influenza to the Director-General at the WHO, admitted that surfaced and by April more than 30 people had died of the crippling conthere is still much to learn about flu to improve the handling of such events, dition. Facing protests, federal officials abruptly halted, and then canmainly due to the fact that it has been impossible historically to predict an incelled, the vaccination programme in December of that year. The swine fluenza pandemic’s impact. He explains that swine flu spread with unpreceflu epidemic failed to materialise. dented speed, reaching 120 countries and territories in about eight weeks, and This all rings true of the past year. And in fact the WHO is currently defendthat it also occurred outside the usual season for influenza causing a striking ing itself against charges from the Parliamentary Assembly of the Council of and unusual pattern of severe illness and death in younger people.

Europe (PACE) in relation to the pandemic. Dr Wolfgang Wodarg, Head of Regarding the accusations from PACE, Fukada says that the WHO takes Health for the Council, has accused the makers of flu drugs and vaccines of influthe issue of providing independent advice very seriously. “The flu pandemic encing the WHO’s decision to declare a pandemic, claiming that pharmaceutical policies and responses were not improperly influenced by the pharmaceuticompanies made “enormous” gains, while countries around the world “squancal industry. Cooperation with a range of partners, including the private secdered” their health budgets and saw millions vaccinated against a relatively mild tor, is necessary, but numerous safeguards are in place to avoid conflict of disease. Wodarg branded the swine flu outbreak as “one of the greatest medical interest. WHO is confident of the scientific validity of it recommendations. scandals of the century”, adding that the seeds of the scare were thrown five years The labelling of the pandemic as ‘fake’ is to ignore recent history and science ago when it was thought the lethal bird flu virus would mutate into a human form. and to trivialise the deaths of over 14,000 people and the many additional se“Associated Press reported on May 19, 2009, that China, Britain, Japan rious illnesses experienced by others.” and a dozen other countries had urged the WHO not to use the proMeanwhile, Luc Hessel, Chairperson of the Pandemic posed new definition of a ‘pandemic’ and to ‘be very cautious Influenza working group for the European Vaccine about declaring the arrival of a swine flu pandemic’, fearing Manufacturers, rejects the fake pandemic motion, claiming The UK that a premature announcement could cause worldwide that the vaccine industry did what it was asked to do – government ordered panic and confusion,” says Wodarg in the hearing on the which was to produce safe vaccines in a timely manner handling of the H1N1 pandemic on 26th January 2010. He and respond to government requests. He says that the indoses of the H1N1 goes on to explain that there were already doubts over the dustry is governed by stringent health regulations and vaccine, but only WHO’s alarm on avian flu in 2005/2006, which in fact was rigorous safeguards against conflict of interest. “The invaccinated 5.25 never transmitted between humans. Given that the WHO dustry responded quickly and effectively and was able to million people officially stated in panic-stricken terms that avian flu could deliver the vaccines ordered by governments. “Our industry threaten mankind it was unsurprising that medication worth bilresponded to requests from WHO and governments who wantlions of dollars was bought up quickly. “From a scientific view, this meded to have fast access to a large quantity of vaccines – it’s too early to ication had never been clinically tested for the disease for which it was marketed, speculate on the overall return for the industry, but in my view the industry given that avian flu had never become contagious among human beings and thus has been a responsible and reliable partner. Pandemic vaccines were properthose medicines could not be tested because the disease they had been proly tested and for the first time in history, vaccines were available shortly after vided for did not exist.” the declaration of a pandemic – this was only possible thanks to a decade of As a consequence of the avian flu situation, contracts between national research and development and 60 years of experience.” states and pharmaceutical manufacturers were signed in order to ensure that However, the vaccine-makers’ profit margins speak for themselves: prothere would be a certain availability of vaccines in case of a real future pandemducers such as GlaxoSmithKline saw their profit margins soar by 30 percent ic. “These contracts and marketing commitments were to take effect when a during 2009 and Roche made a whopping 12 times its profit during the secglobal flu pandemic was declared by the WHO,” says Wodarg. “So the WHO baond quarter of 2009 compared to the same period in 2008. sically held a trigger for the implementation of the pandemic preparedness plans Admittedly, hindsight is a wonderful thing; it’s easy to be wise after the and with this high revenues for the involved producers of pandemic vaccines and event. But the fact remains that there is a lot of unused swine flu vaccine – the some antiviral drugs.” Wodarg reveals that the contracts signed between states UK government for example ordered 90 million doses of the H1N1 vaccine and pharmaceutical companies were, for the majority, kept secret until some with an option to buy 30 million more and only around 5.25 million people were recently made public by whistleblowers. were vaccinated in Britain; and if this situation has occurred in other coun“We can see that the WHO undertook an incomprehensible action, which tries it’s likely there are tens of millions of doses going spare around the world. up to now was never justified by any scientific evidence. WHO ‘gambled away’ And unless there is a fresh pandemic in the next couple of years, these are likepublic confidence. It does therefore seem right that we investigate this matter ly to pass their sell-by date. within the Council of Europe to find out how the WHO could undertake such Whether the swine flu epidemic was exaggerated in order to boost the risky action in spite of lots of warning and protest from scientists and national bottom line of the big pharmaceutical companies or the WHO was justigovernments. It did so in the case of the avian flu and again for swine flu,” says fied in being cautious – despite changing the definition of a pandemic to Wodarg. “The main questions to investigate are: Why has this been done, who fit with the swine flu situation – is yet to be seen. With the PACE report is behind this, what is the core of the public-private-partnership that was introon the poor practice of the WHO not due until the end of April – with a duced 10 years ago, what is at the role of the enterprises, who participates in relpossible plenary debate in June – it’s impossible to say where the finger of evant decision-making processes and who takes overall responsibility?” blame will point just yet. n

90 MILLION

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Swine Flu: All hype and exaggeration?

Canada 25,339 cases // 426 deaths

United States 113,690 cases // 3068 deaths

United Kingdom 28,456 cases // 392 deaths

Russia 25,339 cases // 602 deaths

Turkey 12,216 cases // 627 deaths

Brazil 58,178 cases // 1632 deaths

Mexico 69,949 cases // 986 deaths

Argentina 11,458 cases // 617 deaths

Estimates vs. the actual number of deaths Est. 50,000

Est. 90,000

Actual 3068

Actual 392

The United States

The United Kingdom

China 120,940 cases // 737 deaths

India 28,810 cases // 1229 deaths

The 10 countries with the highest number of swine flu deaths (confirmed cases // confirmed deaths)

Vaccine orders and consumption It was estimated that up to 30-40% of both the UK and US would become ill within six months of a pandemic being announced. Official figures of confirmed cases were much lower.

Number of cases have slowly been declining, resulting in governments having a huge surplus of the vaccine and cutting their initially large orders from the pharmaceutical companies.

France Ordered 90 million // used 5 million United Kingdom Ordered 90 million // used 23 million United States Ordered 251 million // used 160 million

Hospitalised swine flu patients By age With an underlying condition Without an underlying condition

Less than 5 years

5-15 years

16-44 years

45-64 years

65+ years

Geographical spread was rapid 9 countries 29 April 2009

Flu pandemic death tolls 74 countries 11 June 2009

120 countries 1 July 2009

50 million Spanish Flu 1918

3 million Hong Kong Flu 1968 1 million Asian Flu 1957 14,000 Swine Flu 2009

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the truth can really be established about the death toll.

Ultimately though the message coming out of the WHO camp seems to be a complex one. The mixed messages, which have been highlighted by the fact that as a direct result of the H1N1 pandemic and the resulting demand for vaccines the pharmaceutical industry has seen a massive rise in profits, have also been maintained by the ‘unpredictability’ of the influenza.

According to Dr. Nancy Cox of the US Centers for Disease Control and Prevention (CDC) and a member of WHO’s emergency committee, the group has long been struggling to make sure it

WHO: ‘pandemic yet to peak’ The Director-General of the World Health Organisation (WHO) announced last month that it is too early to say the peak of the global swine flu pandemic is over. WHO chief Margaret Chan has decided that it was “appropriate not to make any changes in the current pandemic phases right now”.

The decision came a day after the WHO’s emergency committee of experts recommended against the UN health agency declaring that the peak of the pandemic is over. A committee of experts had warned that the pandemic of H1N1 flu is yet to peak, advising that it would be premature to suggest otherwise.

The warning came despite recent reports speculating that WHO’s ties with the pharmaceutical industry meant the threat of H1N1 had been exaggerated.

Last June, the World Health Organization declared the new virus had caused the first influenza in more than 40 years, after it spread around the world from Mexico and the US in less than six weeks. Since then, however, the impact of the influenza pandemic has failed to reach the levels expected by experts.

But the expert committee has now advised WHO that it would be too soon

to suggest that all parts of the world have experienced peak transmission of the H1N1 virus – adding that additional time and information was needed to provide expert advice on the “status of the pandemic”.

The ruling by the committee, which was addressed in an email from WHO spokesman Gregory Hartl, is of particular significance as it comes from a committee comprised of 15 experts that makes confidential recommendations to the Director-General. From here, Chan is then required to inform the health ministries of WHO’s 192 member states and the Vatican of her decision.

WHO has already confirmed the virus has killed 16,000 people, though stresses that this is a gross underestimate as patients often go undiagnosed or untested. In fact, according to WHO, it may take a year or two after the pandemic is over before

gets the issue across correctly. “It is very, very difficult to get the wording exactly right,” Cox said in a telephone interview.

“We expect the 2009 H1N1 virus to be around for a long time. It is a complex kind of message.”

As such, analysts are anticipating that WHO and other public health agencies will be keen to make clear that the influenza has a ferocious and uncertain future.

What’s more, doubts remain over the reliability of vaccines, largely associated with the fact that drug makers rushed to get vaccines to market as the pandemic spread. In fact, following the outbreak last June the pharmaceutical industry's biggest players literally raced to develop new vaccines, with drug makers GlaxoSmithKline (GSK) and Roche leading the way – but, as the pandemic appeared to be less severe than anticipated, nations who purchased the vaccines are now being left with a surplus of the drugs.

Switzerland, Spain and Britain, for instance, are now considering giving away or selling the millions of doses that they have received or have on order, while the US – which so far has only distributed 160 million of the 251 million doses it purchased for doctors, hospitals and other healthcare providers – is yet to make a decision on whether it will have an overflow and what it will do with any surplus.

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HAND HYGIENE

SAVE LIVES: CLEAN YOUR HANDS A call to action from Professor Didier Pittet, University Hospitals Geneva, Expert Lead for the WHO First Global Patient Safety Challenge.

H

ealthcare-associated infection (HAI) occurs in every country and affects millions of patients annually worldwide. As a global issue, HAI has received much attention from healthcare settings and governments, as well as the public and media. The World Health Organisation (WHO) made the commitment to address this problem through the successful activities of the First Global Patient Safety Challenge: ‘Clean Care is Safer Care’ launched in 2005.

Hand hygiene has been recognised as the single most important measure in these attempts and is the basis of actions promoted by ‘Clean Care is Safer Care’. As part of this challenge, over 120 ministries of health have pledged their commitment to tackle HAI. Healthcare facilities in many countries will be paying particular attention to taking action at the point of patient care on and around May 5, 2010, as participants in the WHO SAVE LIVES: Clean Your Hands initiative (the next phase of the First Global Patient Challenge dedicated to promoting hand hygiene sustainability).

More than 6000 healthcare settings from 126 countries have already registered for the SAVE LIVES: Clean Your Hands global annual initiative, representing over two million beds and five million healthcare workers.

What can you do?

We ask you to support the call for action by: registering your facility to demonstrate a commitment to SAVE LIVES: Clean Your Hands and/ or asking five others to do the same; sharing your plans and successes with others through local and national publications, as well as with WHO; fi nding out if there is an existing hand hygiene campaign in your country and seeing what you can do to support it; listing five areas for improvement in your facility and discussing these with your managers and staff ; using and promoting a multimodal strategy to ensure sustained hand hygiene improvement; 3, 4, 5 including the WHO’s ‘My 5 Moments for Hand Hygiene’ approach; 6 and participating in the inaugural WHO infection control webinar series as an additional way to improve knowledge. During the week of May 3, 2010, five live webinars will take place, including one by me on May 5.

Where is your institution placed in the crusade for optimising and sustaining hand hygiene performance and safe patient care? Assessing the level of your own institution, using a specifically designed approach, and working towards achieving the status of a hand hygiene excellence centre should be paramount. Using a framework to support such an approach will assess the level and improvements required,

within a multimodal strategic context that has been tried and tested as part of ‘Clean Care is Safer Care’. Th is multimodal strategy addresses: system change, healthcare workers’ education and training, monitoring and performance feedback, reminders in the workplace, and institutional safety climate.

WHO initiative The SAVE LIVES: Clean Your Hands annual initiative is part of a major global effort led by the World Health Organisation (WHO) to support healthcare workers to improve hand hygiene in healthcare and thus support the prevention of often life threatening HAIs. This initiative is part of the WHO Patient Safety First Global Patient Safety Challenge, ‘Clean Care is Safer Care’ programme aimed at reducing HAI worldwide, which was launched in October 2005. The clear and central feature of Clean Care is Safer Care thus far has been to target efforts on the importance of clean hands in healthcare. The program has galvanised action at many levels including, as at November 2009, Ministers of Health from 121 countries having pledged commitment to reducing HAI and support the work of WHO. Thirty-eight nations/sub-nations have also started hand hygiene campaigns during this time.

SAVE LIVES: Clean Your Hands was deemed a natural next phase of the Clean Care is Safer Care programme, moving the call to action from a country pledge of commitment to the point of patient care. The central core of SAVE LIVES: Clean Your Hands is that all healthcare workers should clean their hands at the right time and in the right way.

SAVE LIVES: Clean Your Hands incorporates a global annual day to focus on the importance of improving hand hygiene in healthcare as well as WHO providing information and materials to support these efforts and sharing information on the activities of the many others who take action at local, national and regional level.

A suite of tools and materials have been created from a base of existing research and evidence and from rigorous testing as well as working closely with a range of experts in the field. The tools aim to help the translation into practice of a multimodal strategy for improving and sustaining hand hygiene in healthcare.

Source: www.who.int/gpsc/5may/background/en/index.html

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“We must not forget that hand hygiene is a global issue. Patients are infected in healthcare environments everywhere”

Professor Didier Pittet

Clean care is safer care The recent global concerns about influenza A (H1N1) are an important reminder to everyone that hand hygiene is critical. Professor Didier Pittet, lead of the WHO First Global Patient Safety Challenge: Clean Care is Safer Care, said: “To prevent influenza virus spread, cleaning hands with soap and water or an alcohol-based handrub is imperative both at community level, and in healthcare settings. Although droplets spread through coughing or sneezing is considered a major route of influenza transmission, hand contamination is also a critical contributing factor.

Persons suffering from flu-like symptoms should clean their hands with soap and water or by using an alcoholbased handrub, particularly after touching their nose or mouth, and before contact with another individual or patient. The simple act of hand hygiene will contribute to reducing spread of infection. It is also particularly vital when caring for a vulnerable population, including the elderly and the very young, receiving care in hospitals and other healthcare or social-care environments.”

Source: http://www.who.int/gpsc/pittet_message/en/index.html

To truly protect patients, it will take leadership, commitment, a range of actions, continuous assessment, experience-sharing, and time.

Be part of a large cohort of observers and participate in monitoring of practices; we encourage healthcare institutions to consider this as part of their May 5, 2010 activities. The power of such an action can ultimately change behavior, improve care and reduce patient harm.

Have you considered what the patient safety/infection control research priorities are in your healthcare setting and have you considered publishing your work? WHO identified that studies addressing the cost effectiveness of patient safety activities are important in both developed and developing countries. In developed countries, studies on enhancing communications and safety culture were deemed priority areas.

The WHO Guidelines on Hand Hygiene in Healthcare 3 clearly highlight where specific gaps still exist on this topic and welcome further studies and evidence of improving practices. The WHO First Patient Safety Challenge team is actively facilitating sharing of knowledge between nations/sub-nations running formal hand hygiene campaigns through a dedicated network of campaigning countries.

As lead for this exciting and powerful global movement, I firmly believe that we must not forget that hand hygiene is a global issue. Patients are infected in healthcare environments everywhere. It is our firm resolve to make hand hygiene improvement tools readily available so that healthcare workers regardless of their environment can access and utilise them.

For more information, please see www.who.int/gpsc/, savelives@who.int, www.who.int/ gpsc/5may/news/webinars/en/index.html, www.who.int/gpsc/national_campaigns/en/

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NEXT BIG THING

The importance of hand washing Richard J. Verdiramo reveals why HCAI rates are decreasing, and why they need to keep going down.

I

n the European Union, approximately four million illnesses and 37,000 deaths per year are attributable to healthcare acquired infections (HCAI). Th is results in 16 million extra days of hospital stay at a cost of €5.5 billion per year. HCAI seems to increase the risk of death three times, compared to the mortality rate of uninfected patients with the same pathology. Hand washing and hand sanitizing seriously reduce the risk of HCAI as well as reduce the cost. One study showed that a 10 percent reduction in HCAI cases in hospitals would save five times the cost of prevention efforts.

Since 2008, when NHS trusts across England and Wales began promoting hand hygiene to reduce HCAI, there has been a significant decrease in episodes of HCAI: 57 percent less of reported multi-drug resistant Staphylococcus aureus (MRSA) episodes, 61 percent less of Clostridium difficile (C. difficile), and 40 percent less of all other reported episodes. Nonetheless, infection incidence and the resultant suffering, disability and death still are too high. Even one careless person can wreak havoc. French researchers recently found that one non-compliant staff member who sees every patient daily can lower the overall compliance rate by as much 23 percent.

Self-monitoring vastly overestimates compliance.

One study showed that self-reporting doctors had a perceived rate of 73 percent (range of 50 to 95 percent).

Observed reports showed a compliance rate of only nine percent. Because of these concerns, a monitoring system for hand washing that uses radio frequency ID (RFID) technology is now available for hospitals and other healthcare centres throughout the European Union.

The HandGiene RFID system gives administrators the ability to track, improve and meet staff hand-washing goals of up to 100 percent. The monitoring system can also be set to remind individual healthcare workers that they have not washed or sanitized their hands. “We have to look at everyone to fi nd the one person who isn’t compliant,” says John Wu, HandGiene Corporation’s scientific advisory board member.

Each staff member is issued a nametag or wristband that is read by the RFID-enabled system upon entering and leaving a designated area as well as at a dispensing unit for soap or hand-sanitizer. Every instance is logged into a database that can be read in real-time. The system

works with soap or hand-sanitizers for restrooms, lavatories, patient areas and treatment rooms.

“We realised that RFID technology could be used to reduce the incidence of HCAIs, saving lives – and costs – in the healthcare system,” says Vincent Verdiramo, HandGiene President. The most often cited reason for lack of hand washing is easy access. Soaps and hand-sanitizers are simply not located conveniently. This is why the HandGiene inventor, Vincent Verdiramo, included soap and hand-sanitizer dispensers with the system.

“We wanted it to be a complete solution to the problem, not just a monitoring device,” explains Verdiramo.

Whether soap or hand-sanitizer, the gel in the dispensers takes 15 seconds of friction to dissipate, making sure that hands are clean. Because C. difficile spores are frequently resistant to alcohol, HandGiene offers a propriety sanitizer that is not alcohol-based. The sanitizers kill MRSA, C. difficile and other bacteria as well as viruses and fungi.

“In the European Union, approximately four million illnesses and 37,000 deaths per year are attributable to healthcare acquired infections (HCAI)” Unlike alcohol, the sanitizer solution does not dry out the hands when used continually, as alcohol-based products do, thereby reducing the hand-washing rate. “Many healthcare workers complain that alcohol-based sanitizers dry out their hands when used continuously,” says Verdiramo. “We tried to eliminate as many obstacles as possible to hand-washing without compromising efficacy.”

The patented system integrates with existing legacy systems for fast installation and ease-of-use. Web-based soft ware allows administrators to monitor specific employees, teams, departments and shifts in complete or multiple locations.

Richard J. Verdiramo is Vice President and a board member of HandGiene Corp. Since graduating from Providence College in 1986, he has served as a senior executive, board member for, and brought public, a range of companies specialising in internet and new media marketing, healthcare and organic food products.

For more information, please call 00 353 87 635 2787 or visit www. handgienecorp.com

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In an ailing industry desperately casting about for a way to save itself, the rapidly emerging field of pharmacogenomics could provide a life-saving tonic.

By Marie Shields

T Reaping the benefits The potential benefits of pharmacogenomics could include: The ability to make better medication choices: In the UK, 10,000 people a year die from adverse reactions to medications. Pharmacogenomics may be able to reduce the number of adverse reactions by predicting who is most likely to react badly to a particular drug.

Safer dosing options: Standard doses used today can prove toxic to those with certain genetic make-ups. Using pharmacogenomics, doctors may be able to predict which dose will work for which patients.

Improvements in drug development: Pharmacogenomics may help drug companies better focus their drug development programmes, by predicting in advance which people will have adverse reactions to a drug before it is tested. These people can then be excluded from clinical trials.

Source: www.mayoclinic.com

here can be no denying the fact that the pharmaceutical world is in flux, if not downright turmoil. The old blockbuster model has fallen by the wayside, and even the big players are seeking a cure, with some gobbling up their rivals in an attempt to boost flagging pipelines. But there is another option that could be a lifesaver for the industry – pharmacogenomics, also known as personalised medicine.

Personalised medicine in healthcare is defi ned as the need to consider an individual patient’s unique lifestyle and medical history, and how this impacts on his or her response to treatment. In pharmaceuticals, however, personalised medicine aims to develop drug therapies that have efficacy within narrowly targeted groups of patients, based on each person’s genetically programmed reaction to the drugs.

The foundation of this type of personalised medicine is the fact that two people can take the same medication and have completely different responses: one may have severe side effects, and the other none at all. Or the treatment may lead to remission in one person, and seem to have no effect in the other.

One reason for these different outcomes is the variation in our inherited genetic make-up. Genetic variations can determine how we respond to treatment, similarly to the way they cause differences in eye or hair colour. For example, if you have a genetic variation that causes a drug to stay in your body longer than normal, this may cause unwanted side effects.

Researchers are working to identify these genetic variations and match them with responses to medications, so that physicians can take this into account when prescribing drugs. In addition to the usual information such as weight, age, medical history and how any relatives may have reacted to the same medication, doctors in the future may be able to take into account your own personal genetic make-up.

The field of personalised therapies – and the diagnostics used to develop them – is growing so rapidly that at the end of last year PricewaterhouseCoopers released Diagnostics 2009, the fi rst in a series of annual reviews of significant events for personalised medicine.

According to Tony Pillari, PwC’s Director, Healthcare Advisory Services, the report was developed for three key reasons. First, the level of deal activity in the in vitro diagnostics sector, which PwC feels is significant and likely to increase in the coming years, creating a multitude of business opportunities.

Second, the growing importance of diagnostics in the practice of medicine and in the emergence of personalised medicine. And third, the many exciting advances that have been made in recent months in the field of personalised medicine, including those related to diagnostics.

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Testing time The following genetic tests are currently in use. They help guide dosing and prevent toxic levels of medication from building up in patients who lack certain enzymes.

Cytochrome P450 test: This group of enzymes are responsible for metabolising more than 30 types of medications. The test can determine dosing and effect of some antidepressants, anticoagulants, proton pump inhibitors and a number of others.

Thiopurine methyltransferase test: This enzyme breaks down the chemotherapy drug thiopurine, which is used to treat leukaemia and autoimmune disorders.

UGT1A1 TA repeat genotype test: This test detects a variation in a gene that affects the UGT1A1 enzyme, which determines how the body breaks down irinotecan, a drug used to treat colorectal cancer.

Dihydropyrimidine dehydrogenase test: This enzyme breaks down the drug 5-fluorouracil, commonly used chemotherapy medication.

Source: www.mayoclinic.com

In PwC’s definition, a personalised medicine diagnostic is any tool that allows for the generation of data that are then used to tailor prevention and care strategies to the needs of the individual. Such tools would include companion diagnostics, early diagnostics and prognostics.

More accuracy Tailoring the treatment to the patient is not an entirely new idea.

What’s different about this new definition, says Pillari, is the specificity and accuracy that advances in genomics and proteomics and a whole host of related technologies now make possible.

“We now have a much deeper understanding of many diseases, including complex diseases like cancer, at the molecular level, and our knowledge continues to grow,” he says. “That kind of understanding simply wasn’t possible before. As a result, the way we treat disease, including how we design treatment options for patients, has changed to a point where trial and error will hopefully be replaced by trial and success.”

Pharmaceutical companies looking to maximise success rates will be able to determine which subsets of patients would be more likely to respond positively to their drugs. This happens to some extent already, with companies often targeting subsets of patients if initial trials with larger groups don’t yield the expected results. AstraZeneca, for example, did this with its anti-cancer drug Iressa. In 2004, a large randomised study failed to demonstrate a survival advantage for the drug in the treatment of nonsmall cell lung cancer, but it has since been shown to be effective in patients with mutations relating to epidermal growth factor receptor.

Jan Lundberg, formerly AstraZeneca’s EVP for Discovery Research and now Head of R&D at Lilly, says that even in the last couple of years there have been major developments in personalised healthcare and combined diagnostics. He highlights the CNS area of Alzheimer’s disease, where the pathophysiology is increasingly known, based to a large extent on genetic analysis of patients with hereditary Alzheimer’s. “Here we have a PET ligand as a new diagnostic tool,” he says, “and you can see if patients have accumulated amyloid in the brain, which is a strong signal that the risk of developing Alzheimer’s is high. You can follow the accumulation of amyloid and potentially prevent amyloid deposits or reduce them if they are already there, which is likely to influence the disease.

“There are some new agents coming in, which are tested to prevent accumulation of or to deplete amyloid, which offer a way of combining diagnosis and potentially following the effects of anti-amyloid treatments and correlating that with improvement in cognition, again taking a personalised healthcare treatment approach.”

Lundberg believes treatments developed for specific patient populations will become more common within the pharmaceutical industry, as traditional business models change and as progress in technology and science make this possible.

This applies particularly in oncology, as he explains: “In oncology we have the ability to analyse tumour biopsies or blood samples for their respective tumours. We can let science drive the benefits for patients both in relation to maximising the potential for clinical effect and also reducing risk. It’s still an evolution, but the trend is very clear.”

Earlier analysis Lundberg does point out, however, that ideally R&D organisations should work out beforehand which groups of patients are likely to benefit, rather than waiting until the drug has been developed and then looking for people it can help.

“A key aspect will be to identify these opportunities early enough.

With Iressa, we only established which patients would respond when the drug was already on the market. It would be better if we could do this at the time of, or even before, nominating compounds to the clinic in a new area.

We could analyse this tumour population to see if there are specific pathways that are particularly prone to be more responsive, and then design the compounds against these pathways and select patients in early clinical trials that could be maximally responsive, based for instance on genetic analysis of tumour biopsies.”

PwC’s Pillari believes specialised therapies can help pharmaceutical companies improve their bottom line. “The blockbuster model has been the predominant model in the pharmaceutical industry for some time and until recently, it has been very successful. However, the poor return on R&D investment realised by that model over the past few years, in terms of new drugs developed and introduced into the marketplace, has been well documented, as has the number of drugs coming off patent in the next few years.

“As a result, and quite understandably, pharmaceutical companies are very concerned about pipelines and future revenues. In this context, the

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move to specialised therapies is relevant to the pharmaceutical industry for two reasons. First is the potential to reduce drug development time and costs and increase success rates through enriched clinical trials.

“These are trials that only include those people who, based on the analysis of their make-up at the molecular level, are most likely to respond to a given drug. Second is the opportunity to move to a ‘niche buster’ model, that is, one that generates revenue because of the value a specialised therapy delivers to a specific subset of patients.”

There are some within the industry who see a potential downside to the advent of personalised medicine. David Lathbury, AstraZeneca’s Director of Process Chemistry, believes it will only help big pharma improve its business models if it translates to a much more reduced cost of development. If it doesn’t do this, he says, the simple net present value calculation means that companies won’t make money. “If you can very quickly identify the target groups, if you can get through phase III with, for example, 200 patients, then absolutely it will be a benefit. But if you’ve got to go through the same process before you identify that population, it could be very difficult.”

Lathbury says that where personalised medicine could make a difference is in dosing regimens, which could help drive through a better result.

“We tend to give everyone an average dose, that’s the way most clinical programmes are designed. If better titration of dose will reduce adverse events, increase compliance and get a better return on the drug, those steps I think we can take.”

Then there’s the view we could go much further. Dorman Followwill, Partner and VP, Healthcare EIA for Frost & Sullivan, describes his idea of the ultimate version of personalised medicine. “If you’re talking about the holy grail of personalised medicine, it would be walking into a physician’s office, pulling out a smart card that has your genotype on it, and having them plug it into their system and then diagnose you or dispense medication for your genotype.

“Estimates of when we might achieve that vary from 10 to 15 years, to as long as 100 years. However long it takes, we will see increased personalisation over time because that is a mega trend in the world today. In my role, I get to look at some of the 360-degree views of many industries produced by our team, and the topic of personalisation comes up big time

What are biomarkers?

Biomarkers can be a sign of a normal/abnormal process, or of a condition or disease. For example, blood pressure is widely accepted as a biomarker because large epidemiologic databases exist demonstrating a correlation between elevated blood pressures and adverse cardiovascular outcomes. This has been supported by the numerous placebo-controlled studies showing an effect on stroke and coronary heart disease outcomes from lowering blood pressure.

US FDA Pharmacogenomics Guidance further defines three categories of biomarkers: exploratory, probable and known valid.

Markers are included in these categories based upon available scientific information.

in healthcare, in automotive and transportation, and in environment and building technologies.”

Popularity The version of personalised medicine as it exists today has proven popular with regulators. In some cases, they now insist on biomarker testing to guide drug prescribing. Tony Pillari believes their main concern is efficacy. He points out the testing for infection by a specific HIV subtype that is required prior to the use of Pfizer’s Selzentry treatment, which he says is based on the fact that Selzentry blocks the specific receptor that HIV subtype uses to attach to and infect white blood cells.

“Similarly,” he says, “testing for epidermal growth factor receptor (EGFR) expression is required prior to the use of Erbitux because Erbitux binds to EGFR and blocks certain growth factors that ultimately promote the expansion and spread of tumours. We believe this practice will become more common, as everyone in the healthcare value chain, from regulators to pharma to providers to patients to payers, appreciates the benefits of improving drug efficacy as well as reducing the frequency of adverse events.

Yet despite the fact that the clinical case for developing companion diagnostics is strong, the PwC report points out that there has yet to be significant deal-flow between the pharmaceutical and diagnostics industries, because while the existing pathway for drug approval and reimbursement is clear and well-established, this is less so for diagnostics and even less so for drugs and diagnostics developed in tandem.

Pillari does point out that there are a number of encouraging initiatives underway, including by the FDA and the Critical Path Institute, to better define the pathway for drug and companion diagnostics development. As this pathway becomes clearer, and the risks associated with such strategy are mitigated, he expects deal-flow between the two to increase.

However you look at it, and even with its potential downsides, there is no backing away from pharmacogenomics, with its potential to bring once-dead drugs back to life by allowing them to be repurposed for new populations. In a beleaguered industry suffering from the twin ills of dry pipelines and no blockbusters, personalised medicine could provide a life-saving shot in the arm.

Source: www.c-path.org

Biomarkers can be further divided into the categories of predictive or prognostic. A prognostic biomarker is associated with the likelihood of an outcome (eg. survival, response, recurrence) in a population that is untreated or on ‘standard’ (non-targeted) treatment.

A predictive biomarker can predict differential effect of treatment on outcome. A predictive biomarker is a biomarker that is present prior to an event occurring and which predicts that outcome. For example, the KRAS oncogene can be considered a negative predictive biomarker for response to treatment with the EGFr (epidermal growth factor receptor) class of drugs since it can identify which patients are unlikely to respond to treatment with an EGFr inhibitor.

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EXECUTIVE INTERVIEW

Comprehensive diagnostics Guus Simons reveals where the molecular diagnostics sector in Europe is heading.

What are the current limitations of the classical assays for respiratory tract infections?

How is your technology paving a new way to detect respiratory tract infections?

Guus Simons. Numerous viruses and bacteria are involved in acute respiratory tract infections (RTIs) and the clinical presentation is generally not indicative of a specific pathogen.

Up to now, many laboratories still use classical assays to diagnose respiratory pathogens.

These assays can be divided into cell culture, immunofluorescence/antigen detection and nucleic acid/PCR-based tests. Cell culture is still the golden standard for detection of respiratory pathogens. However, cell culture is time consuming and has a low sensitivity. Rapid antigen tests are available for some respiratory pathogens but have been shown to be less sensitive and less specific than cell culture-based approaches. Nucleic acid amplification tests

amplification of more than one target enabling the comprehensive detection of (multiple) infectious disease agents in a single assay.

Up to now, multiplex real-time PCR assays have been suffering from a reduced sensitivity compared to monoplex assays. The sensitivity of PathoFinder’s RespiFinder assay has been extensively compared to monoplex real-time PCR assays and an identical sensitivity was observed. Th is is also reflected in the good results obtained during independent quality control studies like the Quality Control for Molecular Diagnostics (QCMD) initiative.

Multiparameter assays save time and reduce costs compared to sequentially performing multiple monoplex assays. Since diagnostics of infectious diseases is driven by costs and a fast turn around time, multiparameter tests have a great advantage on monoplex assays as long as sensitivity and specificity are not affected.

“Finally, multiparameter assays will also contribute to our understanding of the epidemiology of respiratory infections” have proven to be rapid, sensitive and specific alternatives that can be used in either a monoplex or a multiplex (up to five pathogens) format. PathoFinder’s MultiFinder technology has overcome the limitations of conventional multiplex PCR. Detection and identification of up to 25 pathogens in a single assay is now possible, enabling the introduction of comprehensive molecular diagnostics in the daily clinical routine.

Can you explain the advantages of multiparameter tests compared to monoplex assays? Why are these advantages so important?

GS. The golden standard in nucleic acid based diagnostics is monoplex real-time PCR. However, multiparameter assays allow for the co-

Why is it important to test all relevant pathogens for a certain disease in one assay?

GS. Multiparameter assays offer laboratories the ability to detect a wide range of pathogens in a single assay. Additionally, multiple infections (also know as co-infections) are poorly detected by classical assays whereas dual and triple infections are easily detected by multiparameter assays. The ability to detect multiple infections provides the possibility to investigate the clinical importance of these infections and to see whether they result in a poorer outcome of the patient. Finally, multiparameter assays will also contribute to our understanding of the epidemiology of respiratory infections and provide new information on seasonality, geographical distribution and risk groups.

After obtaining his PhD in molecular biology at the University of Nijmegen, The Netherlands, Guus Simons performed his post-doc period at the University of Ghent, Belgium. Before founding PathoFinder, he held several research and management positions at Dutch biotechnology companies. He has written over 50 scientific publications and 15 patent applications.

Can you give an insight into the future development of the molecular diagnostics sector?

GS. Molecular testing has greatly improved the laboratory’s ability to diagnose infectious diseases. I believe that the future of molecular diagnostics is comprehensive diagnostics.

Th is means the molecular diagnostics of all relevant pathogens in a single assay. The increased sensitivity of molecular tests means that infected patients will be diagnosed more accurately and more often, especially at times when they are shedding low levels of pathogens that would be missed by non-molecular tests. Comprehensive diagnostics will set a new standard in diagnosis of panel diseases and will provide clinicians with important information to assist in better patient management decisions. RespiFinder was the fi rst assay we launched and several RespiFinder products are now on the market in Europe.

Currently we are validating multiparameter assays against viral meningitis and sexually transmitted diseases. We hope to launch these new products in the coming year.

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ECONOMIC CRISIS

The new zombie healthcare model Healthcare may be buoyant now but a zombie economy is driving the sector to a new model of payment by results.

T

he healthcare sector is insulated from the effects of the economic crisis as a result of its ability to generate cash and the attractive liquidity that this provides. People still get sick in a recession.

But we are living in an economy of half-dead-half-alive banks, governments, consumers and companies. This downturn in the economy and the continuing growth in demand for healthcare will have a major, negative impact on healthcare payers’ willingness to pay high prices for new therapeutics. Th is will accelerate a move towards new business models in the sector, according to a new book published by PA Consulting Group entitled The Zombie Economy: Leadership in Times of Uncertainty.

The effect of this zombie economy may be indirect and follow on the tail of the current crisis, but the impact of the zombies cannot be understated. In the zombie economy the banks, which fi nance healthcare companies, are too weak to support lending, government fi nances are too stretched to support expanding healthcare policies, consumer wealth is too depleted to allow them to pay from their own pockets, and companies are saddled with debt they cannot service. These organisations all have roles as payers in the healthcare economy and are increasingly unable or unwilling to pay the prices suppliers seek. The zombie economy is forcing prices and reimbursement prices – set by zombie governments and insurers – down.

Emerging budget pressures mean that healthcare payers must all spend less and prioritise in the zombie world. At the same time, the demand for care is growing because of an ageing population, rising expectations of care, significant increases in the prevalence of lifestyle diseases across all regions, and the development of new treatments. Th is downward pressure on prices is set to intensify thanks to a windfall the payers are about to receive: many companies face imminent patent expiries on the biggest brands. And while this will bring savings to healthcare budgets, it will also mean healthcare companies will lose a large share of their revenues.

Many companies are exploring new elements to their products; predictive tests and approaches that support the correct usage of new drugs, together promise to provide better value for money. However, these new, more complex products bring complex pricing systems. We are seeing a

trend towards payment by results, with perceived value for money defi ning prices and reimbursement levels that may be variable over time.

Today, healthcare companies are paid for providing inputs – diagnostics, drugs, medical devices and some related services. In the future, the healthcare payer could pay companies for delivering an outcome for the patient. This has the potential to open the industry up to a different set of players providing a new wave of information technology innovations, products and services converging, and new business models appearing.

“While the healthcare industry appears buoyant relative to other industries, the combination of the recession and the dynamics of the sector will have a big impact in the fi rst half of the next decade,” says Ken Fyvie, Healthcare Specialist at PA Consulting Group. “If they are to avoid the effects of the zombie economy, healthcare companies must prepare for lasting and fundamental change in how they source and develop the next generation of products, and how they engage with their more diverse and demanding customers. Payment by results could become more a part of how companies are compensated for their products and services.”

How will the sector survive the zombie economy?

The branded healthcare companies need to focus on developing innovative products and cost reduction initiatives, and take radical action to survive, including: • Developing propositions that are more aligned to the demands of all customers – physicians, payers and patients • Exploring new elements to products with perceived value for money • Increasing associations with external sources of new technologies and potential products to realise greater cost-efficiency • Defensive mergers, which are already in evidence; the first among the major players has been Pfizer’s acquisition of Wyeth in late 2009

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Healthcare Reform ed_16 nov 07/04/2010 15:51 Page 118

HEALTHCARE REFORM

winner

And the

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is...

After months of sparring between Democrats and Republicans over healthcare reform, it is the American public that is set to emerge victorious following President Obama’s controversial restructuring of the health sector. By Ben Thompson

I

t was, remarked one observer, like a scene from the civil rights era Republican Scott Brown’s defeat of Democratic candidate Martha Coakley in a half-a-century ago. Rallies outside the Capitol are typically orderSenate special election in Massachusetts – one of the Democrats’ safest seats – ly affairs, with speeches and well-behaved crowds; this one had sent shockwaves through Washington and re-energized GOP activists. Almost baton-wielding police separating furious demonstrators from the overnight, the passage of healthcare reform had gone from being a mere members of Congress making their way to vote on the divisive Congressional formality to a mathematical uncertainty as the Democrats lost the issue of healthcare reform. Racist and homophobic slurs all-important 60-vote super-majority that would have virtually guaranteed were repeatedly hurled at pro-reform lawmakers the bill’s success. And while polls demonstrated overwhelming biwalking by; another was spat upon. Democratic Whip Jim partisan support for individual components of reform, the Clyburn, who led fellow black students in integrating South Republicans seized upon Brown’s victory as being represenThe US spends about Carolina’s public facilities a half century ago, called the betative of public unease with the process by which the arguhaviour shocking. “I heard people saying things today ments were being won. a year on its healthcare that I have not heard since March 15, 1960, when I was The result has been months of wrangling, sniping system, which includes marching to try to get off the back of the bus,” Clyburn and political maneuvering. But in the last few weeks, private, federal and told reporters. Clearly, the issue of healthcare reform is Obama has taken strong action to bring what has been a employer schemes bringing out the nastier side of American politics. year-long legislative showdown over his top domestic priIndeed, such venomous exchanges have been symptoority to a close. “Everything there is to say about healthcare matic of President Obama’s attempts to push through the healthhas been said, and just about everybody has said it,” he asserted care restructuring plans that provided his presidential campaign with at a recent briefing. “Now is the time to make a decision about how to such a strong and popular platform. The debate should have been about docfinally reform healthcare so that it works, not just for the insurance compators, patients, insurance, drug companies and coverage; instead, much of the nies, but for America’s families and America’s businesses.” attention has been focused on the legal and constitutional processes required And on March 21, he finally got his wish. The healthcare reform legislato get any potential reform bill passed into law. tion passed by the House of Representatives by a vote of 219-212, effectively Make no mistake: this has been an exhausting campaign for people on ends a year’s worth of political horse trading and lobbying, and gives an adboth sides of the political divide. Back in December it had only seemed a matditional 32 million Americans access to basic health insurance by 2019. And ter of time before comprehensive healthcare reform became a reality. But even though it is projected to cost US$938 billion over the next decade, it is

US$2.2 TRILLION

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The case for healthcare reform

1

One in every six dollars in the US economy is spent on healthcare today

8

The number of people every minute who are denied coverage, charged a higher rate or otherwise discriminated against because of a pre-existing condition

41

The percentage of adults under the age of 65 who accumulated medical debt, had difficulty paying medical bills or struggled with both during a recent one-year period

50

If you’re an American under the age of 65, there’s a 50/50 chance that you will find yourself without coverage at some point in the next decade

$115 625

The average monthly premium for employersponsored family coverage in 2009

The number of people who lost their health insurance EVERY HOUR in 2009

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President Barack Obama and Vice President Joseph Biden leave after making a statement at the White House after the US House of Representatives passed healthcare reform legislation also set to reduce the budget deficit by US$138 billion over the same period, according to the Congressional Budget Office.

It is the first major revamp of America’s costly and unwieldy health insurance system in decades, and Obama has been keen to stress that the victory is one for America as a whole rather than one for him and his party. “I’ve got a whole bunch of portraits of presidents around here, starting with Teddy Roosevelt, who tried to do this and didn’t get it done,” the President said during a televised inquisition by Fox News in the Blue Room of the White House as the campaign neared its climax. “But the reason that it needs to be done is not its effect on the presidency. It has to do with how it’s going to affect ordinary people who right now are desperately in need of help.”

Indeed, the true winners of the reform process could be the American public. Over 94 percent of all non-elderly Americans will have access to health insurance by 2016, versus just 83 percent now. Health insurers won’t be able to deny coverage based on pre-existing conditions. And generous subsidies will be available to lower-income families to help them get cover. The bill also expands eligibility for Medicaid as part of its coverage mechanism, as well as increasing Medicaid reimbursements, which will make it easier for patients on Medicaid to find doctors who take their insurance. The so-called ‘donut hole’ coverage gap in Medicare Part D plans is also set to be closed.

The influential American Public Health Association (APHA), for one, congratulated the House of Representatives on its historic decision. “For nearly a century, providing quality, affordable care to all Americans has eluded our grasp; today’s vote, however, changes all that,” said Georges C. Benjamin, Executive Director of APHA. “Passing this measure will strengthen our public health system, invest in prevention, improve the health of the American people and move us closer to providing comprehensive and affordable health coverage for all Americans.”

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Breakdown of US federal health expenditure, 2007 There was support from the private sector, too. Gary Lauer, Chairman and CEO of eHealth, Inc., also sees the bill’s passage as significant. “With final legislation awaiting the President’s signature, strategies for implementation of reform and enrollment of Americans in health insurance coverage will be the next and most important order of business,” he says. “We believe that the technologies that have been developed by private sector players are key to ensuring Americans find and receive the coverage this legislation would mandate.”

Of course, the bill as it stands today is far from perfect. And according to Michael Cannon, Director of Health Policy Studies at the Cato Institute, it is unlikely that the health legislation signed into law by President Obama will look the same when it takes effect in four years’ time. “It creates too many unstable situations that Congress will have to address,” he says. For instance, under the new law, insurance companies will have to offer coverage to children with pre-existing conditions within the next six months. But it is not clear how much they will charge. And, Cannon says, young people and healthy individuals will have an incentive to drop their coverage now, knowing that they will be offered a cheaper alternative in the future. That could cause private health insurance markets to implode.

9.5% 4.2% 4.5% 24.7%

57.2% “We proved that this government – a government of the people and by the people – still works for the people” Such ambiguities mean the debate on the merits of the healthcare plan look set to run on well into the second half of Obama’s term – and possibly decades into the future. Insurance companies – despite gaining access to an additional 32 million taxpayer-subsidised customers (Forbes called the new legislation a “cash for clunkers programme for HMOs”) – are amongst those disenchanted with the move. “WellPoint is disappointed that after more than a year of debate, Congress has approved healthcare legislation that does little to reduce cost and improve quality – two important elements to building a sustainable healthcare system that provides affordable coverage for all Americans,” stated Kristin Binns, a spokeswoman for Wellpoint, in the aftermath of the vote.

“We will continue to advocate what we believe is in the best interest of our customers and the country – affordable, quality healthcare that is accessible to all.”

Likewise Jeffrey Kang, Chief Medical Officer at health insurance giant Cigna, believes the legislation only addresses part of the problems facing the healthcare system. “The bill really only deals with the coverage issues or the expanded access issues, and doesn’t deal with the cost or quality issues,” he says. “So you find the expanded coverage is financed by lots of increased taxes.”

There is certainly a case to be made that reforms are going to prove costly. The overhaul will largely be paid for by cuts in Medicare, new taxes on investment income and fees on various industry participants that will almost certainly be passed along to the general public. And while government subsidies for people who cannot afford insurance and insurance exchanges to help people get coverage will not be operational before 2014, the increased costs will begin next year.

But despite continued opposition to the programme of changes, the Democrats are entitled to feel that a significant victory has been achieved. A new Associated Press-GfK Poll finds a widespread hunger for improvements

Other Military (serving) Veterans

Medicaid (Low-income families)

Medicare (Elderly 65+)

Total US$754 billion to the healthcare system amongst the American people, which suggests that Obama has a political opening through which to push his plan. Half of all Americans say healthcare should be changed a lot or ‘a great deal’, and only four percent say they are happy with the status quo. Democrats hope that such a groundswell of support for change will be enough to counter the fact that more than 80 percent of Americans say it’s important that any healthcare plan have support from both parties, and that two-thirds believe the President and congressional Democrats should keep trying to cut a deal with Republicans rather than pass a bill with no GOP support.

Such a scenario means the opinion polls over the next few weeks will make for interesting reading. Can success breed further success and enable the President to steam ahead with difficult laws on immigration and the environment? Or will the protracted nature of the healthcare battle leave his party feeling burnt out, beaten up and short on favours to call in?

If the President himself is in any doubt, he’s not showing it, preferring instead to concentrate on the historic significance of an achievement that has proven too great for every American leader before him. “At a time when the pundits said it was no longer possible, we rose above the weight of our politics,” he said, shortly after the bill was passed. “We pushed back on the undue influence of special interests. We didn’t give in to mistrust or to cynicism or to fear. Instead, we proved that we are still a people capable of doing big things and tackling our biggest challenges. We proved that this government – a government of the people and by the people – still works for the people.” n

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DESIGN 122

Hospital 2.0

More five-star hotel than traditional healthcare institution, NGH reveals why Circle may have just redefined the expectation of what a hospital should look like and how it should function. Welcome to the hospital of the future.

O

ne of Britain’s most famous architects, Lord Norman Foster – and the man who has brought us the Gherkin in London and Beijing Airport – may have changed the future of hospital design and architecture with his very fi rst hospital, Circle Bath. More of a five-star hotel than a hospital, the cleanlined, light-fi lled, stone-paved modern interior is quite different to the traditional NHS building. The smell of coffee and leather seating greets you as opposed to the usual disinfectant, and the plate glass windows give way to views of the green fields surrounding the city of Bath. And rather than signs at the entrance, people are ready to guide you to the right place.

Upstairs, each patient who stays in overnight has their own room: the floor is made of oak, the windowsill has a herbarium and there’s a view. In fact, even the typically windowless operating theatre has a view of the countryside. The equipment is all hidden away and there are no dark, endless corridors to be found anywhere in this building, in fact everything is designed to make patients and visitors calm and relaxed.

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However, these ideas are nothing new. Research has long proven that patients get better in calm environments with natural light. And surgeons have reported that the calmer the patient the less anaesthetic they have to use and in turn the faster people are back on their feet, plus patients are proven to bleed less in operations and are more likely to respond well to treatment.

And while Circle Bath is a private hospital, it will offer operations to NHS patients at the fi xed NHS rate, so there’s hope that the nationwide healthcare system will learn a thing or two from this brand new hospital.

And while the NHS has already won praise for the new children’s wing at Moorfields, Newton Abbot’s Community Hospital and the Norfolk and Norwich, it has yet to fully embrace the light and cheer that are so obviously required. Margaret Hodge, the minister responsible for architecture, spoke last year about the dark rooms and miles of corridors of the new Queens building in Romford.

So we’re not there just yet. In fact, the Commission for Architecture and the Built Environment says there is still a long way to go if the NHS wants to make more hospitals welcoming and attractive. While the government has embarked on a billion-pound programme of rebuilding

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DESIGN 123

Bath Circle in numbers Construction cost: £21 million Site area: 10,103 m2 Building area: 6400 m2 Total height: 13.2m Car parking spaces: 155 incl. 2 disabled Outpatient consultation rooms: 9 Inpatient bedrooms: 26 single, 2 twin/family Operating theatres: 4 Imaging Equipment including: MRI, CT-Scan, X-ray, Ultrasound Structure: Concrete, flat slabs Materials: Brick, glass/rainscreen panel system and Mill finish aluminium

hospitals it’s yet to be seen whether it will continue churning out the same kind of buildings, with some updated styling, or will take on board some of the principals of Circle’s design.

Ali Parsa – a former investment banker with Goldman Sachs – the Chief Executive of Circle, and Spencer de Grey, a Foster partner, both believe that the cost and scale issues won’t be a problem, insisting that they have worked to a budget similar to those of NHS hospitals. They also believe that future projects will be cheaper now that they’ve learnt from the experience of their first hospital.

“The Circle partnership has the most extensive programme of hospital building across the country, designed by leading architects with the ambition to redefine patients’ experience of healthcare,” explains Parsa, the managing partner of Europe’s largest clinician partnership. “Each hospital is controlled and managed by the professionals who provide the services to their patients. Our newly opened hospital in Bath, built by Foster & Partners, with service designed by the team who brought Mandarin Oriental into the UK, and organic-only food from Daylesford, is already redefi ning the expectation of what a hospital can be.”

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7/4/10 16:27:02

REGIONAL FOCUS 124

Fighting a new Cold War The battle to provide good healthcare in post-Soviet Russia continues.

T

he Russian Federation encompasses 83 federal subjects. At 6,592,800 sq miles, Russia is by far the largest country in the world, covering more than a ninth of the Earth’s land area. Russia is also the ninth most populous nation in the world with 142 million people.

Pre-1990s Soviet Russia had a totally socialist model of healthcare with a centralised, integrated, hierarchically organised structure with the government providing free healthcare to all citizens. Despite weaknesses, the integrated model achieved considerable success in dealing with infectious diseases such as tuberculosis, typhoid fever and typhus.

The new Russia has changed to a mixed model of healthcare with private fi nancing and provision running alongside state fi nancing and

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provision. Article 41 of the 1993 constitution confi rmed a citizen’s right to healthcare and medical assistance free of charge, achieved through compulsory medical insurance rather than just tax funding.

Th is and the introduction of new free market providers were intended to promote both efficiency and patient choice.

Unfortunately, none of this has worked out as planned, and the reforms have in many respects made the system worse. Despite the fact that Russia has more physicians, hospitals and healthcare workers than any other country in the world, the health of the population has significantly declined sine the collapse of the Soviet Union.

In contrast to the wealth and prosperity of those who live in cities such as Moscow and St. Petersburg, life in the rest of the country re-

7/4/10 16:22:40

REGIONAL FOCUS 125

mains harsh and short. Life expectancy for males is 61.5 years, which is considerably lower than the figures for the European Union. The reason for this is thought to lie mainly in the high mortality rate of working-age males, who succumb to preventable conditions such as alcohol poisoning, stress and smoking.

Heart disease accounts for 56.7 percent of total deaths, with approximately 30 percent involving people still of working age. About 16 million Russians suffer from cardiovascular diseases, placing Russia second in the world, after Ukraine, in this respect. HIV/AIDS, which was virtually non-existent in the Soviet era, rapidly spread following the collapse, mainly through the explosive growth of intravenous drug use. Cases of and deaths from tuberculosis have also increased.

Moscow

Pharmaceuticals The Russian government’s drug reimbursement programme encouraged an increase in drug consumption and medicine sales and this trend is expected to continue in 2010, according to a report from Frost & Sullivan. The healthcare industry will also benefit from the country’s ageing population as well as an increase in disposable income, consumer spending, demand for healthcare products, and government funding for drugs through a new health insurance system.

As imports account for nearly 60 percent of the total volume of the Russian pharmaceuticals market, the government has been trying to lower the reliance on western drugs by giving an impetus to the local production, mostly of generic drugs, which is a market with tremendous potential.

Moscow is Russia’s capital and is the largest city in the country. It is also the largest metropolitan area in Europe and ranks among the largest urban areas in the world. Moscow plays host to a large number of the world’s billionaires; the emergence of a market economy has produced an explosion of Western-style retailing, architecture and lifestyle. It is rich in culture, most notable is the Tretyakov Gallery, The Bolshoi Theatre and Moscow International House of Music. It also encompasses 96 parks, the world-renowned Saint Basil’s Cathedral and the Tsytsin main Botanical Garden of Academy of Sciences.

Male life expectancy in Russia is 61.5 years

Bridge of Great Peter, St. Petersburg

The government is also actively encouraging the biotechnology sector, as part of the country’s economic modernisation plan.

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7/4/10 16:22:42

IN REVIEW 126

On the shelf From Lean principles to environmental infrastructure and improving research methods, NGH uncovers the best of this quarter’s healthcare book releases.

A Applying Lean in Healthcare: A Collection of International Case Studies

By Joe Aherne and John Whelton Covering healthcare all the way through clinical applications to nutritional services, this book provides a collection of case studies to demonstrate how Lean thinking can be applied to the industry. Offering an international perspecttive, the text introduces key concepts and provides real-life examples to illustrate the practical benefits – including more efficient processes, increased patient satisfaction and cost savings – that can result from a Lean philosophy. The book also features a number of expert contributors who offer practical tips. b NGH SAYS: A must for any professional looking at delivering improvement opportunities and the insightful N examples from other healthcare organisations are particularly useful at seeing how to implement Lean strategies and solutions.

Improving Healthcare Through the Built Environment Infrastructure

By Mike Kagioglou and Patricia Tzortzopoulos L Looking at the crucial issues of healthcare delivery from a built environment perspective, this book addresses the kkey issues related to healthcare delivery in relation to capital investment and infrastructure, design and operations management theories and their application to healthcare. Bringing together key industrialists and academics – all m heavily involved in the formulation and delivery of new practices – the case studies highlight how policies and h healthcare models are implemented in practice and help identify the key challenges for the future. h N NGH SAYS: With the delivery of healthcare continuing to develop and change as new technologies and modalities of care are brought to the market, this book helps academic researchers as well as practitioners understand how the o healthcare infrastructure sector works. A great guide for all those in the fields of planning, delivering, maintainh ing and operating healthcare environments.

Testing Treatments: Better Research for Better Healthcare

By Imogen Evans, Hazel Thornton and Iain Chalmers

How do we know whether a particular drug, therapy or operation really works, and how well? Such timely and pressing questions are raised and addressed in this probing enquiry into modern clinical research, with farreaching implications for daily medical practice and patient care. Aimed at both patients and professionals, this book builds a lively and thought-provoking argument for better, more reliable and more relevant research, with unbiased or ‘fair’ trials, and explains how patients can work with doctors to achieve this vital goal.

NGH SAYS: A great guide to the methods, uses and value of fair testing as well as describing how bad research can slip through the net and what to do about it. A genuine and thoughtfully critical look at the issue of published medical research.

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7/4/10 16:18:48

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Business Management

CXO

What business processes work? What are the proven, successful strategies for taking advantage of domestic and international markets? Business Management is about real, daily management challenges. It is a targeted blend of leadership and learning for key decision-makers in government and private enterprise.

Available for: US, Middle East, Europe

Technology leadership is merging with strategic and financial leadership, and senior management is being called into a partnership for the future. CXO brings together a range of voices with one shared vision: to develop a strategy that considers business needs and technology’s role in moving your company forward.

Available for: EU

Find out more: www.bme.eu.com

Find out more: www.cxo.eu.com

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German Health Minister Philipp Roesler addresses a press conference at the health ministry in Berlin on March 26, 2010. Roesler and members of the health department of the coalition fractions presented the corner points for the long lasting reform of the pharmaceutical market.

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