IHHR 8 - August 2019

AUGUST 2019 Destination spotlight: Vietnam Delving into what healthcare really looks like in the country

Feature: Virtual healthcare, virtually perfect?

How virtual healthcare is being harnessed by insurance providers

Loubna Bouarfa, OKRA The uptake of AI in healthcare

Feature: Virtual healthcare, virtually perfect?

How virtual healthcare is being harnessed by health insurance providers (put this somewhere on the main image)

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This edition of International Hospitals & Healthcare shines the spotlight on virtual care. This is an exciting area of healthcare that is rising in popularity, with more and more doctors and patients embracing its transformative power. Its importance to insurers is also increasing, with more and more plans offering virtual care, providing convenience and enabling healthcare providers to manage care for specific patient populations.

We talk to experts at the forefront of this arena – including Loubna Bouarfa, Founder of OKRA, Dr Sneh Khemka, Head of Population Health at Aetna and Dr Bill Hanson, Chief Medical Information Officer and Vice-President at Penn Medicine – about how virtual healthcare is being harnessed by health insurance providers, how innovative lifestyle management programmes can educate, inspire, engage and motivate users to become more involved in their own care, why AI is a win-win situation for healthcare stakeholders, and much, much more.

4-7. NEWS

The latest in international patient care

8-12. DESTINATION SPOTLIGHT: Vietnam Delving into what healthcare really looks like in the country

In addition, this issue’s Destination Spotlight piece focuses on Vietnam, looking at the country’s medical reputation, and delving into what access to healthcare really looks like there, as well as exploring challenges facing insurers and assistance providers operating in the region.

Before you embark on this exploration of the future of healthcare, all that remains to be said is: happy reading and stay healthy!

P.S. As always, we at International Hospitals & Healthcare are keen to hear from you regarding collaborations, contributions or just a friendly hello. Feel free to contact the team at news@ihhr.global.

Lauren Haigh Editor editor@ihhr.global @Medical_Editor

16-19. FEATURE: Virtual healthcare, virtually perfect?

How virtual healthcare is being harnessed by health insurance providers

20-22. PROFILE: Loubna Bouarfa, OKRA The uptake of AI in healthcare

Editor-in-chief: Ian Cameron Editor: Lauren Haigh Sub-editors: Mandy Langfield, Stefan Mohamed, Sarah Watson, Robyn Bainbridge Advertising sales: James Miller, Kathryn Zerboni, Marton Modis Design: Robbie Gray, Will McClelland, Tommy Baker Finance: Elspeth Reid, Alex Rogers, Kirstin Reid Contact: Editorial: editorial@ihhr.global +44 (0)117 922 6600 ext. 3 Advertising: sales@ihhr.global +44 (0)117 922 6600 ext. 1 Subscriptions: subscriptions@voyageur.co.uk Online: www.itij.com/international-hospitals-and-healthcare

Published on behalf of Voyageur Publishing & Events Ltd Voyageur Buildings, 19 Lower Park Row, Bristol, BS1 5BN, UK The information contained in this publication has been published in good faith and every effort has been made to ensure its accuracy. Neither the publisher nor Voyageur Publishing & Events Ltd can accept any responsibility for any error or misinterpretation. All liability for loss, disappointment, negligence or other damage caused by reliance on the information contained in this publication, or in the event of bankruptcy or liquidation or cessation of the trade of any company, individual or firm mentioned is hereby excluded. The views expressed do not necessarily reflect those of the publisher.

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INTERNATIONAL HOSPITALS & HEALTHCARE REVIEW ISSN 2515-7981 (PRINT) ISSN 2515-799X (ONLINE) ISSUE 8

NEWS

ABPI’s guide to being patient centric The Association of the British Pharmaceutical Industry (ABPI) has published a guide for pharmaceutical companies working with patients that provides guidance on collaborating successfully and ethically, and in line with the ABPI Code of Practice.

The guide is entitled Working with

patients and patient organisations - a sourcebook for industry and covers six topics: principles and agreements; defining a patient organisation, patient or patient advocate; events and meetings; research and development; product launches; and payments.

Jill Pearcy, Director of Code Engagement at the ABPI, who authored the report, commented: “The industry is here to develop medicines that address unmet medical needs and it is clear that to understand that need,

you must learn from the people living with the condition.

We have worked with patient organisations to produce a sourcebook which includes practical guidance, tips and tools, to support pharmaceutical companies collaborate with patients and patient organisations.

It might sound obvious, but if you are not working with patient interest at the heart of what you do, you can’t be truly patient-centric. As an industry, we are committed to this.”

Aetna introduces DNA testing

A new platform for employee healthcare League, a digital benefits platform for employees, has introduced a next-generation digital platform that employees can use to engage with their health, lifestyle and benefit programmes.

The platform is called HBX and focuses on four key areas: better benchmarking health and benefits strategies against others in their industry; empowering employees to better manage their health and wellbeing with a modern benefits portfolio and a digital, mobile experience; improving education and understanding of benefits (i.e. help people enroll in the 4

right plan for them) throughout their lifetime as an employee; and creating a support system within that platform to encourage better healthcare for the individual.

"On average, HR departments are managing up to 11 different systems ─ at League, we empathise with the challenges of HR leaders trying to build programmes and benefits that improve the lives of their employees while managing the costs to the business," said Mike Serbinis, Founder and CEO of League. "We're inviting employers to take control and end costly, fragmented point solutions with a new 'front door' to healthcare, focused on delivering an employee experience like no other."

International Hospitals & Healthcare Review

Aetna International, which delivers healthcare benefits and population health solutions on a global scale, has launched DNA testing to help its members take control of their health.

It is available as an optional part of Aetna’s wellness plans and will look at health and lifestyle, including nutrigenomics, fitness, sleep and stress. “We’re increasingly seeing people take a proactive approach to health, effectively becoming partners in their own care. It’s now possible to take a highly targeted approach to holistic wellbeing, with hyper-personalised and predictive healthcare. By introducing this type of DNA testing, we’re ensuring our members have the

opportunity to take advantage of these advances, combining an awareness of their genetics with digital and social support in changing their behaviours for the better,” said Caroline Pain, Senior Vice-President, Customer Proposition, Aetna International.

The test involves a swab, which is sent to a certified UK lab for analysis, and once results are available members are notified by email and can login to explore and download their results. Pain highlighted the importance of privacy, quality and reliability when it comes to genetic health and lifestyle testing and said that Aetna’s members have reassurance that all three are taken care of.

NEWS

AnaCap acquires Danish private health insurer SundhedsGruppen, which consists of Dansk Sundhedssikring AS, an independent Danish private health insurance provider, and PrimaCare A/S, a provider of healthcare networks, provides health insurance and claims management services to clients’ employees. It has a unique partnership arrangement with medical clinics throughout Denmark that allows for bestin-class provision of healthcare services to its customers’ employees, with a clear focus on specialist support and local availability.

AnaCap will leverage its insurance sector expertise to support

Best US states for nurses To align with National Nurses Week, which took place in May, personal finance website WalletHub released a report on 2019’s best and worst US states for nurses, with Oregon coming up trumps.

WalletHub compared states according to 21 key metrics, including monthly average starting salary for a nurse, healthcare facilities per capita, nursing job openings per capita, and competition.

The report found that Oregon

enhancements in the customer experience and drive growth in new and existing markets such as the Nordics and wider geographical markets. “AnaCap is delighted to be partnering with SundhedsGruppen,” said Tassilo Arnhold, Managing Director at AnaCap. “The Company has created a great insurance technology and data-driven platform with a uniquely differentiated insurer challenger proposition, high customer service standards and competitive underwriting. We are confident that our longstanding expertise in backing businesses poised for international growth will actively support this ambitious growth plan and management team, both through technological and operational investments.”

Dr Dilshaad Ali

Avivo Group to offer specialised healthcare Avivo Group, a healthcare service provider in the Gulf Cooperation Council (GCC), has stated that it will be making a departure from general healthcare services and will instead be offering specialised care for complex medical conditions to residents and medical travellers in the GCC. “The Group is redefining itself with a new business model and moving towards super speciality healthcare for future growth.

We believe that although general healthcare remains relatively attractive for some in the industry, we reviewed our business strategies and have decided to focus our resources on bridging the gap

in complexity management,” explained CEO Dr Dilshaad Ali. “Most of the Group’s general healthcare assets will be transformed into speciality clinics.

We will also relook at the existing specialities that do not fulfil the current demographic needs.”

According to Dr Ali, the Group is in discussions with several global providers about potential partnerships. He said that focusing more on specialised healthcare is likely to keep UAE residents from seeking treatment abroad: “Avivo Group strives to provide access to the right care with the right specialisation to UAE residents at their doorstep. We are confident this refreshing change in the way we contribute to the nation would be a step in the right direction.”

has the highest annual mean wage for registered nurses (adjusted for cost of living), US$83,867, which is around 1.4 times higher than in Vermont, which is the lowest at $58,810.

Utah was found to have the lowest current competition in terms of the number of nurses per 1,000 residents at 8.46, while the District of Colombia has the highest at 20.49.

Overall, the top three best states for nurses were found to be Oregon, Minnesota and Washington, and the three worst are Hawaii, New York and the District of Colombia.

5

NEWS

BIH introduces new international patient programme and telemedecine app Bumrungrad International Hospital (BIH) in Bangkok, Thailand, has launched a new programme that provides patients with access to high-quality speciality pharmaceuticals, vaccines and treatment at a lower cost.

The Hospital’s Medical Tourism programme affords patients savings of up to 80 per cent on

Clinerion to accelerate launch of new treatments in Georgia Clinerion, which works to accelerate clinical research for and medical access to treatments, has announced that it is expanding in Georgia, US, with the addition of the Medison network of clinics to its Patient Network Explorer Platform.

The Medison network of clinics comprises four clinics, which provide medical care to more than 6,000 patients each month. The clinics specialise in outpatient and dental services, with a focus on patient healthcare, disease prevention and timely and correct diagnosis.

6

treatments for complex diseases such as rheumatoid arthritis, HIV, hepatitis C, multiple sclerosis, cancer and orphan/ rare diseases. “Travel to Thailand to have prescriptions filled and authentic specialty drugs expertly administered at a fraction of the cost resolves a major problem for all patients and US-based self-insured employers who are forced to ration care or deny coverage to keep high specialty drug costs from overrunning their operations,” said David Boucher,

Clinerion said that, as part of its Patients Network Explorer Platform, patients of Medison’s network of clinics will gain access to next-generation treatments and therapies by being matched to leading-edge international clinical trials, and that this will help accelerate the launch of new treatments in Georgia.

“We are very happy to have the opportunity to support more patients in Georgia via partnership with Medison,” commented Ian Rentsch, CEO of Clinerion.

“Medison’s high quality of patient care makes it a good partner for Clinerion and for sponsors seeking trial sites in Georgia.

We look forward to drawing more trials to the country.”

International Hospitals & Healthcare Review

Chief Business Transformation Officer, BIH.Boucher explained that, using the programme, patients and their companions can stay in an affordable hotel and access treatment at a price that meets their budget. He highlighted that the Medical Tourism programme furthers BIH’s mission to improve access to affordable care and medications for people throughout the world.

BIH has also introduced a new telemedicine app, Bumrungrad Anywhere, that enables new and existing patients to access one of more than 200 doctors in under three minutes via an app.

The app, which is powered by Doctor Raska, provides access to immediate consultation from 7 am to 11 pm, seven days a week.

There is a consultation fee of THB 500, which is around US$15, for a 15-minute consultation.

Upon launching the app, users can select a physician from those on duty, with their photograph and specific training and certificates displayed, along with ratings from past patients. The user is then

asked to input their symptoms using helpful prompts and can then request a consultation, whether by text, voice or video call. They will receive a reply within minutes.

Jaren Siew, Founder of Doctor Raska and Chief Digital Officer at Bumrungrad Hospital, highlighted the affordable nature of the telemedicine service: “I think most people expect to pay US$200 when coming to Bumrungrad. We want to show people that we’re interested in providing a good service for everyone. And once we are capable of delivering a good quality service at a reasonable price point, we will do it.”

NEWS

AXA expands health insurance strategy

GHA received ISQua accreditation The International Society for Quality in Health Care (ISQua), which is widely known as the ‘accreditor of accreditors’, has accredited Global Healthcare Accreditation (GHA) through its recently formed accrediting arm.

The new arm, The International Society for Quality in Health Care External Evaluation Association (IEEA), was established in 2018 with a view to delivering external evaluation services. It is based in Geneva, Switzerland, and provides third-party external evaluation services to health and social care external evaluation organisations and standards developing bodies around the globe.

The GHA programme is an independent accrediting body that seeks to improve the patient experience and excellence of care received by patients who

travel for their medical care and treatment, both domestically and internationally.

GHA's Chief Executive Officer Karen Timmons commented on its newly received accreditation: "Achieving IEEA accreditation of our standards through ISQua is a watershed moment for GHA in its objectives to improve patient experience, expand organisations' business strategy towards operational excellence and facilitate the creation of narrow networks serving medical travel patients," she said. "IEEA accreditation of GHA's standards provides assurance to patients, insurers, ministries of health, and other stakeholders that an organisation's medical travel services have undergone a rigorous evaluation against the highest international benchmarks for accreditation entities and are focused on both international best practices in medical travel and continuous improvement.”

Insurer AXA has announced that it will be expanding its Payerto-Partner strategy with a view to simplifying the healthcare journey of its customers.

The insurer intends to open as many as 50 medical clinics, which will serve up to 1.5 million clients across emerging markets by the year 2023. It plans to begin in Mexico and Egypt and follow up with clinics in other emerging markets.

In Mexico, AXA will launch a joint venture with health insurer Keralty to develop a vertically integrated

New guide for implementing costeffective telemedicine First Stop Health, which provides telemedicine services through employers to their employees, is releasing a guide to help employers to implement virtual care solutions in order to combat the growing costs of healthcare.

The Buyer’s Guide to Telemedicine offers guidance on finding high return-on-investment virtual care that delivers savings and also provides tips to assist employers in choosing the best possible telemedicine solution for their company.

With telemedicine gaining rapid

health system incorporating quality day-to-day healthcare delivery, while in Egypt it will open diagnostic centres and primary care centres, owned wholly by AXA, with the support of World Health Management as its technical partner.

By launching its own medical centres that are directly linked to its health insurance services, AXA is striving to create a digital and physical healthcare ecosystem.

It said the centres will provide customers with an affordable, high-quality and seamless patient experience, with access to advanced diagnostics, laboratory equipment and medical consultations in key specialities.

traction as more employees and healthcare providers learn of the benefits, this report could be a useful resource for many and also lead to cost reductions. With most telemedicine programmes delivering utilisation rates of one to 10 per cent, First Stop Health’s Guide suggests that employers should look for a solution that achieves at least 25 per cent usage and guarantees employer savings.

“The goal of the Buyer’s Guide to Telemedicine is to help employers choose a telemedicine solution that reduces medical claims and overall healthcare costs while delivering a convenient, quality experience for employees,” said David Guttman, President of First Stop Health.

7

DESTINATION SPOTLIGHT

Robyn Bainbridge investigates Vietnam’s medical reputation to find out what access to healthcare really looks like in the region and how the landscape is changing

V

ietnam is the outermost country that curls around the north-eastern shoreline of Southeast Asia. A 1,092-mile stretch of land lies between the two main metropolises to the very north and very south – Hanoi and Ho Chi Minh City. And that’s a lot of ground to cover for anyone finding themself in need of medical care while travelling outside of these cities. Though an ideal location to buy yourself a sparkly new set of teeth, Vietnam has not always been renowned for having an

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International Hospitals & Healthcare Review

international standard of healthcare.

For many years, patients requiring emergency medical care have often been evacuated to more advanced facilities in the Southeast Asia region, including those in Bangkok and Singapore. And even those local to the area requiring routine procedures would much rather hop on a plane then wrestle with the bedlam of an oversubscribed hospital. However, with the phenomenal numbers of travellers that visit the country every year, the medical landscape is inevitably changing and reputable facilities are popping up.

DESTINATION SPOTLIGHT Bui Vie n St re e t, Ho Ch i M in h Cit y

Vietnamese healthcare system has improved the standards of facilities, including the new Cho Ray Hospital and new Children's Hospital in Ho Chi Minh City, the Vinmec hospitals, Hanoi French Hospital, Franco Vietnamese Hospital and City International Hospital (CIH). “There are more and more internationalstandard hospitals being built, which will give great access to healthcare for international patients in the coming years,” she said.

Having too many patients in higher level hospitals has become an urgent problem in recent years, with two to three patients sharing a bed becoming common in many central and provincial hospitals

Distinguishing the good from the bad There are countless hospitals located across Vietnam’s 63 provinces and cities – Dr Vu Ha Nhu Anh of the house-call doctor team for Care of Asia Ltd cites more than 1,167 public hospitals, 191 private hospitals, more than 30,000 private polyclinics, 87 small-sized maternity hospitals, 30 foreign-invested clinics, and 29 clinics with involvement of foreign doctors across the country – though anyone lacking all but an extensive knowledge of the Vietnamese healthcare industry would be forgiven for not knowing about these, and really, many would argue that only a small percentage of these provide an ‘international standard’ of care.

Niklas Lindberg, Chief Operating Officer at American International Hospital in Ho Chi Minh City, explains that, in the last five years, Joint Commission International (JCI) accreditation has become one of the most important goals for all the international hospitals in Vietnam; but CEO and Founder of Family

Medical Practice Dr Rafi Kot disputes this; he questions the credibility of achieving this accreditation, suggesting that facilities that have JCI accreditation – which he states are few and far between – often only maintain the JCI standards for the few days surrounding the audit date.

a recent surge in foreign investment in the Vietnamese healthcare system has improved the standards of facilities Dr Vu expounded this view: “Generally speaking, medical facilities in Vietnam, in both public and private sectors, are quite basic compared to Thailand and Singapore in Southeast Asia.” But she reasoned that a recent surge in foreign investment in the

Three’s a crowd Medical talent in more rural areas, meanwhile, leaves a lot to be desired. “Outside of the major cities in Vietnam, there is a significant shortage of specialised doctors and nurses,” said Dr Geoff Ramin, Chief Medical Officer APAC Region, Allianz Partners. “Often there is limited access to diagnostics, medical equipment and treatment modalities.” He also said that there are often language barriers, and usually these facilities are not suitable for the standard of care many assistance companies look to provide for their customers.

As a result of this, there is a great strain on those few facilities that do offer quality healthcare. What’s more, Dr Vu explained that increasing expectations of service quality, improvement in convenience of transportation from remote areas to central areas and limited differences in hospital fees at different administrative levels can all contribute to overcrowding in more reputable facilities.

“Having too many patients in higher level hospitals has become an urgent problem in recent years, with two to three patients sharing a bed becoming common in many central and provincial hospitals,” she said. “Bed occupancy rates have reached 120-160 per cent, especially in the central hospitals of some large cities.”

On the other hand, Lindberg notes that, compared to European countries where there are ageing populations with chronic diseases, in Vietnam, a young average age means that >> 9

DESTINATION SPOTLIGHT

patients with a view to transfering the insured to the nearest and most appropriate international hospital. Therefore, Care of Asia stations ambulances and medical team members at various places across the county – in this way, the assistance company is able to reach any patient within a 15- to 45-minute timeframe.

Care of As ia Ltd o n t h e ir in s p e c t io n Dr Ramin notes that Allianz trip to Cit y I n te rn at io n al Ho s p ital aims to provide patient care in more developed or private healthcare facilities, and so avoids infections are more common. “The [bed sending patients to public hospitals. “When occupancy] rate does not reflect the demands placing patients or recommending facilities or needs of a market,” he reasoned. in Vietnam, we also prefer to have inspected Still, overcrowding in hospitals is an inherent them so that we can ensure the regulated problem in Vietnam: “This may lead to a standards of care. As a result, we are limited to drain on resources in higher level hospitals and a small number of facilities in Vietnam. The subsequent wastage at lower levels,” warned Dr only cities we would look to retain patients Vu. “If the current situation is not improved, in would be Hanoi and Ho Chi Minh City.” this will eventually result in major inefficiencies Even then, Dr Ramin reasons that he would across the entire Vietnamese healthcare system.” not consider any hospital in Vietnam to be classified as a ‘Centre of Excellence’. He notes Beggars can’t be choosers that the ones Allianz has successfully inspected With such an unlevel medical playing field, are able, however, to provide an appropriate it’s important for assistance companies and standard of tertiary care for select patients. insurers to have a good lay of the land.

Dr Vu explained: “In emergency cases, many Communication is key insureds get admitted to local rural state-owned But even then, language barriers are not hospitals.” She noted that, because many assistance providers are still quite new to the country, state-owned hospitals will often still not accept direct guarantee of payment from either assistance companies or insurers, and in these facilities, it is also often impossible to ask for a medical report officially.

“English is still spoken poorly among many doctors,” said Dr Kot, referencing medical access in more rural areas. “The notion of operating in a communist state and dealing with mainly local patients left most facilities unprepared for foreign patients in terms of service or payment.

Not so long ago, foreigners paid the same as the Vietnamese for medical services in state facilities, with prices dictated by the state.”

As such, many assistance companies will insist on transferring patients to the closest international hospitals in big cities like Ho Chi Minh City, Hanoi and Danang, commented Dr Vu. She added that Care of Asia is often requested by international insurers in rural hospitals to visit >> 10 International Hospitals & Healthcare Review

exclusive to rural parts of the country. “It has happened occasionally with some local private hospitals where the patient may have received very good medical treatment and pleasant service but some staff may not be able to speak good English," explained Dr Vu. "This wouldn’t make the process of assisting the insured go smoothly.”

Language barriers are not exclusive to rural parts of the country Further still, language barriers are not exclusive to Western society. Dr Vu said that even in big international hospitals in the city, many doctors and staff may speak good English but not Korean, Japanese or Chinese.

In response, some assistance companies will insist on dispatching an interpreter team and providing telecommunication services, so that the treating doctor and patient can communicate with each other for simple outpatient cases. “However, when the requirements get more complicated,” said Dr Vu, “Care of Asia’s multilingual team can be dispatched to the hospital to stay beside the patient and help communicate with hospital staff and doctors 24/7 for any assistance.”

Communication is also essential when it comes to detecting and deterring overcharging and overtreatment. “Considering that the majority of expats and international tourists in Vietnam have health insurance with very broad coverage, some hospitals take advantage of this to inflate bills, which at times can end up being

An a er i a l v i ew of Sout hea s t As i a

INDUSTRY VOICE

11

DESTINATION SPOTLIGHT Bo ats g lid e acro s s t h e lake in Tran g A n , N i n h Bi n h

exaggerated,” warned Dr Vu. Though, for an assistance provider or insurer with a good level of field knowledge that is well-versed in the Vietnamese healthcare system, this is a little easier to manage. Dr Vu explained that her company can dispatch one of its doctors to a treating hospital to help obtain a verbal medical report and settle the insured’s payment by cash, as per instruction from the insurers. “Overtreatment will be considered as fraud and the supplier will be taken off our list,” she said.

Then again, Dr Vu noted that international and private hospitals in Vietnam are adapting quickly to the insurance procedure: “They increasingly have their own insurance department to

International and private hospitals in Vietnam are adapting quickly to the insurance procedure deal with assistance companies or insurers to provide medical reports and estimated costs on a daily basis so that the insurers can validate patient’s policies in a timely manner and assist the insured effectively in due course. Then the assistance company can assist with settling the medical expenses right away.” She added that most international hospitals accept direct billing from insurers or assistance companies.

12 International Hospitals & Healthcare Review

Changing the narrative Ultimately, there is still a deep-rooted mistrust of the Vietnamese healthcare system, according to some experts. “Once international patients contact their insurance providers, in lightning speed, Bangkok becomes an automated referral centre,” Dr Kot said, noting that there is always a temptation for assistance companies to steer patients directly to Bangkok, under the impression that Vietnamese facilities will not be as efficient as those well-known to them in the Thai capital.

This instinctive deference allows issues with the medical infrastructure in Vietnam to come around full circle, say some, resulting in the ‘major inefficiencies’ that Dr Vu referenced above. And yet, many remain confident that things are soon to change.

Kot mentioned that those local to Vietnam seeking medical help are now keen to stay in the country, finding that Vietnamese doctors wield the same levels of expertise as those in neighbouring countries, and are often much cheaper.

Indeed, change has to start from within.

What’s more, the tourism market is changing. “The percentage of European and North American tourists (who are mostly insured) are a mere 35 per cent of the total (they used to be 70 per cent), as massive

There is still a deep-rooted mistrust of the Vietnamese healthcare system

amounts of Chinese, Korean and Russian tourists flood Vietnam,” Dr Kot explained.

“The hospitals, including the government hospitals, are realising that tourists are a source of income as well,” he observed. Still, he noted that only a few government hospitals have established international departments, and he reasoned that Vietnam, with a population of almost 100 million, is likely prioritising its care of resident patients.

Despite the obvious flaws, hospitals and insurers operating in the region seem to suggest that the limitations and restrictions of the Vietnamese healthcare system are only temporary. With foreign investment in the healthcare system increasing, attitudes towards the country’s medical facilities are slowly improving, as is patients’ access to healthcare. The changing face of the tourism market will likely drive further investment from other economically developed countries surrounding Vietnam. And this is a shift that could well see an influx of medical travellers from neighbouring countries eager to benefit from the competitive prices.

For now, the best bet seems to be to prioritise working alongside international facilities – particularly those in the larger cities – and to provide as much in-house assistance as possible. ■

FEATURE

VIRTUAL HEALTHCARE, VIRTUALLY PERFECT? Virtual healthcare is on the rise and is being harnessed by healthcare and health insurance providers. Tatum Anderson investigates

P

atients in Dubai, India, Singapore and, soon, Thailand, can access a primary care physician via a smartphone app.

In addition to online consultations and prescribing, the app can manage a blood test or a scan. It can send a phlebotomist to take bloods, a car to take a patient for, say an X-ray, and perhaps in future, provide home diagnostic kits. Results are uploaded to the app when they are ready and medicines can be delivered straight to the patient.

This is all thanks to vHealth, the virtual care offering from healthcare company Aetna, which has been specifically designed for geographies where

16 International Hospitals & Healthcare Review

primary care is not well used. “If people need to see a doctor they go straight to a specialist and/or a range of specialists and their care isn’t co-ordinated properly,” said Dr Sneh Khemka, Head of Population Health at Aetna. “We wanted to re-establish the whole concept of primary care.” vHealth therefore allows a primary care physician to make the initial diagnosis, triage treatment, conduct investigations, prescribe medicines and escalate a patient to secondary care if needed. If there is secondary care, the follow-up thereafter can be managed remotely as much as possible. “About 60-70 per cent of primary care can be done without laying hands on the patient,” said Dr Khemka. “For the 30-40 per cent, such

FEATURE

as listening to chests or palpating an abdomen, you have to be able to get people to facilities quickly. You need to efficiently organise blood tests. What they [the patient] don’t want to do is wait for hours in a hospital or GP surgery.”

Aetna said that 60 per cent of patients that participated in 35,000 consultations by midDecember 2018, did not proceed to a physical consultation or meeting with a doctor. Indeed, said Dr Khemka, patients saved an average of two-and-a-half hours away from work and outpatient costs decreased by 35 per cent.

Living in a virtual world This is the world of virtual healthcare. It’s different from telemedicine, which is technology that enables the remote diagnosis and treatment of patients. Experts say virtual care is a more holistic approach using digital solutions to serve consumers in their healthcare journey, sometimes independent of place and time. In reality, that means remotely managing other healthcare services including scans and diagnostic tests, the management of chronic conditions and the triaging of conditions. “We are really seeing the trend moving towards this,” said Casey Korba of Deloitte’s Health Solutions Center. “I think most of the US major health systems are implementing some kind of virtual health strategy.”

A key benefit of virtual care is asynchronous

health, said Korba. While synchronous forms require both health professional and patient to be there at the same time – in an online consultation for example – asynchronous healthcare enables more flexibility. Devices are used to monitor patient data, using AI to triage and send, receive and process home diagnostic kits. The doctor and patient do not have to be online and communicating at the same time. Many providers are experimenting with different, and often asynchronous, virtual care applications from hospital-produced apps specifically for several care journeys; a My Baby pregnancy app, for example, provides end-to-end care for expecting mothers.

Adults with diabetes are able to use digital therapeutics provided by companies such as WellDoc and Livongo. Such systems can track data such as blood glucose levels and create a self-management plan. SilverCloud is a service providing online mental health programmes for providers from the NHS to private healthcare, to address a broad spectrum of conditions such as

A variety of different virtual health ideas are being trialled all over the world – from mobile robots with stethoscopes to RFID microchip pills stress, depression and anxiety, as well as specific programmes for long-term chronic conditions (diabetes, COPD, and chronic pain). It believes such programmes to be on a par with face-to-face encounters. According to consultancy Accenture, an AI-powered nurse avatar, piloted at Mayo Clinic in the US and the UK’s National Health Service (NHS), can ask patients questions about their health, assess symptoms, and send alerts.

Trial and error But some attempts at virtual healthcare are likely to work better than others, said Dr Bill Hanson, Chief Medical Information Officer and Vice-President at Penn Medicine, which has invested considerably in virtual health applications. He said that a variety of different virtual health ideas are being trialled all over the world – from mobile robots with stethoscopes to RFID microchip pills. Some, he said, are more successful than others.

According to Dr Hanson, Penn Medicine’s Connected Care programme is a world away from stand-alone online GP services. The

organisation has been running a virtual ICU for almost 13 years as part of a hub and spoke model that allows specialist nurses and doctors to help their colleagues in more remote ICUs to look after patients. Dr Hanson said the programme also provides one-to-one links between doctors and between doctors and patients so that patients can stay at home. “We have patients who have undergone routine surgery and gone to their home, say, 60 miles away. They don’t need to come in for a post-op because they can be evaluated virtually in the postoperative situation,” he said. Such virtual links have reduced readmission rates. “What we are trying to do is use telemedicine to complement our care from the lowest acuity patients – keeping them in their home post operatively – to the highest, as in an ICU situation.”

Dr Hanson said that this is part of a paradigm shift away from a fee-for-service model to one where hospitals are at risk for patient outcomes. “Whereas historically we did the operations and if patients came back in, we would be paid for that readmission, now we would not,” he said. “If they are readmitted because they were sent home unprepared to be at home, or there were some complications, we are suddenly at risk for that.”

That’s why the hospital is ensuring patients are going home, in some cases, with devices such >> 17

FEATURE

as connected scales and wireless blood pressure cuffs that can send information back to the hospital. “We can virtually track patients when they are no longer in our hospitals,” he said.

“It forces us as providers to pay attention to the patient after they’ve left our facility and gone home. So, if a patient with heart failure is gaining weight, we can intervene before they are so sick they need to be readmitted.”

This is significantly different from some of the existing telemedicine models, he said, and are great for some patients, but may not take into account a patient’s overall medical state. “Some of these companies don’t have a connection to a healthcare system. They are a stand-alone and can only carry it so far,” he said. “We believe that this telemedicine connected care paradigm is complementary to the many ways we care for patients to start with. It will not replace them.

It needs to be embedded in older care models.”

Despite many tremendous advances, most of today’s virtual care services are limited to traditional telemedicine-synchronous doctor’s visits, with perhaps some prescribing and online appointments. However, the scale that some of these services is reaching is very impressive.

Apollo Hospitals, one of India’s largest hospital groups, offers telemedicine appointments with primary and secondary care specialists via satellite links to 42-inch inch screens in clinics

18 International Hospitals & Healthcare Review

the Himalayas, via phone, video and even WhatsApp on smartphones in urban centres.

It said that four million patients have used its services, 10 per cent of which, in the 15 months before December 2018, were 380,000 speciality consultations. In the US, Teladoc has a national network of over 3,100 experienced healthcare professionals. Behind UnitedHealthCare Virtual Visits is Amwell and Doctor on Demand, while Livi in Sweden and the UK is run by Kry in Sweden, and HealthTap, a service from Silicon Valley, is behind many BUPA services.

Young people appear to be taking up online mental health services in droves, and some are even bypassing the medical system for online counselling said Sarah Thomas, Managing Director of Deloitte Health Solutions Centre.

Cleveland Clinic said annual virtual visits grew by 163 per cent to 25,502 sessions in 2017, and that launching virtual lower-acuity access options – called Express Care and virtual visits – meant emergency department visits decreased by one per cent to 644,575 in 2017.

Babylon’s GP-at-hand service, used in the NHS, is seen of particular benefit to digitally confident patients with access to a smartphone, commuters, and younger people (aged 20-50).

That said, there may be a great degree of interest by consumers, but physicians tend to be worried, not just about reimbursement,

Some have decried the amount of technology companies, rather than health services organisations, trying to get into the space but about quality and the experience. That’s according to Thomas. “We are beginning to see some traction, but we aren’t delighting consumers yet with the experience they have.

And we are not satisfying clinicians that this is a great avenue of care for them,” she said.

Quality over quantity Reports in the UK on Babylon’s service have raised concerns about the real costs and the possible impact on health inequalities. Deloitte said evaluations of other services have revealed wait times aren’t always that much shorter, as providers struggle to juggle whether their doctors are seeing physical patients or virtual patients. Some have decried the amount of technology companies, rather than health services organisations, trying to get into the space.

Things will improve, said Sean K. Mehra, Chief Strategy Officer of HealthTap. He believes the next generation of telemedicine provision will start to encompass true virtual care. “Today, the world of telemedicine and

FEATURE

virtual health providers is very fragmented and increasingly undifferentiated. The technologies are becoming relatively commoditised so the difference between one vendor and another is disappearing,” he said. “If all you are is a glorified call centre with doctors, it’s hard to differentiate. There are hundreds and hundreds of startups and it’s hard to tell them apart.”

Mehra predicts virtual care will use apps, such as accurate symptom checkers based on AI, to prevent many of the appointments that currently occur when people think they have one condition but don’t, in reality, require a GP’s attention. “The model will be one that doesn't monetise by driving more visits to already scarce human doctors — but monetises by preventing unnecessary visits to a human (virtual or in person) whenever appropriate,” he said.

HealthTap sits behind Bupa’s GP services. It provides AI symptom triage and telemedicine with Bupa GPs, enables prescriptions, schedules in-person visits (with physiotherapists, specialists), pre-authorisation and payment, and displays insurance policy information and deductible balance. It can schedule and order vaccinations at local clinics and, although lab test ordering is not yet done with Bupa specifically, HealthTap has a strategic partnership with Quest in the US for customers there. It plans to launch in Saudi Arabia, expand in the UK and the

Hong Kong area, and move to Australia, New Zealand, and other geographies, said Mehra.

Dr K Ganapathy, who is behind Apollo’s telemedicine offerings, agrees that preventing unnecessary doctors’ visits is a crucial element of these new technologies, although reassurance from

The more evidence, the faster the uptake will be. That will be the greatest test for lots of these technologies and initiatives the doctor is also vital. “Most of the time what we are doing is a sophisticated form of tele-triage,” he said. “But 80 per cent people who normally would have come here for a headache afraid that they have a brain tumour, through telemedicine I can reasonably convince them that they don’t have to go to a tertiary hospital.” Building trust is also key, he said: “Healthcare is not like buying a pizza on a phone. People still want to interact directly, physically with the doctor.”

Dr Khemka agrees. “The main issue is getting people comfortable with seeing the doctor non-physically,” he explained. “We need to make sure the online consultation is as secure

and confidential as a doctor’s office. So, if you are doing that through mobile phones you have to be worried about who could peep through technology,” he said. “We are absolutely scrupulous about making sure platforms are secure, safe and confidential.”

What’s also necessary, will be evidence that any of these services is actually safe, effective and worth paying for, said Deloitte’s Korba.

“As more organisations publish and talk about the results, we will get more and more evidence for different conditions in different populations. We’ll know if people are well served and services are not sacrificing quality,” she said. “The more evidence, the faster the uptake will be. That will be the greatest test for lots of these technologies and initiatives.”

The ability for physicians to remotely care for and monitor patients presents a number of benefits and the rise of virtual care has the potential to reduce healthcare costs and help redefine the concept of primary care. With advancements and improvements in access to technology, this is more and more possible. But physicians want to ensure that quality is not compromised as virtual care becomes more and more prominent, and to be certain that patients have faith in the security and efficacy of virtual care. As results of trials come in, the benefits can be weighed up and the true value of virtual healthcare ascertained. ■

19

INDUSTRY VOICE

THE UPTAKE OF AI: FROM PASSIVE TO PROACTIVE HEALTHCARE Loubna Bouarfa founded OKRA with the goal of impacting patient lives on a wide scale and supporting the ongoing shift to precision medicine in healthcare - giving the right treatment to the right patient at the right time. Here, she discusses the uptake and importance of AI in healthcare and the impact on healthcare providers, patients and insurers

T

oday, AI is mainly applied to group patients to different categories, such as subtypes or risk profiles, which are used to find the best treatment for that patient group. This is what we call stratification medicine. When we group patients like this, we mainly focus on urgent cases where patients are already ill, based on direct observation of their symptoms. AI is also currently applied to imaging technology, where it is used to support diagnosis; for example, by detecting signs of skin and breast cancer.

However, this doesn’t use the full power of AI technology. AI can learn from vast quantities of data, detecting hidden patterns and predicting future occurrences based on that data. Essentially, AI can predict whether you will get ill in the first place, and what treatment would be best suited to you. This is precision medicine. OKRA’s AI is designed to support this shift to precision medicine in healthcare, by enabling healthcare professionals to integrate all their data in one place, generate predictions based on patterns in the data, and make evidence-based decisions, all in real time.

AI can predict whether you will get ill in the first place, and what treatment would be best suited to you 20 International Hospitals & Healthcare Review

All for AI and AI for all AI is a win-win situation for all healthcare stakeholders: patient, healthcare provider, health authorities, drug provider and insurer.

At the moment, we are working with the life sciences industry to maximise precision and speed in decision making, which improves outcomes for patients and reduces costs for the industry. For example, we have predicted how patients will feel about a drug (sentiment reanalysis) in a clinical trial, how drug prescription will shift over time, and what messaging would be most effective for successfully bringing a drug to market. Many pharmaceutical companies are moving from a volume-based to an outcome-based business model, where you don’t pay for the pill but for the outcome.

In the longer term, our technology can support clinicians’ decision-making at the point of care, supporting treatment decisions and diagnoses made by hospital staff and general practitioners, and enabling patients to make better informed decisions about their health.

Turning challenges into opportunities The healthcare industry is changing, which means we face many challenges, but also opportunities.

Traditionally, the life sciences industry relies

INDUSTRY VOICE

AI is a win-win situation for all healthcare stakeholders: the patient, healthcare provider, health authorities, drug provider and the insurer on one-off clinical studies, which are validated with traditional statistics, based on averages in selected patient groups. These studies are not representative of the population at large; for example, only two to four per cent of adult cancer patients participate in clinical trials, and they do not represent the complexities of the real-world environment. With AI, we can move away from the average to the individual, and include all cases instead of just the few that fit the model. This will ensure that every patient receives the best possible treatment. OKRA started on the commercial side, where this change in mindset is easier to achieve, because the business case and benefits are so clear.

We are now also working with R&D departments, and are moving to collaborate at the point of care.

Beyond this mindset change, we also face some technical challenges, notably a lack of data integration and the possibulity that there may not be enough data. OKRA can integrate data that ranges from genomic to clinical data, both structured and unstructured, and this requires great technological sophistication. As part of the High-Level Expert Group on AI, we are part of developing recommendations and frameworks that would support a more effective use of health data. Stakeholders must collaborate across the industry, which is challenging, but we are contributing to make this a reality.

Healthcare providers may also feel that AI systems do not give enough explanation behind their output, and worry that their jobs will be replaced by new technology. However, AI is meant to support healthcare professionals in their work, and eliminate routine tasks to free up time. Today, Europe’s healthcare system is facing unprecedented pressures; populations are ageing, chronic diseases are growing, and according to recent estimates, Europe’s healthcare staff will not grow enough by 2020.

It is clear that more efficiency is needed.

Tangible achievements The OKRA team, our ‘OKRANS’, are working tirelessly to make AI a reality in healthcare and 21

>>

INDUSTRY VOICE

move closer and closer to precision medicine in Europe. We have achieved great things as a team, including recent deliveries for major clients, and winning two awards in less than 24 hours (Best AI Innovation in the Business Weekly

Europe’s healthcare system is facing unprecedented pressures … It is clear that more efficiency is needed Awards, and Best Female-Led Startup in the StartupEurope Awards). At the end of the day, our first priority is to grow – to scale our technology across the life sciences industry, working with technology champions within those companies, and finding the right OKRA employees who want to make a difference for patients.

We are proud to be working with life science technology champions across the globe, who understand that the current gold standard is changing. We collaborate on bringing trustworthy AI to the healthcare industry, to get the right 22 International Hospitals & Healthcare Review

drug to the right patient at the right time.

These individuals have a strong track record of taking calculated risks and will be rewarded for it. It is exciting to be partnering with them.

At the same time, many life science companies are attempting to build their AI capacities in-house, rather than taking help from vendors and experts.

There is a degree of scepticism, where executives feel more in control by keeping their technology under one roof. However, this creates several problems: the data scientist's job is often limited to creating those one-off studies, which prevents AI from achieving its full potential, and in-house staff may lack expertise in deployment of AI given all the ethical requirements such as continuous bias prevention and interpretability of AI systems output. On a European level, I would like to see more initiatives that educate business leaders on the complexity of AI systems, and facilitate dialogue between leaders and AI experts, so we can form even better collaborations. Startups such as OKRA are flexible and can develop their technology much faster and we should make full use of this.

I am also honoured to be part of the European Union High-Level Expert Group on AI. Europe is taking the lead on an ethical discussion around the regulation of AI, which will be crucial for inspiring trust within the healthcare industry.

We collaborate on bringing trustworthy AI to the healthcare industry, to get the right drug to the right patient, at the right time The future is AI Over the long term, AI will move healthcare from passive to proactive; instead of waiting to get ill before we get treated, we will predict and prevent our health issues. The healthcare system will flag us for tests and check-ups, identify the best treatments and physicians, and empower patients to manage their health. I already see real results, and am optimistic that more stakeholders will catch up with the frontrunners of today. ■

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INTERNATIONAL HOSPITALS DIRECTORY (A-Z)

ARGENTINA

EGYPT (continued)

CEMIC Av. Galván 4102, Ciudad Autónoma de Buenos Aires ARGENTINA +54 9 11 6120-4731 cemic.edu.ar

Luxor International Hospital Sharm International Hospital AMC Aseel Hospital for Medical Care

GREECE Dr. Vittorakis General Practitioner/Polyclinic Main Road Platanias Chania Crete

BRAZIL Hospital Mãe de Deus

GREECE 0030 28210 60606 vittorakis.gr

Rua José de Alencar 286 – Porto Alegre/RS BRAZIL

CrossBorderMedCare Euromedica General Hospital of Rhodes

0055 51 3230 2150

HONG KONG

Hospital 9 de Julho Hospital Alemão Oswaldo Cruz Hospital Alvorada Hospital Infantil Sabarà Hospital Memorial Sao Jose Ltda

Matilda International Hospital 41 Mount Kellett Road The Peak HONG KONG

BULGARIA

matilda.org

ACIBADEM City Clinic Tokuda Hospital EAD

INDIA

COLOMBIA Hospital Pablo Tobón Uribe

Rajagiri Hospital

Calle 78 B # 69 – 240 Medellín

Chunangamvely Aluva – 683 112 Kerala

COLOMBIA

INDIA

0057 4 4459000 hptu.org.co

DOMINICAN REPUBLIC Centro Médico Bournigal Hospital General de la Plaza de la SaludÊ

EGYPT

(+91) 484 66 55 000 rajagirihospital.com

Apollo Gleneagles Hospitals, Kolkata Artemis Hospital (a unit of Artemis Medicare Services Ltd.) Asian Heart Institute and Research Center Pvt Ltd Columbia Asia Referral Hospital, Yeshwanthupur Continental Hospitals Limited, Hyderabad Medanta - The Medicity Moolchand Hospital Satguru Partap Singh Hospital

International Medical Center Clinic Km 42,Cairo Ism. Desert Rd., Cairo Near To El Sherouk City, Gate 2 Cairo EGYPT (+20) 224 775 902 imc.org.eg/imc

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ISRAEL

PORTUGAL

Rabin Medical Center/Beilinson & Hasharon Hospitals (Clalit Health Services)

Luz Saúde SA

39 Jabotinsky St. Petah Tikva

Rua Carlos Alberto da Mota Pinto 17-9.º 1070-313 Lisboa

ISRAEL

PORTUGAL

(+972) 3 937 6363 clalit.co.il

ITALY

+351 213 138 260 www.luzsaude.pt

RUSSIA

Centro Chirurgico Toscano Srl Via dei Lecci 22 52100 Arezzo ITALY (+39) 0575 3335 centrochirurgicotoscano.it

Fondazione Poliambulanza IRCCS Centro San Giovanni di Dio Fatebenefratelli Universita Campus Bio-Medico di Roma UPMC San Pietro FBF - Advanced Radiotherapy Center

MALAYSIA Gleneagles Penang (Pulau Pinang Clinic Sdn. Bhd.) 1, Jalan Pangkor 10050 Penang MALAYSIA (+604) 2229 111 gleneagles-penang.com

Pantai Hospital Penang Prince Court Medical Centre The Tun Hussein Onn National Eye Hospital

MEXICO

Euromed Clinic

SINGAPORE Fullerton Healthcare @ Ocean Financial Centre Gleneagles Hospital - Parkway Hospitals Singapore Pte Ltd (Network) Infectious Disease Partners Pte Ltd (Farrer Park Medical Centre) Infectious Disease Partners Pte Ltd (Mount Elizabeth Novena Specialist Centre) Institute of Mental Health KK Women’s and Children’s Hospital National Heart Centre Singapore National University Hospital Parkway East Hospital - Parkway Hospitals Singapore Pte Ltd (Network) Raffles Hospital Singapore General Hospital (SGH) Tan Tock Seng Hospital

SPAIN Best Doctors C/ Almagro, 36 1ª planta 28010 Madrid SPAIN +34 91 308 56 22 bestdoctors.com/spain

Hospital Clinica Biblica

Hospital Amerimed Cozumel Islamed Sa De Cv Calle Adolfo Rosado Salas No 999 entre 85 av y 85 av .bis, C.P. 77670 Cozumel, Q.Roo MEXICO

Avenida 14, Calle 1 Y Central San José SPAIN 506 2522 1000 clinicabiblica.com

+52 (987) 869 55 55 amerimedcozumel.com

Centro Oncologico de Chihuahua Clinica Cumbres Chihuahua Hospital CMQ Hospital de Especialidades (Baja Medical Response) Hospital Galenia Hospital Mexico

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SPAIN (continued) Hospital Unv. HM Montepríncipe

TURKEY Acıbadem Healthcare Group

Av. de Montepríncipe, 25 28660 Boadilla del Monte Madrid

Fahrettin Kerim Gökay Cad No:49 34662 Altunizade İstanbul TURKEY

SPAIN

+90 530 976 8398 acibademinternational.com

(+34) 914 452 126 hmmonteprincipe.com

Hospital Unv. HM Puerta del Sur

Anatolia Hospital

Av. de Carlos V, 70 28938 Mostoles Madrid

Caybasi Mh 1352 Sk No 12 07100 Antalya TURKEY

SPAIN (+34) 914 452 126 hmpuertadelsur.com

Hospital Unv. HM Sanchinarro

+90 242 249 33 00 anatoliahospital.com

Özel Medicabil Hastanesi

Calle Oña, 10 28050 Sanchinarro Madrid

Fethiye Mahallesi, 1/A Mudanya Yolu Küre Sok Fethiye Mahallesi 16140 Nilüfer/Bursa TURKEY

SPAIN (+34) 914 452 126 hmsanchinarro.com

Medical Response International Quironsalud Hospitales Hospital Clinica Benidorm Hospitales San Roque Maspalomas Vithas Xanit International Hopsital

(+90) 444 8 112 medicabil.com

Gayrettepe Florence Nightingale Hastanesi Istanbul Florence Nightingale Hastanesi Medipol Mega Hospitals Complex Memorial Ankara Hospital

UAE

THAILAND Bangkok Dusit Medical Services

Belhoul European Hospital PO Box : 4674 Dubai

2 Soi Soonvijai 7, New Petc buri Rd., Bangkok 10310

UAE

THAILAND

(+971) 4 345 4000 belhouleuropean.com

+66(0)2-310-3000

bangkokhospital.com

Bumrungrad International Hospital Samitivej Sukhumvit Hospital Vejthani Hospital Vibhavadi Hospital

Al Amana Home Health Care LLC Tawam Hospital Thumbay Hospital

UK HCA Healthcare

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USA (continued)

UK (continued) Imperial Private Healthcare

Sharp Global Patient Services

5 Wharf Rd London W2 7BL

8695 Spectrum Center Blvd.

San Diego CA 92123

UK

USA +1 888 265 1513 sharp.com

020 3311 7700 imperialprivatehealthcare.co.uk

Queen Square Hospital

UC San Diego Health System International Patient Program

8-11 Queen Square London WC1N 3AR

136 W. Dickinson Street Suite 109, San Diego CA 92103-8222

UK

USA +1 619 471 0466 health.ucsd.edu

qsprivatehealthcare.com

USA Broward Health International 1608 SE 3rd Avenue Ste 503-B, Ft Lauderdale FL 33316 USA +1 954 767 5587 Sbaig@browardhealth.org

Jackson Memorial Hospital International 1500 NW 12th Avenue Suite 829 East, Miami FL 33136 USA +1 305 355 1211 jmhi.org

Boston Childrens Hospital Brigham and Women’s Hospital (Partners HealthCare International) Cleveland Clinic Cook Children’s Health System Duke Medicine Global Emory Clinic Johns Hopkins Medicine International Mayo Clinic Mount Sinai Medical Center Northwestern Medicine Ochsner Health System Philadelphia International Medicine Uchicago Medicine

VIETNAM Family Medical Practice Co. Ltd 12th flr, Diamond Plaza 34 Le Duan, Dist 1, HCM

Penn Global Medicine 3400 Spruce Street Philadelphia PA 19104

VIETNAM (848) 3822 7848 vietnammedicalpractice.com

USA pennmedicine.org

Philadelphia International Medicine 1801 Market Street, Suite 710 Philadelphia PA, 19103 USA 215-575-3737 philadelphiamedicine.com

Atrium Health Baptist Health International Baylor St Lukes Medical Centre

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