Asian Hospital & Healthcare Management - Issue 44

I S S U E 44

2019

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DIGITALISATION OF HEALTHCARE

The Science of Healthcare Delivery Cardiovascular AI Risk Score Programme

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Associate Partner

Co IT ve Sp rS ec tor ia y

TOWARDS A BETTER FUTURE!

Foreword Healthcare’s Digitalisation Towards a better future!

Digital health has been around for quite some time. Advancements in technology, rising demand for better care, and governments' focus on improved health economy have contributed to the digital transformation in the healthcare sector. Healthcare providers and professionals are continuously challenged to come up with innovative and cost-effective ways of providing effective care and better patient outcomes.

In the past few years, digital technologies have changed the healthcare landscape into becoming more patient-centric, with care givers focusing on engaging patients and improving their experiences.

According a Deloitte report, global healthcare spending is estimated to cross US$10 trillion by 2022. As the global healthcare market embraces digitalisation, innovation has a major role to play. Healthcare companies have been investing heavily in digital technologies to drive innovation and value-based care, while making care giving more accessible and efficient. Digitalisation results in better usage of patient data by care givers enabling them to offer personalised healthcare to the patients.

With telemedicine, healthcare became more accessible for patients even in the remotest of areas. There are a host of digital innovations that help accelerate drug development, high-quality care, effective diagnosis & treatment: Artificial Intelligence (AI), Robotics, Virtual health, Internet of Medical Things (IoMT), Virtual Reality (VR) and Augmented Reality (AR), and Blockchain.

These technologies have led to a disruption in healthcare industry enabling high quality care with speed and accuracy, thereby resulting in improved patient outcomes.

Wearables have made patient tracking for healthcare professionals more seamless and effective. Tracking patient data and providing timely medical advice becomes easier with these applications. AI brings in chatbots, while robotics is being leveraged to make patient care smooth and safe. Meanwhile, big data is helping healthcare professionals identify potential risk factors for the patients leading to offering preventive medicine.

Implementation of virtual healthcare applications allows effective handling of patient care through better services using the telemedicine platform. This implementation will drive growth of the AR and VR usage in healthcare. According to Medgadget, AR & VR Healthcare Market valued approximately US$748.3 million in 2017 is anticipated to grow with a healthy growth rate of more than 30.1 per cent over the forecast period 2018-2025 to reach US$6141.78 million by 2025.

Increasing use of AR and VR also helps reduce medical training costs and simplifies surgical procedures. Patient data stored on smart wearables allows data to be accessed from anywhere.

Such advancements will enhance the development of AR and VR market in healthcare during the coming period.

The cover story of this issue is a collection of articles related to digital technologies in healthcare and commercialisation of the same.

Prasanthi Sadhu

Editor

COVER STORY - IT SPECIAL

DIGITALISATION OF HEALTHCARE

TOWARDS A BETTER FUTURE!

CONTENTS MEDICAL SCIENCES 22 Sleep Deprivation and Disease Risk Pradeep Chowbey, Chairman, Max Institute of Minimal Access, Metabolic & Bariatric Surgery, Max Superspeciality Hospital

26 Cardiovascular AI Risk Score Programme Clinical AI for all Sangita Reddy, Jt. Managing Director, Apollo Hospitals

34 Leading Infectious Diseases among Under-5 Children in Developing Countries Md Moshiur Rahman, Associate Professor, Graduate School of Biomedical and Health Sciences, Hiroshima University Michiko Moriyama, Professor, Graduate School of Biomedical and Health Sciences, Hiroshima University Mohammad Habibur Rahman Sarker, Graduate School of Biomedical and Health Sciences, Hiroshima University

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06 Advancing the Role of Entrepreneurship Healthcare in developing countries Soong-chul (Sam) Ro, Willy Jin Huang, Pradeep Kumar Ray University of Michigan, Shanghai Jiao Tong University Joint Institute

12 The Science of Healthcare Delivery Construct and its impact on service delivery Gurrit Sethi, Strategic Advisor, Global Health Initiatives

16 Lean Management of Emergency Department R B Smarta, MD, Interlink Marketing Consultancy

INFORMATION TECHNOLOGY 40 Digital is set to Change Healthcare Massively Here is how Sanjay Das, Founder and Managing Director, SD Global

44 Commercialisation of Digital Health Yoshihiro Suwa, Partner, Roland Berger

52 The Seven Obstacles Success Factors for Digital Transformation in International Health Tourism and Global Health Mohammed Yassin Blal, CEO & Founder, Caresocius.org

56 Delivering Healthcare Innovation in a Heartbeat Chua Hock Leng, Managing Director, Pure Storage

59 News

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Pradeep Chowbey Chairman Minimal Access, Metabolic and Bariatric Surgery Centre Sir Ganga Ram Hospital, India

SENIOR PRODUCT ASSOCIATES Peter Thomas David Nelson Susanne Vincent PRODUCT ASSOCIATES Austin Paul John Milton CIRCULATION TEAM Naveen M Sam Smith

David A Shore Adjunct Professor, Organizational Development Business School, University of Monterrey, Mexico

SUBSCRIPTIONS IN-CHARGE Vijay Kumar Gaddam HEAD-OPERATIONS S V Nageswara Rao

Gabe Rijpma Sr. Director Health & Social Services for Asia Microsoft, New Zealand

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Advancing the Role of Entrepreneurship

Healthcare in developing countries Healthcare is probably the most important social entrepreneurship sector that can benefit from the innovation and zeal of young entrepreneurship and public-private partnership both of which are being actively promoted in healthcare worldwide. China’s Belt and Road Initiative (BRI) can be leveraged in promoting technology entrepreneurship in the social sector in general and in healthcare in particular.

This article discusses a new multi-country and multidisciplinary initiative called mHealth for Belt and Road region (mHBR) led by the University of Michigan-Shanghai Jiao Tong University Joint Institute. The project involves the application of a range of mHealth technologies (e.g., mobile phones, drones, robots etc.) for Healthcare across the BRI region involving China and neighbouring countries.

Soong-chul (Sam) Ro, Willy Jin Huang, Pradeep Kumar Ray University of Michigan, Shanghai Jiao Tong University Joint Institute

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he United Nations (UN) has recognised the need for a holistic approach of sustainable development where health, environment and social wellbeing are being targeted together through the new global Sustainable Development Goals (SDGs). In the healthcare sector, Universal Health Coverage (UHC) is the platform that seeks to

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overcome inequality in tackling the gap in the service provision and finance that populations face. The role of ICT (Information and Communication Technologies) to build the essential building blocks of UHC has been widely accepted. The proliferation of mobile phones in developing countries, in particular, has raised the expectation for better access to quality healthcare in a cost-effective manner. Widely referred to as ‘mHealth’, ‘mobile communication devices, in conjunction

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with internet and social media, present opportunities to enhance disease prevention and management by extending health interventions beyond the reach of traditional care’ and the World Health Organization (WHO) has announced that m-health has the ‘‘potential to transform the face of health service delivery across the globe”.

However, achieving UHC through mHealth presents some challenges, particularly from the perspective of sustainability and management.

Entrepreneurship in mHealth services provide some mechanisms to overcome these challenges.

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On the other hand, China has undertaken a major initiative called the Belt and Road Initiative (BRI) for the development of the region from the western and southern regions of China through the adjacent countries towards Europe and Africa. This initiative involves developing regions (e.g., Yunnan and Guanxi provinces) of China and other neighbouring countries (Pakistan, Bangladesh, Myanmar, Kazhakastan, Uzbekistan etc.). The BRI scheme mainly funds the infrastructure development of the Belt and Road region and countries through public collaboration; however, once the infrastructure projects are done, it is important to build comprehensive social development utilising increased connectivity through people-to-people collaboration along the BRI countries

and region. For this latter part, entrepreneurship has important roles to play in channeling the benefits of infrastructure and technology to the currently under-developed regions. In view of similarities in the problems for populations in this region, it may be possible to share some cost-effective solutions as well, making such collaboration all the more significant. In addition, although under-represented in the discussions on health-care so far, entrepreneurship has much potential in increasing its significance in relation to healthcare in general and mHealth in particular.

The University of Michigan (UM)Shanghai Jiao Tong University (SJTU) Joint Institute (UMJI) Centre For Entrepreneurship (CFE) is focusing on social entrepreneurship through its initiative on Technology Entrepreneurship for Sustainable Development (TESD) by leading a new multi-disciplinary, multi-country (ten countries) project called mHealth for Belt and Road region (mHBR), as discussed in

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the Research Section of their website.1 As a part of this, a systematic survey was carried out on the role of entrepreneurship in mHealth in terms of four emerging major issues: sustainability, evaluation, social media, and interoperability.

Sustainability in mHealth projects has become an issue because there are many pilot projects in mHealth without leading to any large scale deployment with the exception of some specialised medical devices incorporating mHealth features. There is also an issue of evaluation surrounding the debate on the suitability of expensive, time-consuming randomised controlled trials, a gold standard evaluation methodology for healthcare intervention. Some researchers are questioning this gold standard for mHealth project evaluation given the rapid obsolescence on mHealth technologies. The rapid proliferation of mobile technologies in social media, on the other hand, offers increasing number of options for mHealth solutions but since mHealth represents a class of solutions based on multidisciplinary knowledge involving many complex technologies, often mHealth solutions do not work together, leading to interoperability problems and hence the lack of effective interventions. This survey is an attempt to link the emerging issues on mHealth with the strong interest amongst entrepreneurs on the development of medical devices based on mobile technology.

The Center For Entrepreneurship (CFE) at UMJI has also brought together the works in the international initiative called mHealth for Belt and Road Region (mHBR) and led to a new program called Technology Entrepreneurship for Sustainable Development, which was initiated with the Shanghai 1000-talent Distinguished Professor Award to Pradeep Ray in 2017. Them HBR project is based on ongoing collaborations 1 http://umji.sjtu.edu.cn/entrepreneurship/views/about. html.

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In the healthcare sector, Universal Health Coverage (UHC) is the platform that seeks to overcome inequality in tackling the gap in the service provision and finance that populations face.

ince has been selected as a part of the developing BRI Region in China. The works in this mHBR project can be an illustrative example of the multi-country, multi-stakeholder collaborative approach to the development of BRI region through entrepreneurship in a popular technology (mobile) application particularly in healthcare sector.

Other groups can use this as a model for future development, especially in social entrepreneurship (entrepreneurship to help disadvantaged section of the population, e.g., poor, disabled, elderly etc.)

The OBOR mHBR Initiative is Organised into Six Projects as Follows:

across several institutions in different countries such as Australia (UNSW, University of Sunshine Coast, UTS and University of Wollongong), Bangladesh (Dhaka University, Jessore University of Science and Technology, Yunus Centre, Grameen Shakti), Denmark (Copenhagen Business School), Norway (NTNU, KUC), Japan (Kyushu University, Redcross), Spain (Universidad Politechnica de Madrid), Thailand (Asian Institute of Technology), Shanghai (Shanghai Jiao Tong University) and other BRI Region in China (Guangxi University). The project encompasses multiple disciplines including Software, healthcare, mobile communications, entrepreneurship, business, and social development. Students, faculty, and researchers, in these different institutions and disciplines, are cooperatively investigating the technical and entrepreneurship aspects of mobile technologies (such as phones, robots, drones etc.) for healthcare development in the specified BRI regions and countries. Bangladesh has been selected as a major partner in this project because of its pioneering status in commercialising mHealth (healthcare using mobile phones) through services, such as Health Hotline 789. Guangxi prov-

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1.Robots for elderly: This project follows on from the EU Victrory a home2 to help overcome the loneliness of the elderly living independently using telepresence robots operated by family members using the Internet and mobile devices (e.g. laptop computers, tablets, mobile phones etc.) from geographically remote locations. The robot used in Victoryahome project proof of concept was too expensive for people in BRI region. Hence the first objective of this project is to first develop a low cost, appropriate robot for Belt and Road countries (mainly China and Bangladesh) involving entrepreneurs in the region. The project will have the benefit of the experience of related projects in the EU, Australia,and China where current partners are located.

2. Drones for disaster management: Drones have been successfully used for rescue missions and disaster relief management in Asia, especially in Japan. This project will develop some of these cases applications in developing countries in the region. For example, resource management in the Sunderban region is of great interest to both Bangladesh and India and project 2 www.victoryahome.eu

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partners are from Bangladesh, China, India, and Japan.

3. Portable Health Clinic (PHC): The idea is to use mobile phones for primary healthcare in remote areas in developing countries where the doctor remotely assesses a patient remotely using a mobile phone. Such systems have undergone pilot trials in several countries including Bangladesh, China and Australia This is a well-known project with strong involvement from several countries. The project

name PHC evolved from Grameen Communications and Yunus Centre work called ‘Doctor in a Box’. This project will leverage entrepreneurship amongst village health workers across the OBOR borders (China and Bangladesh) for healthcare applications using mHealth. Project partners are from Bangladesh, China, Japan, Pakistan, and Thailand.

4. Blockchain for social business: This project deals with various aspects of the blockchain technology to help the social services sector (including NGOs) to gain the trust of the donors at minimal cost thanks to blockchain technology in mobile services. Partners include organisations from Australia, China, Denmark, Korea, and Norway.

5. mHealth for parkinsons disease: This project focuses on the application of mobile and wearable technologies for major global chronic diseases

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collaboration and related funding mechanisms. Partners are from Bangladesh, China, Pakistan and Thailand.

These technology entrepreneurship projects study the feasibility and deployment of various mobile technologies for the sustainable development of healthcare in developing regions, such as Belt and Road provinces of China and neighbouring countries.

References are available at www.asianhhm.com

Dr. Soong-chul (Sam) Ro has been teaching political economy, and sustainable development at the University of Michigan– Shanghai Jiao Tong University Joint Institute. He also works for the Center for Entrepreneurship of the Joint Institute, taking an active part in the mobile Health for Belt and Road Region project.

AUTHOR BIO

(e.g., Parkinsons Disease-PD) that is of great importance to China as almost 50 per cent of global PD patients are from China. Researchers are working on using wearable mobile technologies to treat PD patients in very early stages. This project will focus on the use of mHealth for reducing the cost and improving the quality of life of chronic illness patients. The partners are from Australia, China, Japan, and Norway.

6. Global challenge: While all the above projects relate to the application and deployment of a type of mobile technology, this project will deal with the development of entrepreneurship for the social development integrating above technologies in a developing country. This project acts as an umbrella for the development, deployment and evaluation of the mHealth technologies involved in the above projects. The project will carry out relevant case studies across the borders of OBOR region (e.g., China and Bangladesh) to share information (e.g., success stories and knowhow) related to the deployment of these technologies for healthcare from the perspectives of government policies, regulatory environment, entrepreneurial / business support, cross-cultural

Each project will involve academics and entrepreneurs from China and at least one Belt and Road country (e.g., Bangladesh) to collaborate and learn various aspects of the deployment of mobile technologies in healthcare.

The whole project came to a concrete footing in September 2018 through the Entrepreneurship Week event organised by UMJI. As a first such event, it was attended by about 120 participants from 14 countries, and discussed the way forward for them HBR projects. This event led to the initial plan of mHBR in consultation with multi-national partners in academia, business, and the government and consolidated the organisation of mHBR project into six projects mentioned above, led by experts and members from ten countries including Australia, Bangladesh, China, Japan, Korea and several European countries.

This mHBR group will meet again in Sept. 2019 in Asian Institute of Technology to discuss the progress of all projects and their future strategies.

Willy Jin Huang is currently an active member of the UM - SJTU Joint Institute Center for Entrepreneurship (CFE), assisting the various activities listed at the web site of CFE http://umji.sjtu. edu.cn/entrepreneurship/. He is also an aspiring entrepreneur who possesses previous experience of working for multinational companies on various projects.

Pradeep Kumar Ray is a 1000-talent Distinguished Professor in the University of Michigan-Shanghai Jiao Tong University Joint Institute and is currently leading a major collaborative project called mHealth for Belt and Road Region involving seven countries. He is the founder of the WHO Collaborating Centre on eHealth in the University of New South Wales (UNSW)-Australia.

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The Science of Healthcare Delivery Construct and its impact on service delivery The science of service delivery is a skill that can only be mastered by understanding the requirements and the needs of the service consumer: patients and their attendants / family in our context. While the medical talent provides for the requirements, the need is fulfilled by the overall experience through the patient journey. Since we deal with people and lives, the personal touch is critical, alongside expectation setting for medical conditions, outcomes as well as patient movement, all along reflecting empathy and care.

Gurrit Sethi, Strategic Advisor, Global Health Initiatives

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here are many aspects to healthcare delivery: the spread, aided by market factors, government policy and regulations, the enablers like IT, digitisation, connected health etc., the support ecosystem like pharma and device etc., and, the delivery construct at the organisational level. All of these aspects come together at the delivery Segment, aiding the very construct of the services offered.

In my last article I touched upon the spread; in this, let us talk about the delivery construct. Also, because I have had the pleasure of working on this area with hospitals, IT as well as medical devices, segment over the last few years. A very recent incident of hospitalisation of a close family member also exposed me to experience the work flows from the other side of the table—as a patient’s attendant, and have interesting insights to share.

So let me start with my experience as a service consumer. My kin was wheeled into a hospital emergency. As I finished the registration, I looked on in

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anticipation to get some insight on the patients’ condition.

Blood samples were taken, different doctors came in and went out and I kept waiting. As I went to complete the admission procedure I felt as lost as any other patient attendant, forgotten were my years of experience of working in hospitals. It was a great experience though from a professional perspective. While there was no lack of courtesy as I badgered everyone with my questions, which were politely answered, I still felt lost not only from an emotional perspective, but also from a procedural / information / whatdo-I-do next perspective. And this, when I had no financial worries because of the insurance privilege that offered total financial security.

Ever since, I have wondered about the missing link.

Being handed some papers and told to go to the admission desk, I couldn’t find the way–—the sign boards were either too small or confusing or tucked away in a corner so I had to look hard and my brain refused to remember the path instructions given. Of course I finally found another attendant who walked me across. When I walked back, I was as confused—whom do I hand over the document, who will explain what next?

I walked up to the doctor who said it’s a cardiac emergency, the respective team is looking into it. I chided myself to be patient as my kin was put into hospital clothing. And then I realised they were shifting him elsewhere, I quickly ran to ask where and was told to walk along.

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called in the supervisor, told him how and where to get the information he needed regarding the amount I needed to pay so that I could go home while his ‘system’ was down. I promised to return the next day to sign the documents and get a copy of the bill. Two days later, I went to ask for the bill—it wasn’t ready. They didn’t remember!

And once I reminded them, they are finally following me around to get my signatures on it as only then can they submit the bill to the payor for payment—an interesting role reversal!

While the Treatment was Good and Very Satisfactory, what was the Missing Link?

Well the senior physician under whom the patient was admitted, didn’t come along as he was not in the hospital. Of course the treatment went fine through his team and they answered my questions to the point.

But this stood out in my mind that the admitting doctor hasn’t come, hasn’t contacted. I raised my concern to one of the doctors on duty who seemed to be senior amongst those present. I first requested for his name and then asked him next steps. He told me another name (again not the admitting doctor) as the person who will do the angiogram and any further procedure. I politely asked him to introduce me to him on arrival. The nursing staff and a junior doctor got a consent form signed.

When I saw a seemingly important person walk by I ran behind to be told that he is the guy I was looking for as he would do the procedure. The meeting was brief—information about the

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procedure and then told to wait outside the cathlab. The procedure went fine.

I asked the nurse and duty doctor on what I needed to do next—wait? If so, where? Did they need me around?

What are the visiting hours? Etc., Next day the patient was posted for discharge. Having being told in the morning that he would be going home by noon, there was much elation in his eyes. Well, noon came by and went by.

I went up and down—the nurses said they had sent all the documents to billing, billing said they hadn’t received it. Then someone told me to go to the OT to see if they had done their bit of clearance and posting of implants used.

And then the billing system stopped working. The staff was inpatient now with all the questions from the many waiting people.

Slowly I was able to regain my composure, and know how from experience started kicking in. I calmly

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The big C&I all the way—Communication and Information, flow of communication, method of communication, the how of communication, the missing pro-activeness of communication, the level of detailing expected in the communication, who needs to communicate what and when, how does the communication flow, when and where does it flow, what and where are the interconnects with the patient’s family and attendants. And what information flows with this communication.

It is these processes that finally define how the service consumers come out of that experience. And irrespective of the medical outcomes (there will always be terminal cases), if we get it right we will have the patient and family walk out our doors with a good and satisfactory experience. And when they do, they will come back again as well.

The delivery at the organisational level revolves around the design and construct of the organisation itself, the way it is wired, what tools are used; which in turn defines the information flow and who does what. Those who have mastered the art, also take care to define the how and when. The current that flows through this wiring is our big C&I—communication and information—that enables good service delivery. This current is also the culture, the

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capability and the motivation of the people and the team and carry this delivery to the last mile.

There is a growing focus on culture building within organisations these days. It is people who deliver the services. It is the front end staff that finally manage the moments of truth on our floors and not the senior management. However, it is the senior management that drives the environment in which the team members operate. It is finally the environment and the EQ that motivates these front end teams to do what they need to do and how. Therefore, the last mile delivery is so badly dependent and correspondent with the culture / environment of the organisation.

It’s also a common misnomer to read the organisation structure as a hierarchy archetype. By my experience, the organisation structure lays out the basis of the operations—who is required to do what, definition of the what, and the details of the how, the required skill sets and the capability build that forms the basis of the culture. This in turn defines the plugins of the various to dos across the department structures and layers. Information flows through this construct and is relayed by way of communication— across the patient journey and through this system.

I have also come across various organisations that simply ape the structures of other organisations as they come up. It is important to understand the model first before an organisation structure gets defined. Because it is this model that will give shape to the end delivery and how this is to be done. It is advisable to use the requirements of this model to build an org structure that works rather than a copy paste.

As I look through the various service delivery organisations in healthcare—we have miles to go before we sleep, but maybe we need to put this through a sleep study to be able to drive it more scientifically!!

AUTHOR BIO Gurrit K Sethi, Hospital Chief Operating Officer, Care Hospitals; Strategic Advisor for Global Health Services, Global Strategic Analysis, contributes to healthcare by helping providers build and better business efficiencies and concept development, also strives to contribute socially through the Swiss Foundation, Global Challenges Forum as Strategic Advisor, through conception of sustainable health initiatives. She started her career from the shop floor working her way up to lead and set up different healthcare businesses. In her words, her significant achievements have been in bringing to life different SMEs and SBUs signifying a change in the Indian healthcare scenarios, as the opportunity paved the way along the healthcare growth curve in the country. With over 18 years in healthcare under her belt, across different healthcare verticals, she has carried transformational changes in the projects she has led, four of those being early stage start-ups. Gurrit is an avid traveller and voracious reader of varied genres, attributes which she says, provide her with incisive insights about people and systems and what drives them.

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LEAN MANAGEMENT OF EMERGENCY DEPARTMENT

Lean management could prove to be an essential tool for solving a key issue of the emergency department: overcrowding. Lean management works towards reducing the non-required items/ processes/ activities commonly known as ‘waste’ and streamlining the system towards qualitative services. Applying lean management would result in sustainable growth due to realignment of services and processes towards patients and staffs satisfaction. It further reduces unnecessary cost burdens on patients, staff, and the environment while also facilitating continuous improvement for innovative services leading to patient benefits and profitability.

R B Smarta, MD, Interlink Marketing Consultancy

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lobally, healthcare systems are under pressure to improve quality and patient outcomes using evidence-based interventions.

Many healthcare organisations are turning to industrial improvement approaches, such as the lean management system, 5-S model, Six sigma, etc., to enhance quality and safety. The critical part of emergency department is the 24* 7 working hours during which it is almost always overcrowded. Thus, minimising the non-relevant and non-required items/ activities from the system and reducing waste would prove to be beneficial, and this is what lean management aims towards.

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Lean thinking is a visual state of mind, whereby the focus is on the task and nothing else is encouraged. Lean management in healthcare systems was first applied way back in 2004 at the Mason Hospital, Virginia,USA, to improve their process methodology. A study also reveals that some hospitals in USA in 2009 implemented lean system to improve the quality of healthcare services, out of which 60 per cent applied in emergency department.

Essence of Emergency Department

The emergency department is characterised as a critical department in hospital setting and is occupied by varied patient types. Various countries have applied National Emergency Department Inventories (NEDI) survey as a standardised method to benchmark the characteristics of emergency department.

Overcrowding in emergency departments is a global problem and has been recognised as a national crisis in some countries as it hampers the objective of service to the patient.

The improvement, in terms of cost of care, the quickness of service, handling of crowds, swiftness in triage process, and most importantly, patient safety are now widely accepted by means of patient-centricity. The workflow of the emergency department should be planned in such a way that the staff could attend immediately to unscheduled and unexpected patient inflow.

One survey showed that a varied number of emergency departments has high annual visit volumes and long length-of-stay, and most of them are over loaded.

There is no doubt that the emergency department is the most complex clinical department in modern hospital infrastructure. It is always intended to have well designed infrastructure and depending on the condition of the patient and whether the patient is with occupier or not

priority of formalities and treatment needs to be decided. Nothing is more crucial than saving lives!

Emergency Department Process Flow

Many a times, disparity between capacities of the emergency department, requirement of triage process, diagnostic tests and consultation with doctor affects the patient flow to a greater extent in. In addition, some studies have recognised overcrowding as the major reason for adverse patient outcome, delayed treatment, prolonged length of stay and hospital readmission.

Well, to solve those issues revisiting the workflow of the entire process of the emergency department isa prerequisite and needs to be integrated along with collaborative support from all healthcare professionals involved in the emergency department.

Not only does lean management reorganise services and systems for patients, it also indirectly affects employees. Streamlining the work processes directly affects the staff and helps them in managing their work pressure accordingly. Lean is implemented in particular contexts and

Registartion Triage

Early Treatment Zone

Urgent care Unit

2 Hours Figure 1 Emergency department process flow

success is dependent on how it fits into the system.

Let's look at the principles of lean management that help understand the basic concept of lean.

5 Lean Management Principles:

Define value The first stage is to define the value of your products and services as per customer requirements which is directly proportional to beneficiary in terms of footfalls. It is supreme to determine the actual or latent needs of the customer. To better understand the Lean management principles we should start with defining “customer value�. Value is what the customer is keen to pay for. Sometimes customers may also be unable to express it. This is particularly observed when it comes to novel products or technologies. Applying to recent trends, Artificial Intelligence (AI) and machine learning are some that need to be perceived by patients.

There are various ways like focus group interviews, surveys, footfall analysis, demographic information and web analytics that can lead you to know your customers preferences.

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Acute

Inpatient ward

Sub-Acute

Rehabilitation unit for chronic condition

Fast track

Emergency Department Short stay unit

1-2 Hours Source: Overcrowding in emergency departments: A review of strategies to decrease future challenges

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Map the value stream

Leadership Support

Educate entire staff

Encouragement of Continuous improvement

Figure 2 Pyramid of enabling Lean management

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Source: Interlink Marketing Consultancy

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In this step, the objective is to use the customer’s value as a reference point and to identify all the other factors those contribute to these values. Those activities that do not add value to the patient are considered waste and should be eliminated. The waste can be differentiated into two categories: non-value added but necessary and non-value but unnecessary. The latter is pure waste and should be eliminated while the former should be reduced as much as possible depending on the patient preferences and reducing the cost of production of that particular product or service.

Make the process flow Once elimination of non-value added services or products is done, ensure that the rest of the process is smooth.

Strategies to ensure that process runs smoothly, measures that can be taken include breaking down the major stages into two three subsequent steps, levelling out the workload amongst the staff, creating cross-functional departments, and training employees to

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be multi-skilled, talented and adaptive to environmental changes.

Pull from the customer The aim of applying a pull-based system is to limit the inventory to required things and work in progress. Also, assurance of the availability of required materials and data at appropriate time for a seamless process of work is necessary, as it enforces ‘In-time’ delivery. Pull-based systems are always prioritised based on the needs of the end customers.

Work towards perfection Once the process is set in order by implementing the first four steps, the fifth step of chasing perfection is of utmost importance. It makes lean management thinking an integral part of the organisation and lends a continuous process of upgrading accuracy and precision in organisational culture.

Every employee should endeavour to exactness while providing service to the patient. One should always remember there is no limitation to learning, and it is a steady process.

The 5 Lean management principles create a background for wellorganised and active organisation. It allows managers to reduce inefficiencies, deliver better value to customers, create efficient workflow, and develop a continuous improvement culture. This will encourage competitive environment, increased value, decreased cost to run business, and indirectly increase profitability.

Implementing lean in the emergency department should start with cleaning up cluttered spaces by removing or replacing unnecessary items.

This would free-up the space across the overcrowded department and facilitate smooth movement.

A small study conducted in a hospital showed that the average length of stay is approximately 1 hour and 41 minutes. Various factors govern the length of stay starting from the time required for the registration process, time invested by patient’s kin in taking

Figure 3 5 Lean management principles

decisions, making financial arrangements, and to submit documents.

Furthermore time taken by consultant to attend the patient, even the waiting time for radiology investigations or other laboratory reports are time consuming and stressful.

Following is the observation of time required for various processes (in

A study reveals that some hospitals in USA in 2009 implemented lean system to improve the quality of healthcare services, out of which 60 per cent applied in emergency department.

Source: Interlink Marketing Consultancy

minutes) from experience of lean in Emergency department: [1] Environmental Issues in the Emergency Department

The main issue and concern for any emergency department is overcrowding.

Hospital managers need to examine their operational procedures to resolve this concern. Once the reason for overcrowding is known, then tackling it won’t take much time. The standard time an individual spends in emergency department is 5-6 hours. The care provided to in-patient and emergency department should be the same and the processes should ensure safe and qualitative care.

The staff plays a major role in the up-gradation of the organisation.

Taking into account the operational realities, techniques, and relatively inflexible culture make it challenging to implement lean management. Many a times hospitals are not aware of the lack of resources or training of soft skills which may reduce time required for interaction. The in-patient department

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Before (Time in mins.)

After (Time in mins.)

Consultant waiting time

21

16

Final waiting time

29

19

Blood sample result time

69

28

Radiological investigating result time

32

15

Admission waiting time

30

20

Length of stay

123

72

Patient satisfaction

86%

98%

Process

Table 1

Source: Lean thinking in emergency department, TaraknathTaraphdar, presentation at EMCON, Jaipur, November 2017.

is often trained for usage of new devices, but the emergency department tends to get overlooked as a different entity, although the emergency department staff may benefit from it. Empowering the staff with proper training and resources can eventually contribute to other efforts such as improved services and reduced waiting times.

Unique Culture of Hospitals

Although many hospitals share common problems such as overcrowding, it is important to remember that each hospital has its own environmental issues depending upon the culture.

Morality of employee may seem to be a minor issue, but if staff is unhappy then this could hamper services and may escalate to staff inefficiencies that could badly affect the image the of hospital.

In this case, the management leadership should be firm enough to take decisions toward establishing processes and improving inefficient practices.

Way Forward

1. Replacing traditional nurse-based triage with a team of triage including physicians has proved to be beneficial as it could discharge more patients that too without admission.

2. Depending on the patient flow, high/low flow strategies can be implemented when there is overcrowding and some of them may get treated in initial care unit.

R B Smarta has designed management agendas for profitable growth, relevant expansion, launching new concepts, ideas and projects for National and Global clients in Pharmaceuticals, Nutraceuticals and Wellness. Being in the industry for more than 4 decades & amp; in consulting as a pioneer for 3 decades, he has a perfect blend of industry and consulting best practices. He has added value and impact on performance of wide variety of clients, inclusive of start-ups to national and multinational corporate. His firm Interlink has created valuable insights and depth of knowledge in its knowledge bank, along with its consultants and associates.

Lean management through the use of the following initiatives can prove to be an effective way forward:

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3. Another way to tackle overcrowding is to employ a waiting room that allows treatment by the time primary diagnostic tests results are revealed.

A continuous improvement mindset is essential to reach the company's goals. The term ‘continuous improvement’ means incremental improvement of products, processes, or services over time, with the goal of reducing waste to improve workplace functionality, customer service, or product performance. Lean is founded on the concept of continuous and incremental improvements on product and processes while eliminating redundant activities. "The value of adding activities are simply only those things the customer is willing to pay for, everything else is termed as waste, and should be eliminated, simplified, reduced, or integrated".

References: 1. Lean thinking in emergency department, Taraknath Taraphdar, presentation at EMCON, Jaipur, November 2017.

2. Overcrowding in emergency departments: A review of strategies to decrease future challenges, Mohammad H Yarmohammadian, Fatemeh Rezaei, Abbas Haghshenas, and Nahid Tavakoli;J Res Med Sci. 2017.

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SLEEP DEPRIVATION AND DISEASE T RISK Sleep is a restorative process which plays a very crucial role in our physical, mental and emotional health. It has profound consequences on one’s overall health and well being. There is a lot of literature established which points towards a direct correlation between sleep deprivation and a number of chronic health diseases like obesity, diabetes, hypertension and cardiovascular diseases.

Pradeep Chowbey, Chairman, Max Institute of Minimal Access, Metabolic & Bariatric Surgery, Max Superspeciality Hospital

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he cost of sleep debt is much heavier than one may comprehend. Sleep is a restorative process which plays a very crucial role in our physical, mental and emotional health. It has profound consequences on one’s overall health and well being. There is a lot of literature established which points towards a direct correlation between sleep deprivation and a number of chronic health diseases like obesity, diabetes, hypertension and cardiovascular diseases.

Sleep debt may result from insomnia or other underlying conditions that require medical attention. But most sleep debt is due to burning the candle at both ends — consistently failing to get to bed on time and waking up late the next day disrupting the sleep pattern.

MEDICAL SCIENCES

Understanding the Body’s Internal Clock

The body clock or sleep / wake cycle is also termed as the Circadian rhythm.

It is a twenty four hour internal clock of the body which cycles between sleepiness and alertness at regular intervals. The body clock is controlled by an area of the brain that responds to light, which is why humans are most alert while the sun is shining and are ready to sleep when it's dark outside.

The circadian rhythm causes the level of alertness to rise and dip throughout the day. Most people feel less alert between 1:00pm and 3:00pm and then late night between 2:00am and 4:00am, but this can vary from person to person. This body clock also changes with age.

If one follows the body’s natural cues regarding when to go to sleep and wake up, the circadian rhythm should stay balanced, but a change in the schedule like staying up late can disrupt the body clock.

The hormonal imbalance Leptin and ghrelin are two peripheral hormones that regulate energy balance and food uptake.

Leptin is the appetite suppressor hormone which is released by fat cells.

It sends signals of satiety to the brainand instructs to stop eating. During sleep, leptin levels in the body increase, signifying that the body has enough energy and does not need any food.

This hormone significantly decreases with sleep deprivation which results in a constant feeling of hunger and a general slow-down of metabolism.

‘Ghrelin’ is the appetite stimulator or hunger hormone which has the exact opposite purpose of leptin. It is released by the stomach and its function is to stimulate appetite. While sleeping, the levels of ghrelin decrease; however if one is sleep-deprived, it results in an increase

It is scientifically proven and published in many leading journals that even one night of sleepdeprivation can cause insulin sensitivity to drop which impairs glucose metabolism.

Relationship between Sleep Habits and Chronic Diseases

Short-term ill-effects of sleep deprivation include fatigue / tiredness throughout the day, bad mood and inability to focus on task at hand.

However, if one is sleep deprived on a regular basis, it can lead to development of chronic diseases.

1.Obesity Short sleep duration has been documented to be closely linked to elevated Body Mass Index (BMI).

Recent studies suggest that less than 7 hours of sleep can reduce or even undo the benefits of diet and exercise. Sleep deprivation in turn makes one crave food and even calorie dense food. It is well understood that during sleep, the secretion of various hormones varies, contributing to the metabolism and energy balance of the body. Sleep deprivation may disturb this balance leading to weight gain.

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of ghrelin which results in increased hunger and appetite, more so for the carbohydrate rich, starchy and calorie dense foods.

So, sleep debt causes this combination of a decrease in leptin and an increase in ghrelin which results in an increased calorie intake and weight gain. Various studies have established that sleep deprivation leads to increased levels of stress hormones and resistance to insulin, both of which also contribute to weight gain.

Vicious cycle Following the biological clock is the key to good health and well being. Altered sleep patterns contribute to eating at wrong times, thus disturbing metabolism. Seven to nine hours of daily sleep at the right time is imperative.

Odd timings of sleep encourage midnight binging which is mostly junk processed food that is high in calories.

Moreover, no physical activity after that causes everything to be deposited as fat in the body during sleep. The next morning, the person obviously wakes up late and feels lethargic throughout the day with poor energy and concen-

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tration levels due to which there is no exercise in the day time as well.

This slows down the metabolism even further and contributes to weight gain.

Poor metabolism Adequate sleep plays a vital role in regulating metabolism and appetite.

With irregular sleep patterns which causes, sleep deprivation, individuals have a decreased ability to manage blood sugar levels and also may end up being hungrier.

Lack of sleep is also responsible for high stress levels, lower productivity in work and increased likelihood of metabolic disorders.

2. Insulin resistance and Type 2 Diabetes It is scientifically proven and published in many leading journals that even one night of sleep-deprivation can cause insulin sensitivity to drop which impairs glucose metabolism. Few consecutive sleep deprived nights through the body metabolism into complete disarray putting the body in a state of insulin resistance—a common precursor of weight gain, diabetes and other serious health problems.

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In a healthy body, sugar is metabolised by the insulin released by pancreas. When the body develops insulin resistance, cells are less responsive to that signal, and glucose levels rise in the bloodstream. That can lead to diabetes 3. Hypertension and heart diseases Sleep deprivation results in an increase in blood pressure and causes changes in the lining of arteries. This leads to an increased risk of heart disease due to weight gain and also adverse changes in the arteries. Studies suggest that even a single night of inadequate sleep in people with existing hypertension can cause elevated blood pressure through the next day 4. Psychological disorders A single disturbed night of sleep reflects on the working of an individual the next day. The person is fatigued, sleepy, confused and not focused throughout the day. Long term sleep deprivation can lead to chronic long term disorders like depression, anxiety and memory issues.

5. Gastrointestinal issues Sleep deprivation has been associated with Gastrointestinal issues. Both Inflammatory Bowel Disease (IBD) and inflammatory bowel syndrome, have been linked to lack of sleep. Patients suffering from Crohn's disease are twice as likely to experience a relapse when they are sleep deprived.

People always find themselves struggling to lose weight despite moderate exercise and diet management, recent studies suggest that less than 7 hours of sleep can reduce or even undo the benefits of diet and exercise. Sleep deprivation in turn makes one crave food. The millennial lifestyle does not always allow us to follow the right sleep patterns; however, here are few things to do for a good night’s sleep: 1. Try and maintain regularity Maintaining more or less the same time to go to sleep and waking up is vital.

This helps to set the body’s internal clock and optimise the quality of sleep.

MEDICAL SCIENCES

2. Control exposure to light Melatonin is a naturally occurring hormone controlled by light exposure which helps to regulate the sleepwake cycle. The brain secretes more melatonin when it’s dark—triggering sleep—and less when it’s bright— making one more alert.

• Avoid bright screens within 1-2 hours of bedtime • Don’t read with backlit devices • At the time of sleep, the room should be dark.

3. Keep the room cool A temperature of around 18° C with adequate ventilation is considered ideal for a good sleep. A room that is too hot or too cold can interfere with quality of sleep.

4. Be Smart about what you drink & Eat • Limit caffeine and nicotine • Avoid alcohol before bed.

5. Don’t stay in the bed awake If one is unable to sleep and has been awake for more than 15 minutes, it is best to step out of bed and do a quiet, non-stimulating activity, like reading a book. The lights must be kept absolutely dim and screens must be avoided.

3.

The use of multimedia has emerged as the most common factor contributing to sleep deprivation (for example, television, smartphones, and computers) which aggravates sedentary behaviour and increases caloric intake.

4.

Sleep deprivation results in metabolic and endocrine alterations which are • Increased levels of ghrelin, the hunger hormone

• Decreased levels of leptin, the appetite suppressor hormone • These two in combination contribute to increased food intake, high caloric snacking and poor diet quality.

• Decreased glucose tolerance • Decreased insulin sensitivity • Increased production of stress hormone ‘Cortisol’ .

Key Messages:

1.

Various epidemiological studies have established a strong association between short sleep duration and overweight and/ or obesity.

2. The third leg in the tripod of weight management is adequate sleep at appropriate time; the other two being healthy diet and exercise.

Pradeep Chowbey belongs to the cadre of the pioneer laparoscopic surgeons in India. He has graphed his career with singular determination to develop, evaluate and propagate Minimal Access, Metabolic & Bariatric Surgery in India. The advent of Laparoscopic surgery with his hands became a point in India's medical history.

Chowbey established the Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, New Delhi in 1996, which was the first of its kind in the Asian subcontinent.

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MEDICAL SCIENCES

Cardiovascular AI Risk Score Programme Clinical AI for all

Cardiovascular Diseases have grown to epidemic proportions in India leading to high mortality. Apollo Hospitals and Microsoft have come together to develop and implement a model using Artificial Intelligence (AI) and Big Data to help us define risk prediction, create stratified populations and build targeted therapies and treatment, thereby avoiding preventable deaths.

Sangita Reddy, Jt. Managing Director, Apollo Hospitals

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Apollo Hospitals and Microsoft have joined hands to develop the Standard Cardiovascular Risk Score in Indian population based on the available data at Apollo Hospitals using AI and Machine Learning (ML). The basic objective of this unique initiative is in developing a more accurate risk prediction model so that in conjunction with screening, diseases can be averted in high risk groups.

Risk Factor Selection and Modelling: Building the Tech Capability

C

ardiovascular diseases have grown to epidemic proportions in developing countries such as India, where lifestyle patterns have changed significantly due to growing urbanisation, dietary habits, reduced physical activity, and associated psychological stress.

Currently, cardiovascular diseases contribute to more than 29 per cent of deaths, while Coronary Heart Disease alone contributes to around 15 per cent of deaths in India. Though, there have been multiple studies on cardiovascular disease risk factors since early 1940s, they were not specifically applied to Indian population with high accuracy.

Further, most of these studies had selection bias in terms of choosing the risk factors and wouldn’t provide a prospective feedback loop to account for a Cardiovascular event in an individual on a future date.

The study started with the analysis of over 400,000 individual health check records that were collected between 2010 to 2017 from six centres of Apollo Hospitals and matching them with 60,000 patients with discharge summaries of cardiovascular events.

All the records were anonymised by removing patient name and unique identification number. Following the data hygiene and curation, the initial model was built on approximately 7,000 patients with cardiovascular Event discharges and a previous health check record (Cases) with 25,000 individuals who had two or more health checks done in the same period without any cardiovascular event (Controls).

Health check data yields more than 100 clinical parameters for each individuals. The initial step was to filter and identify the applicable risk factors.

As the next step, Spearman’s correlation coefficient was used to correlate risk factors to a cardiovascular event. The data was filtered with respect to all the parameters and were further grouped and normalised. After the clinical validation process, around 21 clinical risk factor was selected for further study and validation.

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MEDICAL SCIENCES

Figure 1 Showing the complete synopsis of the Methodology from Data Collection, Processing, Analysis and Creation of Novel API Tool for Operational Roll Out

Hazard models were used to predict time to event; these models were built to have unique advantage over regression model to further improve accuracy. Applying the recent advances on Deep Learning on Survival Analysis, we could create an integrated model which provided improved inferencing of co-variate (Hazard Model) while giving better prediction score (Deep Learning).

Initial Results

The accuracy of the model looking at the 21 clinical risk factors stands at the AUC 0.83 which is significantly higher than Framingham Risk Score for the same population at AUC 0.47. One of the significant outcomes was about determining the cardiovascular risk in younger (below 40 years) population (16.6 per cent).Secondly, the interplay of multiple factors were more significant than any one individual factor. For example, the study yielded higher correlation between hypertension and diabetes as risk factors for

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cardiovascular event than any one of the factors individually.

The study also highlighted that the higher diastolic blood pressure is a better indicator of cardiovascular disease than higher Systolic Blood Pressure, particularly in a younger population. Specific to Indian population, chewing tobacco is more harmful than smoking for cardiovascular disease (around 7 percentage point more). Lastly, higher BMI (> 27) with either smoking or chewing tobacco increases heart risk by 14 per cent percentage point.

The results of the study were next validated retrospectively with blinded data set from 2 other (larger) centres of Apollo Hospitals with AUC scores of 0.844 (n = 2389) and 0.92 (n=857). During this validation process, another significant inference came out in the form of frequency of health check to the accuracy of prediction. The study concluded that when the health checks are done more frequently, the accuracy of the prediction improves providing a better predictability for cardiovascular event.

MEDICAL SCIENCES

Steps to Tech Adoption

With the technology capability developed and promising initial results of the retrospective study, the Apollo Hospital: Microsoft Team next focused on deploying the AI model into the organisational Electronic Medical Records (EMR) for improved adoption.

A roadshow programme for eight Apollo Hospitals and a prospective longitudinal study with ten Indian Hospitals (including reputed academic institutions) were subsequently designed. The next objective was to focus on empowering physicians to determine risk factors in patients with more holistic way and provide insights to them for lifestyle modification and timely interventions. a)Integrating the AI model as an API to the organisational EMR : The programme was built through novel ideas and designing of the operational processes. The API tool is built for the EMR, where the patient’s current

risks are determined and methods to reduce risk were provided during the discussion with the physician. There are currently no existing tool based on computation on deep neural networks available to predict cardiovascular risks.

Next step in the workflow was to define the inclusion and exclusion criteria as under what clinical condition a physician can choose to generate the risk score of an individual or a patient.

Following the development of the inclusion criteria, the team designed the work flow required to implement the process and integrating the API at personalised health check clinics in the hospitals and Apollo Clinics; Specialty Clinics like Apollo Sugar and Healthy Heart Clinics; Physician OP Clinics in Internal Medicine, Cardiology etc; and finally, developing an App for Peripheral Public Camps and Remote Care – Apollo TeleHealth.

In all of the above situations, the patient- / individual-related clinical

data is collected in the EMR which would auto populate the cardiac risk score user interface. On clicking the ‘Get Prediction’ button, the Cardiac Risk Score is generated with the following features: (Figure 3) – • The risk score of the patient with the optimal score for his / her age.

• The top three modifiable risk contributors, which the patient should work on moving forward to reduce the risk of the cardiovascular disease.

• The patient’s historical risk score that has been generated from the earlier health checks done in the system, which predicts the risk trend.

• The clinical decision support system which provides what the physician should direct the patient towards next lab investigations, Diagnostic imaging, referral to cardiologists, medications, patient and family education and repeat visit timelines.

• A legal disclaimer such as: This clinical

Figure 2 Flowchart of the Inclusion / Exclusion Criteria for Cardiovascular Risk Scoring with the 21 Risk Factors

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algorithm is a general guideline for physicians using the cardiac risk score. Any additional laboratory investigations, diagnostic imaging, treatment or patient education related to lifestyle management is under the physician’s or cardiologist’s discretion. b) Clinical Decision Support Systems

One of the key imperatives for any clinical AI programme is to provide a link between the AI–ML research and integrate this with core clinical functionality for a better adoption of clinicians. The clinical algorithm was developed to support the patient’s risk score and channelise them through appropriate care processes as described above. Figure 4 shows the process. The benefit of the clinical algorithm were two-fold:

One of the key imperatives for any clinical AI programme is to provide a link between the AI–ML research and integrate this with core clinical functionality for a better adoption of clinicians.

• It provided an immediate and handy guideline for the next course of action for the patients with high risk to seek next level of intervention • It standardised the process of the investigations and referral thereby

Figure 3

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helping the physicians to guide their patients better • Prospective Study & Roadshows with Clinicians For the prospective use of the cardiac risk score API tool, the team designed an observational prospective study with appropriate layers of informed consent, data security &confidentiality and applied to 10 institutional ethics committees across the country. Currently, approvals have been obtained for the prospective studies which are underway for further validation and calibration. Similarly, premier healthcare institutions outside India in USA, Europe and Canada are being brought in to make an international data consortium to take the cardiac AI risk score, for global population with multi-ethnic and crossgeographic boundaries. Technically, the opportunity remains to comply

Advertising in AHHM magazine will right away showcase your products to key decision makers in hospital and healthcare industry in Asia Pacific, the Middle East, Europe and USA. With a readership of more than 180,000 in these geographies, your products stand a better chance to recognized and trusted.

To book your ad now: Email: advertise@asianhhm.com Tel: +91 40 4961 4567 Fax +91 40 4961 4555

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MEDICAL SCIENCES

the outpatient clinics and for health check clinics.

The roadshows in August 2018 and January 2019 covered 600 Physicians and 100 cardiologists at eight Apollo locations.

Conclusion

Beginning with an unmet need to standardise a cardiovascular risk score for Indian population, this endeavour looks forward to involve healthcare institutions, public and private health services, corporate wellness programmes, e–Health portals etc., across geographies and multiple ethnicities to use the risk score API. The personalised output and recommendations of the risk score algorithm will benefit both the physicians and the people to prevent cardiovascular events in the long-run.

AUTHOR BIO

with national and international data privacy laws and integrate the API with translatable interoperable EMR / EHR systems.

In the context of rolling this out to clinicians during the roadshows, the team adopted three fundamental principles: 1. Algorithm + Clinician: AI algorithms are not replacements for clinicians, but rather are complementary to clinician decision–making 2.

Risk Identification and Prevention: – This tool does not diagnose coronary artery disease;it provides a risk computation for mitigation and prevention only.

3. For Outpatient and Health Check Clinics: The tool has been prepared for use at preventive cardiology screening programmes at

Sangita Reddy is the Joint Managing Director of the pioneering Apollo Hospitals Group, a proponent of integrated healthcare delivery. In addition to her operational responsibilities, Sangita led the group’s retail and primary healthcare endeavours. Recently, in partnership with the National Skill Development Corporation; she initiated a unique PPP purpose-designed to skill half a million individuals before 2020.

An ardent champion advocating the benefits of a global delivery model through rural hospitals, outreach camps and telemedicine, Sangita is continuously engaged with the governments to deliver innovative health services harnessing digital platforms.

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MEDICAL SCIENCES

Leading Infectious Diseases among Under-5 Children in Developing Countries Although disease patterns change constantly, infectious diseases remain the leading cause of mortality and morbidity in the developing countries; especially, among under-5 children. In the current global context, it is important to understand how international aid agencies and donors prioritise their funding allocations for the prevention, control and treatment of infectious diseases.

Md Moshiur Rahman, Associate Professor, Graduate School of Biomedical and Health Sciences, Hiroshima University Michiko Moriyama, Professor, Graduate School of Biomedical and Health Sciences, Hiroshima University Mohammad Habibur Rahman Sarker, Graduate School of Biomedical and Health Sciences, Hiroshima University

G

lobal child mortality has decreased substantially since 2000 due to vaccinations, adequate nutrition and health education; however, mortality and morbidity remain high among the developing countries. Infectious diseases are the leading causes of death worldwide, particularly in low-income countries, caused by usually microscopic size organisms, such as bacteria, viruses, fungi, or parasites. In developing countries, top five infectious diseases that are responsible for under-5 mortality and morbidity are pneumonia, diarrhoea, HIV/AIDS, malaria and tuberculosis.

Pneumonia

Pneumonia is the foremost cause of death from infectious diseases in under-five year old children worldwide. It accounts for 16 per cent of all deaths, killing 920,136 children in 2015. Pneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi; streptococcus pneumoniae – the most common cause of bacterial

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pneumonia in children; Haemophilus influenzae type b (Hib) – is the second most common cause of bacterial pneumonia; respiratory syncytial virus is the most common viral cause of pneumonia; in infants infected with HIV, Pneumocystis jiroveciis one of the most common causes, responsible for at least one-quarter of all pneumonia deaths in HIV-infected infants. The viruses and bacteria that are commonly found in a child's nose or throat, can infect the lungs if they are inhaled. They may also spread via air-borne droplets from a cough or sneeze. In addition, it may spread through blood, especially during and shortly after birth.

Pneumonia occurs when the air sacks in the lungs, the alveoli, are filled with pus and/or fluid. This makes breathing difficult, and does not allow the infected person to intake enough oxygen. The presenting features of viral and bacterial pneumonia are similar. However, the symptoms of viral pneumonia may be more numerous than bacterial pneumonia.

In children under 5 years of age, who have cough and/or difficult breathing, with or without fever, pneumonia is diagnosed by the presence of either fast breathing or lower chest wall in drawing where their chest moves in or retracts during inhalation. Wheezing is more common in viral infections. Very severely ill infants may be unable to feed or drink and may also experience unconsciousness, hypothermia and/or convulsions.

The risk factors related to the host and the environment in developing countries include malnutrition, low birth weight (≤ 2500 g), non-exclusive breast feeding, lack of measles immunisation, indoor air pollution, crowding, etc. The antibiotic of choice for treatment is amoxicillin dispersible tablets. Most cases of them require oral antibiotics, which are often prescribed at a health centre. These cases can also be diagnosed and treated with inexpensive oral antibiotics at the community level

In developing countries, top five infectious diseases that are esponsible for under-5 mortality and morbidity are pneumonia, diarrhoea, HIV/AIDS, malaria and tuberculosis.

by trained community health workers; hospitalisation is recommended only for severe cases of pneumonia.

Preventing pneumonia in children is an essential component of a strategy to reduce child mortality. Immunisation against Hib, pneumococcus, measles and whooping cough (pertussis) is the most effective way to prevent pneumonia. Furthermore, adequate nutrition, exclusive breastfeeding, avoidance of indoor air pollution and encouraging good hygiene in crowded homes are useful measures.

Diarrhoea

Diarrhoea is the second leading cause of death in children under five years old, and is responsible for killing around 525,000 children every year.

Considering the etiology, rotavirus is the most common cause of acute watery diarrhoea with about 39 per cent of diarrhoea hospitalisations and 199,000 deaths each year, mostly in children; unfortunately, 85 per cent of them occur in low-income countries.

Next to rotavirus, enterotoxigenic Escherichia coli (ETEC) is estimated 42,000 deaths of children under five years of age in 2013. On the other hand, Vibrio cholerae causes an estimated 3–5 million cholera cases and 100,000–120,000 deaths every year with a higher incidence among children. The other responsible

pathogens for diarrhoea are salmonella, shigella, campylobacter, etc. Now, other causes such as septic bacterial infections are likely to account for an increasing proportion of all diarrhoea-associated deaths. Children who are malnourished or have impaired immunity and people living with HIV are most at risk of lifethreatening diarrhoea. These diarrhoearelated infections are mainly caused by unclean drinking water, contaminated food or person-to-person contact and poor hygiene.

Diarrhoea is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual).

Frequent passing of formed stools is not diarrhoea, nor is the passing of loose, ‘pasty’ stools by breastfed babies.

Diarrhoea is usually a symptom of an infection in the intestinal tract, which can be caused by a variety of bacterial, viral and parasitic organisms.

There are three clinical types of diarrhoea: acute watery diarrhoea – lasts several hours or days, and includes cholera; acute bloody diarrhoea – also called dysentery; and persistent diarrhoea – lasts 14 days or longer. The most severe threat posed by diarrhoea is dehydration. During a diarrhoeal episode, water and electrolytes (sodium, chloride, potassium and bicarbonate) are lost through liquid stools, vomit, sweat, urine, and breathing. Dehydration occurs when these losses are not replaced properly.

Treatment includes: rehydration with Oral Rehydration Salts (ORS) solution or with intravenous fluids (severe dehydration or shock), zinc supplements, nutrient-rich foods: antibiotics for specific pathogens. Key preventive measures include: access to safe drinking-water; use of improved sanitation; hand washing with soap; exclusive breastfeeding for the first six months of life; good personal and food hygiene; health education about how infections spread; and vaccination.

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MEDICAL SCIENCES

HIV/AIDS

Human Immunodeficiency Virus (HIV) continues to be a major global public health issue, having claimed more than 35 million lives so far. About 940,000 people died from HIV-related causes globally in 2017. Africa is the most affected region, with 25.7 million people living with HIV in 2017.

Although HIV and Acquired Immune Deficiency Syndrome (AIDS) originally emerged as adult health problems, they have become a major killer of under-5-year-old children, especially in developing countries. Children of HIV-seropositive mothers can acquire the virus directly through vertical transmission; about 25–30 per cent of children born to infected mothers become infected with HIV and almost all of them die before turning five. Thus, the under-5 mortality rates among children of HIV-infected mothers are two to five times higher than those among children of HIV-negative mothers. According to the Joint United Nations Programme on HIV and AIDS (UNAIDS) esti-

mates, about 14 million women of child bearing age currently live with HIV/AIDS in the world, giving birth to children with an elevated risk of HIV infection and death before the age of 5 years. Even among children who are not infected, many will die because the resources needed to ensure their survival and health are used to care for HIV-seropositive adults.

The symptoms of HIV vary depending on the stage of infection.

The initial infection, individuals may experience no symptoms or an influenza-like illness including fever, headache, rash, or sore throat. Afterwards, patients develop other signs and symptoms, such as swollen lymph nodes, weight loss, fever, diarrhoea and cough.

Further more, they also attract severe illnesses such as tuberculosis, cryptococcal meningitis, severe bacterial infections and cancers such as lymphomas, etc. HIV can be transmitted via blood, breast milk, semen and vaginal secretions. Individuals cannot become infected through ordinary day-to-day

contact such as kissing, hugging, shaking hands, or sharing personal objects, food or water.

Childhood risks of contracting HIV include: sharing contaminated needles, syringes and other injecting equipment and drug solutions when injecting drugs; receiving unsafe injections, blood transfusions, tissue transplantation, medical procedures that involve unsterile cutting or piercing; and experiencing accidental needle stick injuries. HIV infection is often identified through Rapid Diagnostic Tests (RDTs), which detect the presence or absence of HIV antibodies. Most often, these tests provide same-day test results, which are essential for same-day diagnosis and early treatment and care.

HIV can be suppressed by the combination of Antiretroviral Therapy1 (ART) consisting of 3 or more AntiretroViral 1 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&s ource=web&cd=3&ved=2ahUKEwj04uWL8sXhAhWEf d4KHVWTCTQQFjACegQIAxAB&url=http%253A% 252F%252Fwww.aidsinfonet.org%252Ffact_sheets%2 52Fview%252F403&usg=AOvVaw0BrC9O7iDnxpX4 MLWlT7r6

TUBERCULOSIS Tuberculosis (TB) is caused by a type of bacterium called Mycobacterium tuberculosis.

It's spread when a person with active pulmonary TB, coughs or sneezes and someone else inhales the expelled droplets, which contain TB bacteria. In 2017, about 10 million people were infected, and 1.6 million died (including 0.3 million among people with HIV). Among them, an estimated 1 million children became ill with TB, and 230,000 children died of TB (including children with HIV associated TB).

Children can equally be affected by resistant strains of Mycobacterium tuberculosis, with an estimated 25,000 children developing multidrug-resistant (MDR) tuberculosis and 1,200 developing extensively drug-resistant (XDR) tuberculosis in 2014 alone.

Peadiatric tuberculosis requires specific considerations in clinical, public health, and research aspects. Signs and symptoms of active TB include: coughing that lasts two or more weeks, coughing up blood, chest pain, or pain with breathing or coughing, unintentional weight loss, low grade fever, etc.

Treatment for TB usually involves taking antibiotics combination for several months.

The usual treatment is two antibiotics (isoniazid and rifampicin) for six months and two additional antibiotics (pyrazinamide and ethambutol) for the first two months of the six-month treatment period. Preventive measures include: Bacillus Calmette-Guerin (or BCG) vaccine, early diagnosis and prompt effective treatment of infectious cases, good infection control, Isoniazid preventive therapy, and Antiretroviral Therapy (ART) for people with HIV.

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Email: subscriptions@asianhhm.com Tel: +91 40 4961 4567 Fax +91 40 4961 4555

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MEDICAL SCIENCES

MALARIA

(ARV) drugs. Antiretroviral drug also uses for prevention and elimination of mother-to-child transmission of HIV. Infectious diseases in developing countries can hold people into poverty and have devastating consequences for the population's health and development. As many of the infectious diseases are preventable, each country in the developing world needs to construct evidencebased strategies and lead effective interventions for the management of childhood infectious diseases.

Malaria is caused by the Plasmodium parasite and spread to humans through the bites of infected mosquitoes. There are many different types of Plasmodium parasite, but only 5 cause malaria in humans; Plasmodium falciparum (mainly found in Africa), Plasmodium vivax (Asia and South America), Plasmodium ovale (West Africa), Plasmodium malariae (Africa) and Plasmodium knowlesi (very rare, southeast Asia). Most often, patients present with non-specific symptoms, such as fever, rigors, and chills. Severe malaria

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Malaria is a preventable and treatable disease. The primary objective of treatment is to ensure complete cure, that is the rapid and full elimination of the Plasmodium parasite from the patient’s blood, in order to prevent progression of uncomplicated malaria to severe disease or death, and to prevent chronic infection that leads to malaria-related anaemia. From a public health perspective, the goal of treatment is to reduce transmission of the infection to others, by reducing the infectious reservoir, and to prevent the emergence and spread of resistance to antimalarial medicines.

Michiko Moriyama is a Professor of Division of Nursing Science under the Graduate School of Biomedical and Health Sciences in Hiroshima University, Japan. She has been involved in various types of research activities such as Chronic Care and Disease Management, Family Nursing, and Population Sciences. She has multidisciplinary collaboration in different countries for sustainable development.

Mohammad Habibur Rahman Sarker is a doctoral student at the Graduate School of Biomedical and Health Sciences in Hiroshima University. He completed his Master (MPH) and Bachelor (MD) degrees from Bangladesh. He is also working at International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) as a researcher and clinical trainer. His major field of interests are epidemiology, infectious diseases, childhood malnutrition, chronic diseases, etc.

References are available at www.asianhhm.com

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develops mainly among children and may manifest as extreme weakness, impaired consciousness, severe anaemia, respiratory distress, convulsions, and hypoglycaemia, among other symptoms. The occurrence of long-term neurological sequelae from severe malaria, subtle developmental and cognitive impairments as a result of both severe and uncomplicated episodes have been reported in children. Moreover, anaemia is one of the complications that accompany malaria infections, and it plays a significant role in its morbidity and mortality.

Md Moshiur Rahman is an Associate Professor of International Health and Medical Care, Hiroshima University, Japan. He has outstanding academic credentials combined with experiences in public health, population and health science, research, administration, and leadership. He has more than 15-year experiences in health-related programs and researches in Bangladesh, Africa, and Japan.

AUTHOR BIO

Malaria, an ancient threat to human health, remains a primary cause of morbidity and mortality globally. The 2016 World Malaria Report indicated that 212 million cases and 429,000 deaths were recorded in 2015.

Two-third of these deaths occurred among under-5 year old children in developing countries mainly in Africa.

The World malaria report 2018 summarises global progress in the fight against malaria up to the end of 2017.

The report reinforces the message from the previous year's report that the world is off track to achieve two critical targets of the reducing malaria deaths and disease by at least 40 per cent by 2020, although there has been a substantial reduction in the burden of malaria since 2010. In 2017, there were an estimated 219 million malaria cases globally, compared with 214 million cases in 2015 and 239 million

cases in 2010. The reduced or reversed progress in countries with the highest malaria burden is one of the main contributors to the stalling of the global progress. For example, in Africa, there were an estimated additional 3.5 million malaria cases in 2017 compared with 2016. In comparing the trends in cases and deaths, it is important to understand that mortality is estimated through a process that first quantifies all-cause mortality in children aged under-5 years. Overall this approach, results in malaria mortality trends that follow those of children aged under 5 years, and is often insensitive to year on year change in malaria case burden.

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DIGITALISATION OF HEALTHCARE 1 2 3 4

Digital is Set to Change Healthcare Massively Here is how

Commercialisation of Digital Health The Seven Obstacles

Success Factors for Digital Transformation in International Health Tourism & Global Health

Delivering Healthcare Innovation in a Heartbeat

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DIGITAL IS SET TO CHANGE HEALTHCARE MASSIVELY Here is how

Today, ‘Value’, ‘Patient Outcomes’ and ‘Quality’ are key watchwords for the healthcare sector. The stakeholders of healthcare are on a continuous drive to discover innovative and cost-effective ways to make this environment more patientcentric, secure and efficient. Here is how digital is transforming the dynamic health economy.

Sanjay Das, Founder and Managing Director, SD Global

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alue’, ‘patient outcomes’ and ‘quality’ are key watchwords for the healthcare sector today. Stakeholders of this ecosystem are on a continuous drive to discover innovative and cost-effective ways to make this environment more patientcentric, secure and efficient. The stakeholders of healthcare are being pushed to identify ways to move from

Co IT verS Sp to ec ry ial move into an age that is decentralised, democratised and smart, helping both patients and healthcare professionals.

Some of the obvious advantages of leveraging digital technologies can be summed up as follows: • Smooth, seamless and transparent communication between doctors and patients that eliminates traditional hierarchies (attendants, assistants, etc.)

• Bandwidth to respond to policy changes and complex regulations • Proactive health management • Increased system efficiencies by reorganising how services are organised and delivered • Improved clinical effectiveness and greater bandwidth to focus on population health management • Shift from the traditional ‘break-fix’ model of health care to preventive healthcare • Greater healthcare access that defeats geographical tyranny and improves rural and remote community access • Improved coordination of care between multiple teams and stakeholders by providing the caregivers with up-to-date information • Timely, accurate and better-informed diagnostic based on data that leads to positive patient outcomes • Better management of chronic conditions and improved life expectancy.

So, what are the key technologies that are making the healthcare sector fitter?

Wearables and IoT

‘volume’ to ‘value’, engage with patients and improve experiences, increase access, and improve care. Creating a positive margin, improving financial performance and operating margins become other areas of concern in a changing and dynamic health economy.

We are moving into a world where information abounds, and patients are no longer passive receivers of care.

Driven by their experiences in other industries, the consumers of healthcare, i.e. the patients, want similar, if not better, healthcare experiences.

The Benefits of Digital Technologies in Healthcare

The good news here is that technology and the innovations arising from the use of technology are helping the industry

Wearables and the Internet of Things (IoT) are two technologies that promise to solve many healthcare challenges.

• Wearable devices can proactively track patient health and provide timely alarms based on defined triggers • The IoT ecosystem helps in providing the entire patient experience by enabling seamless communication between devices and sensors

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• The location-based-real-time services provided by IoT also increases patient safety and helps in making the patient experience smarter in the hospital environment • Wireless parking sensors can make the parking experience more patientfriendly • Smart registration systems help in simplifying the patient registration process, enable self-service and ensure that all key patient-related information is present in one place.

• RFID sensors can help in increasing patient safety. These sensors also help in smarter asset management • We are also witnessing the rise of Neurotechnology or Brain Sensors that help in monitoring brain activity • Along with this, IoT and wearables also enable smart building technology to ensure that the entire hospital ecosystem functions optimally, reduces waste and improves environmental performance.

Augmented Reality and Virtual Reality

Augmented Reality (AR) and Virtual Reality (VR) are two technologies that have moved out of the gaming sector and are providing serious value to healthcare.

• These technologies can give the operating rooms the extra edge by giving surgeons high-level visualisation capabilities, enhancing 3D mapping, lowering risks and improving outcomes • AR and VR add intelligence to departments such as radiology and give the doctors the capability to view a patients’ anatomy in a threedimensional image • These technologies can also be implemented to study how tumours evolve, change the size and compare in their overall size, shapes, and margins • Virtual simulations can be effectively employed to improve learning outcomes and improve patient

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We are moving into a world where information abounds, and patients are no longer passive receivers of care.

experience. Interactive technologies such as these are being employed to provide clear visualisations to patients to help them understand their health conditions • 360-degree interactive guides and games are being employed to help in pain management and also manage phantom-limb syndrome.

Artificial Intelligence

The applications of Artificial Intelligence (AI) are expected to go beyond treatment and touch everything starting from service delivery to supplychain management.

• With AI, doctors get the bandwidth to tap into data orders of great magnitude in less time thereby positively impacting diagnosis and treatment decision-making • AI-powered chatbots, virtual assistants and robotics are ushering in the new age of patient experience making patient care safer and easier • These technologies also ensure that caregivers spend more time providing care and less time in documentation • AI algorithms help hospitals identify ways to best manage expensive constrained resources, decrease wait times, improve patient access and reduce the healthcare delivery costs

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• AI is also poised to give Genomics a huge push that could vastly improve patient outcomes for a myriad of diseases.

Big Data

Data is the new oil in healthcare as well.

• Big data analysis is helping the entire hospital environment become more efficient by identifying resource challenges • It is ushering in the age of preventive medicine by helping doctors identify risk factors faster and more comprehensively • Population health data is being leveraged to predict health care trends for different cultures and communities • From advanced patient care, improved operational efficiency and giving healthcare providers stronger capabilities to discover unknown correlations, hidden patterns, and insights, Big Data is changing the entire healthcare delivery model and making it more proactive.

Cloud and Mobility

Mobility and cloud have made healthcare more accessible. These two technologies are responsible for enabling telemedicine and ensuring that

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of digital technologies. However, as digital becomes more mainstream and healthcare organisations battle several challenges, the transformative benefits of the technologies at play become hard to ignore. These technologies are now helping us deliver the hospital

AUTHOR BIO

patients even in the remotest of areas can receive high-quality care. These two transformative technologies have also ensured greater democratisation of patient health data. Owing to the cloud and mobile, patients and caregivers can access comprehensive health records anywhere, anytime. These technologies also play a key role in improving patient experience by giving the doctors capabilities to improve care coordination, enhance respond rates, amplify data access and communication and reduce health care complexity.

Digital technologies have made a profound impact on a myriad of industries. The healthcare sector, though technology-driven, has until now been able to resist the charm

of tomorrow, the Smart Hospital – one where technology and human interactions co-exist to redefine care delivery, improve operational efficiencies, reduce waste, and promote well -being, both of the patients and the hospital staff.

Sanjay has spent over two decades in the IT industry in Malaysia.

He is passionate about how IT can transform the healthcare industry.

Under Sanjay’s able leadership, SD Global has established itself as a leader in Smart Hospital solutions in ASEAN countries - it has the breadth of vision, depth of technology understanding and ready frameworks to make the smart hospitals journey a guaranteed success for healthcare institutes. Sanjay is the winner of various awards including 100 Most Influential Young Entrepreneurs in Malaysia, Emerging Youth Entrepreneur Excellence award given by the ASEAN India Business Summit, and Perdana Young Indian Entrepreneur Award.

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INFORMATION TECHNOLOGY

Commercialisation of Digital Health Digital Health refers to innovative initiatives that leverage digital technology to achieve a desired outcome in the healthcare industry. Currently, there is a mainstream shift of investment from maturing technologies such as telehealth and mHealth to new fields such as AI and VR. The process of commercialising digital health should begin from identifying the end objectives.

Yoshihiro Suwa, Partner, Roland Berger

M

any market research reports estimate the global digital health market in 2018 to be worth around US$200 to US$300 billion. Supposing these estimates are correct, the size of digital health market was between 20 per cent to 40 per cent of the size of the global pharmaceutical market (US$800 billion) in that same year. Yet, one would be hard-pressed to readily name a business that best represents this enormous market. Has the digital health industry produced a world-class business in the same vein as Pfizer or Novartis? Or is digital health a house of cards?

Red-hot digital technologies such as telehealth, mHealth, AI, VR, the blockchain are strong candidates with the potential to bring further innovation to the healthcare industry.

Indeed, countless long-standing

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players are going through gradual process of trial and error in their bid to identify and define the roles that these technologies will serve in the market.

The commercialisation of digital health technology should begin from each company defining a desired outcome that it wants to achieve, followed by a consideration of how and which digital technologies to best leverage.

Digital Therapies

In 2017, the US Food & Drugs Administration (FDA) gave its approval for the first Prescription Digital Therapeutic toreSETdigital therapy, developed by Pear Therapeutics as a single treatment for dependency on alcohol, narcotics, cocaine, and stimulant drugs. Aimed at treating addiction, reSET encourages modification to a patient’s behaviour

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through communication with the patient via an app. As a follow-up to reSET, Pear Therapeutics has applied for, and is awaiting approval on, reSET-O, a combined therapy for opioid dependence. Furthermore, clinical trials are underway on other digital therapies such as Virta Health’s treatment aimed at diabetes patients and Propeller Health’s treatment for asthma and Chronic Obstructive Pulmonary Diseases (COPD) patients.

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THE

BIG

Pear Therapeutics, Virta Health, and Propeller Health are a few of the many companies that develop digital therapies. When thinking about the development of digital therapies, one might imagine a process much like the development of an iPhone app. However, these businesses have internal structures that bear much closer resemblance to those of a pharmaceutical company, withre search teams, clinical development

teams, quality assurance groups, and pharmaceutical affairs groups.

It has been some time since digital health was heralded as one of the megatrends in the healthcare industry.

Initially, most attention focused on technologies such as telehealth, commonly typified by remote medical servicing, and mHealth, which makes extensive use of apps and smartwatches. Increasingly in recent years, investment has begun shifting to

3

1

Digital Health = An innovative initiative that leverages digital health technology to achieve a desired outcome in the healthcare industry.

2

Mainstream shift of investment from telehealth and mHealth to AI and VR

3

Commercialisation of digital health should start from identifying the desired outcome to be achieved.

new fields such as AI and VR. Market entry activity into digital health has also increased and, through continued offerings of new products and services, the strengths and weaknesses of each underlying technology become more evident.

In this issue, we will first look back at megatrends in the healthcare industry; second, lay out the positions of each technology in digital health industry where before they tend

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to be considered in isolation; and third, identify what roles they could accomplish in the healthcare industry.

In doing so, we hope to answer the question of whether digital health can be a viable business.

Looking at Healthcare Mega-trends

It is difficult to generalise about the entire healthcare industry. The players active in this industry constitute an incredibly wide-ranging group of companies that includes manufacturers such as pharmaceutical companies and medical device manufacturers; service providers such as medical institutions including hospitals and clinics, specimen laboratory operators, and pharmacies; the insurance companies that hold decision-making power over reimbursements for medical bills; and finally wholesalers of medical supplies and providers of systems to medical businesses and institutions. The market is further complicated by differences in health policy, regulations, and insurance regimes from one country to the next. Thus, strictly speaking, trends will vary by country and by player.

Nevertheless, long-term inclinations of the healthcare industry fall roughly under three categories. These three categories are: better quality (improving quality of medical treatment), cost to zero (reducing costs of quality treatment so that anyone can receive it), and universal access (allowing all to receive quality treatment). see figure 1.

The megatrends of the healthcare industry are always aligned with how to transform the industry further to achieve those three objectives. For example, pharmaceutical companies’ focus on drug development for lifethreatening or rare illnesses is one conspicuous effort towards raising the quality of care. At the same time, progress made in consolidating public insurance into national insurance schemes in developing nations like China and Indonesia represents an

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In the future, it is increasingly likely that the AI and VR healthcare industry will make use of collaboration between startups and established businesses.

initiative aimed at improving access to medical treatment.

Nowadays one frequently hears about ‘population health’ or health maintenance for social groups, which represents an effort to control medical expenses by preventing illnesses before they occur. Similarly, “value-based care” or otherwise known as pay-forperformance care aims at improving quality of treatment by focusing on patient outcomes; pursues the delivery of quality care to many people through price (reimbursement) setting that accounts for improved results on patient outcomes.

Between these three objectives, what gets prioritised varies according to country, player, and field of medicine. For example, in developing nations with nascent medical infrastructure or health insurance systems, improvement to access is likely the foremost issue. In various fields of medicine, improvement in treatment quality is sought, especially for diseases like Alzheimer’s where satisfaction is

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comparatively low. By comparison, in the field of hypertension treatments, there is stronger emphasis on the promotion of generic drugs in the interest of trimming costs. Researchbased pharmaceutical companies aim to develop new drugs that improve the quality of care, while manufacturers of generics seek to contribute by controlling costs of healthcare.

Technologies that have Reached Maturity and Technologies Approaching ‘Adolescence’

Telehealth and mHealth: A clear role in sight Dr. Sanjeev Arora of the University of New Mexico launched Project ECHO (Extension for Community Health Outcomes) in 2003 as a telehealth platform that facilitates the online exchange of information between physicians specialising in hepatitis C and clinics around the state. At the time, only 5 per cent of hepatitis C patients in New Mexico could receive appropriate treatment. The lengthy patient waiting-list for Dr. Arora, who was one of just two specialists in hepatitis C in the state at the time, could result in waits of up to eight months. Following the launch of the

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project, this wait time was shortened to just two weeks.

Subsequently, 3,000 medical institutions in New Mexico alone joined Project ECHO and, as its coverage expanded beyond hepatitis C to circulatory disorders, chronic pain, dementia, endocrine disorders, HIV, and mental illness, the project came to contribute to the treatment of more than 6,000 patients. The exchange of ideas between general practitioners and specialists via the platform allowed patients to receive cuttingedge examinations and treatments on par with those offered by a university hospital, even at their local clinics.

According to the paper submitted in 2011 to the New England Journal of Medicine, ECHO achieved a treatment success rate equivalent to that of a university hospital.

Figure 1

Currently, the project has proliferated, not only throughout the United States at hospitals such as MD Anderson and University of Massachusetts, but it has also come into use overseas, in countries such as Uruguay, India, and Canada. ECHO is just one example of how telehealth, in the form of a D2D (doctor-to-doctor) communications platform, has secured results.

Compare to the platform provided

by TelaDoc, launched in 2002, to connect doctors with patients (D2P).

TelaDoc is a 24-hour service that allows non-emergency patients to consult by phone with physicians, receive online examinations including those by specialists, and obtain prescriptions for basic medications. Around one million ‘visits’ were performed on this platform by 2016.

TelaDoc has expanded its business by broadening its platform, which focused on individuals, to target employees of multinational corporations. At present, it is the largest telehealth operator in the world with 7,500 client businesses and 20 million members, and it boasts of a 95 per cent customer satisfaction rate. It acquired Advance Medical of Spain in 2018 and has proceeded into the field of private medical insurance in Asia and South America, broadening its expansion to 125 countries worldwide.

After going public in the US in 2015, its value has seen favourable movements and its market capitalisation exceeds US$4 billion.

As we can see in the above two examples, telehealth in its D2D and D2P forms, can play an active role as a platform to secure patient satisfaction, even in communities that are difficult

Source: Roland Berger

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Figure 2

for specialists to reach, by facilitating effective treatments that are similar to actual visits to specialists. Moreover, there have been recent examples with results surpassing those of actual doctor visits. One telehealth provider has described a case in which mental health patients and pediatric patients, who find it stressful to meet directly with a physician and thus tend to put off visits, could be seen by physician via telehealth technology.

Meanwhile, one advantage of mHealth is how it enables the realtime, continuous collection of data and monitoring of patients. If this technological enablementis leveraged to its maximum extent, mHealth can demonstrate an impressive value in the aspect of improving medication compliance and in preventing disease.

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Source: Roland Berger

According to the Annals of Internal Medicine, the percentage of patients who take their medication as prescribed is under 50 per cent, and the resulting losses are estimated to reach US$100 to US$300 billion. mHealth has so far demonstrated solid compatibility with this sector: there are innumerable services that alert patients by mail or smartphone notification to take their medication. Moreover, in November of 2017, Abilify MyCiteby Otsuka Pharmaceuticals and Proteus USA gained approval from the FDA as the world’s first ‘digital pill.’ For Abilify MyCite, a sensor is embedded in the drug Abilify, which has already been approved as a treatment for schizophrenia and bipolar disorder.

This sensor then transmits data to the patient’s smartphone when the

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patient takes their dose. When the patient shares this data with their physician, the physician can check on the effectiveness of the treatment and make changes to the treatment plan based on data concerning the administration of the drug. By sharing this data with family members, the patient can further avoid forgetting to take their medication.

At the conference of the American Association for the Advancement of AI (AAAI) in February of 2018, research was presented in which patients with a history of diabetes were detected with an accuracy of 85 per cent using the heart rate monitor of an Apple Watch.

The team announced that Cardiogram has so far been able to detect arrhythmia with 97 per cent accuracy, sleep apnea with 90 per cent accuracy,

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and hypertension with 82 per cent accuracy by combining of the heart rate monitor of the Apple Watch with the team’s machine learning algorithm.

While these data are insufficient to make a decisive diagnosis, they could lead to early detection and prevention if they can encourage high-risk patients to have exams performed by physicians.

The roles of telehealth and mHealth have become considerably clearer with the arrival of platforms expanding around the globe, companies going public, and products gaining FDA approval. As these roles have come into view, the greatest issue that businesses face now will be whether they can get insurance companies to reimburse these digital treatments. Though many insurers have acknowledged the roles of telehealth and mHealth, they have doubts with regards to treatment costeffectiveness. There has been sharp criticism over the lack of cases in which treatment has been completed online and whether these technologies merely increase the frequency of medical examinations. ECHO continues to operate with subsidies, while TelaDoc has yet to show a profit at present.

Still, TelaDoc’s shift to a model that targets businesses and its entrance into the field of medical insurance via its acquisition of Advance Medical have potential as one business model solution.

AI and VR: Bringing new choices to medicine While the roles of and issues associated with telehealth and mHealth have become clearer, AI and VR have only recently entered the scene. AI itself, of course, is nothing new for the healthcare industry. The activities of AI in assisting diagnoses, as with IBM’s Watson, are widely discussed. In recent years, however, AI has moved past assistance and into a leading role.

In April of 2018, the USFDA gave its approval for the AI medical device IDx-DR, developed by IDx,

as a diagnostic device. IDx-DR takes a photo of a patient’s retina and analyses it with AI software, then gives a conclusive diagnosis of moderate to severe diabetic retinopathy. There have been other AI medical devices which have received approval from FDA, but this is the first time that one has been assessed as capable of giving an exam result without the interpretation of a physician. By using IDx-DR, patients can receive highly accurate examinations unmediated by a retina specialist. Areas of medicine that rely heavily on imagery—not only ophthalmology but also dermatology, radiology, and tuberculosis—have particularly strong compatibility with diagnosis by AI, and chances are good that the process of diagnosing and prescribing treatments in these realms will be revolutionised by AI. VR has gained significant traction as a technology that could offer new

treatment choices for illnesses in which existing treatments have proved ineffective. The largest clinical trial in the world utilising VR headsets has been conducted at Cedars-Sinai Hospital in California. This study, performed in cooperation with healthcare VR leader Applied VR, investigates to what extent the use of analgesics, hospitalisation times, and patient satisfaction in chronic pain patients can be changed through the use of VR. Studies have also shown that pain can be reduced by approximately 25 per cent in chronic pain patients by watching relaxation videos in VR. VR is particularly anticipated to be effective in the area of mental health for illnesses such as chronic pain, ADHD, and PTSD, where abuse of medications is frequently an issue. As clinical trials using VR are performed worldwide, it would be no stretch to say that the day is not far off when VR

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Commercialisation of Digital Health

As we have seen, the strengths and shortcomings of the technologies that underlie digital health are becoming apparent. For example, it will be new technologies like AI and VR that have the potential to increase the quality of care by increasing the number of treatment options available. By contrast, expectations are already high for telehealth and mHealth in improving access to care-although it would be too early to conclude the roles each technology will play.

On the other hand, by considering the breadth of the market, we can see that there is a strong likelihood that technology can enable a market to expand worldwide if it is able to contribute to quality of care via digital health. Pharmaceuticals and medical devices have a tendency of spreading as-is throughout the world.

By contrast, digital technology's contributions to medical cost controls

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The roles of telehealth and mHealth have become considerably clearer with the arrival of platforms expanding around the globe, companies going public, and products gaining FDA approval.

and access to care must be expanded with consideration over the healthcare systems and medical infrastructure of each nation, and businesses must regard each nation as distinct and respond accordingly. From this perspective, if we simply regard digital health as a standalone business, we may say that the technologies present a large potential to contribute a better outcome for all.

Nonetheless, it will be extraordinarily difficult at the present stage of technological maturity to consider the standalone commercial attractiveness of digital health technologies, given that most of the technologies are still in an early stage of the development. Rather, one should regard digital health not in isolation but instead as an industry that will enable healthcare corporations to reform along their desired lines of objective. Very importantly, we should seek to understand each of these

AUTHOR BIO

takes its place in treatment guidelines as one option for treatment.

Though AI and VR offer great promise, there is still a ways to go before these technologies can penetrate the market. It is worth noting that even if AI and VR secure approval as medical equipment and software, it will be doctors who prescribe them and patients who use them. Doctors and patients may lean towards skepticism over new technologies. Traditional healthcare players like pharmaceutical companies and medical device manufacturers own the full spectrum of capabilities, from establishing evidence, increasing patient awareness, to supporting patients, all of which are necessary to convince doctors and patients. In the future, it is increasingly likely that the AI and VR healthcare industry will make use of collaboration between startups and established businesses, as with the acquisition of Flatiron Health by Roche in February of 2018.

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underlying technologies from the standpoint of whether they will or will not contribute to healthcare reforms along the desired outcome. In other words, it would be better to determine the investment area of digital health not by commercial attractiveness but by each corporate vision – by asking where in the healthcare industry would one want to contribute – to achieve the desired outcome.

If we take telehealth as one example, it would be effective at improving access if used to enable online examinations for patients in sparsely-populated areas. Conversely, if it is used as a communication tool linking physicians in remote areas to specialists at university hospitals, it can effectively contribute to improving quality of medical care.

Businesses who wish to prioritise efforts toward improving healthcare access would likely engage in the online examination aspect of telehealth technology, while businesses that wish to improve care quality would engage in telehealth for its doctor-to-doctor communication tool capability. For businesses interested in telehealth, the crucial question to ask is not, “Of online examinations and D2D communication tools, which is more promising?”, but instead “Which of these areas fits the direction our business wishes to head in?”

What are the unmet needs in the area that your company is currently involved in? Ask if you are able to solve those problems with digital technology, and using that question as a starting point, take a good look at digital health.

Yoshihiro Suwa is a Partner at Roland Berger. He leads the Pharmaceuticals and Healthcare practice in Southeast Asia, with a primary focus on pharmaceuticals, medical devices, and hospitals.

He specializes in growth strategy planning, overseas business expansion, marketing, and market entry. He is a graduate of the Faculty of Law at Kyoto University.

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With Information and Communication Technologies (ICTs) and the associated digitalisation processes that are the engine of our globalisation, the technical implementation of the digital computing principle ‘Universal Machine’ (cf. Turing 1936), the Internet and the World Wide Web, new prerequisites have been created for digitalisation in the field of international health care.

In the course of these processes, global sociality is adapted into applications by transforming cultural techniques into local specific cultural practices.

Mohammed Yassin Blal CEO & Founder, Caresocius.org

THE SEVEN OBSTACLES

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veryone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontier", with these words, the United Nations (UN) spells out a fundamental human right to information in Article 19 of the Universal Declaration of Human Rights.

In our globalised macroeconomic environment, new innovations are emerging almost daily from the earth, but few are truly milestones - as digitalisation (ICTs). With Information and Communication Technologies

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(ICTs)1 and the associated digitalisation processes that are the engine of our globalisation, the technical implementation of the digital computing principle ‘Universal Machine’ (cf. Turing 1936), the Internet and the World Wide Web, new prerequisites have been created for digitalisation in the field of international health care. In the course of these processes, global sociality is adapted into applications by transforming cultural techniques into local specific cultural practices.

But it is precisely at the international level, where different people with individual cultural conceptions meet, that friction arises that have not yet been able to keep up with the pace of digital glocalisation.2 The solution for keeping the most important good in a service society alive, namely trust, is barrier-free communication, and, above all, mutual understanding, which is crucial for success. This applies not only to the health sector, but also in any form to companies with international customers.

Health facilities are placing great hopes in medical tourism and in the exchange of information before and after treatment.

Unfortunately, the international healthcare market is less digitised than almost any other industry-despite its huge potential for care and profitability; the reasons why international digital solutions are being thwarted are yet to be tackled.

Research shows over 100,000 health apps and undefined number of health travel agencies (concierge/assistance) worldwide: possibilities for treatment 1 The translation of Information and Communication Technologies into German is >>Information and Communication Technologies<<. In our idea paper we keep the English word and its abbreviation, because the actors and discourses to which I refer use this form. ICTs are binary digital devices such as computer hardware, the Internet and the World Wide Web, including software applications.

2 Glocalization is a neologism and a suitcase word formed from the terms globalization and localization, whereby these two terms are to be understood as a spectrum of orders of magnitude, i.e. not as opposites, but as connected levels.

(Globalisation at local level)

abroad and technical monitoring of one's own health at home and abroad are hitting a nerve among more and more people. If they are sound and culturally friendly, digital services create better informed and more self-determined patients who are not afraid of treatment or a doctor appointment on the other side of the planet.

This is not the only reason why the international healthcare market is predestined for a digital update: in most countries, file management and data transfer systems are outdated, and economically inefficient, and legal regulations lag far behind technological possibilities. In many areas, the intercontinental healthcare market is still scarcely digitalised and efficiently used.

One reason for the innovation bottleneck is the framework of conditions in the highly regulated national healthcare market are extremely complex, and the regulations in the international market even more so. This suggests that the international digital healthcare market needs to be picked up. Hospitals or governments cannot handle this task alone. While in other industries disruptive business models literally sweep away established companies, digital innovators have a much harder time unfolding here. Mohammed Yassin Blal, CEO of Caresocius.org explains the most important brakes on innovation, initial success stories, and why the international digital healthcare market will still come through.

1.

Stakeholders in a Fragmented Market Block Innovation

What a complex construct the international healthcare market already is can be seen in everyday services - such as financing a preventive check-up for your disabled uncle in Morocco or arranging an appointment for him and bearing the costs. A surprising number of actors are involved in carrying out this task, which appears relatively simple from the outside: clinic, health insurance, doctor, agent, family

members, transport and accommodation. In Switzerland alone, about 2000 medical supply and device-technology companies with an average of 10 to 15 employees compete in the provision of medical aids. In a global and connected economy such small structures cannot compete. Consolidation will certainly be slower than in less regulated markets, but the pressure to consolidate will undoubtedly change the landscape in the healthcare sector as well. For the market entry opportunities of digitally based business models, less fragmentation can only be advantageous.

2.

Business Blindness: the Successful ‘Core Business’ Clouds the View for Innovation Potentials

The healthcare service providers established today (classic SMEs) are optimally networked regionally (in countries with compulsory health insurance) and, as long as the reimbursements flow through private and statutory health insurance, are quite profitable. But they have a hard time with innovation and digitalisation.

Their processes and structures tend to be more conservative and thus are more concerned with defending their position, rather than constructively questioning and changing it. This phenomenon specifically exists in hospitals, clinics and medical travel agencies.

In a sluggish market, however, the risk of over sleeping necessary developments increases.

In addition, industry companies lack a functioning, international, centralized and politically neutral ecosystem of initiators and innovative partners to develop digital services. For most people, the maintenance of their own homepage already becomes an annoying "problem" and a potential point of attack. The establishment of a professional and modern marketing system isn’t even in the scope of discussion.

Here, cooperation in the form of partnerships can make decisive steps

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forward. In Bahrain, the economic development initiative ‘Tamkeen ’took the young Swiss-German software company caresocius.org off the ground with a regional head office for the GCC region. Initial attempts to use Caresocius' novel patient procedure on the international market show a promising potential - for both partners.

This is the basis from which stories will be written for the international health care system.

4.

Rigid Data Protection Regulations: Patient Law vs. Patient

Research shows over 100,000 health apps and undefined number of health travel agencies (concierge/ assistance) worldwide: possibilities for treatment abroad and technical monitoring of one's own health at home and abroad are hitting a nerve among more and more people.

Interest?

Patient data is carefully protected in many countries. This is often criticised as an obstacle to innovation, but often enough also serves as an excuse for a moderately widespread desire to innovate. It's true: the requirements for data security and data protection are high.

But this can also lead to more acceptance.

Legislation and effective regulation give the information security professionals the leverage to do their job.

Although the recent introduction of the General Data Protection Regulation (GDPR) has regional, EU jurisdiction, it has also launched a new privacy and security standard with international consequences on countries trading with the EU. Unlike the US HIPAA standard, that needed the High-Tech Act of 2009 before it had any effect, the

GDPR has the legal power to effect global organisations. It also raises the bar and shifts data ownership back to the data subject, with consequences in the medical data brokerage market.

In the US, it is estimated that there are 880,000 health data brokers and marketing companies using medical data that they have purchased without the data subject’s awareness (Bruce Schneier, 2017). These are not medical centres and so are not normally the focus of the Health Insurance Portability and Accountability Act (HIPAA) regulators. Although GDPR is a EU regulation, it changes the goal posts and introduces a new example of protection to the data subject that the medical profession can use regionally.

Historically, the medical professional handled patient data with the

Regulations and Approval Procedures Strangle 3. National Innovations, but not Really at the International Level Hospitals, doctors, agencies, insurance companies need to be tenacious and have a proven organisational structure when it comes to foreign patients. The way forward for the international healthcare market leads through complicated regulations but has never been so economically important for all the stakeholders.

There is a constant danger of being overtaken by current IT possibilities, including new frameworks and new API’s.

It is important to understand that at an international level, it does not depend on your own internal IT infrastructure, but on a same level of digital solution for all stakeholders and the integration of already existing structures.

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privacy and integrity that the Hippocratic Oath demanded. Now that medical data is handled by so many different, non-medical professionals, in different organisations with different objectives, the Oathno-longer applies, and new standards have to be incorporated into the data management architecture. This places the burden on the information security professional to commit to the cause at corporate level and provide the confidence and security that patients need.

Caresocius recognises this need and using the SABSA approach to enterprise security architecture, they are focusing on a platform that returns control and ownership of patient data back to the hands of the patient. It allows the patient the opportunity to choose what, when, how, and who is reviewing their medical data and who will eventually provide the service.

It is no-longer a concept of tourism.

A holiday tour doesn’t usually have lifelong consequences, but a medical treatment does.

The vision is shifting the focus away from the casual term of “Medical Tourism” back to Medical/Health Provider Selection: where the client can select the playing field, regionally and internationally.

The Swiss-German company Caresocius intends to soon cover the reimbursement process worldwide, with the market for add-ons divided among a few top dogs. The international department in a hospital is networked via a module in the form of an application.

The hospital and the patient agency software provide communication with the Caresocius Server and ensures endto-end encrypted communication with the patient. Maintenance and support are ideally offered in each country. Even if Caresocius would like to be further in spreading the market on the basis of trust in digital solutions through a democratic way, perhaps the most important step for the breakthrough has been taken.

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5.

Security in the International Health System through Sustainable Processes

The legacy architectures of medical IT have made it difficult to build a platform connecting medical stakeholders internationally. Various organisations have been fighting the battle and have presented reliable, secure and efficient packages, but the lack of international medical data transfer standards muddies the waters.

The variety and scope offered by different organisations to establish trusted patient data transfer, has given the medical profession a valuable range of options, but it also creates a maze of options their IT staff have to struggle through.

Looking at the work of organisations such as GlobalMed, PulseSecure, and GlobalScape, the industry has the tools and the will to change the situation, yet it requires the introduction of regulation that has international impact before the business vision changes to include a trans-corporate standard, into the medical data economy. Only when the strategic, corporate assets are challenged does legislation come into effect, and usually to protect the corporate asset rather than the data subject.

The vision to place medical service selection and associated data back into the hands of the data subject, has been helped by the impact of EU legislation. The introduction of higher, accountable data security standards within the hands of data professionals, allows them to select the right security tools to allow the client to drop out of medical tourism and participate in life changing, international, medical service selection.

7.

The International Stakeholders who do not Dare

Stakeholders are usually reluctant to take risks, as it is normal to concentrate on the functioning operative business.

Despite the demographic development, this market is considered to be one of the largest markets of the future. Nevertheless, only a few stakeholders (hospitals, clinics, agencies, insurance companies) are really massively involved in expanding their customer acquisition digitally.

There's a reason for that: the majority of B2C sales are tied to reimbursements from international health insurers, with the exception of private patients. These are, of course, still subject to political changes, albeit less so in the GCCRegion. Those who go with its offers into a smaller, although growing selfpay market and accept the challenge to improve by offering better quality, are often "rewarded" with more patients.

The attitude learned over decades is that all digital services for the patient must be free of charge, or covered completely by hospitals or health insurances, allowing minimal potentials to be increased through digitalisation.

Fairy Tale of Target 6. The Groups far Removed from Technology

A classic problem, which digital health companies are repeatedly thrown against by skeptics is that the important target groups of older people, multi-morbid in particular, are far too remote from technology and the Internet for such ‘gimmicks’.

Those who still think like that today should think about their understanding of customers. Media usage behaviour is now a fairly impressive indicator that the time is improving for broad-based digital business models in the healthcare market. The ‘Silver Surfer’ is no longer a marginal phenomenon.

More and more senior citizens are partaking in the digital world, especially through tablets, for entertainment, to maintain contacts or to inform themselves. They train their physical and mental mobility with fitness apps and brain jogging programs. We won't have to wait another generation until the ‘elderly’ are ready for digital health.

The Lesson is Clear

The hurdles that need to be overcome in order to gain a foothold in the international healthcare market with new, innovative or even disruptive approaches are still high and are likely to rob some stakeholders of their nerves.

The greatest challenge, creating regulations at the international level, will remain for the foreseeable future, at least in part, with such sensitive issues as health and data protection.

However, new software solutions, rising life expectancy, and demographic changes are causing healthcare costs to rise further. And since the funding

pools cannot increase to the same extent, legislators, health insurers and patients will sooner or later have to seek their salvation in productivity gains and efficiency increases. This calls for digitalisation, and digitalisation will come. Also, in international healthcare and health tourism.

AUTHOR BIO Mohammed Yassin BLAL focus on the digital revolution in healthcare and how these will change the different kind of power structure in society. He led the development of Caresocius.org and through travel into countries in Europe, Asia, America and the middle east he came to the topic that continues to occupy him today: the integration of foreigners into a digital national healthcare infrastructure.

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DELIVERING HEALTHCARE INNOVATION IN A HEARTBEAT

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Technology has touched every aspect of our lives, but nowhere does it make more of a difference than in healthcare, where it literally saves lives. We have seen tremendous improvements to healthcare through technology, and now in an era where data is king, we are seeing the ethical use of data take patient care standards to the next level.

With Asia-Pacific (APAC) expected to become the global leader in IoT spending according to IDC1, healthcare is unsurprisingly becoming increasingly connected in the region. However, it is this connectivity that adds complexity to the data challenge.

Healthcare data is now growing at a rate of 48 per cent every year. According to a study by Stanford University, 2,314 exabytes of

Chua Hock Leng, Managing Director, Pure Storage

1 https://www.idc.com/getdoc. jsp? containerId = pr AP44863719

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rtificial intelligence (AI) and analytics are providing clinicians and researchers with actionable insights, from early detection to end-of-life-care, and by changing the way research is done and diagnoses are made. However, unlocking the data treasure trove is not a simple exercise for any healthcare organisation.

Data is the Lifeblood of Medical Care

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healthcare data will be produced every year by 2020. This exponential growth rate is due to a multitude of sensors and devices, including mobile applications and wearables, to support everything from diagnostics to insurance. In addition to storing this growing amount of data, the data architecture also needs to support seamless accessibility as researchers run increasingly complex analyses with bigger sets of data.

For example, radiologists sometimes use 20,000 to 30,000-slice CT and MR exams2 in academic environments and will require smooth and consistent performance with low latency for quick results. More healthcare professionals are also relying on Picture Archiving and Communication Systems (PACS) for more extensive analyses,which will undoubtedly expand with the introduction of new data-intensive modalities such as digital tomosynthesis.

These modern demands of healthcare infrastructure have begun to highlight how legacy data storage and management solutions are fast becoming ill-equipped to support the operation of AI systems. In many of these solutions, data exists in silos, and cannot be accessed or easily moved around different applications. This separation puts restrictions on AI systems that need to sift through data across applications to draw insights quickly and effectively.

The data architecture challenge is also further complicated as cloud adoption becomes increasingly common in the healthcare sector. What this means is that organisations now find their IT systems affixed in a multicloud or hybrid cloud environment, where data and workloads are scattered across various platforms. These cloud approaches have grown out of a demand to let organisations keep up with end-usersâ&#x20AC;&#x2122; rising expectations, 2 https://www.aiin.healthcare/sponsored/9667/topics/imaging/qa-esteban-rubens-machine-learning-reliability-andgrowing-importance

Healthcare data is now growing at a rate of 48 per cent every year.

According to a study by Stanford University, 2,314 exabytes of healthcare data will be produced every year by 2020.

particularly when it comes to always-on applications and connected systems.

While the advantages of scalability and versatility are clear, the emergence of multiple cloud systems can result in even more silos. This further complicates an already complex storage ecosystem, making it difficult for healthcare to realise the innovation benefits of cloud.

Additionally, poorly managed storage usage and sprawl hampers real-time data access and analytics, impeding accuracy and speed â&#x20AC;&#x201C; two factors critical in the treatment of patients. From physicians through to senior management, healthcare professionals need fast, reliable access to vital information, so that they can make better-informed decisions.

Designing a New Innovation Pathway

To ensure that innovation is not restricted by the data deluge, healthcare organisations need a data-centric architecture that is backed by an enterprise-wide data strategy. A datacentric architecture breaks down silos and enables applications to store data on demand, share it easily, facilitate high computing and offer continuous improvements. It also enables data and applications to move freely between multiple clouds and on-premise storage

in order to drive application and data compatibility for providers to benefit from real-time analytics and insights.

This new flexible and agile storage must be able to manage larger workloads without compromising on performance. All-flash storage platforms that consolidate data in a centralised data hub and enable tasks to be performed simultaneously are primed for AI. Building such an environment would unlock innumerable benefits, from the ability to increase sample sizes in clinical studies, to automating decision making and data visualisation.

Getting this right is especially important with the growing interest in AI among healthcare companies in Asia Pacific. An IDC3 report in 2018 has ranked the healthcare industry in this region third in terms of AI spending, after banking and retail. Healthcare companies spent an estimated US$87.6 million in AI in 2018, with most of the investments going into diagnosis and treatment systems.

Despite the burgeoning interest in AI, many organisations remain uncertain about how they can best deploy and leverage this nextgeneration technology. In asurvey4 conducted by MIT Technology Review and commissioned by Pure Storage, 83 percent of senior leaders agree that AI will bring significant enhancements to processes across multiple industries.

Within the Asia-Pacific and Japan region, an overwhelming 87 per cent of companies say that data is critical to delivering results for customers.

Despite this, 78 per cent of businesses say they experience challenges with digesting, analysing, and interpreting the data they have. This indicates an urgent need for an agile, scalable datacentric architecture to unlock the true value of AI. 3 https://www.idc.com/getdoc.jsp? containerId=pr AP43696818 4 https://www.purestorage.com/content/dam/purestorage/ pdf/whitepapers/evolution-global-report.pdf

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For early adopters, the transition to an all-flash data-centric architecture platform is yielding benefits.

The University of California, Berkeley, which is working on genomic analysis, was unable to manage high data volumes with its legacy storage.

A single sample of a person’s DNA takes about 300 GB of raw data.

Considering that such projects involve 50,000 to 100,000 participants and each participant’s DNA is sampled several times over the course of a study, it could mean processing petabytes of data in just a single study. After moving to a data-centric architecture on top of its real-time analytics engine, Apache Spark, researchers at Berkeley can now process heavy workloads faster and generate fresh insights into personalising patient treatment based on genetic profiling.

Another example is Paige.AI. The company is digitising enormous amounts of pathological data to train machines to detect cancer cells with the aim of helping pathologists analyse samples more accurately. Paige.AI requires an advanced deep learning infrastructure that can quickly turn massive amounts of data into clinicallyvalidated AI applications. They achieved this over an all-flash datacentric architecture.

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Early Successes Show Promise

In Taiwan, the Linkou Chang Gung Memorial Hospital, which specialises in genomics, is leveraging Pure Storage’s AIRI, an AI-ready infrastructure that enables AI-at-scale. The hospital also has 29 speciality centers that treat over 10,000 local and international patients a year, and thus needs to store and access a vast amount of data. Its researchers can now quickly access large datasets, identify disease-carrying genes, and develop new treatments and preventive measures at a much faster rate. This has enabled the hospital to spread key insights from its Genomic research to other hospitals and local medical providers in the country – amplifying the impact of the work that they do.

Even outside of primary care and research, other players in the healthcare ecosystem can also benefit from speedier access to data. For instance, the Australia-based Catholic Church Insurance provides insurance, workers compensations and asset management support for a large number of hospitals, churches and schools. By modernising their legacy storage system, the Catholic Church Insurance now enjoys faster data processing and a high level of data reduction. This, in turn, has given the insurer the ability to deliver faster database transactions, and seamless experience on customer portals and insurance systems.

Storage systems themselves also benefit from the use of AI. Integrated healthcare provider Carilion Clinic serves over one million residents, and its IT services are used by 16,000 people internally and across partner organisations. Carilion Clinic's switch to all-flash storage had already unlocked

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faster response time, but the introduction of an intuitive, AI-driven solution on its storage system5 has simplified the administration and maintenance process more than ever before. Traditionally, employees within the storage management team are responsible for ensuring uptime, sufficient data capacity, speeding up sluggish performance, backup and disaster recovery. With the new AI solution, Carilion Clinic is now able to forecast storage capacity utilisation, as well as the load on storage systems and their resulting performance. The team is then able to make adjustments accordingly to accommodate growth in data or performance demands.

Taking Healthcare to the Next Level

These cases highlight the potential of AI to solve some of the most pressing challenges, improve critical patient outcomes and the customer experience for millions. This wealth of data available represents a boon, not a bane, for clinicians and researchers who will now be able to study and analyse this data with greater speed and ease, thanks to machine learning and the use of analytics.

In order to unlock the true value of data, healthcare organisations will need to build a data-centric architecture that meets the needs of tomorrow’s computing potential. Only by adopting a long-term approach to infrastructure and innovation can the healthcare sector reap the benefits of the AI revolution and take healthcare to the next level.

5 https://www.purestorage.com/pure-folio/showcase. html?type=pdf&path=/content/dam/pdf/en/case-studies/cs451-research-carilion-clinic.pdf

Chua Hock Leng is the Managing Director of Pure Storage, Singapore. Together with a talented team and a strong partner ecosystem, Hock Leng is responsible for managing and sustaining the growth of the Pure Storage business in Singapore. He is passionate about mentoring and talent management – motivating his team to help organisations accelerate their businesses on Pure Storage’s all-flash data platform as they make the inexorable transition from legacy disk infrastructure.

News QIAGEN Launches first FDA-approved Companion Diagnostic Tool QIAGEN NV announced the US launch of its new therascreen ® FGFR RGQ RT-PCR Kit ( therascreen FGFR Kit) as an adjunctive diagnostic investigator, using the recently approved FVRI kinase inhibitor BALVERSA ™ developed by Janssen Biotech, Inc. (Janssen)(erdafitinib) supported. The test will help identify patients with urothelial carcinoma whose tumors have certain alterations in the fibroblast growth factor receptor 3 gene (FGFR3 gene). The US Food and Drug Administration (FDA) has approved the new test along with BALVERSA ™, as Janssen announced today.

Urothelial carcinomas appear first in the bladder lining tissues and other urogenital organs and are the sixth most common cancer in the United States. The therascreen Running on QIAGEN's Rotor-Gene Q MDx platform, which is part of the modular QIAsymphony suite of automation solutions, the FGFR kit utilises a worldwide exclusive license for use as an in vitro diagnostic of FGFR3: TACC3 fusions Columbia University.

Philips and Vietnamese Hong Duc General Hospital Enter into Multi-year Strategic Partnership Agreement Royal Philips, a global leader in health technology, and Hong Duc General Hospital in Ho Chi Minh City in Vietnam announced that they have entered into a seven-year partnership agreement covering a comprehensive turnkey solution for high quality general healthcare services. Philips will provide the newly-built Hong Duc General Hospital II with the latest medical imaging, patient monitoring and healthcare IT solutions. In addition, Philips will deliver comprehensive training programs to strengthen the hospital’s clinical capabilities and design services to optimise workflows and enhance the patient/staff experience, with the aim of delivering better clinical outcomes.

The newly-built Hong Duc General Hospital II is scheduled to open in early 2020 to provide high quality general healthcare services, especially focused on cardiology, oncology, orthopedics and pediatrics.

Vizient Enters into Membership Agreement with The Johns Hopkins Health System Corporation Vizient announced that The Johns Hopkins Health System Corporation has joined Vizient as a member with the goal of aligning and accelerating cost and quality performance.

Under the terms of an agreement, The Johns Hopkins Health System Corporation will join Vizient’s group purchasing organisation with the expectation of a decrease in its current supply costs. They have the opportunity to join Vizient’s pharmacy program, including the company’s Novaplus private label program, to reduce pharmacy expenses and minimize the impact of drug shortages on their enterprise. Lastly, they will be deploying Vizient’s Clinical Database (CDB) and Operational Database analytics, across all their hospitals with the goal of aligning cost and quality decisions, engaging physicians in utilisation and supply choices and improving outcomes.

Johnson & Johnson Announces Completion of Acquisition of Auris Health, Inc. Johnson & Johnson announced that Ethicon, Inc. has completed the acquisition of Auris Health, Inc. for approximately US$3.4 billion in cash. Additional contingent payments of up to US$2.35 billion, in the aggregate, may be payable upon reaching certain predetermined milestones. With Auris Health's robotic platform technology, currently used in diagnostic and therapeutic procedures in the lung, Johnson & Johnson will advance its commitment to combatting lung cancer and expand its digital surgery portfolio across multiple surgical specialties.

The Auris technology complements robotic platform technologies currently in development in general surgery with Verb Surgical, through the Johnson & Johnson collaboration with Verily, and in orthopaedics with the acquisition of Orthotaxy. Johnson & Johnson aspires to bring disruptive innovation to the full continuum of procedures, including open, laparoscopic, robotic and endoluminal.

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MEDICAL FAIR THAILAND 2019 Moves to BITEC, BANGKOK

1,000 exhibitors | 60 countries | 20 national pavilions and country groups New highlights: Community Care Pavilion, Start-Up Park

The region’s most established medical and healthcare exhibition returns for its 9th edition at a much larger and expanded show floor at BITEC, Bangkok, featuring more than 10,000 medical and healthcare innovations representing the hospital, diagnostic, pharmaceutical, medical and rehabilitation sectors. Organised by Messe Düsseldorf Asia (MDA), the region’s leading exhibition organizer, MEDICAL FAIR THAILAND is part of the MEDICAlliance global network. MEDICAL FAIR THAILAND shares the expertise of MEDICA – the world’s No. 1 annual medical and healthcare trade fair, organised by the Messe Düsseldorf Group in Germany.

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Continuing on its successful growth path since its inception in 2003, MEDICAL FAIR THAILAND is located in a region that is expected to see its healthcare needs rise to US$740 billion by 2025. The exhibition continues strengthening its international participation with each installment - representative of the growth and potential of the booming medical and healthcare industry in the region, and this year will see MEDICAL FAIR THAILAND 2019 welcome 1,000 exhibitors from 60 countries, and 20 national pavilions and country groups including for the first time, Brazil.

As the must-attend event on the business calendar for all those involved in medical and healthcare, MEDICAL FAIR THAILAND 2019 will present special highlights such as the Community Care Pavilion, Start-Up Park and thought-leading conferences

COMMUNITY CARE PAVILION • Presenting products, technologies and solutions that enhance productivity and efficiency in community care, including remote healthcare monitoring, geriatrics, rehabilitation products and assistive devices.

and seminars presenting industry insights and innovations. This year’s line-up includes the 4th Advanced Rehab Technology Conference (ARTec), a 2-day multi-disciplinary conference jointly organised by the Royal College of

Physiatrists of Thailand, Thai Rehabilitation Medicine Association and Messe Düsseldorf Asia, as well as the WT l Wearables Technologies Conference which will discuss how wearables are digitising the healthcare industry.

START-UP PARK

There will also be the CIO Forum, organised by the Thai Medical Informatics Association, an invitation only event for C-suite decision-makers to share expertise on technology solutions for healthcare service providers.

• A dedicated platform for medical and healthcare start-up companies with innovations in loT, big data, Wearable Technologies to discuss visions and present ideas and new innovations. With a Start-Up ecosystem in South East Asia estimated to be valued at US$13 billion, this represents the region’s openness to new ideas and innovations.

The 3-day exhibition will continue to be the preferred platform for medical professionals to come together in the region and internationally, showcasing a myriad of relevant technologies, innovations, products, and networking opportunities. Online visitor registration is now open. For more information on MEDICAL FAIR THAILAND 2019, log on to www.medicalfair-thailand.com Advertorial www.asianhhm.com

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Books

High-Reliability Healthcare: Improving Patient Safety and Outcomes with Six Sigma, Second Edition

Reframing Healthcare: A Roadmap For Creating Disruptive Change Author(s): Zeev E Neuwirth

Essentials of Strategic Planning in Healthcare (Gateway to Healthcare Management) 2nd Edition

Author(s): Robert Barry, Amy C Smith, Clifford E Brubaker

No of Pages: 0

Author(s): Jeffrey P Harrison

Year of Publishing: 2019

No of Pages: 297

Description:

Year of Publishing: 2016

This book is a step-by-step guide for leadership teams that are intent on improving healthcare at an accelerated pace. Itâ&#x20AC;&#x2122;s written for healthcare organizations that wish to thrive in a customercentric, community-oriented, valuebased healthcare system. This book provides an assessment of the market forces, mega-trends and reframes that are transforming the healthcare market, and delivers a replicable and scalable roadmap for creating better healthcare.

Description:

No of Pages: 270 Year of Publishing: 2017 Description: High-Reliability Organizations prioritize safety over other performance measures and equip staff with operational tactics so that they can anticipate potential problems early on and respond to safety threats. Driven by the desire to improve, healthcare providers have recognized that the principles and approaches of High-Reliability Organizations have much to offer healthcare organizations in meeting important goals related to patient safety and improved outcomes.

This new edition discusses reformdriven changes that impact strategic planning, including the advent of accountable care organizations and patient-centered medical homes.

Through the revised and updated comprehensive case study woven throughout the book, readers gain hands-on understanding by applying what they learn as they go. Accompanying exercises test comprehension and reinforce key concepts.

High-Reliability Healthcare: Improving Patient Safety and Outcomes with Six Sigma explores how the Six Sigma approach to quality improvement which strives to reduce variability by both reducing error and standardizing processes integrates with and complements the culture of High-Reliability Organizations. Six Sigma is the groundup support structure for the Highly Reliable Healthcare Organization. Written in a practical, how-to style, the book provides healthcare executives with a tool kit for understanding variability, managing change, and, ultimately, reducing errors and improving patient outcomes.

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A SI A N H O S P I T A L & H EA LT HCAR E M A N AGE M E N T

Essentials of Strategic Planning in Healthcare, Second Edition,fully explains strategic plan development and implementation from conducting an environmental assessment to communicating the plan to stakeholders as well as the factors that influence strategic planning effectiveness, including organizational culture, physician involvement, and planning across the continuum of healthcare services.

IS S UE - 44, 2019

The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age

The Law of Healthcare Administration, Eighth Edition

Introduction to Health Care Management

Author(s): J Stuart Showalter

Author(s): Robert Wachter

No of Pages: 650

Author(s): Sharon B Buchbinder, Nancy H Shanks

No of Pages: 352

Year of Publishing: 2017

Year of Publishing: 2017

Description:

Description:

The Law of Healthcare Administration, Seventh Edition, examines healthcare law from the management perspective.

The book offers a thorough treatment of healthcare law in the United States, written in plain language for ease of use.

The author addresses the significant changes the 2010 Affordable Care Act (ACA) makes to the healthcare industry, including provisions relating to taxation and compliance, the development of accountable care organizations, and new privacy rules under HIPAA.

Written with a rare combination of compelling stories and hard-hitting analysis by one of the nation’s most thoughtful physicians, The Digital Doctor examines healthcare at the dawn of its computer age. It tackles the hard questions, from how technology is changing care at the bedside to whether government intervention has been useful or destructive. And it does so with clarity, insight, humor, and compassion. Ultimately, it is a hopeful story.

This riveting book offers the prescription for getting it right, making it essential reading for everyone – patient and provider alike – who cares about our healthcare system.

No of Pages: 676 Year of Publishing: 2016 Description: Introduction to Health Care Management, Third Edition is a concise, reader-friendly, introductory healthcare management text that covers a wide variety of healthcare settings, from hospitals to nursing homes and clinics.

Filled with examples to engage the reader's imagination, the important issues in healthcare management, such as ethics, cost management, strategic planning and marketing, information technology, and human resources, are all thoroughly covered.

Guidelines and rubrics along with numerous case studies make this text both student-friendly and teacherfriendly. It is the perfect resource for students of healthcare management, nursing, allied health, business administration, pharmacy, occupational therapy, public administration, and public health.

www.asianhhm.com

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PRODUCTS & SERVICES Company............................................... Page No.

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HEALTHCARE MANAGEMENT

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FACILITIES & OPERATIONS MANAGEMENT

MEDICAL SCIENCES

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Greiner Bio-One...................................................................... IFC

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INFORMATION TECHNOLOGY Troostwijk Auctions.................................................................. 43

DIAGNOSTICS CORIS BioConept..................................................................... 33

SUPPLIERS GUIDE Company............................................... Page No.

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Cantel Medical........................................................................IBC

MDA 2019................................................................................ 21

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CORIS BioConept..................................................................... 33

Medical Fair Thailand 2019.......................................... 11, 60-61

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Greiner Bio-One...................................................................... IFC

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Kompress India Pvt. Ltd........................................................... 05

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1.IFC: Inside Front Cover 2.IBC: Inside Back Cover 3.OBC: Outside Back Cover