Asian Hospital & Healthcare Management - Issue 39

I s s u e 39

2018

w w w.asianhhm.com

Rising to the Health Equity Challenge Artificial Intelligence and Healthcare

Foreword Achieving High Reliability The zero harm way “Despite nearly two decades of intense improvement efforts, healthcare continues to be plagued by serious quality and safety problems. Too many patients suffer from preventable infections, falls with injury, medication errors and other adverse events.”

Mark Chassin, President and CEO of The Joint Commission.

As the proverb goes ‘Prevention is better than cure’, organisations that focus on zero harm rather than trying to minimise risk after an incident are deemed ‘highly reliable’. Industries such as aviation and nuclear power succeed in preventing harm by implementing safety systems with the concept of collective mindfulness and pursuing a zero-defect environment. Healthcare industry is no different as the risk here is with health and lives of people, be it patients or staff. With increasing patient expectations, advancements in technology, achieving zero harm is the key for healthcare industry and organisations alike as delivering effective care continues to be a challenge.

Medical errors cost lives of millions all over the world; the data from American Hospital Association (AHA) indicates medical errors lead to four times more deaths than motor accidents. Whether it is lack of communication about potential health risks or absence of quality care providers, the result could be loss of lives.

In order to attain zero harm in their industry, health leaders have to prepare themselves for supporting high reliability by committing and focusing on providing quality care and safety for every patient, every time. The onus lies on the leaders to trust their teams to deliver quality healthcare with high levels of patient safety. The entire team has to work on the same measure with a common goal and vision.

The frontline workers need to find the errors and unsafe conditions and report them to their leaders for consistent adherence to safe practices. The leaders, in turn, have to self-assess and reassess various areas for process improvements. This is done to anticipate

or detect potential problems early and always respond to early enough to prevent catastrophic consequences.

An organisation is said to be High Reliability Organisation (HRO) only when it is in the next level in pursuit of quality and process improvements. The Joint Commission (JCI) suggests that hospitals and healthcare organisations create a strong foundation as they embark on the transformation journey to be an HRO. The JCI coined the term ‘robust process improvement’ to encapsulate an approach that includes Lean Six Sigma and change management philosophies, methodologies and tools. Applying HRO concepts does not require a huge campaign or a major resource investment. It begins with leaders at all levels acknowledging the need to provide better care and prevent medical errors that cost lives and most importantly establishing a culture of safety for patients and healthcare staff both.

Regulators need to incorporate HRO theory into new or updated regulations. This could help propagate the theory throughout the industry for reducing patient harm. This would reduce the estimated US$38 billion (Debourgh & Prion, 2012) spent on addressing safety incidents, and improve the quality of life for patients.

The cover story of this issue by Sangita Reddy, Jt. Managing Director of Apollo Hospitals delves into the aspect of Zero Harm in healthcare industry.

Prasanthi Sadhu

Editor

Contents 18

Cover Story

Diagnostics 28 Diagnostics Industry Shaping the transformation of the healthcare industry Lance Little, Managing Director, Region Asia Pacific, Roche Diagnostics

The High Reliability Challenge

FACILITIES & OPERATIONS MANAGEMENT 32 Improving Patient Experience, Safety and Progression through Care Model Redesign & Lean Management System R B Smarta, Managing Director, Interlink Marketing Consultancy Pvt. Ltd.

38 From ICU to I See You Small things make a big difference in healthcare Nancy Michaels, President, NancyMichaels.com

in healthcare, continuing the journey Sangita Reddy, Jt. Managing Director, Apollo Hospitals

44 Surgical Safety in Operation Theatres Pradeep Chowbey, Chairman Max Institute of Minimal Access, Metabolic & Bariatric Surgery

INFORMATION TECHNOLOGY 48 Use of Telehealth Technology to Increase ED Capacity during Times of Surge SB Bhattacharyya, Health Informatics Expert

HEALTHCARE MANAGEMENT

52 Artificial Intelligence and Healthcare

K Ganapathy, President, Apollo Telemedicine Networking Foundation

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06 Rising to the Health Equity Challenge Jeff Thompson, CEO, Emeritus

10 The Growing Trend of Open Innovation Approaches is Stimulating Health Innovation John Battersby, Account Director, Bridges M&C Pte Ltd.

14 Assessments and the Crucial Role it can Play while Preparing Future Leaders in the Healthcare Space Amogh Deshmukh, MD, DDI

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MEDICAL SCIENCES 24 Measuring the Health-Related Life Quality of Patients with Chronic Kidney Disease Md Moshiur Rahman, Associate Professor, Graduate School of Biomedical & Health Sciences, Hiroshima University Abu Sayeed Chowdhury, Graduate School of Biomedical & Health Sciences, Hiroshima University

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Advisory Board

Editor Prasanthi Sadhu Editorial Team Debi Jones Grace Jones Art Director M A Hannan Product Manager Jeff Kenney Senior Product Associates Peter Thomas David Nelson

John E Adler Professor Neurosurgery and Director Radiosurgery and Stereotactic Surgery Stanford University School of Medicine, USA

Sandy Lutz Director PricewaterhouseCoopers Health Research Institute, USA

Peter Gross Chair, Board of Managers HackensackAlliance ACO, USA

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

Vivek Desai Managing Director HOSMAC INDIA PVT. LTD., India

Product Associates Austin Paul James Taylor John Milton Veronica Wilson Circulation Team Naveen M Nash Jones Sam Smith Subscriptions In-charge Vijay Kumar Head-Operations S V Nageswara Rao

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HEALT HCARE MANAGEMENT

Rising to the Health Equity Challenge Health Equity is not only poorly understood but poorly managed in most organisations and countries. The difference between equity and equality needs to clear. The leaders path to address these basic issues for Staff, those we serve, and the community is not complex, it is just very hard.

Jeff Thompson, CEO, Emeritus

H

ealth equity is a hot topic. It is a common issue rolled out by leaders when describing their vision for their high-performing healthcare institutions. It receives thoughtful nods, clear verbal support and declarations of it being a priority.

But if they are pressed to describe specific progress they are making…or even what exactly they include in their definition of Health Equity, things get less firm very fast. Many will point out they have a policy in HR that addresses equity, or that they have a code of conduct among their staff that insures they would always treat everyone ‘equally’. Some have even received national awards and have been recognised by their community as a great partner on many important social projects. Surely that all adds up to delivering on health equity?

But this is exactly the problem.

Because many organisations have done those things, we assume we must be making significant progress. It is true those things are necessary, but they are woefully insufficient.

Derek Feeley president of the largest international healthcare improvement organisation, Institute for Healthcare Improvement1, says Health Equity is one of the least well understood and most difficult to demonstrate significant progress of the Six Pillars put forth by the IOM2: 1 http://www.ihi.org/Pages/default.aspx 2 https://www.ahrq.gov/professionals/quality-patient-safety/ talkingquality/create/sixdomains.html

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• Safe: Avoiding harm to patients from the care that is intended to help them • Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding under use and misuse, respectively) • Patient-centred: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions • Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.

• Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy • Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

The most universally used definition for health equity comes from The World Health Organisation3: “The absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically. Health inequities therefore involve more than inequality with respect to health determinants, access to the resources needed to improve and maintain health or health outcomes.”

A very import feature is that it draws a clear distinction between equity and equality. Being clear in your language that you have equal access for employment, equal access to care or equal opportunities in your community for people to partner barely scratch the surface of heading in the direction towards equity. Equality always favours the better educated, better resourced, better connected. Equity addresses issues based on the situation of those

served. The figure below helps solidify this concept.

Next we need to appreciate the breadth of the issue. Alan Weil in Health Affairs4 gives us strong examples of the scope of how the problem is far beyond the very important and unsolved issues of race and gender. Inequity is also prevalent with struggles related to age, sexual orientation, socioeconomic status, food water and power availability to name several of the top few. With this large group of issues staring us in the face, there is no chance an HR policy, no matter how thoughtful will serve this need. It will take broader thinking, courage to take a stand and discipline to follow through. Beyond the huge moral imperative there is a significant strategic advantage to take on these difficult

changes in how we function. Health Equity must be a Strategic Priority5 A clear path forward as a leader of the healthcare organisation is not to get buried by the expanse of this responsibility but to break into manageable pieces that you can make measurable progress on in a definable future timeline. Your role is to set Equity as a priority and then teach how progress can be made in the three major areas of opportunity, see figure 2: As you can see the major efforts would be attention to your own staff, the activity of your staff in relation to your patients, and then finally your connection with your community.

5 https://catalyst.nejm.org/health-equity-must-be-strategicpriority/

4 https://www.healthaffairs.org/doi/full/10.1377/ hlthaff.2017.0583

3 http://www.who.int/healthsystems/topics/equity/en/

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You’re not alone in any of these.

The diagram shows there are multiple opportunities to interact with people that have started this work to help guide your efforts and make you more efficient and more effective. It will improve your organisation will prove your community and will give you both a mission consistent and a competitive way forward.

The plan is not complex, it is just hard. First, you need to call equity out as an issue that is going to be a part of the core functioning of your organisation. Verbally, in writing, and in the consistent deeds of the senior leaders there can be no doubt on what acceptable behaviour is going to look like and act like in regards to race, gender, age or the many other issues where equity can be a problem. This cannot be left in HR policy. It needs to be clear to all leaders regardless where they are in the hierarchy that this is the only path forward….not optional…not intermittent. This is an important and measurable part of everyone’s work. A recent article in the Asian Hospital & Healthcare Management6 has several easy to use tools to get started with then modify to fit your needs. You can’t possibly expect your staff to treat

your patients in an equitable manner if your staff is not treated similarly. - M. Bisognano (Thompson, page 92).

The treatment of your patients can no more be left to chance than the treatment of your staff. It has to be clear and explicit the patient will be given equitable (not just equal but equitable) care delivery in all settings at all times.

If someone feels that is not possible, a system needs to be in place to raise the issue up to the level of senior leadership. Outcomes need to be searched for on both staff and patient evaluations.

Without asking the impact of frontline decisions may not be perceived by even diligent senior leaders.

One might say those two pieces of work (staff and patients) are enough for the next decade. It certainly is a large task and very few of organisations have really accomplished anywhere near what needs to be in those two areas, but the third is equally important.

If healthcare is going to move out of the business of sitting in our boxes waiting for sick people to show up and move into the communities and show that we are a true partner to improve broad health and well-being, then we have to

6 https://www.asianhhm.com/healthcare-management/ becoming-world-class-with-class

do that in a way that is grounded in equity. It is a very short walk in most communities to go from the healthcare institutions to neighbourhoods with limited resources for the basics of food, housing, or power. Although you might argue that those are all responsibilities of the government or individuals, the best science shows that we will make little gain in the health of the community without addressing these as well as “sick” care problems. BMC Medicine7 You do not have to figure this path way on your own. There are many resources to help. For example the group called Health Leads8 has developed a roadmap to help address social determinants like housing, food, and power. Their advice could be found at Health Leads and can be modified for multiple diverse settings.

It can be started with very small time and materials but get you on a path to have these critical conversations, build a plan, and start moving forward. Asian Food Security9.

If we are going to be a partner and leader and be seen as a major asset rather than just a business, then we need to look to the availability and distribution of food and housing. We need to use our economic power to source local materials, to hire in an equitable fashion, to share our inclusive staff development programs, to build connections with the schools to help prepare all for their future opportunities not just those who are already doing well. We have the ability to influence local and regional investment by how we behave and how we use our assets. It has been shown in multiple situations the positive influence on the growth and development of communities if healthcare truly lives its mission of improving the health and well being of the whole community. Not just the easiest or those who already have the most assets.

7 https://bmcmedicine.biomedcentral.com/articles/10.1186/ s12916-015-0342-3 8 https://healthleadsusa.org/tools-item/the-social-needsroadmap/ 9 https://www.ncbi.nlm.nih.gov/pubmed/19965356

Figure 1 Equity vs Equality:What's More

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Health Equity Pathway • Leadership declaration and staff education on equity beyond equality Staff

• Measyre outcomes, request feedback, transparent reporting • Hiring, training, promotion without implicit bias towards race / gender / ethnic / or socioeconomic status • Change your systems to adjusts for variable needs of social and medical determinants

Patients

• Measure access, outcomes, research against equity from patients view • Adjust health literacy, language, and payment reform support to reflect long term equity goals

• Lead the discussion and policy generation elevating equity across the community Community

• Demonstrate equity based regional investment, purchasing, housing development • Connect your staff and patients with other community services to improve housing, power, food and education security

Figure 2 Health Equity Pathway

10 https://www.healthcareanchor.network/ 11 http://www.equityinitiative.org/who-we-are/ 12 http://internationalforum.bmj.com/melbourne/

In summary, we have to move past the illusion that an HR policy or a directive to the staff is somehow accomplishing health equity. It will take a concerted effort with our own employees to be clear about the expectations, a system to help them stay on the path and consistent leadership to help move this to our patients and families. The community will need this same leadership to help set a course that is both morally sound but strategically advantageous. Raising everyone up will strengthen the fabric of the community. culture-of-health.html

Author BIO

Another resource, The Health Anchor Network10 has published several documents to help you get started inequitable hiring, training and investing in local communities. There are examples of great successes of small startup investments or tens of millions dollars. These examples are not limited to North America. Across Asia there are many organisations that are pushing forward leadership training (Equity Initiative11) as well as large gatherings of like-minded leaders, for example International Forum on Quality and Safety in Healthcare: Asia-Pacific12.

The focus is on getting started to not just do something but accomplishing something in an equitable manner to serve the mission and our communities.

Health Equity must be a Strategic Priority13 / Building a Culture of Health 14.

It is unlikely to have economic health with out personal health. And it is unlikely to have personal health within a weak economic environment. They complement each other. We are better off if all can come along in both of these dimensions. This is a great opportunity to lead forward on equity. This is a very difficult problem that no one has really solved. It gives you a chance to show that you can start making measurable progress and live up to the values, mission and vision of your organisations.

References are available at www.asianhhm.com

Jeffrey E Thompson is Executive Advisor and Chief Executive Officer, Emeritus at Gundersen Health System. Thompson is a trained pediatric intensivist and neonatologist, and served as Gundersen’s Chief Executive Officer from 2001 to 2015. After completing his professional training in 1984, Thompson came to Gundersen with a desire to care for patients and to teach. He was asked to serve on Gundersen’s boards beginning in 1992 and was chairman of the board from 2001 to 2014.

13 https://catalyst.nejm.org/health-equity-must-be-strategicpriority/ 14 https://www.rwjf.org/en/how-we-work/building-a-

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The Growing Trend of Open Innovation Approaches is Stimulating Health Innovation Collaborations between academia, industry and government are increasingly creating the kinds of fertile environments where health innovation can sprout and flourish.

John Battersby, Account Director, Bridges M&C Pte Ltd.

S

ingapore’s thriving entrepreneurial start-up environment is a case in point. Singapore’s government has recognised the value of innovative thought leadership and entrepreneurial

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experimentation and has set about providing the infrastructure and support needed to foster them with a variety of accelerator and incubator spaces.

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National University of Singapore, for example, offers NUS Enterprise, their own entrepreneurial arm for those with an entrepreneurial spirit and the drive to find innovative

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solutions to the world’s problems. It actively supports them by offering experiential entrepreneurial education and exposure to active industry partnerships. Major industry players are collaborating with NUS Enterprise providing grants, mentorships, and their own open innovation programmes. A major focus of such collaborations has been the area of public health, and in particular the problems facing Singapore’s ageing population which are creating a need for innovative health solutions.

Grants4Apps Singapore, a collaboration between global lifescience company Bayer and NUS Enterprise is an example of this trend.

A web-based crowd sourcing initiative that called for innovative health tech solutions in Singapore and across Asia Pacific to improve medication adherence in elderly people with chronic diseases, Grants4Apps received 80 entries from across the Asia-Pacific region. Three winning teams were selected, two from Singapore and one from Thailand, each receiving a grant plus access to mentorships, incubator space, and global and regional networks to help them develop their concept ideas into working prototypes. In November, the three winning teams had completed their 100 days of mentoring and successfully demonstrated the prototypes’ viability to overcome medication adherence barriers in elderly people with chronic diseases.

The prototypes were presented at the Modern Aging Finale in Singapore on 24th November.

Speaking at the Modern Aging Finale, Mr Claus Zieler, Senior Vice President & Head of Commercial Operations, Bayer Pharmaceuticals Division Asia / Pacific, said, “According to the UN, a quarter of Asia’s population will be aged 60 and above by 2050. That will inevitably lead to an increase in age-related conditions such as cancer and chronic

The GlycoLeap platform gives diabetes patients a structured, digital behaviour change programme to easily monitor progress while analytics-enhanced coaches guide and support them.

heart diseases. That makes driving scientific innovation more important than ever. We need to develop new and better medicines to address the needs of the ageing population; to reduce hospitalisation, improve health and well-being and increase independence of seniors. The best way to achieve that is through a multi-stakeholder approach which drives partnership across the wider community to address these public health challenges.”

The two Grants4Apps winners presenting their working prototypes at the event were the EyeDEA team from NUS and the Glycoleap team from Holmusk.

The EyeDEA team demonstrated a three-in-one solution that will improve patient adherence to glaucoma medication, comprising a personalised visual medication prescription card, an intelligent portable storage box for eye drops, and a mobile app.

Glaucoma patients typically have complex medication regimes involving several different kinds of eye-drops that have to be taken at different times of the day and sometimes in different eyes. This often leads to medications being mixed up or forgotten. The pictures of the different medications on the wallet-size EyeDEA card improves patients’ understanding and recall of

medication regimes, while the portable storage box can be programmed to give visual and audible alarms to indicate when medication is due and which drops to use. The box, which can hold up to five different medications, will even indicate which eye the drops are for. It is also WiFi-enabled so it will automatically report when medication is taken and alert the doctor and or caregiver if medication is not taken when it should have been. The third element of EyeDEA, the app, will allow patient, doctor and caregiver to monitor the box and ensure compliance and will even automatically order fresh medication when stocks run low.

“As a small team, winning the award was a great boost for us and we are delighted to have the opportunity to work with industry leaders and to collaborate with NUS Enterprise and Bayer. The mentorship and resources played a pivotal role in developing EyeDEA rapidly and we are another step closer to achieving our vision of preventing blindness from glaucoma.

Our innovation will shed valuable insights on our patients' adherence trends and preference to their eye drops so that individualisation of therapy is possible. In the future, EyeDEA has the potential to be adopted by other medical disciplines for other patients requiring multiple forms of medications,” said Tey Min Li, co-founder of EyeDEA and final-year medical student at Yong Loo Lin School of Medicine, National University of Singapore.

Although originally designed for glaucoma patients with poor eyesight, the system has attracted attention from the wider medical community because of its potential to help elderly patients who often have comorbidities such as diabetes and cardiovascular disease requiring multiple oral medications.

The GlycoLeap team went one better than demonstrating a viable prototype of their app designed to help diabetes patients. They have already

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perfected the app and launched the service in Singapore and several other countries.

The GlycoLeap app monitors Type 2 diabetes patients’ food habits, glucose readings, activity levels, weight, and medication adherence on a daily basis. As it monitors glucose level of patients on a daily basis, dieticians are able to ascertain if a patient has forgotten to take his/her medication.

The GlycoLeap platform gives diabetes patients a structured, digital behaviour change programme to easily monitor progress while analytics-enhanced coaches guide and support them. With a combination of technology and human intervention, the application helps to overcome the barriers of medication adherence.

The app is also fun and easy to use. One function that has proved both useful and popular among users is the meal assessment function. App users can simply snap a photo on their phones of the meal they are about to eat and send it with a brief description to GlycoLeap. The GlycoLeap team of experts will assess the meal and send back feedback and advice in real time.

Like the EyeDEA system, the GlycoLeap app is also versatile and adaptable. Holmusk, the Singapore company that developed and run the GlycoLeap service, have adapted the app, at the request of the Singapore Health Promotion Board (HPB) to be used as an interactive dietary aid for overweight children. HPB are already running trials of the app in some schools in Singapore.

“From the start, we were clear that we didn’t want to develop just another health app, but a real service with data-driven human coaching to drive behaviour change for measurable health improvement. To achieve that we developed GlycoLeap to be a data and technology based approach to providing an end-to-end solution to the management of Type 2 Diabetes including food habits, activity levels,

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weight, and medication adherence,” said Nawal Roy, CEO and founder of Holmusk. “Winning the Grants4Apps award gave us more exposure. We had the opportunity to showcase our winning Grants4Apps concept to an international audience; including presenting it at the Digital Silver Forum in Helsinki, Finland in December 2017. Our product is already available to the public via our website and Android and iOS App Stores and such exposure will help us find the B2B partners we need to help us get our app and service into the hands of diabetes patients who need it.”

Both of the organisers, Bayer and NUS Enterprise, were pleased with the successful completion of the Author BIO

John has twenty years’ experience as a science and technical writer. Focused on medical and healthcare issues for the past decade he has written on many topics including dentistry, cardiology, immunology and pharmaceuticals.

He has lived in Singapore and South East Asia for twenty years working as a freelance journalist and media adviser to the pharmaceutical industry.

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inaugural edition of Grants4Apps and the stimulus it gave to the innovation and entrepreneurial communities in Singapore and the region.

“Grants4Apps® Singapore is a first for NUS and Bayer in harnessing the strengths of startups from Singapore and around the region to take on challenges posed in the area of medication adherence. We are proud to have been instrumental in the entrepreneurial journeys of the teams, helping them gain market readiness and providing incubation support, industry connections and mentorship.

The successful response to this call encourages us to plan for another challenge in the future,” said Dr Lily Chan, CEO NUS Enterprise.

A market intelligence leader delivering research and consultancy for the Global Healthcare Industry

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Assessments and the Crucial Role it can Play while Preparing Future Leaders in the Healthcare Space What parameters would help identify successful leaders? i.e. assessing leaders internally – from Hospital administrators to COO of an organisation or from technical expertise to hospital administration.

Are leaders ready to take on newer roles? How Assessment can help identify this and how it is extremely detrimental to the success of the leader and in turn detrimental to the institution.

Amogh Deshmukh, MD, DDI

H

ealthcare has become one of India's largest sectors both in terms of revenue & employment.

The total industry size is expected to touch USD280 billion by 2020.

The hospital segment is highly fragmented with ~90 per cent of the hospitals being established and operated by doctors & trusts and the balance are being managed by corporate hospitals chains. The age old unorganised and extremely fragmented sector has started seeing a lot of change in the last 5 years. There is a big buzz happening in the healthcare space. We are seeing a rapid rise in the organised hospital chains.

This is great news for the industry, finally we will start seeing growth in a planned manner, quality

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standards being raised, patient care showing significant improvement, newer technology getting introduced at a much rapid pace.

This growth comes with its own set of challenges. I agree that the fundamentals of running a hospital does not change but the business is evolving at a very fast pace. The organised hospitals are using all the tricks in the books of marketing and management to raise their game. You might have not realised but these hospitals are fighting the marketing battles just like any other FMCG, Consumer Durable, Retail giant. They are using all mediums of communication – traditional and modern to reach you. You might have not realised but they are also visible in your favourite blockbuster movies. They are luring you with health checkup packages. They are engaging you over emails, test messages, television, radio, everywhere. They are engaging external survey companies to check the employee engagement and patient satisfaction scores. Right from the time you step into the hospital, when you are in the queue for getting your OPD appointment or IPD appointment, when you are in the waiting area or cafeteria you are surveyed so hospitals can build a better experience for their target audience.

This business model is very different from the ones hospitals were used to running. And it is evolving very quickly. In fact, it is very close to the one that corporations in the other industries are running. The CEOs and the senior leaders of these organised hospitals have not experienced this ever before. So how do they prepare themselves for running these professional organisations differently yet work with the unique fundamentals of running a hospital operation?

I would suggest simple 3 steps IDD (Identify, Diagnose, Develop)

Success ProfilesSM

Identify

Regardless of the business priorities and changing business context, the CEO will always need the right talent to execute their strategies. But if the leaders don’t know what to look for then what? It is almost like playing football without the goal posts. The key is to determine competencies and creating what we call “Success ProfilesSM” which is tied to your organisational future goals.

There is too much of emphasis given on what people know (the knowledge) and what people have done (the experience). While these two are very relevant, they unfortunately have very little impact on what leaders in the healthcare sector are expected to do. The challenge is that no one has experienced or anticipated this kind of growth in the healthcare space. So whatever leaders have learned in the past or have gained rich experience of is almost irrelevant to what is expected off them in the future. Hence the organisations will

have to dive deep into the future and foresee the competencies they need to adopt and learn. At the senior leadership positions, leaders’ personal attributes will become increasingly important. With an unknown and uncertain future, a lot of ambiguity and uncertainties are attached, and how leaders deal with this is largely riding on their personality profiling. The grave mistake most organisations end up making is that they put excessive emphasis on personality. I always tell leaders: “Personality is like a horoscope, it can be read in different ways. The fundamental principle is that behaviour always rules.” What we display to the world in action is what counts. Also, personality profiling does not account for a very critical element in an adult learning ‘The Learnt Behaviour’. Many evolved leaders with years of experience and experimentation with their own self have learnt who they are and what can stop them. These leaders adapt!

Their personality scales might show

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something very contradictory to what they demonstrate as behaviour day-in and day-out. Hence looking at the complete Success ProfileSM in its totality is critical.

Personality is like a horoscope, it can be read in different ways.

The fundamental principle is that behaviour always rules.

Diagnose

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ProfileSM are configured carefully to give the leaders a safe environment where they can demonstrate their proficiency on the target competencies.

Basis this simulated assessment the leaders are able to get a detailed feedback on the strengths and development needs as they relate to the unique demands of a CEO, COO or CNO in the health care industry to accelerate the development process at a fast pace.

Develop

Once the simulated assessment has identified the top strengths and development areas leaders will have to work on a robust development plan

Author BIO

The first critical step of identifying the futuristic competencies that are relevant for your hospital business is over. But the job is half done. If you want to know answers to one of the following questions, then read on….

• Are my senior leaders future ready?

• Are my promotion / placement decisions giving me leaders that can be strategic, operational and yet drive clinical excellence in this fastchanging world of healthcare?

• Are my leaders getting targeted development inputs and am I able to coach and guide them with job relevant inputs?

If these are the voices playing in your mind, then you will need to assess them against the target competencies defined in the Success ProfileSM. The options are many when it comes to assessing leaders on the target competencies.

• A multi rater tool like 360 degree inviting others working with the leader to respond to the survey. This is good to capture perceived behaviours but it looks into leaders behaviours demonstrated in the past and not look into the future • An in-depth behavioural interview is a very effective tool but it as well looks at past behaviours The challenge with these two options is that they are looking back in the past to predict the ability of the leaders to do deal with future which these leaders have never experienced before • A simulation-based assessment centre has the highest face validity as well as predictive validity. The senior leaders are immersed in a simulated hospital setup and made to run the business for one whole day. At the backend the target competencies from the Success

with SMART (Specific, Measurable, Achievable, Relevant, Time bound) development goals. The key here is not in just writing a development plan, but how the leaders reviews his development goal and measures progress against the plan. Critical business metrics are reviewed in detail regularly, development goals need to be treated like critical business metrics and need to be actioned and reviewed similarly.

Let me make a disclaimer here: given that we are talking about leaders at the top of the house in the healthcare space, I am not going to discuss about the accountability and ownership that the leaders will have to display for driving their development.

I am assuming it is a given and the leaders are motivated to development themselves and will take charge of their development to build an edge for themselves in the healthcare space.

I often get this question: “Which of the three steps is most important?” and my response is that just like in business where one has to drive multiple things simultaneously, these three steps go hand in hand. One cannot put over emphasis on one and underplay the others. If leaders are finding themselves not getting relevant development inputs to sharpen their saw, it is time they look for alternative mediums that will provide them with deep and relevant inputs.

As managing director for India, Amogh is responsible for the creation and implementation of the region's business strategy. Amogh is accountable for managing all aspects of the DDI operations in India (including Consulting, Sales, Marketing and Operations) An expert on a broad range of leadership and talent management practices, Amogh provides business-relevant counsel to a diverse range of both multinational and Indian organisations, identifying needs and proposing solutions primarily in the areas of leadership strategy, development, succession management, and talent acquisition.

Conducting research to support the effectiveness of DDI interventions and writing DDI publications is his passion.

ISSUe - 39 2018

www.asianhhm.com

17

HEALT HCARE MANAGEMENT

cover story

The High Reliability Challenge

in healthcare, continuing the journey

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HEALT HCARE MANAGEMENT

The healthcare industry has embarked upon several initiatives to raise standards of clinical outcomes, quality and patient safety, yet a lot more is needed to ensure the absolute best for the patient. An exemplary case in point, the aviation industry’s repute for safety has been built over decades of perseverance. Similarly, healthcare’s journey towards a Zero Harm state must begin with a priority to hardwire appropriate methodologies, processes and policies.

Sangita Reddy, Jt. Managing Director, Apollo Hospitals

T

he contemporary healthcare ecosystem is a complex entity. It is driven by huge expectations, limited by scarce resources and rampant with co-morbidities and complexities.

Combine this with an ageing population, multiple inter-personal relationships within hospitals and less than optimal usage of information technology, and you have an environment that is prone to errors. Medication errors, healthcare associated infections, patient falls and pressure ulcers in hospitals are more common than we care to admit and they pose a massive predicament in the aspect of patient safety. This brings us to the burning question: why is it that the healthcare industry is not as reliable as other industries? Why is an industry as critical as this not geared towards zero harm?

Commercial airlines, the nuclear power sector, electrical power grids and even amusement parks, although different in nature, are perfect examples of High Reliability Organisations (HRO). These are the organisations that have high potential for errors and yet they ensure nearly error-free systems and zero harm. An insight into their optimised efficiency may be understood by observing the way they approach risk management. HROs do not overlook their failures but rather use them as windows to look into their systems and processes! They anticipate unexpected events and build up the capability to avert disasters pro-actively.

It is said that every time an aircraft malfunctions, it makes future flying safer. Given the intricacies of healthcare, the guiding principles of HRO give us an opportunity to improve the healthcare scenario. The healthcare system has to cease being satisfied with marginal improvements. A radical shift can occur only when the entire healthcare environment commits to work towards zero harm, or an errorfree system. A commitment is a must to commence the process of taking up the high reliability challenge. Setting the “goal of zero harm” is the first step towards this journey.

Healthcare Institutions Emerging as HROs

The healthcare ecosystem is continuously adapting itself to take steady strides towards high reliability. The first step towards the commitment to zero harm in healthcare is the responsibility of leaders to lead by example. It is the attitude, belief, and behaviour of the leaders in healthcare organisations which is essential to bring about the change in the organisational culture that supports and encourages zero harm. “A culture of safety that fully supports high reliability has three central attributes: trust, report, and improve” (Reason and Hobbs, 2003). When these three essential components of a safety culture work in tandem, they help achieve high reliability systems and processes which will eventually take us closer to our target.

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HEALT HCARE MANAGEMENT

Various initiatives from different high reliability industries including the aviation sector have been identified and implemented in the healthcare system.

These include the use of checklists and bundled interventions that help in eliminating errors such as the WHO Surgical Safety Checklist which is used widely by many healthcare entities to ensure patient safety and in preventing wrong site, wrong procedure and wrong patient surgery. The three parts of the checklist are organised in a logical sequence and require the participation of the anaesthetist, the surgeon and the nursing team, in union to ensure a safe surgical environment for the patient.

Another potential area where errors may occur is the clinical handoff between the care givers. The changing patterns of work culture in hospitals and high patient volumes have created the need for improved handover of clinical responsibility and information.

Here again, various checklists, tools, and methodologies are used to ensure compliance and reduce scope of error.

Robust Process Improvement (RPI), a multiplex of Six Sigma, Lean, and Change Management are a powerful set of methodologies and targeted processes introduced by the Joint Commission for healthcare organisations to take precise steps towards reducing errors and patient harm. It helps the healthcare organisations to move from a low reliability to a high reliability set up.

It helps in identifying issues which are crucial to quality, patient safety and in classifying and eliminating waste. The process uses extensive data to drive this improvement.

Today, with the advent of information technology, healthcare organisations gather an ocean of data from various touch-points, but the fact remains the same: these organisations are data rich and information poor.

This change is of the highest priority as it is pivotal that data is collated, sorted, churned, analysed, understood and converted into useful information

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A culture of safety that fully supports high reliability has three central attributes: trust, report, and improve.

(Reason and Hobbs, 2003)

which eventually guides the actions of the organisation.

Apollo Hospitals is hardwiring the HRO principles towards zero harm.

Apollo Hospitals is committed to healthcare quality and clinical excellence, Apollo uses a structured and wide-ranging set of initiatives in an integrated plan. Apollo Hospitals took on the goal of being accredited by the Joint Commission International (JCI); the undisputed gold standard of quality in global healthcare. Way back in 2005, Apollo Hospitals, Delhi became

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the first organisation in the country to be accredited by JCI. The hospitals fine-tuned systems and processes to get them in sync with the established international standards. The International Patient Safety Goals helped Apollo to implement processes to get rid of the most common causes of sentinel events. Today, eight of the Apollo hospitals are accredited by Joint Commission International and fourteen hospitals are accredited by NABH and all locations follow the ‘Apollo Clinical Excellence’ model.

While on its journey towards international and national accreditations, ‘The Apollo Standards of Clinical Care’ (TASCC) were developed with a vision to establish uniform standards of clinical care across the Apollo Group of Hospitals to deliver safe and quality clinical care to its patients and ensure zero harm. It embodies a set of process requirements and outcome measures that underlie Apollo Hospitals' approach to clinical care.

TASCC comprises of the six components including Apollo Clinical Excellence Dashboard (ACE I and ACE II), Apollo Quality Improvement Plan, Apollo Incident Reporting System, Apollo Critical Policies, Plans

HEALT HCARE MANAGEMENT

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must ensure that all staff members are encouraged to share their thoughts for preventing any errors or sentinel events. Staff members have to be empowered to report errors and near-misses; raise concern with any practitioner for unsafe behaviour and if needed, even stop a process that poses a risk to the safety of a patient.

A practice of ‘walk rounds’ by the senior leadership, ‘safety briefings’ at shift changes and ‘multidisciplinary huddles’ must be included into the work flows.

On similar lines followed by other industries, in a healthcare organisation, the path towards high reliability begins with the commitment to patient safety.

A key characteristic of an HRO is to create an atmosphere of collective mindfulness; an environment, where the employees are not hesitant to report even the smallest of problems or raise concerns about any unsafe conditions, thus enabling the system to intervene and achieve zero harm. Over time, several leaders across the globe have introduced different ways and methods to make their organisations into high reliability organisations; however, there are some key characteristics that are common to such organisations.

As described by Karl E. Weick, PhD, and Kathleen M. Sutcliffe, PhD, in their book “Managing the Unexpected: Resilient Performance in an Age of Uncertainty”, they have identified few unique characteristics of an HRO. There must be a preoccupation with

Author BIO

and Procedures and Apollo Mortality Review, all of which focus on providing care of the highest quality and ensuring safety for patients.

Apollo Clinical Excellence Dashboard is a clinical balanced scorecard focusing on outcomes, clinical excellence, patient safety and the functional efficiency of a hospital, benchmarked against some of the world’s best published outcomes in high impact journals. Apollo Hospitals has also developed a comprehensive set of best practices, the Apollo Quality Program, which helps monitor clinical handovers, International Patient Safety Goals, surgical care improvement and zero medication errors, are a few. All these initiatives promote a safety culture and quality improvement DNA across all levels of the organisation from Housekeeping to Senior Clinicians.

The Apollo critical policies, plans and procedures are 25 policies covering clinical care, nursing care, managerial processes, utility systems and infrastructural requirements.

Apollo Hospitals has established a system for reporting and tracking of incidents/near misses and other serious health care errors including sentinel events that pose an actual or potential safety risk to patients, families, visitors and staff; these events include patient falls, needle stick injuries and patient pressure ulcers. For Example - Two checklists, including one for surgical safety and the other for the patients admitted in ICUs have been developed to mitigate any adverse events and ensure high quality safe patient care.

Regular mortality review of all deaths is conducted to help detect quality issues that would have otherwise remained hidden and subsequently prevent learning from the situation.

This review involves senior clinicians, along with the hospital leadership; it helps to identify areas of improvement in clinical care processes.

In the end, a culture of safety is the bedrock of an HRO. The leadership

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failure where an organisation should not be satisfied with no accidents for a length of time and is to be alert to the smallest signs of new threats to safety that may be developing, along with a reluctance to simplify observations.

The system should be able to identify subtle differences among threats that may be the differentiator between an early and late indicator for a potential error. All HROs must also show sensitivity to operations, commitment to resilience and deference to expertise in any field.

Conclusion

The foundation of creating a high reliability organisation with the mission of zero harm is laid down by committed leaders. The journey starts with the leaders guiding the entire team on the quest for the highest levels of patient safety and improvement in healthcare quality. With the ever increasing complexity of healthcare systems, higher patient expectations, the omnipresent web and introduction of advanced technology, it’s the need of the hour for the healthcare organisations to raise the bar higher, and strengthen their processes to ensure that zero harm is the common vision that guides every facet of modern healthcare delivery.

Finally and most significantly, if the team feels like family and are committed to a common vision and mission, the universalisation of Quality is possible.

And then the team can focus on treating every patient like FAMILY.

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

Measuring the Health-Related Life Quality of Patients with Chronic Kidney Disease High prevalence of Chronic Kidney Disease (CKD) among the general population is a major global concern. CKD can be treated. Early diagnosis and effective treatment can stop CKD progression improving patients’ Quality of Life (QOL). This article overviews the health-related aspects of QOL of patients with CKD. Md Moshiur Rahman, Associate Professor, Graduate School of Biomedical & Health Sciences, Hiroshima University Abu Sayeed Chowdhury, Graduate School of Biomedical & Health Sciences Hiroshima University

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T

he simultaneous assessments of medical care quality and outcomes are equally essential. However, routine measurement of patient’s Quality of Life (QOL) requires intensive attention. QOL instruments measure individual’s own views of his wellbeing. The core components of QOL are physical, psychological/emotional, functional, and work/occupational. QOL has been considered a crucial factor in the definition of successful treatment for chronic

MEDICAL SCIENCES

illnesses, and many related studies have been reported. According to the World Health Organization (WHO), QOL is defined as ‘individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”.

It is a wide-ranging conception affected by the person’s complex physical health, psychological state, social relationships, level of independence, personal beliefs, and their relationship to leading features of their environment. QOL has implications to measure health system performance, mortality indicators, and compare the health of groups.

Chronic Kidney Disease (CKD) and End-stage Renal Disease (ESRD) are two leading global health concerns with high prevalence and extremely costly treatment procedures. The worldwide increase in the number of adult patients with Diabetes Mellitus (DM), Hypertension (HTN), and ageing has been causing a rapid increase in the incidence of CKD. Globally, the estimated prevalence of CKD is 11 to 13 per cent with the majority stage 3.

CKD is a major determinant of poor health outcome of noncommunicable diseases. Although the scientific advances have been contributing to the

gradual improvement of medication, medical treatment, medical care and health technology, still the concern of living a better life is most important towards patients rather than living longer. The effect of the treatment is not only measured in terms of survival, but also in terms of this perspective, and wellbeing claims more highlights than survival when the question of the effective outcome of treatment rises.

Findings from previous reports related to factors affecting QOL (genetic, environmental, psychosocial, stress, emotional, and comorbidities) have shown that lower scores on QOL were strongly associated with higher risk of death and hospitalisation than clinical parameters; such as serum albumin levels in cases of ESRD patients. DM has also been correlated with low QOL. More sociodemographic factors were associated with declined QOL than physical factors as age, ethnicity, gender, education, income, and professional activity. It may explain the difficulty in establishing a linear relation with the glomerular filtration rate (GFR) for the influence of these different factors on the assessment of QOL. Thus, these findings demand more attention towards patients’ primary QOL measures and indicators.

Usually, both the positive and negative aspects of life are assessed regarding the objective and subjective QOL evaluations. Researchers have reported demographic, clinical, social, psychological, and treatment-related associations with QOL. A recent research described the functional definition of QOL conceptualisation by discussing following attributes: the ability to engage in vigorous activities; the ability to participate in social and occupational roles; and the ability to perform activities of daily living.

Some reviews stipulated an overview of the instruments used and evaluated the instruments concerning their comprehensiveness, reliability, and validity. Few studies sought to establish

the domains of QOL which are the most affected by ESRD. Another study has articulated a variety of generic and disease-targeted health-related QOL instruments for patients suffering from ESRD. Still, as per the WHO definition of QOL, the reviews have rarely discussed whether existing QOL instruments have covered both objective and subjective patient experiences.

QOL instruments provide a standard assessment of health, including questionnaires designed to be applicable for general public health measures, such as the Sickness Impact Profile (SIP), the Nottingham Health Profile (used for primary care), the Medical Outcomes Study Short Form 36-Item Health Survey (SF-36), SF-12, the European Quality of Life Instrument - EQ-5D, the McGill QOL (MQOL) scale, and GHQ-28. Researchers use instruments designed by WHO such as WHOQOL and WHOQOL-BREF. WHOQOLSRPB is also used to assess Spiritual, Religious and Personal Beliefs (SRPB) within the quality of life. Each QOL tool covers some domains (measurements of different characteristics), and they measure quantitative outcomes. Every instrument is scored on different domains; however, no instrument alone measures all the domains. In previous research reports, the most commonly used instruments were SF-36 and Kidney Disease Quality of Life (KDQOL).

Researchers have narrated either a linear or an inverse relationship within factors that improve or lower QOL. They have described attributes or used frameworks or models that encompass certain aspects of QOL, such as demographic data, information on diet, treatment patterns and outcomes, anthropometric biomarkers, and data related to mental health such as depression or anxiety. The low QOL scores are associated with higher rates of mortality and morbidity.

Higher Health-Related Quality of Life (HRQOL) score is an important

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MEDICAL SCIENCES

Globally,the estimated prevalence of Chronic kidney disease is 11 to 13 per cent with the majority stage 3.

performance indicator for dialysis centres in managing ESRD. The main concepts of HRQOL are functional, social status, health status, wellbeing, patient satisfaction, patient preferences, role limitations, pain, mental health, and general health conditions.

Sensitivity, reliability, validity, and cultural differences are to be considered in the KDQOL-36 scoring system and its scales. Many past studies highlighted that KDQOL-36 has high reliability and validity with some adjustments to cultural differences.

CKD in children causes additional burden on parents or caregivers in terms of socio-economic factors, longer treatments, and the successful transition to adult CKD care.Notably, children with CKD have a worse QOL than healthy children. GFR is one of the most important factors related to QOL; the levels of haemoglobin and serum albumin have been known to be QOL-related factors in adults with CKD. In a previous study, boys were found with better QOL than girls in the physical, emotional, and school functioning aspects. Growth parameters such as the height Z-score and weight Z-score of children with CKD indicated a close connection to the QOL, irrespective of CKD stage. There

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are some age-specific features, especially growth-related factors associated to growth and development in the QOL of children with CKD. Short stature is common in children with CKD and is linked with lower QOL scores in the physical functioning domain. It has been reported that behavioural disorders are closely related to lower QOL in children and adolescents with CKD in development. Based on a previous study, the QOL of children with pre-dialysis CKD is affected by several factors including sex, socioeconomic status, anaemia, GFR, existence of co-morbidities, growth retardation, and behavioural disorders. To improve the QOL of children with CKD, it is important to understand the respective effect of these factors on QOL and the attempt at early intervention. Instead of being limited to survival rates, the effective management of children with CKD demands comprehensive health care, including growth and development management.

The interaction of genetic factors, sedentary lifestyle, unhealthy habits, unbalanced diet, nicotine dependency, and elitism are the most common causes of health problems of the elderly people. CKD is considered as an irreversible and progressive syndrome

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that damages kidney functions until kidney failure. The estimated GFR decreases physiologically and exposes the elderly to a higher risk of developing CKD. Approximately, half of the world population aged 75 years or older has CKD at different stages. In the ageing process irrespective of expected physiological loss, studies show that adult patients with CKD undergoing conservative treatment have greater hearing loss compared to the healthy population, as well as to chronic kidney patients experiencing dialysis.

It is recommended that auditory damage occurs due to pathological characteristics and the drugs used in the CKD treatment. A common clinical outcome in elderly with CKD is the manifestation of multiple comorbidities.

A previous study established a positive relationship between the number of comorbidities and the number of complications. As comorbidities increase, the complications of CKD also upsurge. Consequently, as the complications rise, the quality of life falls.

In the developing countries, there are insufficient data available regarding the QOL of patients with ESRD. Over the following several years, the burden of CKD in the developing

MEDICAL SCIENCES

utilities have also improved. Although healthcare practice using the Internet, telemedicine, electronic/digital processes in health, video conferencing with patients, and electronic medical records have been applied, these services are not evaluated effectively for QOL. For example, there are very few published research works on telehealth in CKD. Telecare can extend homecare to peritoneal dialysis patients as patients usually prefer to stay at home, but the usage of telemedicine has experienced least researches. QOL instruments could be incorporated into telehealth-assisted technologies for broader understanding and application.

Physicians are now considering palliative care services to concentrate in symptom management for ESRD patients. It is particularly important in frail, illiterate, elderly multimorbid patients with limited physical activity, where dialytic treatment may not alter prognosis. In such situations, palliative care may provide immense help to improve QOL. Several studies have revealed that QOL has improved with haemodialysis treatment in comparison to peritoneal dialysis. Another study has mentioned better QOL outcomes for patients treated at home. In case of homebased peritoneal dialytic treatment, it is essential to identify whether the type of treatment or the place of treatment

Author BIO

world is anticipated to rise intensely. It relates to the dramatic increase in the incidence of HTN and DM, improved economic outlook, and increase in life expectancy. Moreover, the continued/recurring high occurrence of infectious diseases (HIV, hepatitis B and C, malaria, skin infections, etc.) will continue to contribute to the high prevalence of kidney disease.

Thus, initiating the development of acceptable methodologies for assessing the QOL of their patients is important for each country. Culture plays a vital role in modelling individual QOL. An individual’s values affect perception towards QOL that diverge within cultures as shown in a previous study.

Cultural differences, outlook on life, literacy, economic status, access to the basic needs of life, nutritional status, mental health support, and involvement of national health systems should be highlighted. Gender concerns are also remarkable. Women face discrimination, get no or limited support, and have limited access to healthcare and educational opportunities in many societies of the developing world. QOL assessments need to take this problem into consideration.

Determining the feasibility of using standardised instruments of the developed world can be a useful measure to assist the developing world.

The continuous development of Renal Replacement Therapy (RRT) is improving survival outcomes for CKD. Therefore, an important disease management goal must be to ensure that the QOL of children and young people with CKD remains adequate.

To find a new kidney from appropriate donors for increasing life expectancy and life quality is the best way to treat CKD. However, it is a herculean task to find enough living or cadaveric kidneys in most of the developing countries due to economical and cultural reasons.

Additionally, combining the advanced medical-equipments, technologies (e-health) and medical services’

affects QOL. Studying and statistically analysing other factors that are included in the model, it will be feasible to detect which factor affects QOL the most.

Many instruments do not cover health literacy, which also has an impact on QOL evaluation. Data insufficiency of illiterate patients may be helped with pictographic forms of the instruments.

The instruments and reviewed models make only partial assessment of QOL by considering the WHO definition of QOL and its multidimensional aspects.

Appropriate measurements for accurate scoring of QOL of CKD patients are not given much attention. As a result, instruments with ability to capture the greatest number of QOL characteristics to get a broader understanding are highly needed.

Never the less, QOL is multidimensional and many indicators are linked that affect a person’s overall QOL. Indicators based merely on certain characteristics of the patients pose serious limitations to the measure of QOL, which ultimately confines the QOL predictivity. Next decades challenges will includes imultaneous designing of a QOL instrument so that both diseasespecific and culture-specific, subjective and objective factors, can be taken into account for the complete assessment of QOL of ESRD patients.

References are available at www.asianhhm.com

Md Moshiur Rahman is 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.

Abu Sayeed Chowdhury is a graduate student at Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan. He holds Master and Bachelor of Business Administration degree from University of Dhaka, Bangladesh (Accounting and Information Systems major). His research interest includes sustainable development, development economics, public health, epidemiology and organisational behaviour.

www.asianhhm.com

27

Diagnostics

Diagnostics Industry Shaping the transformation of the healthcare industry

Long considered the ‘silent champion’ of healthcare, In Vitro Diagnostics (IVDs) influence over 60-70 per cent of clinical decision-making, while accounting for just 2-3 per cent of total healthcare spending. But changes in the healthcare environment are driving demand for improved healthcare delivery, and sustainable healthcare depends on diagnostics.

Lance Little, Managing Director, Region Asia Pacific, Roche Diagnostics

1. How do you see the medical diagnostics industry evolving over the next 10 years?

The transformation we’re witnessing in the healthcare industry today is unparalleled and sets the tone for the evolution we will witness over the next decade. I see three major drivers that will shape the future of our industry.

The first is the role and relevance of technology. Technology will continue to play a pivotal role in democratising healthcare services—putting what was once accessible by a few, into the hands of the masses. It has, and will continue to, enable the transfer of medical knowledge from institutions to individuals. The ever-growing availability of health management tools and information through online and smartphone devices has made us more aware of our health needs than in the decades prior.

This has brought about a fundamental shift in how we approach healthcare—organising care around patients’ needs.

We can access data at the touch of a button. So the ease with which people can access many different types of information, including information about their health, is changing how

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they perceive healthcare. As a result, patient centricity is becoming a focal point for innovation and healthcare delivery.

Patients today want easier access to care and demand better service.

More and more view themselves as consumers, not passive receivers of treatment. In the future, this will become further pronounced, and its impact far-reaching. As a society, we will have to meet the growing expectations of the community.

Let me elaborate. There will come a time when, through the use of embedded sensors and wearables, biomedical information systems will continually track and upload information about an individual onto a personal intelligence cloud. The information about a patients’ health will be managed in much the same way as they manage their bank accounts today.

This cloud also nudge behaviour.

In the case of someone with a predisposition to diabetes, he or she may get alerts to exercise more or avoid making poor diet choices. But what will be truly game-changing is that an individual’s personal intelligence cloud could also feed into a larger population gathering database. This is where the

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public sector will access information.

For example, health policy decisions could be more tailor-made for specific populations.

Which brings me to my second point. As a society, we will move from focusing on reactive treatment-based care to predictive and preventive healthcare. So instead of treating the rising burden of diseases, we hope to deploy early interventions to prevent the incidence.

Electronic health records and the aggregation of research data into medical databases will allow healthcare institutions and practitioners to make the shift towards evidence-based medicine, and whilst this is starting to happen now, the scale will be much bigger in the future.

Finally, healthcare systems will need to maximise value for patients by helping them achieve the best outcomes at the lowest possible cost.

Delayed diagnosis can result in higher upstream costs of treatment, poorer outcomes for patients, and put tremendous burden on healthcare systems.

A proven and more effective approach to healthcare is now in our grasp, one in which diagnostics plays

Diagnostics

Lance Little became the Managing Director,

Region Asia Pacific for Roche Diagnostics in 2012.

In this role, he oversees 16 markets across the region. Lance joined Roche in 1995 and has since held various management and leadership positions across technical support, sales and marketing.

an even more integral role. Valuebased healthcare is linked to the future of our industry because it is the best way to make healthcare sustainable now and in the longterm.

2. Do you think the diagnostics market is poised for a consistent, steady growth holding great potential in the future? What are the major growth drivers in the Asia-Pacific market scenario?

Yes, diagnostics will continue to see an upward trajectory across most markets in Asia-Pacific.

We know that the rising burden of chronic diseases, combined with an ageing population, has put immense strain on healthcare resources around the world.

Moreover, the industry is facing growing demands from various stakeholders, with physicians seeking tools that can improve decision-making; hospitals seeking faster, more accurate solutions; laboratories looking for ways to efficiently use existing resources; and health systems adjusting their delivery models to reduce healthcare costs.

In this changing landscape, diagnostics is emerging as a key driver in helping to address these needs. The in vitro diagnostics (IVD) market in Asia-Pacific is expected to

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Diagnostics

Diagnostics is no longer just about the detection of diseases.

It plays a pivotal role across the entire healthcare continuum from screening, diagnosis and prognosis to patient stratification and treatment monitoring.

reach US$19.64 billion in 2021 growing at a CAGR of 6.3 per cent1.

This growth will be fuelled by several factors. Asia-Pacific is home to more than half of the world’s population and a bulk of this population is still hugely underserved. The region is made up of diverse countries with varying needs; we have developed countries in the region with well-established healthcare systems and other countries where healthcare delivery is still in its infancy. Furthermore, countries like China and India are seeing the emergence of second tier cities, while healthcare is still concentrated in the major metros in countries such as Vietnam and Indonesia. But the needs are the same: getting more value out of healthcare.

3. What are the areas of development or growth?

As the population ages and the prevalence of chronic disease rises, patients require frequent monitoring and often for longer periods of time. This has fuelled the demand for diagnostics tools for monitoring. In the case of cardiovascular diseases, biomarkers 1 Frost & Sullivan: Growth Opportunities in the APAC IVD Market, Forecast to 2021

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such as Troponin T and NT-pro BNP help doctors to diagnose as well as monitor and better manage the patient’s condition.

Another area of growth is in the use of predictive biomarkers, as healthcare systems are starting to realise the value in being able to detect at-risk patients. If we can one day predict cancer before it occurs, we can intervene early with the right treatment and save lives. This is a significant change from the current approach of waiting until symptoms show before identifying the condition.

We will also see an uptake of companion diagnostics, where a device or tool is used in conjunction with treatment. Patients can take tests that identify the exact mutation of their disease, allowing for more targeted treatment, and doctors can monitor and manage the progression of a disease.

Finally, Point-Of-Care (POC) testing—where speed of information is vital—can help doctors perform tests using smaller machines close to the patient, rather than in a laboratory. This offers huge potential in Asia-Pacific. For instance, the POC Troponin T test can be used in places where heart attack

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patients are first seen: an ambulance, the emergency room, in a primary care setting or the general practitioner’s (GP) clinic. Since it requires no sample preparation or lengthy setup procedures, healthcare professionals can quickly identify patients with a suspected heart attack in the pre-hospital and emergency room setting, helping to ensure correct diagnosis and appropriate interventions.

4. In what ways do you see diagnostics revolutionising healthcare?

Diagnostics is playing a significant role in shaping the transformation of the healthcare industry from volumebased to value-based care, where not only is care organised around the needs of patients but also allows healthcare providers to deliver measurable value and outcomes at lower costs.

Diagnostics can enable the shift from reactive, episodic treatment to predictive and integrated care. Earlier, personalised interventions can reduce health problems; help avoid adverse outcomes; decrease time spent in hospital; and help to avoid the cost of late-stage or unnecessary treatment.

Increasing the use of appropriate diagnostic testing provides one of the greatest cost-savings opportunities around the world. In the US, for example, it has been estimated that earlier detection of certain cancers could save around US$26 billion per year2. Closer home, a study in South Korea found that the early detection and treatment of common cancers can result in considerable savings in treatment costs. Advanced stage at diagnosis was associated with a 1.8-2.5 fold increase in total cost3.

2 Zura Kakushadze, Rakesh Raghubanshi and Willie Y: Estimating Cost Savings from Early Cancer Diagnosis 3 Shin JY, Kim SY, Lee KS, Lee SI, Ko Y, Choi YS, Seo HG, Lee JH, Park JH: Costs during the first five years following cancer diagnosis in Korea. Asian Pac J Cancer Prev.

diagnostics

Diagnostics is no longer just about the detection of diseases. It plays a pivotal role across the entire healthcare continuum from screening, diagnosis and prognosis to patient stratification and treatment monitoring. It helps to enhance clinical practice and quality of care, and ultimately improve patient outcomes.

So I would say that whilst diagnostics has always been one of the foundations of healthcare, it is now positioned to play a key role in revolutionising healthcare. Diagnostic solutions empower doctors to make the right decisions, allow patients to have more control over their health and well-being, and give payers and policymakers the confidence that they are investing in the right solutions.

5. What are the major innovations impacting the healthcare system in Asia-Pacific?

Artificial intelligence, robotics, embedded sensors and digitisation are already, and will in the future, disrupt our industry globally, not just in AsiaPacific. Rapidly ageing populations, the prevalence of non-communicable diseases, the shift towards chronic conditions, and an increasingly knowledgeable consumer base who expect high-quality care at an affordable price are driving the need for such innovations. However, the sheer size of the population in this part of the world and the non-homogenous healthcare delivery models means the impact is much more pronounced here.

However, as with any innovations they must bring value. At Roche Diagnostics we are committed to this.

As we continue to advance innovation across the patient care pathway, we are pursuing our vision of delivering tangible value to healthcare systems.

The result we aim for is better, healthier lives for patients and better equipped 2012, 13: 3767-3772. 10.7314/APJCP.2012.13.8.3767

healthcare systems that can meet the changing needs of patients and address pressing public health challenges.

6. What do you see as the biggest challenge in the current diagnostics market?

As a tool, diagnostics is still massively under-valued and under-utilised. It represents just 2 per cent to 3 per cent of all healthcare spending but influences 60 per cent to 70 per cent of medical decision making. This shows that while there is very little spent on diagnostics, the amount that is spent has significant influence on clinical decisions.

As an industry, we need to articulate the role of diagnostics in delivering sustainable healthcare by highlighting the value it provides across the entire healthcare continuum. This cannot be done by any one company or country, and requires an industry-wide effort to help uplift the knowledge and understanding of the role of diagnostics within the healthcare environment.

One way to do this is by educating various stakeholder groups on what the value of diagnostics means for each of them. For governments, it could mean cost savings at a national level that allows for resources to then be allocated elsewhere. For a patient it could mean access to the right treatment at the right time.

It is when we collectively harness the true potential of diagnostics that we can enhance the overall standard of care.

7. You oversee the entire Asia-Pacific arm of your company. How do you ensure the region stays agile and innovative?

Part of our philosophy in Asia-Pacific is ‘strong locally, powerful regionally’, ensuring we empower local operations while still leveraging our regional and global network when needed.

Given the differences between markets in Asia, we’ve categorised our smaller market into two sub-regions –

established markets and high growth markets – so that countries with similar needs and challenges can learn from shared experiences, the exchange of knowledge and best practices to ultimately benefit patients.

This starts by understanding where countries are in their journey. In more developed countries, the conversation revolves around maximising return on investment, high-throughput instruments to cope with the volume, and performing new tests. The focus is on affordability and the use of high medical value tests.

In developing countries, the concern pertains to coverage, logistics and limitations of infrastructures.

The question typically is "how can we make this test accessible to everybody?"

So, our aim in Asia-Pacific is to support the needs of the countries by making available diagnostics solutions and expertise that can benefit the community.

This ranges from supporting infrastructure and capacity initiatives in countries such as Myanmar, to working with industry associations to address unmet medical needs. For instance, in Vietnam we are spearheading a LEAN Clinical Laboratory Practice programme in partnership with the Asian and Pacific Federation of Clinical Biochemistry (APFCB), the Vietnam Association of Chemical Biochemists (VACB) and others to improve laboratory quality standards in the country.

In Hong Kong, we are running a pilot programme which aims to decrease cases of cervical cancer in the underserved communities. In India, we are working with various stakeholders at a national and local level to increase the access to safe blood.

These are just some examples.

Across the region, our efforts are focused on delivering the best possible diagnostic solutions that can improve patients’ lives and address unmet medical needs.

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Improving Patient Experience, Safety and Progression through Care Model Redesign & Lean Management System Care models help hospitals set up measures to ensure a positive patient perception to increase loyalty & branding and to ensure smooth patient flow and pathways, thereby increasing hospital productivity & turnover.

Today as healthcare becomes an out-of-pocket expense, consumers are seeking value in their health purchases. In this context, value is the cost relationship between an expense and quality, which most healthcare consumers equate with service and a positive experience.

Hospitals that respond to this are poised to thrive in this era of healthcare consumerism.

R B Smarta, Managing Director, Interlink Marketing Consultancy Pvt. Ltd.

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I

t is the duty of care providers to realise that a hospital is more than a business; it is an imperative service to patients and families and supporting them morally at the most challenging and critical times of their lives are our duty. Apart from keeping patients informed and engaged, mollifying the censorious environment, and ensuring that the patient feels supported at their stress times helps accelerating the healing process. This leads to improving their experience and creating positive brand image.

The process of creating good perception of the organisation starts from a very when a patient or family approaches the organisation; thus

the role of the receptionist is in influencing and providing embossing guidance. In today’s world, customer is considered the king, making it essential for every organisation to keep its consumers satisfied by providing excellent quality service and value and maintain in the competitive market.

Thus, customer satisfaction is the keyword in today’s powerful competitive business world.

Care Model Design

A care model can be designed in such a way that it remains seamless, profitable and enhances patient/ consumer experience. At each touch point, patient experience is crucial.

The 5-Touch Point Model

As healthcare pursues the goal of providing access to maximum number of population, its objective is to do so at lower costs. Adoption of new technologies, medications, and approaches have altered the way of delivering care. The old saying, "If you don’t create change – change creates you” applies over here. The care model represents the various ways by which the healthcare services are provided.

The referrals provide insights and direct the patients towards medical and healthcare services. The medical providers like doctors, paramedical staff, provide medical services to patients and service providers including diagnostic

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5-Touch Point Care Model

The Keys to Attract and Influence the Customer

Facilities:

Referrals:

Pure drinking water, Clean environment food, Hygiene, Safety, Aesthetic surrounding, Entertinment, Family support

General physician and satisfied patients

Enablers:

IT, Insurance, Daycare, Homecare, Ambulance services

Service Outcome

Medical Outcome

Service providers: Diagnostic services

Medical providers: Doctors, Nurses, aramedicos

Patient Experience

Figure 1

services, blood banks, and pathology labs provide service outcomes while treating the patient. In addition to the services the surrounding environment and facilities available in the hospital plays a major role. Facilities like pure drinking water, food canteen, clean and hygienic environment, entertainment, aesthetic surrounding, and availability of essential requirements to support family members leads in creating positive image of the system. In addition to these basic services, health Insurance to take care of bills, daycare services, homecare services, ambulance services with life support and medical staff in emergency cases, robust IT services in supporting the services and

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technologies are playing the role of enablers in healthcare system.

Designing the processes to streamline the healthcare services technology is bringing a revolutionary change across healthcare sector.

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The parameter that attracts the patient apart from the treatment is the services, and facilities that satisfy their needs and provide comfort. The key points that patient will look at in the hospital system includes appropriateness (relevant to patient care), timeliness, efficacy & effectiveness (right treatment at right time), safe & clean environment, and digitalisation to make processes impler.

The basic elements that The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) are tracking covers the points mentioned below. The personal effort by everyone at the facility incorporates good customer service. Some items listed, such as clean rooms and quiet atmosphere, can be improved by administrative policies and protocols. Fig 2.

In order to really meet and exceed the expectations of customers from diverse communities, it is important to learn and practice the basic principles of customer service, which are: • Staff has to be respectful, courteous and polite • Staff should make the customer feel welcome • Give your undivided attention and time when interacting with customers • Be friendly and learn about the cultures in the communities you serve • Develop excellent communication skills with patients and families to bridge language and cultural barriers • Appreciate the value of the customer’s time • Develop excellent communication skills with co-workers • Be dependable/ credible • Make the extra effort to build relationship with customer.

These basic principles will let

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patients know you care, that they are not just another number, and that their business is invaluable.

Four Enablers

1.Waiting Period Reduction in waiting times operationally and implementing self-service kiosks to speed up the registration process and is found to be associated with higher patient satisfaction.

Some distractions like televisions, Wi-Fi, or a garden for children’s play areas helps to reduce patient anxiety.

Depending on the majority of customer age group the nature and content of the distraction can be chosen. For example, educational posters displayed in waiting rooms will impart knowledge and educate the people thereby providing distraction from waiting time period.

2. Digitisation Digitisation is enabling centralised database that would contain all aspects of patients’ health, reducing the errors, and making processes easier.

By going digital, delivery of healthcare services can be made flexible and efficient beyond the brick and mortar constraints of traditional medicine.

The power of digitisation in healthcare is observed in eHealth, which is a part of the government programme Digital India. Other online processes like ePharmacy, eDiagnostics, eInsurance, eReferrals, would provide a robust ecosystem support to the patients and service providers. The inconvenience resulting due to registration and other formalities can be tackled by customers identifying themselves through the Aadhar number.

3. Behavioural Economics The principles of Behavioural Economics (BE) can be related to the social aspects of healthcare. Patient-related decisions which often involve a certain amount of risk, an understanding of which can be benefited from BE. The doctors can help patients to make informed decisions by offering clear comparison.

Example-Giving feedback to patients

on how they are reacting to treatment and what is the progress, will motivate people towards treatment, & effectively trigger a desire to change behaviour and improve to do better than average. This has been used, to convince patients to quit smoking, by giving them feedback on the ‘age’ of their lungs.

4. Impact of Technology Technology will help in reduction of healthcare costs by allowing clinical

staff to remotely work together and instantly access patient data. This will serve a growing population of patients by allowing physicians to remotely monitor the chronic illnesses, patient’s long—term health, and out of hospital care. Improvisation in diagnoses by bringing together data from disparate devices (e.g. monitors, images, therapeutic devices) over time will help to form a complete picture of a patient’s

Key Platforms to Improve Patient Experience 1. Customer service & Service satisfaction 2. Internal outcome 3. Technology used in hospital 4. Medical staff, Reputation & Behavioral economics 5. Physicians, Referral management & Relationship 6. Facilities available inside the hospital 7. Teaching & Research 8. All hospital related touch points including Receptionist, Housekeeping, Room service, Check outs when it involves finance

Figure 2

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Benefits of aligned customer services

Health benefits

Business benefits

• Improves patient data collection • Increases preventive care by patients • Increases cost savings from a reduction in medical errors, number of treatments and legal costs • Reduces the number of missed medical visits

• Incorporates different perspectives, ideas and strategies into the decisionmaking process • Decreases barriers that slow progress • Improves efficiency of care services • Increases the market share of the organization

Social benefits • Increases mutual respect and understanding between patient and organization • Increases trust • Assists patients and families in their care • Promotes patient and family responsibilities for health

Figure 3

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way forward for healthcare to address major challenges.

The benefits that an organisation will gain from systematic and aligned customer services are mentioned below.

Fig3.

Degree of maturity in hospitality

Lean management applied in healthcare aims at boosting productivity, improving customer and employee satisfaction thereby reducing the lead time. Analysing the current situation of

Author BIO

health status. Technology helps improve medical equipment functionality and maintenance. For example, wireless sharing of information improves the functioning of healthcare ICT systems.

Technology also allows monitoring of the consumption of medicines on time, reduction in the time taken to settle insurance claims and admissions for insured persons, and provide the data generated in an ambulance during the transit to the hospitals and doctors in real-time, thereby making the emergency care more efficient. In most of the cases, however, the ambulance and the ICT system of hospitals have difficulty in integrating and exchanging information.

Designing the processes to streamline the healthcare services technology is bringing a revolutionary change across healthcare sector. By enabling telemedicine to reach to rural communities, technology is creating a

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the hospital and to assess the suitability of lean activities is essential. As per the needs and requirements of the hospital, optimisation of the goals, methods and accompanying change management can be carried out. This ensures the success and sustainability of lean hospital projects. Lean hospital management offers leaders many possible ways to establish professional, process-driven healthcare organisations.

References are available at www.asianhhm.com

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 & 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.

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From ICU to I See You Small things make a big difference in healthcare

Small Changes to Make a Big Difference in Patient Care - Once an ICU patient for three months (two of which were in a coma), Nancy recognises the incredibly challenging job of medical professionals committed to delivering the highest quality healthcare to the most ill patients.

Through her unique perspective Nancy identifies communication strategies and multiple low-cost, high-impact techniques to achieve higher patient satisfaction.

Nancy Michaels, President, NancyMichaels.com

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O

n May 15th 2005, on a flight back home after a speaking engagement in Atlantic City, I suddenly fell ill. I was too weak to walk and I had to be taken off the airplane in a wheelchair and brought to my local ER. The following morning, I was transported by ambulance to the Intensive Care Unit (ICU) at Beth Israel Deaconess Medical Center in Boston. I was sick—really sick. On death’s door kind of sick. But like many of your sickest patients, I didn’t know how ill I really was. Within three days of arriving to the ICU, I was told that I was undergoing complete organ failure. Although my kidney's improved, my liver would need to be replaced. I never thought I’d be the recipient of an organ donation….

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until then. Three days later, I was in a medically-induced coma waiting for a viable organ.

I would either wake up with someone else’s liver, or I would never wake up.

When I awoke on July 17th, I learned that I had survived a liver transplant and had died twice—the second time for more than two minutes leaving my medical team to wonder if I’d be the same cognitively if and when I woke up from the coma. They had found a blood clot in my new liver after finishing the transplant and needed to remove it in order to take the blood clot out and make sure there were none remaining.

They told my family to be prepared as I might need long-term medical care, after a more than 13-hour surgery that started on a Sunday night and ended the following Monday morning.

Two weeks after the transplant, while still in a coma, I underwent emergency brain surgery for an abscess that was found during a routine CT scan. I became septic and a hole was drilled into my skull to alleviate the cranial pressure

A Doctor’s Case for Moving Forward with a Life-Saving Procedure

What matters to us patients are the small things that are said and done that keep our spirits up and give us hope.

I was also trached so I couldn’t speak or move and was in an almost constant state of panic.

When you’re as critically ill as I was it takes a miracle and a lot of ‘big’ changes and saves by an esteemed medical team to get you to the other side of being healthy again. It also takes so many ‘small’ things that may seem inconsequential to the nurses, aides, interns and cleaning staff that make a huge difference in a patient’s physical, mental and emotional health—all important parts of healing.

According to my liver doctor, Dr. Michael Curry, “Nancy was transferred into us with abnormal liver blood tests and she was quite ill when she arrived here. Within a matter of a few hours we determined that Nancy actually had liver failure— her liver wasn’t working correctly. And she had developed this unusual form of liver failure called acute liver failure; this is an illness that occurs in patients who have no prior history of liver injury. And as a consequence to exposure to a virus or some other [sic] and damaging effect to the liver, the liver actually becomes dead tissue in a matter of a few days to a few weeks. These patients are as close to dying as one can get.

At that time the only thing that was going to save Nancy was a liver transplant.

In some patients who develop acute liver failure they can also develop a problem where their brain begins to swell with fluid and they develop a condition called cerebral edema.”

As Dr. Curry stated I was as close to death as a human could be; so sick in fact, they almost elected not to do the surgery. Thankfully, Dr. Curry made a life-saving case for moving forward with the transplant given that I had no prior illness, was young and relatively healthy and the mother of three young children.

One Person can Make a Huge Difference

When a team of at least 10 physicians left my room shortly after my arrival into the ICU, and after what felt like hours, Frank, a nurse, came along who was able to make me feel more at ease.

He was the first person who greeted me in the critical care unit, with a warm smile, twinkle in his eye and a salt and pepper beard. He made me feel like the most important person he’d ever met.

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Author BIO

In 2005, Nancy was the picture of success: a sought-after business speaker, the president of her own company, and a mother of three. Suddenly, Nancy found herself in a health crisis that would twice nearly end her life.

Miraculously, her extensive rehab left her with no residuals; but, Nancy's life - and the message she wanted to bring to her audiences - were irrevocably changed.

Frank normalised things. He would make a gesture with his two fists and put them together a couple of quick times: giving me the sign that I could do it, that I could make it through this. It was Frank’s version of a high-five and it was a small gesture that offered me great emotional and mental support—all without saying a word.

That first afternoon he commented on my manicure and pedicure and said that he’d never seen this on someone before.

He mentioned it at least three times and asked me what the white tips at the ends of my nails and toenails were called. I told him it was a French manicure. “No wonder you look so great, a French manicure” he said. I was not looking great by any means, but he told me that if I took such good care of myself, he would take care of me the same way; and I believed him. Frank took the time to connect with me as a person, and not just his patient.

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A Seemingly “Small” Thing to do Was a Lifesaver for Me

One week to the day after I arrived in ICU, I received a non-compatible blood type organ from a young woman named Erica from Appalachia, Virginia.

She had died in a car accident.

And was survived by her two children who were ages two years old and eight months at the time. When she was only 16 and received her license, she made the seemingly ‘small’ decision to become an organ donor.

Erica and her family’s immense loss became my lifeline.

Because of that beautiful young woman, the because of the medical community—researchers to surgeons—, from the anti-rejection drugs that keep my new liver working, I’m able to offer you my perspective as a patient.

When Over-Communicating Lessens Fears

I thought that after surviving the transplant that the worst was over.

The last month in the ICU left me in a constant state of fear that I would die of suffocation trying to be weaned off the respirator.

I wish that someone had explained to me that since I wasn’t breathing on my own, the machines were breathing for me, and they were gradually and deliberately being dialled down to help my lungs work harder and become stronger on their own so I could eventually get off the ventilator.

Instead, I thought my medical team was trying to kill me. What I didn’t know was that I was suffering from ICU psychosis.

So, would I have understood the nuances of my respirator and what my medical team ultimate objective was going to be? I’m not sure, but my advice would be to continue to send the same simple message and know that your patient may or may not fully believe you. However, there’s a great possibility that she will

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begin to understand and be grateful that you stayed the course in trying to communicate something that could very well be terrifying her.

Nothing but Blue Skies…

While trached, I had been mouthing out that I wanted to go outside. I was consistently told “no”, “you’re too immune suppressed, you need to stay inside for now.”

It was August when Frank came in to see me and took me for a CT scan.

We went down the all too familiar corridors, and he waited until I was finished. As I came out of radiology, he smiled and began to wheel my bed down several long halls deep in the bowels of the hospital— all unrecognisable to me at the time, which I thought was odd, until we pushed through two huge double dark doors blackening the end of another long corridor. Where were we going I wondered?

Suddenly, we were outside on the loading dock of Beth Israel Deaconess Medical Center in the shining sun and breezy fresh air on the most amazing August day.

He pushed my stretcher until my legs could feel the sun’s warmth beating down for the first time in months.

It was an unforgettable moment for me. It meant so much that he would take time to do this for my sake. It is probably my most positive memory of being hospitalised (other than taking my trachea out).

Never Underestimate the Power of Providing Hope

After being transferred from the ICU to Rehabilitation and re-admitted for ‘failure to thrive’ diagnosis, I returned 11 more times over the next six months for various complications. I had two rejection episodes, high potassium levels, aspergillum in my lungs, and an inner ear imbalance causing an almost constant state of being nauseous and unable to eat.

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One day, Erin my nurse practitioner was telling me when I needed to make the next appointment, and when to take another new medication that I had been prescribed. I was at an all-time low, feeling horrible several months after my transplant, and I looked at her with raw emotion and asked her, “Erin, will I ever get better?” She looked at me with an expression of almost disbelief and said, “Yes, yes, you will get better.”

I realise now, that Erin hadn’t a clue as to whether my situation would turn around or not, but she did know what to say. She gave me hope when I had none. I know there’s a fine line between lying and offering encouragement, but her words and the way she said them, gave me strength in that moment that I held onto. I remember deceiving myself into believing that “if Erin said I’d get better, then I will.”

Final Thoughts

Obviously, patients want great technical expertise (that doctors have), we want the best physician to make the diagnosis, perform the surgery, and continue to administer treatment to ourselves and/or family members. But what matters to us patients are the small things that are said and done that keep our spirits up and give us hope.

There’s an expression that “little hinges swing big doors,” and that’s so true. It doesn’t take a lot of effort to make a significant difference.

I hope that my experience can help you become more effective communicators and even more compassionate and empathetic to your patients. It can help to reduce their fears, drive better outcomes, increase compliance and patient satisfaction. In the end, it may be the small things that mean the most.

You save lives; we provide the right environment

Multicare

OptiCare

Eleganza 3XC

Eleganza 5

icu.linet.com Members of LINET Group

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Surgical Safety in Operation Theatres The patient safety in the operating room commences before the patient enters the operation theatre and includes attention to all applicable types of preventive premedication errors, but surgical errors are unique and need to emphasised. Potentially preventable surgical errors have received increasing attention in recent years. A structured communication pattern between the patient, the surgeon and other members of healthcare team form basis to prevent surgical errors. The surgical environment presents a challenge to safeguard patient safety.

These injuries can be serious and advised to monitor patient with the help of checklists, systems, and routines that reduce the chances of wrong-patient, wrong-side, wrong-part surgical errors, and retained foreign objects. Patient safety in surgery demands the complete attention of skilled surgeons using well-functioning equipment under adequate supervision.

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

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S

urgical care is a fundamental part of healthcare around the globe. Ensuring surgical safety in operation theatres is the need of the hour. A safe and salubrious operating theatre is achieved only through careful planning, maintenance and periodic checks, as well as proper ongoing training for staff.

An operating theatre is a complex system with numerous risk factors, including not only the features of the structure and its fixtures, but also the management and behaviour of healthcare workers. The Safe Surgery

Facilities & Operations Management

Saves Lives initiative was established by the World Alliance for Patient Safety as part of the World Health Organization’s (WHO) efforts to reduce the number of surgical deaths across the world. Safe surgeries ensure less morbidity and mortality, improved quality of work, less liability, and greater efficiency.

There is increasing evidence that to achieve the full benefit of the checklist, there needs to be an understanding of, and a strategy for, mitigating the technical, socio-political, and psychological barriers to using the checklist. Freestanding surgical units may need to be particularly vigilant in ensuring that personnel and equipment are in good condition for surgery. Protocols and procedures to identify and manage stress and fatigue in surgical personnel may help to avoid surgical errors and patient injuries.

The operating room is an appropriate educational environment, but the presence of observers at any level must not be allowed to compromise patient safety. Patient safety in surgery demands skilled individuals using well-functioning equipment under adequate supervision.

Modern Issues of Patient Safety

Medical errors are inescapable in healthcare profession. The identification of causes and implementation of safety plans to reduce these errors will help to establish an effective patient safety in operation theatres. The causes advocated

by WHO are enlisted below: • Lack of continuous training and education • Past tolerance of unsafe practice • Lack of regulations /rules • Gaps in communication among different healthcare providers • Gaps in communications between healthcare providers and patients • Unstable /unreliable systems • Fear of admission of guilt / wrong doing • Human factors

There are various theories which are proposed for system failure. One of the most common is referred to as the “Swiss Cheese Model” of accident causation. Every step in a process has the potential for failure.

The ideal system is analogous to a stack of slices of Swiss cheese. Consider the holes to be opportunities for a process to fail, and each of the slices as ‘defensive layers’ in the process.

An error may allow a problem to pass through a hole in one layer, but in the next layer the holes are in different places, and the problem should be caught. Each layer acts as a defence against potential error impacting the outcome as described in (Figure 1).

For a an error to happen, the holes need to align for each step in the process allowing all defences to be defeated and resulting in an error (Figure 2). If the layers are set up with all the holes lined up, this is an inherently flawed system that will allow a problem at the beginning to progress all the way through to adversely affect the outcome. Each slice of cheese is an opportunity to stop an error. The more defenses you put up, the better. Also the fewer the holes and the smaller the holes, the more likely you are to catch / stop errors that may occur.

Figure 1&2 Surgical safety operation theatre-swiss cheese

Special Considerations for Surgical Procedures

Procedure Scheduling Scheduling the procedure is very important and is a form of OT planning. All surgery requests should be made in writing and verbal requests by the medical staff should be avoided to prevent any errors in scheduling the procedure. Verification of every document including consent, history, and surgeon orders at the time of scheduling is necessary.

Electronic medical records improve the safety process, decreases misunderstandings and missing documents.

Pre-operative measures to prevent errors A preoperative check up by the concerned doctor gives an added opportunity to correct any mistakes and inconsistencies in the documentation.

All discrepancies should be mended at this step before proceeding further with surgical procedure. The informed consent should be duly signed before the procedure. Patient should be explained about the surgical procedure, associated complications, additional procedures, placement of foreign material (Meshes, Plates, Screws, Stents).

The next approach is to mark the site of the procedure to avoid wrong site surgery. The formulated guidelines for marking the site are; involving the patient while performing site marking, to be marked by a licensed practitioner who is responsible for the procedure and the marks should be unambiguous and uniform within the institution and should be semi-permanent to be visible after skin preparation and draping.

The institution should have a written process to ensure that the correct site is operated on. Alternatively, radiopaque markers can be used in the procedures involving fluoroscopy.

Surgical armamentarium (e.g. required instruments, guide wires, laser fibres, scopes, stents, loops, prosthesis, etc.) should be verified prior to procedure.

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Facilities & Operations Management

In OT Just Before the Commencement of Surgery

Implementation of safety checklist as proposed by WHO is the main objective at this stage. This helps in improving the outcomes. In a study by Russ S. et al., more than 40 per cent of cases had absent team members, and over 70 per cent of the team members failed to pause and focus on the checks. The timeout is a critical advantage to pause and be sure that the team is aligned about what is being done to whom in which location," Double- and triple-checking a patient's surgical information is worth the extra time to avoid errors. Conduction of timeouts on electronic white boards ensures correct patient identification, site marking, draping and other essential elements are followed. The collaboration of team members in this task is essential at every step for smooth work up.

In the modern age of medicine, digital images, displaying the CT-scan, X-rays on an auxiliary monitor during the procedure act as a guide for surgeons and improve patient safety.

The consequences of positioning related injuries are preventable but can be profound and can result in morbidity, and litigation. Neurological, vascular, musculoskeletal, and pressure ulcers are the most common position related injuries in surgical patients.

Neurological complications can be avoided by placing forearms in neutral position or slightly supinated to minimise pressure in the cubital tunnel. It is advised to strap and place them adequately to maintain the correct limb position during the procedure even if the surgical table is moved. The patient’s head should be placed in a neutral position and the arm should not exceed abduction of more than 90° to avoid brachial plexus injury. Straps should not be too tight to prevent ischemia and compartmental syndrome. Padding under osseous prominences can help

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avoid pressure-related complications.

Surgeons must be observant to avoid possible compartment syndrome (limbs) when positioning patients for open, endoscopic, and laparoscopic surgeries.

Collection of Biopsies and Surgical Specimens

A large amount of patients, multiple samples from the same patient, lack of staff, and lack of continuous education and training of healthcare workers account for medical errors.

Approximately 1 per cent of general laboratory specimens are misidentified and can lead to serious harm for patients.

Implementation of safety strategies and educating healthcare workers to perform those tasks with as few errors as possible is the mainstay objective.

Documentation, writing policies and protocols detailing responsibilities makes the task simpler and avoid errors. To make the process as simple as possible, reducing the number of steps between collecting the samples and receiving the laboratory report should be encouraged.

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Procedures that involve biopsy and tissue sampling a specimen may pass through the hands of more than twenty individuals in several workplaces until the final pathology report is given.

These handoffs significantly increase the risk of a mix-up and can lead to serious diagnostic errors. Mutual cooperation for supervision of clinicians, technicians, and administrative assistants is essential to prevent and detect errors. The most precarious steps of the biopsy process include labelling of the specimens, appropriate request forms, and accessioning of biopsy specimens.

The modern methods for data entry, automated systems for patient identification and specimen labeling, as well as two or more identifiers during sample collection are important steps to reduce misidentification. If misidentification is detected, rejection then recollection is the most suitable approach to manage the specimen. The introduction of innovative methods DNA analysis to assist with correct identification can be used when recollection is not available.

Facilities & Operations Management

Planning a discharge has been shown to influence patient outcomes; patient safety can prevent readmissions and improve patient satisfaction. Patient education (Postoperative instruction charts) is when they are discharged home with catheters, stomas, stents, drains, or any other medical device that needs special care. Patient education can reduce complications and improve their quality of life after surgical procedures.

Healthcare workers must be aware that language barriers, socioeconomic status, and age can impact patient comprehension of instructions.

Medication Safety During Administration

Medication safety is ensured by applying the five R’s: right drug, right route, right time, right dose, and right patient. Medication errors are barriers that prevent the right patient from receiving the right drug in the right dose at the right time through the right route of administration at any stage during medication use, with or without the occurrence of adverse drug events.

Modern systems of information technology, such as computerised order entry, automated dispensing, barcode medication administration, electronic medication reconciliation, and personal health records are essential in the prevention of medication errors.

Electronic medical records help in rapidly screening the medication regimens of hospitalised patients and deliver timely, point-of-care intervention when indicated.

The most common prescribing errors are incorrect drug, incorrect dose, allergies, and drug-drug interaction.

It is important to tailor prescriptions for individual patients, identifying allergies, pregnancy, lactation, age, co-morbidities. Healthcare workers must be familiar with the medications they prescribe and need to know the medications in their specialty that are associated with high risk of detrimental

effects. Drug interactions can lead to serious adverse events or decrease drug efficacy. Prescribing health-care workers should ask patients of any use of over-the-counter medications or dietary supplements because they are frequently under reported and may cause drug interactions. Prescribing the generic name of drugs simplifies the communication among healthcare workers, reducing errors. However, patients need to be educated that their medication may be called by different names (brand and generic name) and they should be encouraged to keep a list of their medications, including both the brand and generic name of each drug.

Education and Training of Healthcare Workers

Formal training to doctors, nurses, and other operating room staff is essential to help foster a team approach. This helps in break-down of the hierarchy present in the operating room. The nurses and other operating room staff should be more comfortable in questioning the physician if they felt that something was going wrong. This operational behaviour forms a pillar of strength in operation theatres.

Technological advances, novel surgical devices, and minimally invasive techniques are rapidly increasing within the surgical community. Concerns about device safety and training are increasing, making it important to protect patients from harm. Devices need to be extensively evaluated in research before and after FDA approval.

Author BIO

Postoperative Discharge Work up

The residents are subjected to follow a pre-planned schedule during their duty hours and it is imperative to consider ensuring that patient safety is not jeopardised by breach in the care. The handover process is the bridge to continuity and safer patient care. Medical educators and clinicians should work toward adopting and testing principles of optimal handover processes in their local practices by applying the knowledge of patient safety issues discussed in this report.

Conclusion

It is better to be safe than sorry. The universal operative procedure for OT etiquette is to be followed to decrease the risk of random inappropriate practices. The voluntary pre-operative briefings in the operation theatre allows the surgeon to make the process on their own. The overall acceptance is slow and adherence to the protocols in operation theatres will be more robust if every surgeon claims ownership. A good and well furbished OT set up with implementation of staff education will prepare the healthcare personnel to reduce the probability of unwanted incidents—delivering safe, effective, and a high standard of care to all patients.

Acknowledgment

I thank Dr. Rajesh Sardana, medical writer, Max Institute of Minimal Access Metabolic and Bariatric Surgery for compiling the content of article References are available at www.asianhhm.com

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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Information Technology

Use of Telehealth Technology to Increase ED Capacity during Times of Surge Emergency Departments (ED) usually function with limited staff trained for its proper functioning. During times of surge, the situation gets complicated due to nonavailability of sufficient resources. Telehealth technology, through its ability to bridge the physical divide between casualties and their care providers, is could to be very successful in helping to deliver higher levels of care.

This article discusses how this is made possible.

SB Bhattacharyya, Health Informatics Expert

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E

mergency departments by nature exist to take care of those that are critically ill and demand attention of an immediate nature to lessen mortality. They require personnel with special skills to be able to discharge their required functions most effectively. For a number of reasons, such personnel are not available in sufficient numbers at the best of times.

Their paucity is particularly felt during

Information Technology

times of surge when all the available resources in terms of personnel and material are employed to over-capacity and fresh arrivals threaten to throw the entire effort off-gear more frequently than what is comfortable.

Many times it makes more sense to treat those in need of attention in the field or at locations that are not geared up for emergency medical care in terms of the right personnel even if much of required equipment may be available. In such instances, telehealth technology can act as a “care multiplier” of sorts by having the specialists be available virtually instead of physically. This helps in enabling the delivery of better care leading to better outcomes in terms of both morbidity and mortality.

Let’s look at the ways and means of how this can be accomplished.

Telehealth Technology

Telehealth technology can be defined as the employment of modern day telecommunications and information technology to help provide healthcare services anytime anywhere. Mobile technology, handheld devices, the cloud, smartphones, tablets, ability to handle big data, Hadoop systems, Map Reduce, connectivity using Wi-Fi, Bluetooth®, Near Field Communication (NFC), QR codes, authentication using One Time Passcode (OTP), message encryption-decryption technology, etc., are all helping make telehealth emerge from the pages of articles and the ivory towers of academia to help transformation of healthcare delivery a reality.

Challenges of ED

On any given day, the emergency department is typically a beehive of activity. At out-of-office hours (read outside-of-OPD timings) it is usually the first port of call for any person with a health issue. Unfortunately world-wide, the department is almost

Telehealth technology has the potential to, and indeed can, deliver the much required care multiplier capabilities to all areas of healthcare.

invariably short of well-trained staff due to a variety of reasons, one of which is high rates of burnout due to high stress. Emergency care is the doorstep of critical care, where time is of the essence. Clinical situations handled within the “golden period” proves crucial to a successful outcome more often than not.

Surge and Emergency Care

During epidemics or situations with mass casualties, the emergency department, and consequently emergency care, resemble more of a fall-out shelter and often an extension of the disaster zone if the facilities are located in proximity. In fact, it is nothing short of a picture of utter chaos during times of surge with patients dead or dying being placed in any are that happens to free at that time and providers having to mill about in any available free space, often leaping over people and equipment, many of whom are not normally accustomed to dealing with anything like it.

This leads to a situation where a department already working at maximal or even beyond maximal capacity is forced to deal with an overwhelming situation. Although with an “all hands on deck” approach by all available

personnel this situation is handled, the paucity of the “right” kind of personnel capable of making the difference forces the situation to be somewhat hamstrung from the very beginning.

At this point, any help of any sort is more than welcome. Unfortunately, it is the human resource, so vital to make a difference between living and dying, that is in severely short-supply.

Telehealth as Care Multiplier

The situation, therefore, is clearly helped by something that would alleviate, even partially, the lack of availability of the experts. This is where telehealth technology can come to the rescue in a very significant manner.

Through its ability to successfully “bridge” the physical distance between the care provider and receiver, it permits experts to provide care to people who need it irrespective of where they are actually located.

However, telehealth is not just limited to “bridging the physical divide” through a variation that can loosely be termed as tele-consultation.

It is capable of doing a whole lot more. To name a few, it can help the outputs of monitors and other assisted living devices including ventilators and pressure sensors to adjust body positions to be telemetered through to the remote experts coupled with the use of appropriate rules-based alerts and triggers that prioritise provider focus and auto-initiate actions to help in providing optimal care.

Methodology

A schematic diagram accompanied by a brief explanation is provided below to help illustrate this concept and understand the methodology that can be used to augment care in times of surge in the emergency department.

Telecommunications technology in terms of communication protocols are used to connect various monitors and audio-video equipment via the Internet and or direct networking to the

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Information Technology

@Remote End Connection Methods / Protocols

@ED

Figure 1 Telehealth technology in action in ED (schematic)

Conclusion

Telehealth technology has the potential to, and indeed can, deliver the much required care multiplier capabilities to all areas of healthcare. The visible

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impact of which would be most apparent in the areas of critical care and emergency services, that is precisely those areas that need high levels of skills and expertise to help ensure lowering of mortality in highly morbid cases.

Sadly, the technology is ill-understood, as a consequence of which it remains abominably under-utilised. The sooner the stakeholders such as providers,

Author BIO

emergency department. Information technology is used to process the clinical data collected at remote locations and present to the emergency and critical care specialists located in the ED for necessary action.

The specialists can then take an appropriate decision to either evacuate a casualty to the emergency department or treat the person locally, based on their informed clinical assessment regarding the most likely outcome, level of ability to be brought across, degree of injury, etc. The triage may even reveal that the likelihood of an optimal outcome is more if treated at the remote location than being brought across to the ED by providing guidance from a distance to less experienced and/or less qualified personnel.

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authorities, payers, and particularly the patient, begin to appreciate the immense potential it holds, the sooner will it be appropriately harnessed to help keep people healthy and attain the goal of WHO of health for all aka universal healthcare.

References: A DIY Guide to Telemedicine for Clinicians, Dr SB Bhattacharyya, Springer 2017, ISBN 978-981-10-5304-7

SB Bhattacharyya is a practising family physician and health informatics professional with more than 29 years of experience as a general practitioner and business solution architect for digital applications in healthcare, pharmaceutical and medical devices domains. He is currently Member, National EHR Standardisation Committee, MoH&FW, Government of India; Member, Healthcare Informatics Sectional Committee, MHD 17, Bureau of Indian Standards; Member, IMA Standing Committee for Information Technology, IMA Headquarters; and Head – Health Informatics, TCS.

Advertising in AHHM magazine will right away showcase your products to key decision makers in hospital and healthcare industry in Asia PaciďŹ c, 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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Information Technology

Artificial Intelligence and Healthcare A in AI should stand for Assisting, Augmenting and Amplifying. AI is at the best an extension of NI. What is artificial about it? Can machines learning problem solving and other cognitive functions associated with the human mind, be deployed in healthcare? Perspectives of a neurosurgeon trained in the BC era are shared here.

K Ganapathy, President, Apollo Telemedicine Networking Foundation

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Information Technology

T

he term AI or Artificial Intelligence was first introduced

by Mcarthy in 1956. I personally feel that the A in AI should stand for, Augmenting, Amplifying, Accelerating, and Assisting and in an Ambient milieu.

What is artificial in AI? AI is after all an extension, a by product of the Natural Intelligence which Homo Sapiens are endowed with. Augmented intelligence can help expand the role of any domain expert, whether a musician or a doctor, so they can know more in order to do more. Assistive and ambient intelligence can help people execute mundane secondary operations so they can focus on their primary job. Accelerated engineering, analysis and workflows can help expedite the processing of data or accelerate data-rich workflows.

AI will become an integral part of the healthcare delivery system only when

its adoption results in consistently better outcomes and reduced costs. For AI to be successful, the models must be interpretable, not just intelligent. The more that people can understand how the models arrived at their output, the more credible and actionable they can be. This is important in the healthcare space, as health is incredibly complex and full of confounding factors.

AI is defined as “the use of computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, decision-making, and translation between languages”.

Tomorrow’s 5P (Predictive, Personalised, Precision, Participatory, and Preventive) medicine when fully functional will have AI as a major component. This presupposes availability of genomics, biotechnology, wearable sensors and

high speed real time super computing.

Tomorrow’s healthcare will essentially be Big Data analysis. As 80per cent of the 41 Zetabytes (410 trillion GB) of digital information currently available is unstructured, AI will be required to detect patterns and trends, which our grey matter at present is unable to decipher.

Healthcare, normally not an early adopter of new technologies, has seen some of the greatest advances in AI. AI engines are today assisting doctors improve diagnoses, pick the right treatment and monitor care. Bernard J. Tyson, CEO of Kaiser Permanente told Forbes magazine: “No physician today should be practicing without AI assisting in their practice. It’s just impossible (otherwise) to pick up on patterns, to pick up on trends, to really monitor care.”

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‘Chipping’ perhaps indicates the cultural transformation to accept AI in our daily lives. Individuals are having RFID (Radio-Frequency Identification) microchips injected into their hands so they can open office doors, log in to computers, share business cards, and even buy snacks with just a wave. Eye Control now makes Windows 10 more accessible by empowering people with disabilities to operate an onscreen mouse, keyboard and text-to-speech experience using only their eyes and a compatible eye tracker like the Tobii 4C. Who is liable if an AI system makes a false decision or prediction? Who will build in safety features? How will the economy respond if AI makes redundant certain jobs? Forecasting and prediction used in AI are based on precedence.

In the case of machine learning, algorithms can be under performing in novel cases of drug side effects or treatment resistance where there is no prior example to build on. Hence, AI may not replace tacit knowledge that cannot be codified easily. As is common with technologic al advances, AI could replace jobs that previously required humans with computers. AI could be applied to repetitive types of jobs or actions in healthcare.

Machine learning, the basis of AI, is a field of computer science that gives computers the ability to learn without being explicitly programmed. Evolving from the study of pattern recognition and computational learning theory ,these algorithms can learn from and make predictions on data. These analytical models allow researchers, data scientists, engineers, and analysts to "produce reliable, repeatable decisions and results" and uncover "hidden insights" through learning from historical relationships and trends in the data. Can this be extrapolated to individual patient care?

Where are We Heading?

A robot made in China scored 456 in a National level qualification test for

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doctors compared to the pass mark of 350. The same test was answered in the same time in a designated room without internet access! The robot had mastered self-learning and problem solving abilities to a degree.The robot, now certified, will soon make home visits – of course, in driverless cars!

Saudi Arabia has gone one step further.

It became the first country to grant citizenship to a robot. A very attractive intelligent Sophia was introduced at a large investment conference in the Saudi capital, Riyadh. She1 was able to think and respond appropriately at a global press interview. Mirai, a 7-year-old humanoid chat bot whose name means 'future' in Japanese and who functions on the Line messaging app, has become a resident of Shibuya, a Tokyo ward with a population of around 224,000 people. The goal is to "make the district's local government more familiar to residents and allow officials to hear their opinions.”

Key Factors Driving Growth of AI & Deep Learning AI in Clinical Applications

• Analysis of Patient’s Electronic Health Records • Population Health Management • Predictive Care Guidance • Effectiveness of Care Metrics • Physician and Hospital Error Reduction • Medical Image Processing • Oncology Diagnostic Assistance • Large Datasets G.P.Us (Graphics Processing Units Algorithms • Convolutional Neural Networks inspired by the brain • Medical knowledge is doubling every few years • 0 per cent of medical data is unstructured text and images • Aid in early detection & prevention • Decrease diagnosis & treatment errors 1 (I cannot use the term it, otherwise even our definition of living and non-living will have to be reviewed)

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• Ideally suited deployment.

for

telemedicine

AI for the Consumer

Elimination of Unnecessary Procedures and Costs Diet Guidance Payers Claim Processing Cost Comparison Physician, Hospital Staff & Patient Training & Education Predictive Modelling Supply Costs and Management Social Networking Interoperability & Security Wearables Integration Staff Management Virtual Personal Assistants Network Co-ordination Personalised Activity Coaching.

AI in Workflow Optimisation

• Privacy of patient data, HIPAA Regulations • Integrating into existing workflows, EMRs & systems • Resistance to change. Educate yourself and your team about AI • Partner with domain experts in health and AI • Solve the easy problems first with AI to gain acceptance • Focus on goals and patient outcomes, not just the technology • View AI as a tool complementing human expertise & not as a replacement • Fear about AI taking jobs.

AI in Radiology

• Filtering incoming images based on priority using deep learning. The algorithm looks at the images to identify brain hemorrhage or stroke, if the computer detects one of the flagged factors, the patient will move up on the priority list to have their images analysed first. If the algorithm does not detect any critical factors, the patient’s case falls towards the bottom of the priority list.

• Image quality control, imaging triage, efficient image creation,

Information Technology

computer-aided detection, computer aided-classification, and automatic report drafting • Deep learning algorithm can improve MRI image quality even notifying the technologist that images are too fuzzy to be read accurately. MRI image quality will improve reducing patient time in the machine InnerEye is AI-powered computer vision designed to dramatically improve the productivity of radiologists, trained on thousands of 3-D images and radiologist inputs • Diagnosing Skin Cancer: A Stanford study trained on a database of > 130,000 images of skin lesions representing > 2,000 different diseases AI accuracy measured by ability to correctly identify both malignant lesions (sensitivity) & benign lesions (specificity). Evaluated against diagnosis by 21 dermatologists.AI Model achieved accuracy of ~ 91% - matching diagnostic accuracy of dermatologists • Both IBM’s Watson for Genomics and Watson for Oncology are examples

of state of the art AI systems that are currently available to doctors and scientists. In research, the Watson team also is working on a system that will take this classification and reasoning system to the next level, by applying it to images. The project is called Medical Sieve and is ongoing work to use AI to identify instances of breast cancer and cardiac disease. Google Research team has been focusing on increasing accuracy of detecting lesion-level tumors in gigapixel microscopy images • Image Analysis & Diagnosis: Using AI for Diabetic Retinopathy, Input Images from Fund us Cameras With a Deep Learning Model Output Diagnosis grading diabetic and hypertensive retinopathy. The Google Research team is developing state of the art computer vision systems for reading retinal fund us images for diabetic retinopathy and for detecting lesionlevel tumors in giga-pixel microscopy images.

Illustrations of deployment of AI in Healthcare AI in Mental Health

• Cognitive Science is a new field intersecting computer science and psychology. AI engines today not only simulate human conversation, they listen, learn, plan, and solve problems • For a student worried about exam results, a new mother dealing with post partum depression, or a successful businessman with a gambling addiction, talking to their families is often not an option. Even if they share how they feel, it is likely that they will be judged rather than supported • AI can make great coaches helping people learn mental health skills in a safe, yet personalised environment. A bot does not judge, and could be the first step in helping to find support. Wysa is an AI based emotionally intelligent penguin. It listens, chats with and helps users build mental resilience by learning skills like reframing negative thoughts and mindfulness. ‘She’ is a

Tyson, CEO of Kaiser Permanente told Forbes magazine: “No physician today should be practicing without AI assisting in their practice. It’s just impossible (otherwise) to pick up on patterns, to pick up on trends, to really monitor care.”

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non-judgemental, empathetic resource with whom one can share just about anything, anytime, and anonymously.

She can be trained in different languages and cultural contexts, establishing trust and connect across socio-economic strata. In three months, Wysa had crossed a million conversations with fifty thousand users. Over five hundred people had written in to say how much it had helped them with a mental health problem, and while it was clearly new and learning, it was better than any other option they had. Some of these users had been suicidal, others lived with Post Traumatic Stress Disorder, social anxiety, depression, or bipolar.

Practitioners started offering Wysa between therapy sessions as a way of practicing skills. For millions who feel lonely and don’t have a support system of friends and therapists around them, AI may well build resilience, provide support and save lives.

Predictive clinical analytics is a major component of AI in healthcare.

The process of inputting historical

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patient data into models to identify and forecast future events, such as the likelihood of a patient relapse, is a sophisticated tool for risk assessment.

The latter is the basis of every doctor patient interaction.

Microsoft’s developments in AI for healthcare have “followed the data.” Healthbot enables healthcare organisations to create conversational interfaces that provide always-accessible information about health, wellness, benefits and intelligent triage, making use of natural language and conversational AI models developed for Bing, Xbox, Cortana and more. Patients can, anytime and anywhere, converse with an intelligent health agent, Microsoft’s Healthbot, go through an efficient triage, and then get intelligently handed off to a nurse or physician in a way that is more efficient, costs less and is more satisfying. The dependence of today’s AI on data has major consequences for healthcare.

The industry is highly regulated, and so is access and use of medical data.

So when systems are set up for accessing

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healthcare data in a compliant way, one will increasingly see the application of AI and machine learning Augmenting Natural Intelligence

Eric Leuthardt, a neurosurgeon entrepreneur, believes that chips can be inserted into the brain to connect with the internet. With no room for hubris or delusion he exemplifies the certitude of a true believer. He is not alone. Last March Elon Musk, founder of Tesla and SpaceX, launched Neuralink, a venture aiming to create devices that facilitate mind-machine melds. Facebook’s Mark Zuckerberg has expressed similar dreams, and last spring his company revealed that it has 60 engineers working on building interfaces that would let you type using just your mind. Bryan Johnson, the founder of the online payment system Braintree, is using his fortune to fund Kernel, a company that aims to develop neuro prosthetics which he hopes will eventually boost intelligence, memory, and more. These devices are not just better hardware

Information Technology

Tomorrow’s 5P (Predictive, Personalised, Precision, Participatory, and Preventive) medicine when fully functional will have AI as a major component.

paralysed limb, Leuthardt has found, he can actually help a patient regain independent control over the limb, far faster and more effectively than is possible with any approach currently on the market. Importantly, the device can be used without brain surgery.

"The good physician treats the disease; the great physician treats the patient who has the disease; Medicine is a science of uncertainty and an art of probability.

One of the first duties of the physician is to educate the masses not to take medicine.

Listen, listen, listen the patient is telling you the diagnosis”. I often wonder how Sir William Osler, author of the above statements would respond to the introduction of ‘Artificial Intelligence’ in healthcare, 110 years later. For centuries, the essence of practicing medicine has been a physician obtaining as much data about the patient’s health or disease as possible and making decisions. White hair (like I have) presupposed experience,

Author BIO

to facilitate seamless mechanical connection and communication between silicon computers and the messy grey matter of the human brain. They need to have sufficient computational power to make sense out of the mass of data produced at any given moment, with many of the brain’s 100 billion neurons firing.

One of neuroscience’s most daunting tasks is to break the code by which neurons talk to each other and the rest of the body—developing the capacity to actually listen in and make sense of precisely how it is that brain cells allow us to function Software relies on pattern recognition algorithms—specific programmes can be trained to recognise the activation patterns of groups of neurons associated with a given task or thought. With a minimum of 50 to 200 electrodes, each one producing 1,000 readings per second, the programmes must churn through a dizzying number of variables. The more electrodes and the smaller the population of neurons per electrode, the better the chance of detecting meaningful patterns, if sufficient computing power can be brought to bear to sort out irrelevant noise. One has to extract the one thing one is really interested in. That’s not so straightforward.

A prosthetic implant could allow one to use a computer and control a cursor in 3Dspace. Users could turn lights on and off, or turn heat up and down, using their thoughts alone. The device consists of brain-monitoring electrodes that sit on the scalp and are attached to an arm orthosis; it can detect a neural signature for intended movement before the signal reaches the motor area of the brain. The neural signals are on the opposite side of the brain from the area usually destroyed by the stroke—and thus are usually spared any damage. By detecting them, amplifying them, and using them to control a device that moves the

judgement, and problem-solving skills using rudimentary tools and limited resources. Today with the imminent disruptive technology, fashionably termed AI is poised to become a reality even in healthcare, do we need to sit back and critically evaluate what this would actually mean.

Altruism, benevolence compassion, commiseration, concern, consideration, empathy, humanity, kindness, knowledge, sympathy, trust, understanding, and wisdom, - these are the characteristics a doctor of the twentieth century was identified with. Will the Sofias and Mirais of the next decade shed tears when a patient dies? Who knows, may be they will! But then the old individualised family doctor patient sanctified relationship, is being replaced with terms like ‘the healthcare industry’, ‘healthcare provider’, ‘consumer’ client’, ‘predictive analytics’, ‘machine learning’ and AI. Doctors of today beware your grandchildren will consider you a relic belonging to the Neolithic era.

So buck up, become familiar with ‘deep learning’ and ‘Bayesian Networks’ if you want to understand the language tomorrow’s medical students will be talking. These are, of course, the perspectives of a neurosurgeon trained in the BC era! CharlesDickens began his immortal ‘Tale of Two Cities’ with the statement : “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us”.

He could very well have been referring to AI and NI. After all, good and evil are two sides of the same coin.

K Ganapathy (Neurosurgeon) is a Past President of the Telemedicine Society of India. Former Secretary and Past President of the Neurological Society of India. Formerly an adjunct professor at the IIT Madras and Anna University, Chennai. He is currently Emeritus Professor at the Dr MGR Tamilnadu Medical University. He was formerly honorary consultant and advisor in Neurosurgery at Armed Forced Medical Services.

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MEDICAL MANUFACTURING ASIA 2018 Delivering solutions for the future of medtech Mark your calendar for the 4th Manufacturing Processes for Medical Technology Exhibition and Conference from 29-31 August 2018

Innovative medical technology is an increasingly important driver for delivering efficiencies in the global healthcare system. Through advances in medical technology, precision engineering, micromanufacturing processes, and IT, medical devices and solutions have become more sophisticated, accurate and effective.

As a specialist exhibition on manufacturing processes for medical technology, the 4th edition of MEDICAL MANUFACTURING ASIA will focus on new manufacturing technology and automation which play vital roles in driving innovation and operations.

The upcoming edition will highlight companies that cover the spectrum of additive manufacturing or

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3D printing technologies, imaging and diagnostic imaging solutions, as well as nano manufacturing and automated solutions.

Singapore continues to grow its medtech presence on the world stage, with a sizeable number of complex scientific instruments already designed and manufactured in the country, the 3-day exhibition strongly reflects Singapore’s focus on moving upstream to not just production but also value engineering. For companies keen on engaging global medtech companies and see Singapore as an ideal base to develop products for the Asian region, MEDICAL MANUFACTURING ASIA 2018 provides a highly relevant springboard.

MEDICAL MANUFACTURING ASIA 2018 comes against a dynamic backdrop which sees the Asia Pacific medtech market expected to surpass the European Union by 2020 as the world’s second largest medtech market after the United States1, while on the global front, the medtech sector is expected to grow 5 per cent or more annually through to 2022, to reach nearly US$530 billion2.

With Singapore’s positioning as Asia’s top location for medtech and home to over 30 globally-recognised medtech companies, MEDICAL MANUFACTURING ASIA 2018 continues to attract a highly international exhibitor base coming mainly from Asia and Europe and a trade visitor base that is predominantly represented by the medical devices and instruments, medical and healthcare, and electrical and electronic sectors from around the region.

Complementing the exhibition is the half-day forum on High-technology for Medical Devices where exhibitors will present and share latest developments and trends on the global and domestic fronts and market opportunities for medtech products from Europe. Organised by IVAM Microtechnology Network, the German-based international association has an extensive membership with companies in the fields of microtechnology, nanotechnology, advanced materials, and photonics.

MEDICAL MANUFACTURING ASIA 2018 is also synergistically co-located with the region’s leading medical and healthcare exhibition, MEDICAL FAIR ASIA – thus providing an end-to-end solutions 1. APACMed Annual Report 2016

and business sourcing platform across the entire value chain for the medical, healthcare, medical manufacturing and medtech sectors. Jointly organised by SPETA (Singapore Precision Engineering and Technology Association) and Messe Düsseldorf Asia, the exhibition is modelled after the No.1 global trade fair in the medtech sector, COMPAMED, held in Düsseldorf, Germany.

The 4th edition of MEDICAL MANUFACTURING ASIA is fast gaining traction as the region’s leading specialist trade exhibition for the medtech and medical manufacturing sectors. Following the success of the 2016 edition, the exhibition welcomed 200 companies from 18 countries, and 5,420 trade visitors from 52 countries. For booth space booking and more information on MEDICAL MANUFACTURING ASIA 2018, please visit www.medmanufacturing-asia.com.

For more information on the exhibition, please contact: Exhibitor Contact: Daphne Yeo Senior Project Manager Tel: (65) 6332 9682 daphne@mda.com.sg Press Contact: Melvin Chye Marketing & Communications Executive Tel: (65) 6332 9652 melvin@mda.com.sg

2 EvaluateMedTech™ World Preview 2018

Advertorial www.asianhhm.com

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Products & Services Company............................................... Page No.

Company............................................... Page No.

HEALTHCARE MANAGEMENT GlobalData...................................................................... 13

MMA 2018.......................................................... 05, 58-59

IMMEXLS........................................................................ 03

MREPC........................................................................ OBC

MMA 2018.......................................................... 05, 58-59

Radiometer..................................................................... 37

MEDICAL SCIENCES

FACILITIES & OPERATIONS MANAGEMENT

Bexen Cardio.................................................................. 21

Cantel............................................................................ IFC Greiner BioOne............................................................... IBC

TECHNOLOGY, EQUIPMENT & DEVICES ARBOR Technology Inc................................................... 23 Bexen Cardio.................................................................. 21 Cantel............................................................................ IFC

Linet............................................................................... 43 MREPC........................................................................ OBC Radiometer..................................................................... 37

Greiner BioOne............................................................... IBC

INFORMATION TECHNOLOGY

Medipac SA.................................................................... 17

ARBOR Technology Inc................................................... 23

Suppliers Guide Company............................................... Page No.

Company............................................... Page No.

ARBOR Technology Inc................................................... 23 www.arbor-technology.com

Linet............................................................................... 43 http://icu.linet.com/en/

Bexen Cardio.................................................................. 21 www.bexencardio.com

Medipac SA.................................................................... 17 www.medipac.gr

Cantel Medical............................................................... IFC www.medivators.com

MMA 2018.......................................................... 05, 58-59 www.medmanufacturing-asia.com

GlobalData...................................................................... 13 www.globaldata.com

MREPC........................................................................ OBC www.mrepc.com

Greiner BioOne............................................................... IBC www.gbo.com/preanalytics

Radiometer..................................................................... 37 www.radiometer.com

IMMEXLS........................................................................ 03 www.immexls.com

To receive more information on products & services advertised in this issue, please fill up the "Info Request Form" provided with the magazine and fax it.

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

0LQL&ROOHFWÙ Capillary Blood Collection System Simple sampling for different patient groups Easy sample transfer with integrated blood collection scoop No accessories necessary, such as capillaries or funnels Leakproof caps for safe transport Complete version particularly for automated analysis of the sample Greiner Bio-One GmbH | Bad Haller Straße 32 | A-4550 Kremsmünster Phone: (+43) 75 83 67 91-0 | Fax: (+43) 75 83 63 18 | E-mail: office@at.gbo.com

www.gbo.com/preanalytics