Asian Hospital & Healthcare Management - Issue 42

I S S U E 42

2018

w w w.asianhhm.com

DIGITAL TRANSFORMATION OF HEALTHCARE BENEFITING MEDICAL PROFESSION

Virtual Patient Advocates To Be . . . or Not to Be? Space Medicine as a Speciality Improbable yes; impossible no

Foreword Digital Transformation in Healthcare “With digital transformation, the consumer, rather than the technology, is in the driver’s seat, and this matters.” – Forbes

Digital transformation has been the buzz word across industries the world over. Healthcare as a sector has been relying on technology to provide better care in an efficient and effective manner. Technology has revolutionised the relationship between care givers, patients and the health systems, enabling healthcare providers offer accurate care with great impact.

EMRs and telemedicine were the buzzwords a few years ago. Now we are talking about wearables, artificial intelligence, surgical robots, big data and machine learning etc. The advent of technologies such as cloud, Internet of Things has led to a disruption in the sector. Interestingly, this disruption is caused by behavioural changes with modern day patients looking for choice of care and control over the same.

Over the last few years, the healthcare sector has begun to focus on creating better patient outcomes through a shift from volume to value-based care. The sector has been trying to catchup with other industries to lay focus on customer-centricity. According to World Health Statistics 2015 by the World Health Organization (WHO), life expectancy of a child born in 2013 is seven years more than a child born 25 years prior. Understandably, technology has played a key role in improving life expectancy through better care.

Healthcare organisations and care givers have at their disposal enormous patient data, which can be analysed to serve patients better and focus on continuous improvement.

Realising the goal of digital transformation in the sector would be possible when healthcare providers and companies rethink business processes. Digital transformation is way beyond just use of various technologies. It’s about making patients the key stakeholders in managing their health. For organisations, it’s about being patient-centric, focusing on patient needs, and leveraging latest technologies and innovations to help patients lead their lives better. Engaging patients at every stage of care giving helps achieve desired outcome of improved health.

The cover story “Digital Transformation of Healthcare - Benefiting medical profession”

by SB Bhattacharyya, Founder & CEO, BC2RI LLP discusses the digital transformation of healthcare accrues various benefits to the medical profession and the professionals.

Prasanthi Sadhu

Editor

CONTENTS

COVER STORY 44

HEALTHCARE MANAGEMENT

Digital Transformation of Healthcare

Benefiting medical profession

06 Patient Experience The past, the present, and the future

SB Bhattacharyya Founder & CEO, BC2RI LLP

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

12 Virtual Patient Advocates To Be . . . or Not to Be? Nancy Michaels, President, NancyMichaels.com

16 Space Medicine as a Speciality Improbable yes; impossible no Ganapathy K, Director, Apollo Telemedicine Networking Foundation

MEDICAL SCIENCES 24 Quality Primary Care for Disease Prevention and Management Md Moshiur Rahman, Associate Professor, Graduate School of Biomedical & Health Sciences, Hiroshima University Michiko Moriyama, Professor, Graduate School of Biomedical & Health Sciences Hiroshima University

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Kana Kazawa, Assistant Professor, Graduate School of Biomedical & Health Sciences Hiroshima University

30 The Mother of Rivaroxaban Discusses the Importance of Accurate Patient Profiling when Prescribing NOACs Sylvia Haas, Emeritus Professor of Medicine, Institute for Experimental Oncology and Therapy Research

34 Obesity is a Disease Pradeep Chowbey, Chairman, Max Institute of Minimal Access, Metabolic and Bariatric Surgery

FACILITIES & OPERATIONS MANAGEMENT 38 Managing IV Infections in India Ninad Gadgil, Country Business Leader, Health Care Business, 3M Health Care

56 Books

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

SENIOR PRODUCT ASSOCIATES Peter Thomas David Nelson Susanne Vincent PRODUCT ASSOCIATES Austin Paul James Taylor John Milton

David A Shore Adjunct Professor, Organizational Development

CIRCULATION TEAM Naveen M Sam Smith

Business School, University of Monterrey, Mexico

SUBSCRIPTIONS IN-CHARGE Vijay Kumar Gaddam HEAD-OPERATIONS S V Nageswara Rao Gabe Rijpma Sr. Director Health & Social Services for Asia Microsoft, New Zealand

Peter Gross Chair, Board of Managers HackensackAlliance ACO, USA

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The products and services advertised are not endorsed by or connected with the publisher or its associates. The editorial opinions expressed in this publication are those of individual authors and not necessarily those of the publisher or of its associates.

Copies of Asian Hospital & Healthcare Management can be purchased at the indicated cover prices. For bulk order reprints minimum order required is 500 copies, POA.

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HEALTHCARE MANAGEMENT

Patient Experience

The past, the present, and the future Looking at the market shift from industry centricity to patient-centricity, patient care is a core element of quality of care. Patient perspective is a critical parameter that should be captured using tools and techniques, as it helps in shared decision making and permissively shows the impact of care on patient’s experience. As we follow the thought- past is experience, present is experiment and future is expectation, use patient experience to conduct ethical experiment to achieve tomorrow’s expectation. Tools capturing patient satisfaction and medical outcomes might guide HCPs to understand various nascent aspects of care which will improvise quality of the patient care.

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

T

he term ‘patient experience’ is subjective to the factors not directly associated with the quality of processes. The measurement of patient experience is complicated

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by numerous terms and usages that have been applied. Therefore, patient experience is seen as a central outcome alongside clinical effectiveness and safety. Despite the convolution

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surrounding which definition to embrace or which components to measure, the patient experience in a healthcare context incorporates the patient’s journey as a whole and that is a

practically, managerially, and clinically important concept to measure.

It is of utmost importance to know the experience of patients and their family and friends in an attempt to improve the services that are available, to further enhance strategic decision making, to improve care and meet patient expectations and effectively manage and monitor health care performance. Besides that it links to clinical outcomes and costs.

In order to get an insight on patient experience, different approaches are carried out based on the depth of information provided by patients and the extent to which the information is collected, that may be generalisable to wide range of population. The common approaches include surveys, interviews and patient stories.

Healthcare Organisation

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Perception of Management regarding Patient experience G2 Translation of Patient perception into Quality services G3

G1

Delivery of Quality services

G5

Patient

Since the literature on quality of services provided is not enough to provide a base to prove the facts of lack of quality services, a qualitative study must be undertaken to investigate the concept of quality services. For example, focus group interviews with patients and executives of management of healthcare organisations can help to develop a conceptual model of quality services.

In-depth interviews of executives can also guide in the development of such a model. Qualitative study covering five nationally recognised hospitals, could have the questions like: a) What do staff, executives of healthcare management think about the key attributes of quality services? b) What issues and tasks are involved in providing high quality services? c) What do patients perceive to be the key attributes of quality services? d) Analysis of the answers received from executive, staff of Healthcare organisation and patient, studying whether there is any disparity between the perceptions of patient, staff of healthcare organisations.

Exterenal communication to Patient

Perceived services

Descriptive Investigation

G4

Expected services

Personal needs

*G - Gaps

Past Experiences

Source: Conceptual model of Quality services, Journal of Making

Figure 1 Gaps in process of implicating the Quality services

e) Can the perception of patient and executive be combined in a general way that elaborates the need of patient for quality services?

Well, some of the commonly observed gaps in the perception of staff and patient needs are the major issues in attempting to deliver a quality service which probably might be incorrectly perceived as being of high quality. The process of implicating the Quality services with gaps is elaborated below in figure 1.

Gap1- Perception of Management Regarding Patient Expectations and Expected Services:

Gap between management perception of patient expectation and actual patient expectation will impact the patient’s evaluation of quality services.

This is the major backlog that is faced by a number of healthcare organisations, for which they need to carry out a qualitative study that will support their decision to improve the quality of services.

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6 Essential Steps of Shared Decision Making

1

2

3

4

5

6

Gaining Patient’s Participation

Providing information and letting patient explore

Asking for patients preferences

Evaluating patient feedback

Discussing available treatment options

Mutually deciding the treatment and maintaining transparency with patient

Figure 2 6 Essential steps of Shared Decision Making

More Descriptive

Gap2- Perception of Management Regarding Patient Expectations and Translation of Patient Perception to Quality of Services:

More Generalised

The translation of the patient perception into services can be hampered because of lack of trained service personnel and fluctuations in demand. For this the trend of patient needs should be observed and accordingly work plan has to be designed.

• Surveys • Comment Cards • SMS questions • Kiosk questions

• In-depth Interviews • Focus groups / panels

• Online ratings • Public meetings

• Patient stories • Ward rounds/ observations • Complaints/ compliments

Less Generalised

Gap3- Translation of Patient Perception to Quality of Services and Delivery of Quality Services:

Though there are specifications and guidelines to deliver the services

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Figure 3 Various approaches to perceive feedback from patients and staff of Healthcare organisations

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Less Descriptive

Shared decision making leads to exploring and comparing the benefits, harms, and risks in measuring quality by the means of patient’s feedback. Shared decision making helps in taking decisions with mutual understanding in case of more than one treatment is applicable, but no treatment has clear advantage over other. Various technology tools go hand in hand with shared decision making, like interactive decision aids, patient portals, and health records. Six steps of shared decision making are shown in Figure 2.

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Approach

Advantages

Limitations

In-depth Interviews

Provides in-depth information Can probe to get reasons Easier to handle sensitive topics

• Provides intensive data • May have difficulty interviewing same samples overtime • Generalisability issues with small samples

Focus groups & Panels

In-depth information Can reconvene same group over time Group dynamic can spark ideas

• Generalisability issues • Resource intensive • High rates of sample drop out over time

Narrative stories

In-depth information Focuses on what is most important to patients and carers

• Generalisability issues • Difficult to draw out key themes • Difficult to track the changes in sample of people over time.

Complaints and compliments

Indicates areas in need of improvement Identify things that people feel particularly passionate about

• Biased towards the most serious aspects of care • May focus upon individualised issues

Photovoice

Gains unprompted feedback & about issues that matter most to participants.

• Participants need to be trained in the approach and in writing captions • Requires camera

Surveys

Descriptive feedback Can use multiple administration methods (online, comment cards, telephone, text messages, in-person)

• May collect only a surface level picture, rather than understanding why people feel a certain way • Subject to self-selection and literacy bias • Closed-ended questions may be more likely to gain positive feedback

Online rating tools

Increasingly promoted and available to large sample of patients

• Only those who use websites provide feedback • Surface level- information • Only cover selected components of patient experience

Table 1

smoothly, the employee’s performance cannot always be standardised.

Sometimes the performance can be excellent, and sometimes it just matches the job needs. Well, one can’t standardise performance but should complete all assigned duties.

Taking into account those duties, the management should plan to implement quality services.

Gap4- Quality Service Delivery & External Communication with Patient:

Communication to patients about the services is critical. Patients are usually not aware of the available services and sometimes hesitate to resolve their

issues. Also, staff should be aware while promising the patient to deliver the services as per needs, as this leads to expectations that when not fulfilled lower the perception of quality.

Gap5- Perceived Services and Expected Services:

The judgement of high or low grade services depends on how patient perceives it in the context of their expectation and needs.

Pros and cons of various ways to get feedback from patients: Measures and approaches provide an opportunity to improvise the services of care, expand strategic initiatives to meet patient satisfaction level and efficiently

manage the healthcare organisation.

There are many variables to measure and apply the approaches that will increase the patient satisfaction level, thus it’s important to start by asking what, how and when to measure.

The preliminary point to start is to set standards and indicators to measure the variables. The variables should cover the domains and dimensions of the factors that lead to the study of patient experience. A key component of a successful strategy to understand and improve the experience is to understand the factors that matters to the patient. For example,nowadays patient-centred services are trending but tools to measure patient experience

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AUTHOR BIO

for quality improvement goals are missing. Nothing can be provided at the cost of quality. Thus, quality of the service provided is one of the most important variables to be measured. To measure patient experience the data can be collected using various formats that collect descriptive or grading feedback. Some of the ways that are commonly used to measure experience are enlisted in figure 3 based on how generalised and descriptive it is.

Following is the list of approaches with advantages and limitations: Patient preferences: Patient perception is an exclusive source of information about the convenience or effectiveness of care. The patient's view directly states the compliance level of treatment and the steadiness of the patient–physician relationship, and hence care outcomes. The patient perceptions help to evaluate the quality, in contrast to other approaches that mainly focuses on the measurement of inadequate processes or undesired outcomes. In several reviews it was found that those organisations that provide “personal” care are associated with higher levels of satisfaction. Achieving and producing health satisfaction goals for individual members is the ultimate validator of quality of care.

A key component of a successful strategy to understand and improve the experience is to understand the factors that matters to the patient.

Evaluation of feedback: The credibility of the research study is based on the concept of validity, reliability and its analytical process.

The feedback received normally follows a pattern representing the thematic framework. The feedback can be coded for a variety of comments; and broad themes should be identified within a framework. The second level of analysis is to identify patterns and relationships in the data that indicate similarities and points towards certain factors. A tentative conceptual model of the experiences of participants can be designed further that might help clarify and support the findings of the quantitative survey.

Patient touch points: As we have seen earlier, the ways to capture the patient feedback and the gaps which we need to bridge, the patient touch points or interactions with healthcare facility and professionals is at the heart of patient healthcare.

The patient touch points determine

patients experience and satisfaction which is not only the clinical task but also determines the patient outcome.

A better healthcare experience will be provided when all those touch points are mapped. Various touch points include scheduling, responding to emergency services, support during testing processes, helping during their transport, treatment procedures, and at the end coordination while billing. This will shift the focus from operations and technology to the customer, and explains the emotions behind each one of the actions that healthcare organisations take.

Way forward: The quality of healthcare depends on the relationship between patients and health practitioners. One recent survey shows that a care-management approach which includes patient involvement is more effective than a standard one-sided approach of healthcare professional. This is particularly marked in the management of chronic diseases like diabetes. However, “patient involvement” is usually overlapped with other terms such as patient participation, patient empowerment, patient centredness, and patient engagement. The concept of patient involvement aids to the benefits to have a central position in overall healthcare process. The benefits are anticipated to be in the form of upgraded outcome for the patient as a result of the improved interaction between the healthcare provider and the patient.

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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All other trademarks are property of their respective owners 9-18

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Virtual Patient Advocates

To Be . . . or Not to Be?

A virtual patient advocate can be the bridge to providing proper care and guidance to a patient and care post discharge. It makes sense that having this extra effort would put a patient’s mind at ease and allow them the freedom to reach out if they have a question they’d like answered.

Nancy Michaels, President NancyMichaels.com

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A

s a speaker and consultant on ways for medical personnel to be more effective communicators with their patients, I am often described by people as a patient advocate. That I am not – it’s not because I don’t believe

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patient advocacy, but it simply wasn’t my experience or my own ability to advocate for myself because of the emergent nature of my organ failure and subsequent surgery and treatment.

I was fortunate to be conscious when

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I entered the hospital and I changed my healthcare proxies to be my parents, rather than my estranged husband who it would have defaulted to.

Having an advocate when you’re a patient is crucial, and to the degree that

you are able to advocate for yourself, even better.

Today, there’s a trend among insurers and hospital systems to provide patients with a Virtual Patient Advocate (VPA) post-surgery and or hospitalisation.

Similar to another type of patient advocate, a VPA is someone who helps to support a patient when they’re no longer under the daily watch of a doctor, healthcare system, or hospital. Ideally, as a patient or family member, you want to have a certain amount of trust in that person and feel confident that he or she is willing to assist you as well as be an effective communicator with members of your healthcare team of physicians and nurses.

An advocate may be a member of your family, such as a spouse, a child, another family member, or a close friend.

It can be a challenging time for patients and care givers after leaving a hospital setting. However, with the help of a VPA, you are offered accessibility to a medical professional who can: • Obtain information for you when you have specific questions or concerns in mind • Help to overcome your fears by letting you know that your wishes, challenges, successes or setbacks will be articulated to your team and potential solutions will be discussed and addressed in a timely manner • Clarify your options for hospitals, doctors, diagnostic tests, and procedures or treatment choices when necessary • Keep track of information that you receive from your medical team with instructions on what might be expected of you as a patient to continue your healing process • Be someone to talk with regarding your procedure, and treatment moving forward • Discuss treatment decisions and changes in your condition? Test results? Keeping track of medications?

Make sure your doctor and nurses have your advocate’s phone number and make sure your advocate has the numbers for your providers, hospital and pharmacy, as well as anyone else you may want to contact in the case of an emergency.

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The landscape of healthcare is changing at an amazingly fast pace.

With emphasis on value-based care, while simultaneously keeping costs in check, technology is and must play a critical role.

As a long-term proficient communicator turned patient within the past 13 years (emergency live transplant 2005), I can tell you that nothing replaces a face-to-face interaction with another human being.

Nothing. However, moving toward a hybrid model of delivering care is necessary for both healthcare systems as well as patients.

Timothy Bickmore, PhD, assistant professor of computer and information science at Northeastern University in Boston, developed the concept of being a virtual patient advocate.

He did this during a clinical trial at Boston University Medical Center to increase a patient and family member(s) understanding of instruction after being discharged from the hospital as well as what was expected from them in their own care routines.

My article in Asian Hospital & Healthcare Management issue 40 was Discharge Begins at Intake that speaks to this topic precisely – but perhaps in reverse order – by helping to educate patients and families from the prior to a hospitalisation if at all possible. Patients and care givers are people who need and want instruction on what they should be doing upon being discharged from a hospital. Providing as much information available and delivering it to each patient and caregiver from the get go is a wise idea. At a minimum, when patients are leaving, clearly stated expectations and instructions should be provided.

A virtual patient advocate can be the bridge to providing proper care and guidance to a patient and care post discharge. It makes sense that having this extra effort would put a patient’s mind at ease and allow them the freedom to reach out if they have a question they’d like answered, are unsure of instructions

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Having an advocate when you’re a patient is crucial, and to the degree that you are able to advocate for yourself, even better.

on how best to care for themselves, or simply want to double check something they may have misunderstood earlier, etc. Because of my experience of more than a decade of being a patient myself, I feel at ease reaching out to my medical team (nurse practitioner most often now) to have a question answered – but it’s taken years.

In the early days, when my parents were helping me after leaving the hospital they were less likely to pick up the phone and call a member of my team for a variety of reasons. If they had a VPA, they would have been more likely to do so because their understanding would be that it is that person’s job to assist them and patients post-discharge.

A year and a half ago, I had a hip replacement due to steroids I had received during two rejection episodes early on after my liver transplant. The x-ray and MRI showed that I had A vascular Necrosis and I would need a total hip replacement. After a brief hospitalisation, I was released and it was my insurance provider, Blue Cross Blue Shield of MA, who had a virtual patient advocate call me to check in and see how I was doing physically – as well as emotionally and mentally. She seemed more like a health coach and it was comforting to know that I had someone

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I could talk to post surgery – when you feel almost forgotten or alone. BCBS is a bright organisation and I’m sure they – like other providers – would find value in offering this kind of support post-discharge as not only a great service to the patient, but as a way to curb increasing costs. Perhaps if questions are answered after a patient returns home, there’s a less likely chance that a patient or care giver would feel that only going back to the hospital or doctor’s office would be the only option. I can’t help but believe it’s the payer’s desire to curb hospital readmissions as well as unforeseen or necessary visits to a doctor when a brief conversation might be all that is needed.

It seems that preparing patients to take the best possible care of themselves when they are home has a positive impact not only on the patient, but also providers and insurers. Makes sense.

That’s why I was provided with a virtual patient coach and I’m certain the field will grow and expand to help patients and caregivers at the onset of a hospitalisation as well.

It’s every medical system and professional’s goal to meaningfully engage with patients and caregivers before, during and after a hospitalisation. Sadly, this isn’t always the case. Virtual patient advocates could work through each part of this process. Before, by reaching out after a pre-op appointment to make sure the patient/caregiver understood the directions of how to prepare for their hospital stay. During a patient’s hospital stay, it might be nice for someone to check in with the patient or caregiver to check in on them and see if they need something or to talk with someone as well as begin to prepare them for the transition back home. Finally, a virtual patient advocate could work to help them transition to a home setting where the patient and caregivers are more comfortable, the cost is significantly reduced making all parties view this as a win-win-win. Win for patients. Win for providers. Win for payers.

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Physician’s medical rounds can be quick and less frequent than what most patients or caregivers need or want – so using a virtual patient advocate could help in these situations as well.

Obviously, upon discharge it makes sense to have this kind of support available for patients and family members or friends who are helping to care for the patient.

More communication is far better than less in most circumstances – especially in ones dealing with an individual’s health and well-being.

Other educational tools are used virtually after patient discharge in the form of mHealth and telehealth tools including wearables, web-based learning, and the ability to call a healthcare professional with a question.

According to a recent survey of more than 900 health plans by Gartner and DirectPath, there’s an increasing number of employers who are making telehealth a part of their health plans and encouraging their employees to opt for telehealth before visiting their doctor or ER/urgent care centre. Clearly, this is a strong indication that employers are thinking very seriously about decreasing medical expenses, but also acknowledging employee’s desire for a greater selection of healthcare service options that are easily accessed.

That’s the take-away from a study in the “2018 Medical Trends and Observations Report , 55 per cent of those surveyed are now offering telemedicine in their health plans – this is a dramatic increase from the

approximately 33 percent who offered the service in 2017.”

From 2002 – 2012, I worked with a big box office supply retailer who hosted a Web Café series specifically for their small business customers – my area of expertise at the time. I produced (recruited authorities on various topics that were important to their customers/ viewers, helped to create their decks, wrote the Top 10 Takeaways from the webinar – and even hosted or presented occasionally. In 2002, it was innovative and unique to provide content via the web to your consumer-base. Today, it’s not so much.

This has changed and continues to a rapid pace and healthcare is catching up in a big way. It’s no longer viewed as going above and beyond to provide additional information or greater “access” to the brand of a service provider or product line. As consumers, we assume it’s part of what comes with the sale. I realise many people in medicine don’t like to consider patients as customers . . . but, we are and this trend will continue as more and more patients become e-patients.

Being ill is incredibly stressful – for both patients as well as their families.

Caring for the ill is quite trying as well and there are plenty of opportunities for situations to escalate. Having a virtual patient advocate can help to alleviate an influx of questions, concerns or

challenges from a patient or family member that can decrease some of these tensions.

As a patient, whether your entry into a hospital is an expected one – or an emergent one – oftentimes, plans fall short of expectations. To say that you’re not at your best is an understatement.

Another relatively easy fix for this is to post-discharge services is to assign a Virtual Patient Advocate. It could be a much more desirable option for the patient and their caregivers, as well as decreasing hospital readmissions and insurer’s responsibility for paying for a much more expensive option of healthcare. It allows patients to still feel cared for and connected to their medical team after they leave the hospital.

AUTHOR BIO In 2005, Nancy was the picture of success: a soughtafter 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. Nancy can be reached at nmichaels@nancymichaels.com

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Space Medicine as a Speciality

Improbable yes; impossible no

T

he recent announcement by ISRO (Indian Space Research Organisation) that India would be embarking on a Human Space Programme Gaganyaan1, scheduled for launch in December 2021 has excited hard core telehealth evangelists in India. India will now be the fourth country in the world, after Russia, USA and China, to launch a manned space flight. Monitoring in real time, the health parameters of the three Vyomanauts—Indian term for astronauts— travelling on a Low-EarthOrbit mission at an altitude of 300-400 km for 5 to 7 days would indeed literally be an ‘out of the world’ task.

We have less than 39 months to get our act together. Travelling @ 27,000 km/h, the spacecraft will complete one orbit around the Earth every 90 minutes.

Manned space missions do pose health risks before, during and postflight for the crew members onboard the spacecraft. There are communication challenges for medical doctors monitoring them, from the ground.

1 https://en.wikipedia.org/wiki/Gaganyaan

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The announcement by ISRO (Indian Space Research Organisation) that India would be embarking on a Human Space Programme was closely followed by media reports of a Japanese billionaire becoming the first space tourist to go to the moon. Several private companies in addition to NASA and the European Space Agency are planning manned trips in outer space. Space medicine therefore will soon become a reality. This article introduces this fascinating subject.

Ganapathy K, Director, Apollo Telemedicine Networking Foundation

Image Courtesy Canadian Space Agency

Physical and mental changes related to adaptation to the space environment, need to be monitored in real-time.

Changes in clinical parameters and management of unexpected medical emergencies need to be addressed and prepared for. Removing the effect of Earth's gravitational force alters all organic functioning. Space motion sickness, characterised by impairment of performance, nausea, vomiting and a diffuse malaise, occurs in astronauts and lasts for the first 72 hours of a space mission. Normal process of bone formation and resorption is disturbed. All of these aspects still require further study and understanding. The space environment has factors such as weightlessness, electromagnetic fields and radiation, that may influence the function and structure of the Central Nervous System (CNS).CNS changes known to occur during and after longterm space flight include neurovestibular disturbances, alterations in sensory perception, changes in proprioception, psychological and cognitive.

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HEALTHCARE MANAGEMENT

Neurophysiological Changes

Image Courtesy ISRO

Headache is a common, but rarely voiced, complaint during space flights.

This is usually attributed to be part of space motion sickness (SMS). It has been suggested that space headache is a separate entity though similar to the clinical syndromes of cerebral venous hypertension. Astronauts have a 53–68 per cent increased risk of experiencing moderate to severe Low Back Pain and a fourfold increased risk of developing herniated intervertebral discs during microgravity exposure and within one year following spaceflight. European Space Agency reported Low Back Pain in 12 out of 20 astronauts during spaceflight. The report highlighted the importance of maintaining spinal movements,

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Acute and chronic effects of hypobaric exposure upon the brain have been evaluated. These include Decompression Sickness (DCS), a commonly experienced condition which may progress to severe neurological or pulmonary symptomatology. The brain (confusion, memory loss, visual changes, diplopia, scotomas, headache, seizures, vertigo, unconsciousness) spinal cord (dysesthesias, parasthesias, constriction and pain around chest or abdomen, ascending paralysis, bowel and bladder incontinence) and the peripheral nerves (fasciculations and parasthesias) can all be affected during space travel. Recurrent exposure to hypobaria is associated with increased White Matter Hyperintensities in MRI images. This is coupled with subtle but significantly lower neurocognitive profiles, leading to concerns regarding short and long-term effects.

Cortical reorganisation in an astronaut's brain after long-duration spaceflight.

Significant differences were found in functional connectivity between motor cortex and cerebellum in the resting state. Changes in the supplementary motor areas were observed during a motor imagery task. These results highlight the underlying neural basis for the observed physiological reconditioning due to spaceflight.

Effect of Gravity on the Nervous System

Microgravity of space appears to affect every single organ and body system, in different intensities and manner, both during short- and long-term missions.

A progressive shift of body fluids and blood from the lower extremities to the upper body occurs in the absence of Earth’s gravitational force. This condition has been nicknamed the “puffy-face and bird-legs syndrome”, as the face of the astronaut becomes rounded, redder and more swollen, while the legs become thinner, due to the redistribution of fluids and blood from the lower to upper body.

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Knowledge about the impact of increased and decreased gravity on the nervous system, is essential to assure the success of human survival in space Mars and Moon have a reduced gravitational force of a third and a fifth of the Earth’s gravitation. Since the first manned spaceflight of Yuri Gagarin in 1961, the effect of microgravity on the human body has been intensively investigated. The many experiments performed, made apparent the gravity induced changes on astronauts.

Persistent modulation in the sensory and motor system and the resulting structural loss of muscle and bone mass have been reported. This is in addition to recalibration of sensory perception, vestibular and proprioceptive functions, changes in muscle synergies and coordination, decline of muscle force as well as changes in posture control, locomotion and functional mobility.

These adaptations are of clinical relevance. Significant adverse effects entail fragility and even bone fractures.

Microgravity of space appears to affect every single organ and body system of astronauts, in different intensities and manner, both during shortand long-term missions. A progressive shift of body fluids and blood from the lower extremities to the upper body occurs, in the absence of Earth’s gravitational force. Microgravity during spaceflight occurs when the force of gravity is unbalanced and the net force becomes so weak that virtual weightlessness results. Application of lower body negative pressure partially reverses the headward shift of blood and body fluids occurring in microgravity. This contributes to the reduction of cardiovascular de-conditioning and has been successfully applied as a countermeasure during space flights. A better understanding of the mechanisms by which microgravity adversely affects the nervous system, will lead to more effective treatments. Several neurologic changes, including Space Adaption Syndrome (SAS), ataxia, postural disturbances,

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HEALTHCARE MANAGEMENT

perceptual illusions, neuromuscular weakness, fatigue, perceptual illusions, and ocular changes have been attributed to the effects of microgravity.

Raised ICP is considered the most mission critical medical problem identified in the past decade of manned spaceflight. Astronauts often develop impaired vision, with a presentation, that resembles syndromes of elevated Intra Cranial Pressure on Earth. Gravity has a profound effect on fluid distribution and pressure within the human. A retrospective review of published observational, longitudinal examination of neuro-ophthalmic findings in astronauts after long-duration space flight revealed that after 6 months of space flight, 7 astronauts had ophthalmic findings consisting of optic disc edema in 5, globe flattening in 5, choroidal folds in 5, cotton-wool spots in 3, nerve fiber layer thickening detected by optical coherence tomography in 6, and decreased near vision in 6. The 300 post-flight questionnaires documented that approximately 29 per cent and 60 per cent of astronauts on short-duration and long-duration missions, respectively, experienced a degradation in distant and near visual acuity.

Future missions in space would involve long-term travel beyond the magnetic field of the Earth, subjecting astronauts to radiation hazards posed by solar flares and galactic cosmic rays, altered gravitation fields and physiological stress. Neurological effects from this prolonged exposure could be detrimental. Data from Mir missions had shown that bone loss continues in space, despite an aggressive countermeasure program.

Average losses were 0.35 per cent per month, but some load bearing areas lost >1 per cent per month. A 1 per cent loss rate, if it continued unabated for 30 months, could produce osteoporosis.

Microgravity, confinement, isolation, and immobilisation have to be

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A better understanding of the mechanisms by which microgravity adversely affects the nervous system, will lead to more effective treatments.

endured during space missions. Longduration space travel could therefore have detrimental effects on human physiology. Preliminary spaceflight studies have shown an involvement of the cerebellum, cortical sensorimotor, somatosensory areas and vestibular pathways. Medications are administered during space flights under the assumption that they act in a similar way as on Earth. Decreased drug and formulation stability in space could also influence efficacy and safety of medications.

Heart and vascular functions are susceptible to changes in weightlessness. The altered cardiovascular function in space causes physiological problems in the post flight period.

Cardiovascular adjustments to microgravity, bone demineralisation, and possible decompression sickness and excessive radiation exposure contribute further to medical problems of astronauts in space. Space programmes to the Moon and Mars would result in increased exposure to space radiation. The biological effects of extended exposure to high-energy heavy ions on the nervous system is not yet understood. However, experimental studies suggest that there could be a risk for developing cancer. Experts are focusing on an increased understanding

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of the oncogenic potential of galactic cosmic rays.

Cardiopulmonary changes, intraocular pressure changes, elongation of the spine, back pain, lack of sleep, circadian rhythm alteration, decreased food consumption, psychological stress and orthostatic intolerance have been reported.

Dressing becomes difficult due to weightlessness(the correct term is microgravity not Zero gravity). Food and drink may float away.

Shaving would be restricted. Disposable clothes would be replaced every three days. Washing would be with wet towels. Solid human would be collected, compressed and stored for later disposal not recycled.

Five hundred and forty two individuals from over 40 countries have been in outer space in over 1,220 space flights, with a total of 46,847 person days in space from 1961 till 2016.

Seventeen non-fatal yet severe medical emergencies have been documented during spaceflights between 1961 and 1999. Astronauts work on tasks for which they have trained for months.

Huge amounts of time, money and effort have been invested in the mission and nobody can afford for an astronaut to be grounded or for a mission to be aborted due to ill health.

The Vyomanauts selected will have to be in super health. They will have to work for a very long time in extreme environments simulated to be as close to outer space. They will have to be well trained in health care including giving IV injections, CPR, being familiar with defibrillators etc. The “Space doctors� on the ground looking after them must be multi-faceted personalities. They need to be an embodiment of patience and perseverance, have problem solving and communication skills, be able to work as part of a close-knit team and keep calm under pressure. Providing remote health care of the highest standard in outer space pre supposes a passionate dedicated team with domain expertise in space medicine,

HEALTHCARE MANAGEMENT

space nutrition, space pharmacy, space nursing, biomedical engineering, Health related ICT and so on.

The relevance of space medicine in an emerging economy, may be questioned.

While it is unlikely that there will be immediate clinical applications for space medicine,knowledge of physical changes due to zero (micro) gravity and radiation will eventually offer additional insights into how the human body functions on earth. We need to understand and accept that the future is always ahead of schedule. Who knows one day some of the younger readers of this magazine may actually be evaluating a space tourist.

Getting such a team together all with a “Made in India” stamp will do wonders for the morale of all the 13,000 individuals who will be part of this mega event. The US$1.5 Billion earmarked for this project will certainly yield rich dividends in creating a new

mindset that we have the potential to be “better than the best”. More important there will be many, many spin offs which will have a major application in exponentially increasing the role of

Health Care IoT. Smart Health will no longer be a hyperbole. The Human Space Programme Gaganyaan2 will ensure this.

2 https://en.wikipedia.org/wiki/Gaganyaan

AUTHOR BIO K. Ganapathy Former Secretary and Past President Neurological Society of India, Telemedicine Society of India & Indian Society for Stereotactic & Functional Neurosurgery. Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services. Emeritus Professor TamilNadu Dr. MGR Medical University URL: www.kganapathy.com E Mail: drganapathy@ apollohospitals.com

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QUADRIA CAPITAL

Servicing healthcare companies

1)Please elaborate on the most important factors that you look up to while providing investment services to healthcare companies.

First, focusing on companies that have the potential to become market leaders and these companies typically exhibit scalability, market differentiation and strong growth potential.

Second, investing in businesses with strong financial track record, generating strong and regular cashflows over a period of time such that their underlying risk is low. Third, choosing only to invest in established, growth businesses and as such, do not invest in companies with binary risks (e.g. biotech or standalone greenfield hospitals / facilities).

2) What does it take to become regional healthcare leaders and witness maximising of company's growth and ROI? To set on the path to leadership, a company first needs to define the areas of leadership that are the most meaningful to their business partners and the definition can be across metrics (e.g. brands sales, market share, clinical reputation

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/ recognition), geography (e.g. region or country) and subsegment (e.g. secondary, tertiary or single specialty). Having defined the areas of leadership, the company needs to have clear plan to build enablers and differentiators in its business model to achieve the desired position.

3) How do you identify and drive strategic initiatives that are uniquely impactful to the businesses?

Identifying strategic initiatives that are uniquely impactful to the businesses can be done by having a clear roadmap to value creation for every company we invest in, which starts with aligning with the promoter and management on the value creation roadmap pre-deal. Here, we have to focus on initiatives with the greatest potential for impact and translate them into 100-day and 3-year business plans.

Businesses must dedicate an investment and operating team for every portfolio company and facilitate inspire ownership through participation on the Board, Executive Committee and specific value-driven committees of our portfolio companies.

4) How do you see Asia as a prime hub for private equity investment? Is it in the right track now, what would it take to be there?

Asia is already a prime hub for PE investments and most major PE funds and PE investors are accessing Asian growth story. For example, The Asian healthcare industry is expected to grow at 12.5 per cent per annum, far outstripping the global healthcare market growth of 4.5 per cent. By 2020, Asia’s healthcare markets will be worth US$3 trillion and by 2030, a US$4.3 trillion market which is larger the U.S. and Europe healthcare market combined. Driving the shift in the global centre of gravity from the developed western market to Asia are irreverisble, fundamental trends. We believe that the sheer size of the Asian growth opportunity and the interplay of fundamental growth drivers will only increase the level of investments in Asia. As the size and maturity stage of companies grows, as more global leaders emerge out of Asia, the existing investors will increase their exposure to Asia

5) Do you have any plans to create a home-healthcare segment as it is gaining interest from stakeholders given its ability to deliver convenient and cost-effective care?

Home healthcare business model has a huge potential to provide a win-win solution to hospitals, doctors, patients and insurance companies. Hospitals and doctors gain by de-clogging scarce bed capacity and transfer out low yield patients and focus on more critical ones, patients gain by mental and logistical convenience of being treated at home at much lower costs and insurance companies gain by reducing their pay-out burden relating to un-necessary hospitalisation.

6) In your opinion, can India hold a place among the top three global healthcare markets by the end of 2019?

growing income levels, availability of entrepreneurial and clinical talent and a conducive policy framework.

Today, India boasts of few of the largest hospital chains in Asia, few of the largest generic pharmaceutical companies globally (over 10 per cent of the global pharmaceutical production and 20 per cent of the global exports of generic drugs), high end diagnostics companies that serve the global markets and some of most exciting new age healthcare models (for example, home healthcare). This will only grow with time and catapult India into a pole position in the global healthcare space, both as a consumer and supplier of healthcare products and solutions.

7) Please explain the ways helpful to identify and drive strategic initiatives that are uniquely impactful to the businesses.

It primarily comes from our understanding of the trends which are going to shape the future of the industry and how the company should adapt and improvise to address the opportunities and challenges which those trends are going to present. After aligning on these with the owners and management teams of investee companies, a three or five year business plan will be addressed to address them and set objective goals.

8) How do investment returns and constructive social and financial impact go hand-in-hand?

The key is to find mass market sustainable business models that focus on making profits via high volumes and operational efficiencies and not via charging high prices. Aligning to this approach, we can screen investment opportunities for their potential to increase access to high quality and affordable healthcare while generating awareness about better health outcomes and healthy living in the communities they serve.

AUTHOR BIO

For us, India is the biggest investment market and we are very positive on its prospects to keep generating high returns for investors over the next few years. It will ultimately become one of the largest healthcare markets, given its large population,

Amit Varma, Founder and Managing Partner with extensive M&A, strategic and operational leadership and board level experience in healthcare organisations across USA, Asia and Australia. He is a renowned Critical Care Physician, having practiced in the domain for over 21 years, including a decade in the USA before returning to Asia. He has also served in various operational & managerial roles at Manipal Hospital, Narayana Hrudayalaya, Fortis Healthcare and Religare Healthcare He has a significant investment experience as Principal Investment Officer at RHC Principal Fund and IC Committee head at IBOF.

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MEDICAL SCIENCES

Quality Primary Care for Disease Prevention and Management Many people in this world are not receiving recommended healthcare.

Several constraints have been shown to limit the delivery of preventive services and control of diseases. Comprehensive high-quality management of primary care can play an important role in disease prevention and risk management.

Md Moshiur Rahman, Associate Professor, Graduate School of Biomedical & Health Sciences, Hiroshima University Michiko Moriyama, Professor, Graduate School of Biomedical & Health Sciences, Hiroshima University Kana Kazawa, Assistant Professor, Graduate School of Biomedical & Health Sciences Hiroshima University

T

he universally-accessible primary care is a fundamental component of an effective health system as per the Declaration of Alma-Ata (1978). Global comparisons among different countries have repeatedly indicated that healthcare systems with a strong primary care sector evidently achieve better health outcomes and cost savings than underdeveloped primary care sectors. This finding led to international declarations and political movements with an aim to strengthen primary care and set up more primary care-centred health systems. An achievable initiative demanding a healthcare reform has been launched in 2009 and is still under development. Concerns about the difficulties of managing the global health issues with the quality of care

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MEDICAL SCIENCES

in primary care settings are remarkably increasing. Due to the rapid ageing of the population and greater longevity, the number of individuals with chronic diseases (CDs) and multi-morbidity is on the move toward a higher peak. The environmental changes also drastically affect human health. There are multiple factors demanding for structural reforms of the healthcare system. The purpose of this article is to explain the rationale for quality primary care highlighting the appropriate health system infrastructure, and to indicate what attempts to be done in the future to maintain and strengthen its potential.

A quality primary healthcare approach can strengthen early detection and timely treatment, reduce the disease burden and improve the quality of life. In the current healthcare system, primary healthcare providers face difficulties in maintaining care continuity and applying guidelines due to lack of coordination. The quality of

healthcare is defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge�. Quality improvement involves understanding and modifying measures of care to ensure sustainable

quality by reducing unintended and unwanted variation. Most importantly, public and patients demand primary healthcare in assessing and improving the quality.

Primary care is widely considered as a usual nexus for coordination of clinical care, public health, and communitybased services. Access to individuallevel or practice-level quality data on the social determinants of health (SDH) is crucial for health inequalities in primary care. In recent years, there has been increasing recognition of the SDH and the primary care professionals mentioned that social determinants could introduce a major challenge in providing effective primary care. The SDH is associated with higher rates of morbidity, mortality, and other adverse health outcomes. The existing health systems and quality of care strongly emphasise the careful consideration of social determinants through various

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MEDICAL SCIENCES

investments, and recently penalties in the United States (US). In the US and Canada, recent health system reform has recognised the importance of focusing on the demands of critical and high-needs patients. The social complexity factors (housing, income, mental health, family structure, social status, etc.) are linked to poor physical and mental health outcomes. Thus, it is important for developing and implementing interventions to address future healthcare needs by defining the specific social complexities that affect the population health. In addressing the SDH is feasible by expanding the role of primary care professionals with the patient-centred healthcare model.

Quality primary care is associated with the reduction of harmful health effects of income inequalities to create a most proper environment for assessing and intervening on SDH. The World Health Organisation (WHO) concluded that SDH should be kept foremost in the health policy of all countries.

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Dramatic shifts in the pattern of diseases have been observed ranging from infectious diseases to the current leading causes of mortality led by CDs accounting for 71 per cent of death globally. Cardiovascular diseases account for the most chronic disease induced deaths of 17.9 million people annually, followed by cancers (9.0 million), respiratory diseases (3.9 million), and diabetes (1.6 million). These four groups of diseases account for over 80 per cent of all premature CDs deaths. In addition, chronic kidney disease (CKD) is gradually becoming a major health problem (yearly 1.1 million deaths worldwide). Modifiable behaviours like tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets increase the risk of CDs and account for over 16.2 million deaths every year. Poverty is closely linked with CDs. Due to limited access to healthcare services, vulnerable and socially disadvantaged people quickly get affected by a disease and face accelerated death.

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CDs disproportionately affect people in low- and middle-income countries, and over 85 per cent premature deaths occur.

CDs are the result of a combination of genetic, physiological, environmental and behaviours factors. Many studies reported that the increasing prevalence and complexity of CDs will account a significant increase in healthcare cost, and impose much wider burden in near future. This trend represents a challenge for a growing capacity problem in the healthcare system. Many countries with inadequate health insurance coverage are unlikely to provide universal access to essential chronic disease interventions.

CDs threaten the progress towards the 2030 Agenda for Sustainable Development Goals. A strong primary healthcare system can recognise the role of primary care to ensure the appropriate utilisation of professional skills for CDs management.

Patients with CDs are the maximum and repeated users of healthcare services. It is essential to

MEDICAL SCIENCES

increase our understanding of primary healthcare needs for CDs prevention and management services and conceptual models of multidisciplinary approaches in primary care settings.

This multidisciplinary team could be comprised of specialists, primary care physicians, general practitioners, nurse practitioners, practice nurses and other relevant allied health and government professionals. The opportunistic primary prevention is also possible by engaging community pharmacies as they have close links to local populations and widespread distribution with recognised trust and expertise. Connecting them into the identification of high-risk individuals and appropriate referral to primary care is a potential measure. Selfmanagement and disease management are the timely initiatives as the healthcare system is increasingly strained in providing health and medical services to the growing number of people with chronic illness. Implementation of selfmanagement programs can support patients’ awareness, skill development, coaching, and behavioural change.

Many studies on specialised CDs interventions suggested that short-term intervention can improve patients’ selfefficacy, and in the long-term reduction of risk factors and psychological distress with an improvement in the quality of life. There are various ways to explain practice characteristics and their linkage to the quality of care in different settings resulting in heterogeneous findings. The Chronic Care Model suggests a multicomponent remodelling of services to improve patient outcomes. Quality improvement is associated with practice abilities related to the detection of patients at risk, management procedures and incorporated continuous providers' education into the healthcare system.

Integrated disease management programs for patients with CDs promoting self-management result in improved disease specific quality of life, and a substantial reduction in hospital stay and admissions.

The ever growing and changing demand for healthcare is causing higher costs. There is also an impending shortage of professional healthcare workers. Both issues are jointly increasing the burden on healthcare, which is compromising quality, accessibility, and sustainability. Over the past few years, time constraints in primary care and the shortage of primary care physicians have been shown to limit the delivery of the services. The required time to meet preventive, chronic, and acute care treatments frequently exceeds the total available time of physicians for patient care. Compared with most developed nations, US citizens have less access to primary healthcare services while the waiting time is shortest for seeking specialist care. A promising solution is to develop the care management models requiring least time of primary care physicians. One proposed solution is to increase physician supply through programs and policies offering incentives for entry into primary care to overcome providers' shortage. An alternative approach can be maximum utilisation of non-physician providers, including physician assistants, nurse practitioners and other advanced practice nurses, midwives, and health educators who can provide the recommended health education, counselling, and follow-up guidance. A recent study suggested that

To prevent healthcare system gaps, integration of multi-sectoral services is a promising innovation in primary care delivery.

the expanded use and full deployment of nurse practitioners is one promising strategy to alleviate the primary care shortage, and advanced practice nurses can perform as like as physicians in terms of clinical outcomes and patient satisfaction in primary care setting. The full extent of education and training can remove the barriers to allow nurses to practice to be a safe, logical and effective approach for addressing the primary care shortage.

Evidence from the developing countries are examples of diversification in primary care strategies. Brazil introduced a tax-based health services system in 1990 based on establishing strong primary care facilities.

Throughout this period, there were remarkable improvements in maternal education, increased contraceptive use, vaccine coverage, antenatal care, skilled birth attendance, and large reductions in child mortality, stunting, and hospitalisations. Other studies comparing primary care intervention areas in Haiti, Bangladesh, India, Liberia, Zaire, and Bolivia also showed decreased inequalities in primary care.

An integrated approach to primary care in low- and middle-income countries found improved health associated with primary care. It has been established that a strong primary healthcare system is associated with better health indicators and more sustainable costs. To prevent healthcare system gaps, integration of multi-sectoral services is a promising innovation in primary care delivery.

Primary care improves health system functioning through managing and triaging services, corresponding patients’ demands with healthcare resources, and strengthening systems’ ability to adapt to new circumstances. The benefits are a consequence of the joined effort of four unique attributes of primary care namely, first contact, person-focused care over time, comprehensiveness, and coordination. Improving the strategy for quality control in primary care could assess how well functions can be carried

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patients to pay due respect, the term ‘evidence-based medicine’ and ‘evidencebased-healthcare’ were developed to set the scope of implementation in healthcare practices. All stakeholders, including decision-makers and health professionals have to consider reliable evidence-based approaches to manage the allocation of resources as efficiently as possible and to improve the quality of care.

Healthcare systems include people, organisations, and technologies to achieve the better results. Improvements in process, outcomes and safety depend on the better understanding of interactions, which can help designing better healthcare system. Today, the 21st century’s healthcare system needs to use innovative strategies to evaluate the ongoing process and outcomes of interventions. Successful application of healthcare reform involves new concepts and directions that are strongly supported by outcome measures.

Continuous program evaluations will promote the attainment of the primary goal of the healthcare improvement. The regulation of medical and healthcare professionals is an important component

of quality improvement for ensuring a basic standard. Effective governance and regulatory reforms can encourage partnership and collaboration among a wider range of stakeholders to stimulate quality improvement.

The functions of primary care are wellknown and measurable. Accountability of health system for quality primary care orientation is possible. The future challenge is to make it a reality in moving towards developing similar approaches for speciality services as well.

We conclude that the developments of the last two decades have led to a small increase in primary care quality.

However, the future development needs to address the inequitable distribution of health resources, low priority of primary care in medical education and training, lack of formal guidelines for health professionals, and less attention in widespread implementation of electronic record keeping system.

Quality improvement and safety are now essential knowledge for healthcare staffs in medicine, nursing, and allied health professionals.

References are available at www.asianhhm.com

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

AUTHOR BIO

out based on these four key features and reduce the adverse events. Research on the quality of care consistently showed that primary care physicians provide a higher quality of care for personfocused measures of care. In the past, quality and improvement efforts in healthcare have focused on health professional perspectives. The 21st century healthcare quality indicates to patient-centredness together with safety, timeliness, effectiveness, efficiency, and equity as the essential components.

Technological evolutions in healthcare are the key requirements for earlier detection and appropriate treatment of diseases. In many cases, the necessary integration of required data into electronic medical records is still too limited to providing contextual information for clinical decision-making and recommended care. Primary care has been brought close-to-home incorporating technology developments and innovations.

Nevertheless, deploying newer technologies and interventions has no alternative for better patient care management. Electronic health (eHealth) application helps in controlling diseases and patients' management, serving high-quality care with a reduction in healthcare costs and consumption, and therefore, uprising the satisfaction of patients and service providers. Depending on the expectation and level of education, eHealth is a useful tool to support chronically ill patients by increasing their understanding of diseases, sense of control, and willingness to involve in self-management. It is important to develop technological solutions to support decision-making and integration of care in general practice.

Healthcare programme assessment represents an important measure in the adaptation of evidence-based medicine to primary healthcare reality.

Many countries and areas have adopted policies and standardised primary care measurements in their health reform efforts. To encourage practitioners and

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

Kana Kazawais an Assistant Professor of Division of Nursing Science under the Graduate School of Biomedical & Health Sciences in Hiroshima University. She has been involved in research and nursing education such as Chronic Care. She is a certified nursing specialist majoring in Chronic Care Nursing.

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29

Sylvia Haas, Emeritus Professor of Medicine

THE MOTHER OF RIVAROXABAN DISCUSSES THE IMPORTANCE OF ACCURATE PATIENT PROFILING WHEN PRESCRIBING NOACS We caught up with Professor Sylvia Haas, the grand doyenne of Novel Oral Anticoagulants (NOACs), after one of her presentations at the APSC 2018 Congress in Taipei. Prof Haas has been involved in the research and development of direct factor Xa inhibitor NOACs for more than 25 years. In that time she has been a co-developer of several NOACs including rivaraxoban (marketed as Xarelto) the most widely used NOAC today.

During her presentation Prof Haas pointed out that although the use of NOACs for stroke prevention has increased in Asia it still lags behind that of Europe

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and the United States, potentially putting millions of patients at greater risk of stroke than they need be.

She also noted that doctors in Asia have a tendency to prescribe lower doses of NOACs than those stipulated in seminal guidelines such as the European Society of Cardiology (ESC) 2016 Guidelines for the management of atrial fibrillation and the 2017 consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation.

We took the opportunity to ask her what doctors should take into consideration when prescribing NOACs.

MEDICAL SCIENCES

What are the key considerations when choosing a NOAC for AF patients in stroke prevention?

Prof. Haas: When choosing a NOAC for AF stoke prevention it is crucial to consider the pivotal phase three trials and to understand how they were developed and then to compare those with feedback from phase four studies of registry analysis. The main focus in this regard should be on the prospective studies. Of course we also have retrospective data analysis which can also be used to inform our decision-making but my main concern with retrospective studies is that we often don’t have all the relevant information. For instance we know what dose was proscribed but we don’t know how the medication was taken. Was it a once per day dose or a twice per day dose, and what was compliance like across 500 patients?

We know from experience that compliance rates, adherence and persistence, are much higher with once per day dosing so if this information is missing from a retrospective study it could affect the accuracy of the results. That’s why I prefer to base my decisions on prospective real world data.

Next of course we must consider the individual patient’s characteristics, and particularly kidney function; measuring kidney function is very important. If there is impaired kidney function it makes the decision quite clear that we should not use a drug that is mainly eliminated via the kidneys and should instead go for one of the Xa inhibitors which are much more benign for renally-compromised patients. Now among the Xa inhibitor NOACs we have different dosing recommendations but I am very convinced that the evidence for one Xa inhibitor, in this case rivaroxaban, is addressed in the pivotal trial, the ROCKET AF study, where all patients with a creatinine clearance below 50 (CrCl15–49 mL/minute) were assigned to a lower 15mg dose (1) and this was followed up by the J-ROCKET AF study (2). The evidence from these trials makes it very clear to me how to treat a patient and also demonstrates the importance of prospective studies for informing our treatment decisions.

Would you also take into account body age, weight, and frailty as well as creatinine clearance; might those also be reasons to consider a lower dosage?

Prof Haas: That’s an excellent question. That is something that is intuitively done by many doctors. But I would go back to the pivotal trials and the sub group analysis like those from ROCKET AF pointing to the fact that elderly patients have higher risk of both stroke and bleeding but the standard 20mg dose of rivaroxaban performed very well in both groups, so age would not be a major factor in my choice of dose.

We don’t have a specific sub group analysis for low body weight but low body weight often associated with reduced kidney function, particularly in females so some doctors

intuitively prescribe lower doses for tiny ladies however I would always recommend testing renal function and then if we see it is impaired we know we have a clear indication from the ROCKET studies for the reduced dose. However, what we see from subsequent phase four studies is far too many patients are missing creatinine clearance values and this indicates that doctors are making dosing decision intuitively but we should discourage this and encourage doctors to primarily stay with the labelling. This is because we also saw that the patients that received the lower doses also had more concomitant comorbidities and may even have higher bleeding risks. Also in the real world XANTUS study, it was seen that the patients receiving 15mg rivaroxaban had higher incidence of bleeding because they had more concomitant medication and more comorbidities.

So I think we have clear guidance that measuring kidney function should be the number one reason for considering a lower dosage NOAC before considering other patientrelated factors because the bottom line taken from the many patients included in phase four studies is that for patients with creatinine clearance above 50 we do not expect to see higher bleeding rates with the 20mg dose.

Is there any evidence that higher doses of NOACs significantly increase the risk of bleeding?

Prof Haas: From what we have seen bleeding risk is not exclusively correlated with the dose of any anticoagulant.

Rather it is the patient who is driving the bleeding risk more than the dose of an anticoagulant. We have not seen a distinct difference between the higher and lower doses, it is the CHADS2, CHADSVAC scores that primarily drive the bleeding risk. Other factors to consider are the manageable risk factors such as hypertension and other comorbidities, concomitant medications, and alcohol consumption.

Are some NOACs safer than others for patients with renal impairment?

Prof Haas: We should separate the IIa inhibitors that target the enzyme thrombin from the Xa inhibitors which act directly upon Factor X in the coagulation cascade because the IIa direct thrombin inhibitors (DTIs) like dabigatran are mainly excreted via the kidneys up to 80 per cent of circulating dabigatran is excreted, unchanged, by the kidneys. Therefore, any reduction in renal function can affect the plasma concentration of the medicine.

However, within the Xa inhibitors we only have one, rivaroxaban 15mg, which has a clear recommendation based on renal function and on which we have clear data; so I would stick with that.

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XANTUS together with the ROCKET patients and matched the patient populations and found that the bleeding and stroke rates for both studies were similar. That tells us that it is the patient characteristics driving the risk. From these two studies we also have excellent experience and evidence for rivaroxaban for both higher and lower risk patients.

For high risk AF patients with renal impairment, what are your challenges in prescribing NOACs to prevent stroke in these patients?

What are your experiences with rivaroxaban in terms of its effectiveness in stroke prevention and bleeding rates in low risk and high risk patients?

AUTHOR BIO

Prof Haas: We have so much real world information now supporting the safety and efficacy of rivaroxaban for both high and low risk patients. What we have seen in the studies is that it is the patient characteristics driving the risk, and not just for stroke but also for bleeding. There is a sub group analysis from the XANTUS study which is not fully published yet but was presented as a poster at last year’s ESC (European Society of cardiology) Congress in Barcelona which brought the patient characteristics from ROCKET AF and XANTUS together. ROCKET is a high risk patient population, they needed to have a CHADS2 score of at least 2 but the mean score for the study was 3.5 while for XANTUS there was a mean CHADS2 score of 2 but it also included some patients with higher CHADS2 scores. Using an accepted, validated statistical method we brought the high risk patients from

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Sylvia Haas is an emeritus professor of medicine and former director of the Haemostasis and Thrombosis Research Group at the Institute for Experimental Oncology and Therapy Research, Technical University of Munich, a position she held for almost 30 years. An authority on the development of new antithrombotic therapies, biomarkers, and tumour-associated thrombosis, she is a respected researcher and also in charge of various integrated teaching programmes.

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Prof Haas: For me renal impairment is not a challenge for a NOAC, it’s an opportunity. Because compared to Warfarin which is not suitable for renally-impaired patients we now have the opportunity with Xa inhibitors to offer much better treatment. The evidence is clear for prescribing the lower 15mg dose rivaroxaban for stroke prevention in renally impaired NVAF patients.

In your presentation earlier today at APSC you talked about the importance of reducing manageable risk factors when treating NVAF patients…

Prof Haas: Yes that is something very important that came out of the sub group analysis of patients from XANTUS with modifiable risk factors. I think the number one consideration when seeing a new patient is not just to think of them as a NVAF patient but also to take into consideration any other comorbidities and in particular any concomitant medications to discover what other cofactors they might have associated with bleeding risk. For example uncontrolled hypertension, high alcohol consumption and the intake of other medications. Check if any drugs such as NSAIDs (non-steroidal antiinflammatory drugs) have been prescribed by other doctors, for arthritis for instance. Also aspirin; many NVAF patients will previously have been on aspirin and we see many patients still on it who don’t need it anymore. We have also discovered that the over-the-counter drug acetaminophen (Paracetamol) increase the bleeding risk to the same degree as NSAIDs. Fortunately acetaminophen is usually only taken sporadically for the occasional headache or whatever, unlike NSAIDs which are often taken chronically. Here in Asia there is of course also Traditional Chinese Medicine (TCM) to consider, and that is largely a black box to western medicine when it comes to interactions. So it is important to question the patient about what else they might be taking, to see if perhaps some medications can be withdrawn, and to council them on reducing manageable risks such as alcohol consumption and hypertension. That way we might be able to reduce the risk and possible even consider reducing the dose.

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MEDICAL SCIENCES

OBESITY is a DISEASE

Obesity is a global epidemic in all age groups and in both developed as well as developing countries.

In 1995, there were an estimated 200 million obese adults worldwide. In developing countries, it is estimated that over 115 million people suffer from obesity-related problems. A rapid increase in childhood obesity has also been reported.

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

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O

besity terminology and its existence as a disease has been surrounded by controversy in the fraternity.

Though the recognition of obesity as a disease is increasing, variable acknowledgment in health policies continues to exist across the globe. The recognition of obesity as a disease is important and has been long debated.

The conventional Biostatistical Theory of Disease (BST) states that a disease is a type of internal state of the organism which,

MEDICAL SCIENCES

(i) interferes with the performance of some natural function — i.e. some species-typical contribution to survival and reproduction — characteristic of the organism’s age; and (ii) is not simply in the nature of the species, i.e., is either atypical of the species or, if typical, mainly due to environmental causes’’.

It is not clear that obesity is a disease according to BST. First, obesity is not a ‘‘type of internal state.’’ Obesity may of course be characterised by excessive amount of fat, fat cell influence (adipokines), or insulin resistance, but is primarily measured, categorised, and referred to by external factors or indexes, such as BMI. Obesity as a medical problem or a social or cultural phenomenon appears to be a relevant and crucial question with vast implications for health policy and health care. Despite pragmatic arguments for designating obesity as a disease from professionals involved in treatment of obesity, patient organisations, and from health policy makers, it is still an open question whether obesity is a disease.

Etiology of Obesity

Obesity is a complex disorder and a major health risk factor linked to cardiovascular disease, stroke, cancer, hypertension, diabetes, and mortality. Large scale developmental activities and urbanisation in India have brought significant changes in lifestyle and dietary habits in the growing population. According to a World Health Organization (WHO) survey, worldwide obesity has doubled since 1980. The studies reveal obesity is killing three times as many as malnutrition. Obesity is a global burden on society which has a potential to destroy Nations medically and economically. The prevalence of both type 2 diabetes and obesity has globally increased and attributed to adoption of sedentary lifestyle and dissemination of the western diet. Diabetes is also complex. No one knows this better

Pooled data of eight longitudinal studies with 10-years of follow up, comprising 61,386 subjects, showed a 24 per cent increase in cardiovascular disease in the metabolically healthy obese group.

than the physician managing this entity of myriad presentations. It is also well known that despite best efforts by the treating doctors, a large segment of this population struggles to bring the disease under control.

There are several lines of evidence that inflammation of fat directly causes obesity and diabetes. Inflammation begins in the fat cells themselves. Fat cells are the first to be affected by the development of obesity. As fat mass expands, inflammation increases.

Diabesity causes inflammation. Insulin and leptin resistance impair glucose metabolism. When fat cells become insensitive to insulin, they can’t store any more glucose and hyperglycemia results. Dr. Francine Kaufman coined the term diabesity (diabetes + obesity) to describe them. Diabesity can be defined as a metabolic dysfunction that ranges from mild blood sugar imbalance to full-fledged type 2 diabetes.

Diabesity is a constellation of signs that includes: • Abdominal obesity • Dyslipidemia (low HDL, high LDLand high triglycerides) • High blood pressure • High blood sugar (fasting above 100 mg/dL, Hb1Ac above 5.5)

• Systemic inflammation • Increase formation of blood clots.

There is no doubt that there is direct co- relation between diabetes and obesity and the more severe the obesity, the more stubborn will be the diabetes management for treating diabetes associated with obesity.

Weight gain appears unavoidable when patients with type 2 diabetes are commenced on insulin. Body weight increases by 2 Kg for each percentage point decrease in HbA1C during the first year. Gain in weight mainly represents an increase in fat mass, which enhances insulin resistance and increases the risk of obesity related complications.

Causes of weight gain • Reduced glycosuria • Anabolic action of insulin • Fluid retention • Hypoglycaemia and increased calorie consumption • Excess insulin administration • Combination of obesity and muscle impairment: 'sarcopenic obesity'.

There is enormous scientific evidence that weight loss inevitably helps in resolving this condition. If one needs to lose 10-20 kgs, it can be done by healthy diet and lifestyle changes, however, if one needs to lose more than this, surgical intervention must be considered Morbidity of Obesity:

Medical • Chronic heart disease • Osteoarthritis • Gall stones • Diabetes Mellitus • Dyslipidemia • Hypertension Economical • Cost of futile weight loss treatment • Cost of treating various medical conditions • Inability to obtain insurance coverage or increased premium • Cost of special clothing

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Social • Social isolation • Daily prejudice • Verbal abuse • Physical abuse • Limited Mobility • Difficulty with hygiene Psychological • Depression • Insomnia • Self hate and feeling of guilt • Neurotic disorders Evolution of Obesity as a Disease

The obesity was first referred as a disease in 1985, the Consensus Development Conference on Obesity.

This meeting was organised by the US National Institute of Health (NIH). The WHO Consultation on Obesity and the Institute of Medicine both have labeled obesity as a disease in mid-1990s. The Obesity Society defined obesity as a disease in 2008.

The American Association of Clinical Endocrinologists recently updated their 1998 position that obesity is a chronic, complex, multifactorial condition, and released a consensus statement in 2012 clearly delineating obesity as a “primary disease”. Finally, in 2013, the American Medical Association (AMA) has classified obesity as a disease.

There is a derangement of appetite modulation with ghrelin, leptin, insulin, and peptide YY may in the obese state causing it difficult to achieve sustained weight loss.

Obese individuals have anatomical signs and symptoms like increased joint pain, immobility, and sleep apnea.

They also have metabolic signs and symptoms of cardiovascular disease and type II diabetes. Increase in BMI is also associated with increased adipose tissue and increased waist circumference.

Obesity-associated inflammation and its metabolic consequences (e.g., DM2, heart disease, nonalcoholic fatty liver disease) has contributed to increased morbidity and mortality.

Epidemiological studies have shown that obesity [defined as a Body Mass Index (BMI) ≥30 kg/m2) is associated with increased all-cause and causespecific mortality from heart disease and diabetes.

The Recognition of Obesity as a Disease

Disease has been defined in many numerous ways. The American Medical Association House of Delegates 2013 have defined obesity as a disease considering the following criteria: an impairment of the normal functioning of some aspect of the body, characteristic signs or symptoms, and harm or morbidity.

Obesity is caused by an imbalance between energy intake and energy expenditure which leads to increased body fat. However, it does not account for the complex role between the Central Nervous System (CNS) and metabolically active organ systems.

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The arguments which support obesity as a disease include the urgency to address this condition and increased public awareness of the detriment to one’s health. The classification of obesity as a disease may provide context of healthy body weight and reinforce the importance of healthy lifestyle choices.

Labelling obesity as a disease holds great potential for reducing the stigma associated with obesity. Studies have reported that a model emphasising factors such as unhealthy eating or sedentary behaviour increases level of stigma toward obese people. Cataloging obesity as a disease will help reduce the weight bias and emphasise that obesity is not just a lifestyle issue but a disease process that requires both medical and behavioural treatment. The survey has presented obese individuals as physically dependent on food and reduced blame toward obese people.

MEDICAL SCIENCES

The Fat but Fit Hypothesis

In 2012, the AMA Council of Science and Public Health stated that obesity should not be classified as a disease.

The evidence of few obese individuals not exhibiting metabolic abnormalities, such as insulin resistance, and may be considered otherwise healthy. Pooled data of eight longitudinal studies with 10-years of follow up, comprising 61,386 subjects, showed a 24 per cent increase in cardiovascular disease in the metabolically healthy obese group.

Similarly, the metabolically unhealthy obese groups displayed a two- to three-fold increase in cardiovascular disease. However, this significant increase in cardiovascular events noted in the otherwise healthy obese group compared to non-obese metabolically healthy individuals have made the authors to conclude “there is no healthy pattern of increased weight.”

Similar results have been noted in the Edmonton obesity staging system.

The Issue Against Obesity as a Disease

Those who argue the classification of obesity as a disease stated it does not meet established criteria of disease.

Experts contemplate, changing its designation would be expensive and would sequester funding from the medical treatment and research of other important conditions. Few opponents of the disease argue that public opinion holds obesity as a lifestyle decision.

Obesity is considered to be selfimposed, it’s a lifestyle choice and a risk factor for a disease and not a disease.

“Medicalising” is one of the argument for not characterising obesity as a disease. Medicalising is an act of being dependent on clinical treatment, such as medications or surgery, in lieu of lifestyle changes. Moreover, few oppose saying patients do not deserve treatment due to their behaviour related issues, habit of excessive, compulsive eating with lack of discipline in themselves.

However, availability of effective

treatments should not precondition obesity to be considered as a disease The Global Challenge for Obesity

The global switch from diseases of nutritional deficiency to conditions of over nutrition has occurred, and continues to occur over a remarkably short time span. Not only does this provide a great challenge relative to diabetes risk but also for a large variety of pathologies. The availability of the mass media and web networking has tremendously enhanced global communication to spread the awareness regarding the deleterious effects of obesity.

Nevertheless, it remains a global challenge to imagine how to get a significant number of individuals in first and second world countries to alter their lifestyle in terms of reducing caloric intake, as well as increasing physical activity. There are a variety of interventions that have involved local or federal regulations (nutritional labelling, calorie labelling, taxing the soda, etc.) or incentivising healthy eating and exercising (insurance companies or employers can reward

individuals that maintain a healthy body weight or exercise regularly).

The impact of this modern day epidemic can be felt today. Our current treatment options and preventive measures, while helpful, have only a minor influence on individual patients.

The high risk of associated medical conditions, the clear recognition of a need to treat, as well as the drastic changes in an individual’s physiology of energy metabolism are strong arguments to classify obesity as a disease. Benefits of this classification would emphasise the urgency to eradicate this modern epidemic. For an individual obese patient, labelling this condition as a disease will ensure access to treatment. For the population as a whole, designating obesity as a disease will increase awareness, potentially drive policy development, and dedicate resources for further research and preventative measures.

Acknowledgement: I would like to acknowledge our Medical Writer Dr Rajesh Sardana in helping me compile the content for this article.

References are available at www.asianhhm.com

AUTHOR BIO

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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Managing IV Infections in India

Intravenous (IV) infections are a major cost-centre for any hospital. It causes higher mortality rates in patients, loss of productivity and less quantifiable costs. The main causes are non–protocolised processes, lack of infrastructure, technology, and overcrowding. The risks of antibiotic-heavy patient maintenance leads to many resistant strains and are getting difficult or impossible to treat. However, a large proportion of IV infections are preventable. For example, CRBSI is a serious threat. This is the most expensive HAI incidence and has a mortality rate of 25 per cent. In US, the cost per CRBSI is Rupees 32 lakhs per incidence. The rates of CRBSI in India is higher than the global average (In ICU it is 7.57 per 1000 catheter days). With implementation of the CDC-IHI Bundle & CDC-INS recommended practice adoption of CHG impregnated dressings and ‘Scrub the Hub’ protocol, infections can be significantly reduced.

Ninad Gadgil, Country Business Leader, Health Care Business, 3M Health Care

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FACILITIES & OPERATIONS MANAGEMENT

H

ealthcare-acquired infections or Hospital - Acquired Infections (HAIs) are the most common complications of hospital care, leading to high morbidity and mortality. While the World Health Organization (WHO) estimates about 7-12 per cent HAIs burden in hospitalised patients globally. The figures from India are alarming, with an incidence rate varying from 11 per cent to 83 per cent for various kinds of HAIs. Intravascular catheters access has become a very common practice in

the hospital and outpatient settings for various purposes, including haemodynamic monitoring, renal replacement therapy, nutritional support, medication administration, the administration of fluids, blood products, nutritional solutions (parenteral therapy). A central venous catheter is a catheter whose tip resides in a central vein, whereas the tip of peripheral venous catheter does not.

Central venous catheter and central line are used interchangeably. A long-term central venous catheter is a central venous catheter that is

intended to remain in place for a prolonged period of time; it is either tunnelled subcutaneously between the percutaneous exit site and the site of vein entry, or it is fully implanted with a subcutaneous chamber that has a rubber surface which is accessed by a non-coring metal (Huber) needle. A short-term central venous catheter is intended for temporary use and it is neither tunnelled subcutaneously nor fully implanted.

Catheter-related Bloodstream Infection (CRBSI) is defined as the presence of bacteremia originating

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from an intravenous catheter and accounts for 10 per cent to 20 per cent of hospital-acquired infections in the UK and is associated with both increased ICU stay and mortality. It is one of the most frequent, lethal, and costly complications of central venous catheterisation. The most common cause of nosocomial bacteremia the incidence of CRBSI varies by type of catheter, frequency of catheter manipulation, and patient-related factors, such as comorbidity and severity of illness. A recent review

by Maki of over 200 published reports found estimates of incidence and incidence density of CRBSI to

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vary between 0.1 per cent and 22.5 per cent and between 0.1 and 2.7 per 1000-line days, respectively, by catheter type.

Several factors are responsible to participate in the pathogenesis of catheter related blood stream infections. The catheter itself can be involved in 4 different pathogenic pathways like colonisation of the catheter tip and cutaneous tract with skin flora; colonisation of the catheter lumen caused by contamination; haematogenous seeding of the catheter from another infected site; and contamination of the lumen of the catheter with infusate.

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Potential risk factors for catheterrelated blood stream infections include underlying disease, technique of catheter insertion, site of catheter insertion, for example, femoral vs jugular vs subclavian site, duration of the catheter and purpose of catheterisation. The administration of parenteral nutrition through intravascular catheters increases risk of catheter-related blood stream infections. Risk factors, such as poor aseptic technique at the time of insertion, catheter manipulation, occlusive dressings, moisture at the exit site increase the risk of bacterial colonisation in the pathogenesis of catheter related blood stream infections.

FACILITIES & OPERATIONS MANAGEMENT

Earlier the belief was that hub contamination resulting in intraluminal catheter and subsequent bloodstream infection occurred exclusively in long-term central venous catheters. More recently, hub colonisation and intraluminal migration of infection has been recognised to be a common cause of both short- and long-term central venous catheters. Unusual causes of CRBSI are intrinsic contamination of infusate and haematogenous seeding from distant infection.

The different microbiologic criteria of the CRBSI and CLABSI (central line-associated blood streams infection) definitions reflect the different purposes for which each was developed. The CRBSI was developed for use in research investigations of the risk factors and pathogenesis of bloodstream infections complicating vascular catheters in which it is critically important to establish a standardised, objective, unequivocal outcome. The CLABSI was developed for surveillance of health careassociated bloodstream infections in non-research settings in which standardised, objective, unequivocal outcomes are not available due to differences in the diagnostic laboratory investigations requested by different providers and therefore CLABSI was developed to serve as a surrogate measure of CRBSI. The diagnosis of CRBSI requires a positive culture of blood from a peripheral vein for the confirmation that the catheter is the source. A diagnosis of CRBSI is achieved by any of the following three criteria: • same organism recovered from percutaneous blood culture and from quantitative (>15 colony-forming units) culture of the catheter tip • same organism recovered from a percutaneous and a catheter lumen blood culture, with growth detected 2 hours sooner (ie, 2 hours less incubation) in the latter

Catheter-related Bloodstream Infection (CRBSI) accounts for 10 per cent to 20 per cent of hospitalacquired infections in the UK and is associated with both increased ICU stay and mortality.

• same organism recovered from a quantitative percutaneous and a catheter lumen blood culture, with 3-fold greater colony count in the latter.

CRBSI means a patient with an intravascular catheter has at least one positive blood culture obtained from a peripheral vein, clinical manifestations of infections (i.e., fever, chills, and/or hypotension), and no apparent source for the BSI, except the catheter.

Early diagnosis and treatment are vital to reduce the morbidity and mortality involved. Different measures have been recommended by various guidelines i.e., CDC, INS, SHEA, IHI etc. to reduce the risk for CRBSI, including use of maximal barrier, effective cutaneous anti-sepsis, and preventive strategies based on inhibiting micro-organisms originating from the skin or catheter hub from adhering to the catheter.

New technologies as per the updates CDC Guidelines -2017, Use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients which have been shown to reduce the risk of CRBSI. Catheter-related bloodstream infections are costly complications of

hospital care that have occurred with greater frequency in ICU settings.

Accurate diagnosis can be established by culture of appropriately collected specimens of blood and catheter tips.

Evidence-based guidance is available to inform antibiotic treatment and catheter management when infection occurs. Risk of CRBSI can be reduced by optimising catheter selection, insertion and maintenance, and by removing catheters when they are no longer needed.

The process of vascular infection prevention is complex, ongoing and can involve several care providers from catheter insertion through removal.

Nurses are often the best positioned clinical team members to help reduce infection risk. Whether you are an experienced infusion nurse specialist or new to your role, there are many ways we can all help curb CLABSI at the bedside.

Own it

It can be difficult to specifically pinpoint what triggered a bloodstream infection.

That’s why personal accountability to following protocols for every patient, every time, is critical. Adoption of evidence-based CRBSI preventive practices remains low, despite data showing bundled approaches can specifically reduce CLABSI risk. In a U.S. hospital survey, about 25 percent of respondents indicated they are not routinely following the recommended best practice of using maximal sterile barrier precautions during central line insertion or using Chlorhexidine Gluconate (CHG) as a site disinfectant, according to the Centers for Disease Control and Prevention's (CDC) 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections. It’s important to stay focused on your infection prevention goals and recognise that your actions can make a big difference in protecting your patients. Adhering to all recommended evidence-based central

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line insertion practices is critical. In addition, don’t forget about the other recommendations from the Institute for Healthcare Improvement’s (IHI) central line care bundle. These include hand hygiene, allowing the skin antiseptic to dry before catheter insertion, optimal catheter site selection that avoids the femoral vein in adult patients and daily review of the line necessity, with prompt removal of any unnecessary lines.

Stay Current to Increase Compliance

Several industry associations and governing bodies provide evidencebased standards, best practice guidance, useful toolkits, and scientific meetings to help you stay up to date on the latest recommendations for preventing intravascular catheterrelated infections. When major guidelines and clinical standards are published, it’s a great time for nurse leaders to revisit and refine vascular access policies and procedures, identifying new clinical data and innovative technology advancements that can help ensure your facility is compliant. One of the most widely used resources comes from the Infusion Nurses Society (INS), who recently issued revised standards published in the January/February issue of the Journal of Infusion Nursing. The 2016 “Infusion Therapy Standards of Practice” features the latest body of evidence in vascular access, including updates related to the expanded use of CHG, passive disinfecting caps and dressing securement to prevent dislodgement. 3Mark your calendar too - we’re anticipating the CDC to release updates soon, hopefully later this year.

Seek Support

There’s more to vascular access infection prevention than a checklist of hand hygiene and contact precautions during insertion. There’s no silver

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bullet in a CLABSI prevention bundle, so it’s important to strive for continuous site observation and visible evidence of compliance. Each line and site need ongoing monitoring and maintenance, especially since the surface of the patient’s skin and the catheter port are the two most common sources of CRBSI. However, most nurses can relate to the feeling of being rushed throughout the course of a shift. There never seems to be enough hours in the day to accomplish all you would like to do for your patients. Unfortunately, it’s often when we’re rushed that errors occur. If you’re struggling to perform the necessary maintenance tasks due to time constraints, ask for help. For example, trusted supplier partners can suggest innovative solutions and tools to help enhance efficiency, consistency and compliance, along with clinical support to help implement and audit new techniques, technology and training.

Be Open to Change

When a CLABSI occurs, participate in your facility’s version of a ‘root cause analysis’ to help identify ways to increase best practice adoption and further refine your protocols. Advocate for implementing any identified changes as swiftly as possible, leading by example. Even though process change can be difficult, you can feel good that you’re doing everything you can to reduce infection risk for your patients. Finally, encourage a culture where accountability can be safely voiced, and openly received promoting teamwork and safety for all.

Celebrate Success

When your facility has achieved a major CLABSI-free milestone marker, take time to celebrate. Celebrations as simple as a pizza party, certificate or giveaways of CLABSI reduction swag

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(like tote bags, t-shirts and mugs) can go a long way towards renewing the team’s commitment to achieving even more days CLABSI-free. This pause to acknowledge your ‘village’s’ success can also help reinforce everyone’s commitment to evidence-based best practices and overall cultural change within your unit and across your facility.

References are available at www.asianhhm.com

AUTHOR BIO

Ninad Gadgil is Country Business Leader for the 3M Health Care Business in India and Sri Lanka with products being sold in the Hospital, Dental, Medical device, Food Safety and Drug Delivery markets. He is also a member of the Management Committee of 3M India.

Ninad Gadgil has 23 years of industry experience and has been working with 3M India for over 20 years. Apart from various positions in Healthcare, he has also been responsible for Marketing Excellence, Sales Excellence, Six Sigma, General Management, New Business Model Creation, Business development and Strategic Planning for the company.

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

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

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COVER STORY

INFORMATION TECHNOLOGY

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DIGITAL TRANSFORMATION OF HEALTHCARE BENEFITING MEDICAL PROFESSION

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INFORMATION TECHNOLOGY

With digital enablement of the various processes and care delivery-related tools, no medical practitioner may choose to remain immune from it. This article discusses the digital transformation of healthcare accrues various benefits to the medical profession and the professionals.

SB Bhattacharyya, Founder & CEO, BC2RI LLP

D

igital transformation of healthcare has been happening for quite some time now.

With the advent of Computerised Tomography (CT scan), and Ultrasound Scanning closely followed by Magnetic Resonance Imaging (MRI) scan and Positron Emission Tomography (PET) scan, the practise of radio-diagnostics was transformed from collecting X-ray images to visualising internal organs in three dimension and identifying lesions with pin-point accuracy.

Computer-guided radio-therapy to deliver radiation therapy as accurately as possible minimising healthy tissuedamage and use of robotic surgery have all contributed in helping deliver levels of care which was no more than a pipedream even a couple of decades ago.

Digital Transformation of Healthcare

Digital transformation is the integration of digital technology into all areas of a domain, fundamentally changing how the various players operate and help deliver value to consumers. It is also a cultural change that requires organisations to continually challenge the status quo, experiment and get comfortable with failure .

With computerisation of medical records, availability of test results almost instantaneously, and big data,

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INFORMATION TECHNOLOGY

Item

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Benefit

Effect

Impact

Process Automation

Increased efficiency and income

Direct

High

Alert System

Decreased errors and omissions

Indirect

Moderate to high

Better Care

Increased reputation, income

Indirect

Moderate

Complaints and compliments

Indicates areas in Identify things that

Indirect

Moderate

Continuous Improvement

Satisfied patients and providers

Indirect

Moderate

Transparency

Increased confidence of stakeholders, decreased losses due to delayed payments and levy of penalties

Indirect

Moderate

the medical professional of tomorrow will have to contend not only with a massive body of knowledge but also align them with an equally impressive volume of data to deliver the best of possible care on a continuous basis.

short of catastrophic. This should not be so. Like everyone else, the medical professional completely justified in seeking the answer to ‘“what’s in it for me?”’ Once that question is effectively addressed, healthcare will really be what it should be.

Impact of Digital

Digital’s Benefits

While all of these have largely benefited the patient, the focus of all healthcare activity, the effect on the medical profession at large and the professional who must handle all the technology has not been given much attention.

This is unfortunate since it is the man behind the machine who is the most important factor for the success or failure of the machine. A medical professional today is a much-stressed person having to not only deal with a large body of knowledge that is ever-growing almost daily but also continuously upskill to be able to handle all the various ‘“gadgets”’ that are now demanded by the consumers of their services.

The impact has been significant, particularly since all this transformation never really considered what it all means to them. When the onslaught of expectations of the patient, carers, payers, administrators and the law are factored in, the impact is nothing

It is true that digital transformation has benefited the patient, and this is rightfully so, the medical professional is unable to comprehend how exactly it has made his life any easier. All the available evidence, if anything, appears to indicate that it has made it more stressful; at least on surface.

This is not exactly the case. The benefits, although tangible, are largely hidden due to their ‘“soft”’ nature.

These are largely indirect that need to be derived.

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Let us Study Each of the Points above in Some Detail.

Process Automation Through automation of manual processes using machines enabled by digital technology such as image scanners, auto-analysers, robots, and systems for such tasks as test results reporting, patient administration, billing, inventory management,

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communication, generation of results, tracking of patients and their payments, ensuring materials required and informing all stakeholders are accurate, on-time and performed on a mass-scale.

The utilisation of such instruments and systems has been delivering visible improvements of care delivery by reducing delays that almost always results in negative impact overall.

There is enough evidence to prove beyond any reasonable doubt that this has helped medical professionals to care for the ever-growing population with continuously increasing diseaseburden better and faster.

Alert Systems Such system form part of the broader clinical decision support systems that are capable of instantaneously identifying conflicts in terms of clinical assessments and order items that are due to allergies, contra-indicated conditions, wrong doses, interactions, missed allergic conditions.

Iatrogenic errors are a well-known contributory factor in increasing both morbidity and mortality that can be avoided by reducing errors and omissions by incorporating these systems into one’s care delivery processes.

INFORMATION TECHNOLOGY

Better Care Through the introduction and regular use of diagnostic analysers, imaging scanners, radio-therapy units, robotics, telemedicine, and digital systems the ability of medical professionals to provide better care is greatly enhanced.

This is consequent to factors such as reduced inpatient stay and outpatient visits, that lead to more patients with pressing problems to be cared for thus ensuring better utilisation of the time and effort of medical professionals instead of precious resources such as hospital beds or appointment slots being occupied by people who are convalescing and do not require immediate attention or constant supervision. It has definitively been found that much of morbidity and mortality is caused by hospital visits

or stay due to nosocomial infections.

These are reduced to the point of elimination when patients are discharged to home and followed up using remote consultation or telemedicine.

This causes people being cared for to be happier as they are able to spend more time in the comforts of their home surrounded by their near and dear ones with lesser physical exertions.

Both of these are not possible in hospitals and during visits to doctors just to be told everything is good and either to continue the same treatment or stop as they have now achieved the expected outcomes.

Medical professionals benefit from the increased reputation due to satisfied patients and payers who benefit from lesser pay-outs. The provider facility

also has reasons to be satisfied as more patients get served and with the most income being generated within 72 hours of admission, their higher turnover within that time-frame leads to the bed being freed up instead of remaining unoccupied by those who pay less while consuming the same amount of services. The incentives to medical professional is simply too large to ignore.

Continuous Improvement This is basically an extension of better care mentioned above, additionally using analytics that help ensure optimal outcomes at optimal costs.

Unfortunately, this is mostly an aspirational technology that is largely confined to the “nice-to-have� space as robust data collection systems that are effectively able to demonstrate

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INFORMATION TECHNOLOGY

their usefulness in delivering continuously improving levels of care are mostly unavailable. Ones that do exist, are still largely in experimental stages running in very large institutions and by early adopters. Up until they are in mainstream use, their ability to benefit the medical professional will continue to remain largely unproven.

Transparency Rigorous use of information systems, particularly those that help capture medical records, transparency in the clinical decision-making that results in case management can be established in a most effective and demonstrable manner. Using secured access control and robust audit trail, the various legal requirements related to data privacy, confidentiality and provenance of decisions can be met.

Unfortunately, and most regrettably, proper and effective medical record systems that medical professionals can meaningfully use in clinical settings, particularly critical ones, are largely conspicuous by their absence even in this day and age.

Busy medical professionals find it very difficult to re-skill themselves in non-clinical activities like recordkeeping that requires them to learn the use of keyboards or even to interact with machines throughout the day while examining patients, making critical decisions that could be the difference between survival and fatality, and generally being in high levels of stress is an ask that is way too much.

However, making the use of such systems a part of their repertoire makes patients, payers, administrators and the law, feel confident about all that goes on in the near-opaque world of clinical decision-making, to the point of gaining enough knowledge to feel confident about all that was done and the reasons thereof.

All of this leads to increased revenues, albeit indirectly, due to fewer denials and elimination of penalties

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

the greatest of determination, yet sadly given the short-shrift due to lack of suitable systems that can facilitate it.

There is enough evidence to prove beyond any reasonable doubt that this has helped medical professionals to care for the ever-growing population with continuously increasing disease burden better and faster.

levied due to instances of errors that are suspected to be those of negligence but found to be not.

Interestingly, this particular digital transformation has the potential to have maximal and almost instantaneous impact on the medical professional from the benefits pointof-view by lessening their liabilities while concomitantly increasing their reputation as an ethical practitioner thereby restoring the long-lost God-like devotion that the people under their care used to have in the past. A factor not be trifled with, nay aspired to with

Conclusion

Digital transformation has permeated through the entire fabric of our daily existence. Healthcare has not been immune to it, although the process itself has largely been insidious. With the advent of easy accessibility of information to every individual and the love-for-self, it is only natural that a person in sufferance will demand the best of care to help alleviate their condition. The medical professional must ensure that he is able to deliver.

The process cannot be one-sided with the professional’s requirements not being met. After all, it is he who is behind the machine and makes the difference between success and failure of the machine. Had he not been suitably impressed, no digital scanner so vital for delivery of healthcare today would have ever seen the light of day. Therefore, the industry needs to ensure that all digital solutions that are available for healthcare are robust enough to suitably empower the healthcare professional and provide sufficient incentive for him to make it an integral part of his daily practice.

AUTHOR BIO SB Bhattacharyya is a practicing family physician and health informatics professional with more than 31 years of experience. Currently, Founder & CEO, BC2RI, and Member, Standing Committee for IT, IMA Headquarters, his main interests include EHR, applications of machine learning techniques for treatment protocol planning, predictive analytics in medicine and telehealth.

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Building the Future of Private Hospitals

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Many countries across Asia are experiencing demographic changes that are likely to have a significant impact on future opportunities for private hospitals and clinics. Population demographics are rapidly ageing for some countries, accelerating demand for acute and emergency care.

far worse mid-week, with much longer average delays and extremely high bed occupancy rates. It should come as little surprise that the Singaporean Government is aiming to increase the number of hospitals from 27 to 33 by 2022, which will be achieved by a combination of public and private hospitals.

This has forced some Governments to play catchup, building capacity after years of under-investment in public healthcare infrastructure. These pressures have also led to a stronger focus on holistic primary care and home based care initiatives, designed to provide access to more appropriate care for patients with chronic care needs, and reduce reliance on emergency acute facilities.

As Governments scramble to build overall capacity in the healthcare system, this rapidly increasing demand for healthcare services clearly offers opportunities for investments in private hospitals and clinics across the region. It also points to the need for the private sector to find more effective ways to scale service delivery, and improve the patient customer experience.

Even countries with strong investment flows into public health infrastructure, such as Singapore, have found it difficult to keep up with the challenge. According to a 2018 research report by Value Penguin, Singaporeans are now faced with the reality of overcrowded public hospitals, with waiting times across 6 Singapore public hospital emergency departments averaging 2.5 hours. According to the report, the figures are

United Family Healthcare (UFH) group is China’s largest foreign-invested healthcare provider. UFH operates private hospitals and health clinics in major cities throughout China, delivering comprehensive, integrated healthcare in a personalised, patientcentered way. Their patients include both local residents and international visitors, with an emphasis on holistic family care.

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innovate more rapidly, and make it easier to consistently deploy new workflows that reflect best clinical practice. The end result of these EMR workflows, are fewer delays for both patients and clinicians, with information being available in real-time to relevant clinicians.

According to Jenny Shao, UFH’s Director Health Information Systems, private healthcare organisations are able to provide more individualised care than the public providers. “United Family Healthcare has a hub and spoke model of hospitals and primary care clinics. We are setting up a healthcare ecosystem of coordinated care delivery using an InterSystems TrakCare Electronic Medical Record (EMR) solution.”

“We talk about the three Ps: the patient, the provider and the payer. We also offer an insurance program called Unity, where UFH is a provider as well as a payer. As a result, our purpose is not only to treat the customer, but to keep them in a healthy condition. Our clinicians are now starting to select cohorts of patients for care coordination, and will soon have disease management groups. We use TrakCare with InterSystems HealthShare to carry out patient cohort analysis, so our clinicians can understand which patients should be targeted for care coordination, and what their risk profiles are.”

With waiting times and bottlenecks increasing the pressure on the public system, recruiting and retaining high caliber clinicians is likely to become more challenging across the entire sector. Private hospital operators that are seeking to grow patient revenue and volume will need to focus their efforts towards lifting clinical productivity while delivering a superior patient experience.

By automating clinical workflows within the EMR, healthcare providers are able to better standardise clinical care across the organisation, and more easily and efficiently coordinate handover. Best practice EMR implementations also create opportunities to

Self-service technologies and mobile technologies are also playing an increasing role for patients, and will undoubtedly be deployed more widely throughout healthcare organisations over the next few years. The ‘self-service’ trend is well established in retail, where it has been enthusiastically been adopted. In healthcare environments, self-service is likely to focus on areas such as appointment scheduling, billing, hospital admissions, and medication dispensing.

Clinical settings themselves are also changing, with in-home care, primary care clinics, and ‘wellness’ clinics growing in importance for private hospital operators. As these more diverse care settings become more integrated at an organisational level with traditional acute care hospitals, the breadth of care settings that need to be managed expands, and it can become much more challenging to consistently deliver high quality care. EMR workflows can help ensure best practice clinical methods are followed across the various locations and settings, while helping to reduce delays for patients, streamline billing processes, and ease the burden of scheduling and coordinating care.

United Family Healthcare United Family Healthcare (UFH) is an international hospital and clinic network that provides private, premium healthcare.

• founded in 1997 • pioneered private international healthcare in China • hospitals and clinics in Beijing, Shanghai, Guangzhou, Wuxi, Tianjin, Qingdao, Bo’ao and Nanjing • delivers premium, personalized healthcare Leading private hospitals across Asia are partnering with InterSystems to transform healthcare delivery.

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Books

Bioemergency Planning: A Guide for Healthcare Facilities Author(s): Angela Hewlett, A Rekha K Murthy No of Pages: 236 Year of Publishing: 2018 Description: This text gathers the weaknesses revealed during recent infections outbreaks and organizes them into a guide for combating the trends in emerging infections as they relate to hospital preparedness. As the first book to exclusively explore infectious emergencies, the text begins by reviewing potential pathogens and the clinical issues that may threaten hospital safety before delving into the best operational guidelines for commanding a staff under extreme circumstances, including incident command, communication, transport, maintenance, and a myriad of other topics that can remain manageable with proper protocol. Written by experts in the field, this text is the only one that offers the most effective clinical responses to a crisis at every level of care, including special population, laboratory techniques, care of the deceased, behavioral support, and medical documentation. The text concludes by focusing on the reality of care by introducing true examples from the field and the lessons gained from these cases.

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Infection Prevention and Control: Practical Guide for Healthcare Facilities Author(s): Serge Blaise Emaleu No of Pages: 286 Year of Publishing: 2017 Description: This book is a handy guide for the conscientious health worker who wants to keep their patients safe.

Dr. Emaleu’s helped Finalizing and to disseminate, IPC policy and Guideline documents, build and strengthened ability in preventing nosocomial/ Hospital Acquired Infection (HAI) in Sierra Leone and the subregion transferred Knowledge in preventing emerging and reemerging infectious diseases.

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Planning and Designing Healthcare Facilities: A Lean, Innovative, and EvidenceBased Approach Author(s): Vijai Kumar Singh, Paul Lillrank No of Pages: 278 Year of Publishing: 2017 Description: The planning and design of healthcare facilities has evolved over the previous decades from "function follows design" to "design follows function."

Facilities stressed the functions of healthcare providers but patient experience was not fully considered.

The design process has now crucially evolved, and currently, the impression a hospital conveys to its patients and community is the primary concern.

The facilities must be welcoming, comfortable, and exude a commitment to patient well-being. Rapid changes and burgeoning technologies are now major considerations in facility design.

Without flexibility, hospitals face quicker obsolescence if designs are not forward-thinking.

Cybersecurity for Hospitals and Healthcare Facilities: A Guide to Detection and Prevention Author(s): Luis Ayala No of Pages: 129 Year of Publishing: 2016 Description: By understanding and detecting the threats, hospital administrators can take action now—before their hospital becomes the next victim. This book shows you how to: • Determine how vulnerable hospital and healthcare building equipment is to cyber-physical attack.

• Identify possible ways hackers can hack hospital and healthcare facility equipment.

• Recognize the cyber-attack vectors—or paths by which a hacker or cracker can gain access to a computer, a medical-grade network server, or expensive medical equipment in order to deliver a payload or malicious outcome.

• Detect and prevent man-in-themiddle or denial-of-service cyberattacks.

• Detect and prevent hacking of the hospital database and hospital web application.

Healthcare Facility Planning: Thinking Strategically Author(s): Cynthia Hayward No of Pages: 200 Year of Publishing: 2016 Book Description: This new edition addresses current issues new financial incentives, fluctuating utilization and demand, constant pressure for technology adoption and deployment, rising turf wars among specialists, intense focus on patient safety, and aging physical plants that affect the way facilities are used, planned, financed, and built. Detailed examples, guidelines, and case studies, many new to this edition, lead the reader step-by-step through the facility planning process. This book s planning process reveals how a new facility can improve operational efficiency, enhance customer satisfaction, and create new revenue streams, in addition to being aesthetically pleasing and well engineered. Highlights include: Deploying an integrated facility planning process tailored to an institution s unique needs; Understanding the trends that affect space allocation and configuration; Defining strategic direction and future demand; Coordinating operations improvement initiatives and planned technology investments with facility planning.

Healthcare Architecture as Infrastructure: Open Building in Practice Author(s): Stephen H Kendall No of Pages: 224 Year of Publishing: 2018 Book Description: Healthcare Architecture as Infrastructure presents these new approaches.

Advocating an infrastructure theory of built environment transformation in which design and investment decisions are organized hierarchically and transcend short-term use, the book draws on ten case studies to showcase best practice from around the world. Written by experts with experience in policy making, designing, building, and managing complex healthcare environments, it shows professionals in architecture, engineering, healthcare and facilities management how to enhance the long-term usefulness of their campuses and their building stock and how to strengthen their physical assets with the capacity to accommodate a quickly evolving healthcare sector.

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Books

Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again

Improving Patient Safety: Tools and Strategies for Quality Improvement

PACS–Based Multimedia Imaging Informatics: Basic Principles and Applications

Author(s): Eric Topol No of Pages: 400 Year of Publishing: 2019 Description: Medicine has become inhuman, to disastrous effect. The doctor-patient relationship--the heart of medicine--is broken: doctors are too distracted and overwhelmed to truly connect with their patients, and medical errors and misdiagnoses abound. In Deep Medicine, leading physician Eric Topol reveals how artificial intelligence can help. AI has the potential to transform everything doctors do, from notetaking and medical scans to diagnosis and treatment, greatly cutting down the cost of medicine and reducing human mortality. By freeing physicians from the tasks that interfere with human connection, AI will create space for the real healing that takes place between a doctor who can listen and a patient who needs to be heard.

Author(s): Raghav Govindarajan, Harleen Kaur, Anudeep Yelam No of Pages: 200 Year of Publishing: 2019 Description: Based on the IOM's estimate of 44,000 deaths annually, medical errors rank as the eighth leading cause of death in the U.S. Clearly medical errors are an epidemic that needs to be contained. Despite these numbers, patient safety and medical errors remain an issue for physicians and other clinicians. This book bridges the issues related to patient safety by providing clinically relevant, vignette-based description of the areas where most problems occur. Each vignette highlights a particular issue such as communication, human facturs, E.H.R., etc. and provides tools and strategies for improving quality in these areas and creating a safer environment for patients.

Author(s): H. K. Huang No of Pages: 672 Year of Publishing: 2018 Description: PACS-Based Multimedia Imaging Informatics is presented in 4 sections.

Part 1 covers the beginning and history of Medical Imaging, PACS, and Imaging Informatics. The other three sections cover Medical Imaging, Industrial Guidelines, Standards, and Compliance; Informatics, Data Grid, Workstation, Radiation Therapy, Simulators, Molecular Imaging, Archive Server, and Cloud Computing; and multimedia Imaging Informatics, Computer-Aided Diagnosis (CAD), Image-Guide Decision Support, Proton Therapy, Minimally Invasive Multimedia Image-Assisted Surgery, BIG DATA. PACS-Based Multimedia Imaging Informatics: Basic Principles and Applications, 3rd Edition is the single most comprehensive and authoritative resource that thoroughly covers the critical issues of PACS-based hardware and software design and implementation in a systematic and easily comprehensible manner. It is a must-have book for all those involved in designing, implementing, and using PACS-based Multimedia Imaging Informatics.

Innovative, provocative, and hopeful, Deep Medicine shows us how the awesome power of AI can make medicine better, for all the humans involved.

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Molecular & Diagnostic Imaging in Prostate Cancer: Clinical Applications and Treatment Strategies (Advances in Experimental Medicine and Biology) Author(s): Heide Schatten No of Pages: 194 Year of Publishing: 2018 Description: The second of two companion books which address the biology and clinical aspects of prostate cancer. This volume, Prostate Cancer: Molecular & Diagnostic Imaging and Treatment Stategies, discusses both classic and the most recent imaging approaches for detection, early diagnosis and treatment of prostate cancer. The companion title, Cell & Molecular Biology of Prostate Cancer, covers classic and modern cell and molecular biology as well as genetics, epigenetics, mitochondrial dysfunctions and apoptosis, cancer stem cells, angiogenesis, progression to metastasis, and treatment strategies including clinical trials related to prostate cancer.

Taken together, these volumes form one comprehensive and invaluable contribution to the literature.

Quality Management in the Imaging Sciences, 6e

How to Perform Ultrasonography in Endometriosis

Author(s): Jeffrey Papp PhD RT(R) (QM) No of Pages:384 Year of Publishing: 2018 Description: Quality Management in the Imaging Sciences, 6th Edition gives you complete access to both quality management and quality control information for all major imaging modalities. This edition includes a new chapter on digital imaging and quality control procedures for electronic image monitors and PACS, revisions to the mammography chapter, updated legislative content, and current ACR accreditation requirements. It also features step-by-step QM procedures complete with full-size evaluation forms and instructions on how to evaluate equipment and document results. The only text of its kind on the market, Papp's is a great tool to help you prepare for the ARRT Advanced Level Examination in Quality Management.

Author(s): Stefano Guerriero, George Condous, Juan Luis Alcázar No of Pages:195 Year of Publishing: 2018 Description: This structured dynamic book outlines, step by step, an evidence-based systematic approach to the sonographic evaluation of the pelvis in women with suspected endometriosis. This “how to” guide is intended for those with basic ultrasonography skills who want to further develop their capabilities in performing the relevant sonographic techniques to identify endometriosis. The International Deep Endometriosis Analysis (IDEA) group consensus statement was the culmination of the work of 29 authors from 5 continents. With the publication of How to Perform Ultrasonography in Endometriosis the authors intend to provide the basis for quality improvement and benchmarking of ultrasound in the world of endometriosis.

This book not only offers sonologists, radiologists and sonographers valuable insights into the field of endometriosis ultrasound, but also enables them to develop their practical skills in assessing women with chronic pelvic pain.

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

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