Asian Hospital & Healthcare Management - Issue 46 by Ochre Media Pvt. Ltd.

I S S U E 46

2019

w w w.asianhhm.com

Associate Partner

Health Hackathons An overview

Intelligent Healthcare From vision to reality

Foreword Blockchain Enabling a safe and secure integrated healthcare ecosystem A latest report from IBM indicates an average size of data breach is above 25,000 records and an average cost of breach is US$3.92 million. As a result, the US has emerged as the country with the most expensive healthcare. The global healthcare industry has been plagued by challenges such as counterfeiting drugs, fraud, data protection. While the industry continues to explore technological innovations aimed at enhancing care and patient safety, securing patient data remains a priority for healthcare organisations. Blockchain has emerged as one of the technologies that healthcare organisations are slowly but surely heading towards to address data security concerns. Deloitte’s blockchain survey 2018 indicates blockchain to be among the top 5 priorities for 40 per cent of healthcare executives. A latest report by BIS research estimates that healthcare market spend across the globe can touch US$5.6 billion by 2025. Blockchain, being a decentralised distributed ledger system, helps address challenges pertaining to interoperability of electric records, drug supply chain and traceability, patient data security, digital identity and regulatory compliance. When it comes to electronic health records, blockchain facilitates encrypted data storage that can be accessed only by authorised personnel validated by smart contract Blockchain can also be leveraged for claim and billing management, and other financial transactions. The shared data can be accessed only by authorized personnel validated by smart contract under which all participants can use information.Essentially, blockchain helps in building a universal data sharing platform that enables storing data in fragmented systems and allows for seamless and secure data transfer across networks. While blockchain offers great promise for the industry, there arise certain challenges related

to implementation. These include: deployment on a large scale, partnership with technology organisations, integration with existing infrastructure, accordance with laws, regulatory and compliance requirements. The industry’s investment in blockchain was US$53.9 million in 2018 and this is expected to surge exponentially to US$829 million. This could possibly result in saving billions of dollars otherwise lost due to rising IT and operational costs, data breaches etc. The healthcare of the future is becoming increasingly patient-centric, towards creating an ecosystem that offers experience not just care giving. A study published by the Journal of American Medical Association indicates the US spending on healthcare was around 20 per cent of its GDP while other nations (part of the study) spent around 10-12 per cent for their healthcare programmes. Healthcare remains a key priority for governments with a lot of budgets and spending going into transforming the current landscape. Case in point is Australia, a country currently in the process of digital healthcare transformation. However, government regulations allow only practitioners to access their patients’ electronic medical records. The cover story of this issue delves into the current state of health system in Australia, the transformation approach and how blockchain can help drive this transformation to make the country’s healthcare system more effective and efficient.

Prasanthi Sadhu

Editor

CONTENTS COVER STORY

HEALTHCARE MANAGEMENT 06 Health Hackathons An overview K Ganapathy, Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services

BLOCKCHAIN IN HEALTHCARE Keeping patient data safe and secure Alessio Bonti, Lecturer and Innovation lead, Deakin University

12 Smart Hospitals, Smart Care Gurrit K Sethi, Hospital Chief Operating Officer, Care Hospitals

MEDICAL SCIENCES 24 PCOS & Obesity Pradeep Chowbey, Chairman, Max Institute of Minimal Access, Metabolic & Bariatric Surgery, Max Super-Speciality Hospital

30 Anticoagulation of Patients with Atrial Fibrillation and High Bleeding Risk In the era of new oral (non-vitamin K antagonists) anticoagulants Rami Riziq Yousef Abumuaileq, Palestinian Medical Services/Palestinian Ministry of Health- Gaza / Palestine

DIAGNOSTICS 36 Molecular Diagnostics Empowering patients for better outcomes, diagnosis, and treatment Suresh Vazirani, Chairman and Managing Director, Transasia-Erba Group

TECHNOLOGY, EQUIPMENT & DEVICES

INFORMATION TECHNOLOGY

42 Can Thailand become a MedTech Innovator instead of a MedTech Customer?

51 mHealth Technology Privacy & Control

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

Karpurika Raychaudhuri, University of New South Wales (UNSW) Pradeep Ray, University of New South Wales (UNSW)

FACILITIES & OPERATIONS MANAGEMENT

56 Intelligent Healthcare From vision to reality Nalin Amunugama, General Manager, Boge Kompressoren, Asia Pacific Pte Ltd

48 Green Hospitals Towards sustainability

60 Mental Health Challenges in the Asia-Pacific

Hina Gupta, Operations Department, MG Cooling Solutions

Madhav Ragam, VP Government Industry, IBM Asia Pacific

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Advisory Board

Beverly A Jensen President/CEO Women's Medicine Bowl, LLC EDITOR Prasanthi Sadhu EDITORIAL TEAM Debi Jones Grace Jones

K Ganapathy Director Apollo Telemedicine Networking Foundation & Apollo Tele health Services

ART DIRECTOR M Abdul Hannan Pradeep Kumar Ray Honorary Professor and Founder WHO Collaborating Centre on eHealth UNSW

PRODUCT MANAGER Jeff Kenney SENIOR PRODUCT ASSOCIATES Peter Thomas David Nelson Susanne Vincent

Nicola Pastorello Data Analytics Manager Daisee

PRODUCT ASSOCIATES Austin Paul John Milton Jessie Vincent

Gurrit K Sethi CEO Canta Health

CIRCULATION TEAM Naveen M Sam Smith SUBSCRIPTIONS IN-CHARGE Vijay Kumar Gaddam

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

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

HEAD-OPERATIONS S V Nageswara Rao

Associate Partner

In Association with

A member of Confederation of Indian Industry

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

Peter Gross Chair, Board of Managers HackensackAlliance ACO

Malcom J Underwood Chief, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital

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HEALTHCARE MANAGEMENT

HEALTH T HACKATHONS An overview

The very concept of a hackathon first originated in 1999. In 2010, the first dedicated health hackathon took place. While there are many URL’s which invites applications for specific individual health hackathons and some, which describe in informal language what occurred during the hackathon, the number of articles published on health hackathons per se are not many. This overview is a synopsis of the information currently available also utilising the author’s participation as a mentor and judge in an international and national health hackathon. The article is from the perspective of an IT interested clinician. K Ganapathy, Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services

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he term ‘hack’ generally signifies writing a computer programme for enjoyment while ‘thon’ is taken from the word ‘Marathon’ denoting a specific, clearly defined, difficult, time-restricted objective involving concentrated effort. The prefix ‘hack’ sometimes results in an erroneous misconception that this activity is related to unauthorised intrusion into a computer or a network. A hackathon is a design sprint1 -like event in which computer programmers, project managers, healthcare providers, data scientists, technologists, businessmen, subjectmatter-experts and other stake holders collaborate intensively on software projects. A working product needs to be developed before the hackathon is over, deploying appropriate software or hardware. Programming language, operating system and API used are normally specific to the event. Creating new areas for innovation 1 https://en.wikipedia.org/wiki/Design_sprint

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and funding is the primary goal. In many ways, hackers are model citizens of the digital era. They are creative, persistent, and resourceful, viewing every problem as an opportunity. A health hackathon aims at productising high impact innovations better than existing alternatives, relevant to the local context, simple, easily tested, and visible to others. The ‘hacker way’ has been successful outside of healthcare, because the developer or hacker can identify themselves as the final user of the product or service. Developers for the most part create products that they themselves would use. In travel, banking, media, and social networking the developers have easy access to the fundamental users: either themselves or the people around them. However, in health, there is a barrier of access to users. Fundamentally, those with technical skills to build solutions are separated from those who have the frontline experience and understanding, to know which solutions should be built. In healthcare even if a hacker could develop a solution, it cannot be tested and implemented without a clinical partner. Each needs the other to move from idea to a working product Hackathons have a lot in common with the ‘Lean Startup’ philosophy. Basically, it revolves round the statement “how can we learn more quickly what works, and discard what does not?”Lean startup is a methodology for developing businesses and products. A minimum viable product (MVP) is developed with sufficient features to satisfy early adopters. The final, complete set of features is designed and developed after getting feedback. High morale, safety, and customer delight are additional goals and benefits. The Lean-agile mindset, which provides tools needed to empower and engage teams to achieve high productivity, quality, and engagement is also desirable while participating in a healthhackathon. John Gage of Sun Microsystems is credited

After the first healthcare hackathon was held in 2010, there have been about 138 medicalthemed hackathons worldwide

with introducing the term ‘hackathon’ in 1999 at a programmers conference in Silicon Valley. It wasn’t until 2010 that the first health focused hackathons was launched at a national scale. The complex issues in healthcare need multiple solutions at multiple times. A healthcare solution is not just a function of deployment of hard-core software programming. Scientific, economic, political, emotional, and ethical issues need to be addressed. A number of perspectives need to be integrated. Working in crossfunctional teams and testing of ideas leads to development of complete functional prototypes. hackathons offer an opportunity for spotting talent and creating new opportunities. Non-clinicians can begin to understand the complexities of the clinical thought process and the factors that drive quality improvement. A few days even of concentrated, cross-disciplinary creativity is unlikely to yield necessary proof. Ideas are in plenty. Proving that the proposed healthcare intervention work is more difficult than demonstrating working of a software code or a business model. Hackathons are a great way to generate a spark. But in medicine, it’s a long way from spark to fire. Innovations are the end result of likeminded people coming

together. Perspectives may be different but goals are the same. The hacker way is a model for rapidly solving problems through intense, inexpensive sessions. Programmers and web designers get together, without prior planning and with total freedom. Facebook, a US$100billion corporate giant, started in a dormitory room. Thousands of small improvements made Facebook what it is today. Healthcare providers can define a problem and suggest solutions but do not have access to people who can develop solutions. Individuals with solutions cannot get close to the health-care system. In a health hackathon, they are together. Hackathons are not just for coders. All organisations are starting to use these intense brainstorming and development sessions to create new ideas. A concept is being translated into new products and processes that improve customer experience, increasing growth. Participants need to step out of their normal roles and skill sets – outside their “comfort zone. Asking the right question is critical. The best hackathons start with an openended but clear challenge. The question should be focused and inspiring, with multiple solutions. If new information is forthcoming the original question itself could be reviewed. Conceptualisation, Planning and Execution of a Healthhackathon

Opportunities need to be provided for new learning. A hackathon is a refuelling pit stop/ training session to prepare participants for solving problems .Every participant needs to be occupied with building new data, writing a document or jointly investigating a problem. The problem must be precise, unambiguous with possibility of a reasonably specific solution. A “subject matter expert” guides the project to realworld relevance, identifying problems. However, they may not be able to convert these into workable technology projects. Ideas discussed should be

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can be utilised regionally nationally and even globally will score higher. In the Taipei Medical University hackathon with SANA MIT, judges were provided with a mobile app, which specified various criteria. The judges who were also the mentors had to mark each individual criteria as they were listening to the presentation. As there were 15 judges, and many were outside the country, any possible bias was removed. After all the presentations were over the judges met and reviewed the computer based ranking. If the difference in marks were marginal this was reviewed and the majority opinion Intellectual Property

confined to those, which can actually be worked upon during the hackathon. At the beginning of a healthhackathon, mentors define a problem in one minute. Participants also suggest ways of tackling the problem. They then divide themselves into groups based on problems they are interested in solving. Competition adds to the challenge. Teams with the best ideas win cash prizes and opportunities to promote a start-up company. The main work may take several hours to several days. Participants sleep on-site bringing adequate clothes and power strips! As most of the ‘hackers’ are millennials, there is a general air of informality. Each team consists of 4-5 individuals of diversified backgrounds. It is presupposed that the ‘problem’ experts will understand the language spoken by the solution providers and vice versa. An entrance fee, primarily to defray operational expenses and food, is collected from the participants. This varies from US$ 25 for a student to 100$ for a non-student. Companies sponsor prize money and expenses to be incurred for getting mentors etc. Each team is required to start from scratch. Bringing prototypes/ beta versions is strictly prohibited. Participants are required to sign non-disclosure agreements (NDAs) before commencement

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of any work. Teams are formed based on complementary skill sets, potential solutions and strategies. Participants can choose to work on a concept or on a data set. Participants need full access to exhaustive databases, which would be a reliable source of information. Organisers need to pay attention to food, power, Wi-Fi, excellent time management, proper distribution of teams and mentors. Mentoring

Mentor rounds and meetings occur throughout the event. Mentors go round the hall to check individual teams’ progress and to provide answers to problems. In addition, each team also has at least two scheduled mentor meetings in a private room, when progress is reviewed by a panel of mentors. Ideally, a mentor should be an advisor to two or maximum three teams. A single team should also ideally have two or three mentors. This however would depend on local logistics. Language can often be a constraint for international mentors. The author experienced this at a health hackathon in Taipei. Judging

The main parameters judged include innovativeness, feasibility, and societal value of the projects. Solutions which

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Participants may be uninformed or unconcerned about Intellectual Property (IP) as they come from different organisations. As hackathons are often viewed as recreational social events, organisations deputing employees need to be aware of IP rights. Individuals form teams with ‘strangers’, brainstorm together, generate at least a proof-ofconcept prototype product, and then publicly disclose it, all in a few days, reducing chances of filing for a patent. It may be unclear who contributed what, and who has proper claim to the IP, hackathons have potential to create disruptive technologies, attract young talent, and identify leaders. Twitter and GroupMe both originated in hackathons. A forward-thinking business might, therefore, run its own hackathons internally as all products are then owned by the company. Speciality Health Hackathons

Introduction After the first healthcare hackathon was held in 2010, there have been about 138 medical-themed hackathons worldwide. These events have focused on broad health topics, such as improving digital health forums, creating mobile health apps, and managing big data related to healthcare. Narrower scopes have also been addressed, includ-

HEALTHCARE MANAGEMENT

ing paediatric obesity, diabetes management, and stroke prevention. Radiology hackathons Opportunities for radiologists to gain experience on technologic innovation, practice dynamics, interdisciplinary and patient relations are restricted. These aspects of patient care extend beyond clinical acumen. Today these are as important as clinical image diagnosis. The healthcare hackathon offers this opportunity. In 2016, Journal of American College of Radiology hosted its first hackathon, aimed at improving access to peer-reviewed medical literature. The Center for Biomedical

Innovation and Technology and an experienced MIT Hacking Medicine group, hosted the first radiology department–sponsored hackathon. The theme was “Re-Engineering the Patient Experience and Provider Engagement,” with aims to adapt a hackathon event to problem-solve broad issues within radiology, not just those related to technology programming or patient interactions. Additional goals of the event were to innovate solutions to these problems and to create an integrative environment for radiologists, other physicians, students, and industry members to collaborate.

Medical education hackathons A start-up ‘doctorpreneur’ partnered with another organisation MedX to organise the world’s first ‘medical education’ hackathon in Glasgow in September 2015. Innovative clinicians, software developers, and entrepreneurs jointly sought to create new solutions to medical education problems Mental healthhackathon HackMentalHealth was exclusively devoted to Mental health. Over twenty mental health professional mentors participated resulting in the hacks being targeted towards actual end-users.

ILLUSTRATIONS OF SPECIFIC HEALTHHACKATHONS India

Jugaad-a-thon1, probably the first health hackathon organised in 2014 in Bangalore, by CAMTech, MIT Hacking Medicine and Global healthcare, Jugaad-a-thon stands for ‘totum maior summa partum’: the whole is greater than the sum of its parts. The tag line: “We’re not here to win money; we are here to solve problems.” The event lived up to its name by bringing together over 200 participants, 70 mentors and 30 clinicians for a weekend of healthcare innovation.

Figure 1: Author atValedictory Function in one center @ Smart hackathon 2019

Smart India Hackathon

To promote a mass movement of innovation the Ministry of Human Resources Govt. of India , the All India Council of Technical Education, Inter Institutional Inclusive Innovations Centre and Persistent Systems have jointly organised a Smart India hackathon (SIH) from 2017. This event seeks to identify new and disruptive India centric technology innovations. A non-stop product development competition, problem statements are posed to technology students helping harness creativity and expertise. The first two editions, SIH2017 and SIH2018, were successful in promoting innovation, out-of-the-box thinking in young engineering minds. Of the 450 plus problem statements uploaded in the website, in 2019 many are from the health sector. Disclaimer: the author was the Principal Coordinator for the eight ‘hackable’ problems submitted from Apollo Hospitals2. This is a forward step and perhaps will lead to dedicated national level health hackathons soon in India as well.

Figure 2: Author having a talk with students

1 http://www.jugaadathon.com/ Figure 3: Author with the winning team

2 https://www.sih.gov.in/

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HEALTHCARE MANAGEMENT

ILLUSTRATIONS OF SPECIFIC HEALTHHACKATHONS The primary objective of SIH is to harness the creative energy and ability of technology students across all technology institutions (more than 5 million students from 6000+ institutions). SIH has helped India establish world’s largest Open Innovation Initiative. Other countries Thailand: Khon Kaen University conducted the first health hackathon in Thailand. The primary topic was deployment of mHealth in resource-constrained settings. Teams from health sciences and computer technology were formed ahead of the event including matching and merging as it was felt that Thais were generally shy and required time to get to know a stranger. A team from KKU and mentors addressed requests from participants. Stanford: At the second-annual Stanford’s health hackathon, 300 bright engineering, product design and technology innovators met to address health challenges by prototyping health tech products and apps. Black box thinking was the hallmark. Taipei Medical University in conjunction with MIT conducted a hackathon on health IoT (HiOT) from October 19 ~ 21, 2018. The theme was “From Complex Healthcare Data to Serious Clinical Solutions – the AioT approach”. This hackathon emphasised the use of Big Data. By combining AI and IoT into the normal clinical process, it would enhance the traditional clinical experience Finland - October 2017 saw the Dash design hackathon, the biggest design hackathon in Europe. The hype around Dash was big and the participants were eager to get their hands dirty with the challenges. NO participant had a clear idea of what they would be working on during the weekend or what the end product would be like.

Figure 4: The author @ healthhackathon Taipei Medical University

Figure 5: Hackathon in progress

Figure 6: Author mentor of team, which won fourth prize

Conclusions:

Health hackathons are here to stay. Their increasing popularity worldwide stands testimony to this. To be sure, hackathons will never ever replace conventional prolonged work in the IT or clinical laboratory. However, this hitherto considered unconventional approach has its own rewards.

AUTHOR BIO

K Ganapathy, Past President, Telemedicine Society of India. former Secretary and Past President of the Neurological Society of India, former Secretary of the Asian Australasian Society of Neurological Surgery , Past President of the Indian Society of Stereotactic & Functional Neurosurgery. He is a pioneer in introducing Telemedicine in India.

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SMART

HOSPITALS SMART

CARE

The answer to our healthcare expense woes can ultimately come from smart hospitals and smart care along with the new tech based care options that support preventive care, early detection and outside of hospital care curriculum using connected devices setup on a strong healthcare physical and digital platform. Gurrit K Sethi, Hospital Chief Operating Officer, Care Hospitals

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mart is an often-used word today with varied and interlinked meanings. Who would have ever thought of smart hospitals a few years ago? And yet this term is today fast becoming the key to delivering smart care. “Seamless service made available alongwith the right tools and technology” is what I came up with when I first heard of this term. A good hospital has expectations from the patients rooted in impeccable service delivery, medical as well as non-medical. ‘Impeccable’

HEALTHCARE MANAGEMENT

here would represent timeliness, quality, foolproof approach, hassle free care, and above all, safety. The ‘impeccable’ aspects of healthcare are a multitude of things and very different from all other industries. Hence also that the tools and technology come in varied shapes and forms to support both medical and non-medical aspects. And much more, as we strive to provide better connectivity and care within and outside the realms of hospital buildings. In one of my previous articles, I wrote about communication and Information (C&I) as being the backbone of service delivery. A smartly designed hospital combines with smart devices and tools across the spectrum of different services enabling a smooth physical flow of patients and related activities alongside the not so visible flow of information and communication. This is not just about a smart building that offers all facilities in a ‘coherent to service manner’, but also combining the physical aspects with smart equipment, tools, devices, programmes etc. From entry of patient, as well as staff, to exit and after —encompassing the medical as well as non-medical bits. The smart here embraces hospital buildings, smart software, smart medical equipment, smart non-medical equipment, smart healthcare devices, and most importantly, smart teams!! Smart buildings entail much more than a beautiful design. These buildings look more deeply at patient and staff movements ergonomically, well designed storage, service areas, waiting areas and as well as patient areas also the space available for attendants and visitors. When a patient enters the premises, where does he or she go for the first point-of-contact that is the reception areas?Are the reception areas convenient for different categories of patients like the handicapped and elderly? Is there enough waiting space to offer areas for passing time, eating spaces, educational areas, nursing pre-checks, entry to the doctors’ clinics, support desks etc.?And

New age modalities such as telemedicine, video consultation options and even E-ICUs have created anenormous opportunity to cut through challenges of scarcity of medical personnel in remote and far flung areas.

the list goes on. On the in-patient side, areas need more focussed designing and detailing. Operation theatres (OTs) and cathlabs need close access places; waiting areas for attendants in waiting while their near and dear go through the procedures; the doctors need to inform them, take consents etc. These places also need a good sterile connect to the critical care units. While these things sound simple, many a hospital are created out of makeshift arrangements using buildings made for other uses. One sees very many ‘good looking’ hospitals but only when you start organising the services does one realise the hazards, such as, a poorly placed nursing station takes away the watchful eyes of the nurses from the patients, open stairways and multiple entries and exits can at times become safety hazards, and poorly designed waiting areas can be another menace. Entering into the care zones, life can be way better when the spaces are designed keeping staff ergonomics in mind. Many hospitals get built without the mindfulness of the work flow thus increasing the operations costs in turn pushing up costs of the care offered. In fact, some of these costs may not even be easily visible. The patient service gets defined by a plethora of tools today. Starting with call receiving to booking of services,

enabling patient reminders, taking advanced deposits, billing and queuing at out-patient department (OPDs) are the first indicators of a satisfactory patient experience of any facility. Today, there are a plethora of tools available to enable these services. A point to note is that these can help better plan service delivery, reduce the drop-out rates, and help pick up signs of dissatisfaction early on so that service recovery can kick in on time. These are an important smart tools to welcome patients into the system. Good customer relationship management (CRM) and Electronic Medical Record (EMR) systems are an important and critical tool to know your patients better, for record keeping, and better care. This is followed by the medical care itself, which gets defined not only by the skill of the attending physicians, nurses, technicians, and a plethora of medical and para-medical staff, but also by the quality of the equipment, tools, software support such as clinical decision support, various medical keys etc. available to them. The technical definition of the investigative and diagnostic equipment underlines the explorative results and the precision that will help pin-pointing the diagnosis. This diagnosis, in turn, supports the smart physician to speed the patients’ recovery. It is again smart tech tools that support the analysis of treatment outcomes and further research of more and better treatment modalities. The beginning of the treatment also depends on the speed of availability of drugs and medicines. It is virtually impossible to store all the different types of medicines, injectables and consumables available. Also, what with the new brands hitting the market every now and then. The hospital has to create a formulary and stock items based on this. The maintenance of stocks and the to and fro information of the requirements for each patient again is managed by smart logistic systems. Today, smart care also defines the availability of care across difficult

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along-with a home-grown super basic reporting system, the team was able to better the gross earnings by introducing smart spend and smart analysis. This was achieved by reducing spends as well as enhancing the top line in a leaner manner. The effects showed in the bottomline within weeks in a high single digit number. Another hospital, running fullfledged teams up and down and at times, helter-skelter to ensure smiles on the patients faces was actually doing a good job. However, when one got the teams into a room for a workshop designed to help identify workplace issues, there came out a plethora of events and things that they faced daily which were very much avoidable. And, if avoided, they would improve the patient experience by many notches. Along the journey of re-engineering, the team not only made their own lives easier but pushed up the customer satisfaction scores by couple of points as well as reducing the cost of care by a few percentage points. This

AUTHOR BIO

terrains. New age modalities such as telemedicine, video consultation options and even E-ICUs have created anenormous opportunity to cut through challenges of scarcity of medical personnel in remote and far flung areas. The doctors can be consulted over a video call, reports shown etc. This technological advancement alone can help various governments and health organisations to scale their challenges with comparative ease. As these are evolving, the policies and regulations need to evolve as well to support them and to take advantage of these in a meaningful manner. Alongside all this, to build a smart hospital offering smart care, one also needs to apply lean tools to see that there is no waste in the system as well in other areas, especially in manpower, and in movement and deployment of different types of resources. The manpower resources need to be smart as well, and well trained. Having worked across a few projects there are many interesting stories to tell. An upcoming luxury unit, bogged down by luxurious spending, struggled to keep track of where and how the resources were deployed across materials and manpower. While the initial capex spend was mind-boggling, more incredible was the operational spend. There was simply luxury everywhere, even in the minds of employees! With a bit of process re-engineering

also slowly helped change the case mix towards better business profitability. One may think that creating a smart hospital is an expensive affair. Indeed, in the beginning it is. However, it is also mindful spending, ensuring overall better quality, better patient experience, satisfied work place experience, skilled staff offering a service with a smile, and, most definitely, lower day-to-day operational spend. Operational spends also depend on the service levels you lay out for your target audience â&#x20AC;&#x201D; be it the 5-star luxury or the more economic fuss-free model, this gives a value for service all the way. While this sounds amazing, let me also leave you with a warning! For green field projects this is much easier to achieve, not easy though. What is difficult is the change management which needs to be â&#x20AC;&#x2DC;managedâ&#x20AC;&#x2122; in a brown field taking this up. For all the green and black belts, finding the solution is the easiest, it is the implementation which is the devil! The key to success is also governed by this devil. Make sure that the top management team is on board with all the solutions proposed. And post implementation, please do remember that this is a journey. You would need the right tools and teams to continue in the right direction especially in the VUCA world! For those listening, it is never too late to get started now and you will be amazed to see how this churns up care at a much better value for all stakeholders! Value for care and value for investment of money and skill!

Gurrit K Sethi, Hospital Chief Operating Officer, Care Hospitals; Strategic Advisor for Global Health Services, Global Strategic Analysis,contributes to healthcare by helping providers build and better business efficiencies and concept development, also strives to contribute socially through the Swiss Foundation, Global Challenges Forumas Strategic Advisor, throughconception of sustainable health initiatives. She started her career from the shop floor working her way up to lead and set up different healthcare businesses.

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COVER STORY

Blockchain in

Healthcare Keeping patient data safe and secure

Data privacy and transaction efficiency are major issues in today's health system. But worryingly, these may result not only in personal data breaches, but also create events that may lead to a poor health practice. Blockchain technology allows for patients to fully own their data, and the tractability features make it transparent for fault proof transactions and auditing. Alessio Bonti, Lecturer and Innovation lead, Deakin University

his article focuses mainly on the Australian health system; nonetheless, most of the issues and current solutions are true for most practices around the world. For the reader who is not accustomed to blockchain technology, here is one of the most complete definitions provided by Deloitte. “Blockchain is a distributed system recording and storing transaction records. More specifically, blockchain is a shared, immutable record of peer-

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to-peer transactions built from linked transaction blocks and stored in a digital ledger. Blockchain relies on established cryptographic techniques to allow each participant in a network to interact (e.g. store, exchange, and view information), without preexisting trust between the parties. In a blockchain system, there is no central authority; instead, transaction records are stored and distributed across all network participants. Interactions with the blockchain become known to all participants and require

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verification by the network before information is added, enabling trustless collaboration between network participants while recording an immutable audit trail of all interactions” In short, it is the immutable distributed shared database that you would use when you don’t trust the other participants, because it is almost impossible to subjugate. It makes it the perfect way of storing data such as medical or financial, that require heavy regulation and are subject to thorough auditing.

HEALTHCARE MANAGEMENT

For the keen observer, blockchain is merely a database system, in fact, a very low performing database system, with a difference in executions per second that can go hundreds of times lower than a traditional database system. Blockchainâ&#x20AC;&#x2122;s main advantage comes from its immutability and consensus mechanism. We are trading performance for a system where trust is enforced and almost impossible to break, it may seem like a small thing, but it is the biggest change in how we handle data in more than a thousand years.

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HEALTHCARE MANAGEMENT

Also, when we say “blockchain is almost impossible to violate”, we refer to the fact that in order to do so, the most straightforward way would be a 51 per cent attack. As described before, blockchain uses a consensus mechanism, meaning that all nodes must agree in order to commit the execution of an operation (adding data for example), to be able to subjugate the network, and force data into the system, the attacker should own at least 51 per cent of all the computing resources on the network. I will now return to describing where all of this started. Australia is currently transforming its healthcare system into a digital system where medical records are stored electronically. Medical records display patient identification, information relevant to diagnosis or treatment, history, allergies, medications, etc. Management of these medical records has always been a matter of concern as currently there is no unique way of storing this data. It has been seen that every practitioner uses his own style of storing patient data which creates several issues related to the ownership and integrity of the data. As per Australian legislation, patients can’t have access to their own records as sometimes it could harm them, and all the rights are reserved with their current practitioners.

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Hence, whenever they want to access their information or if they want to take advice from some other doctor, they need to request the current practitioner in writing to provide their information to them or to the other GP. So, if we consider the case of an emergency, every minute counts and it could bring the patient’s life at stake. So, if we look at the overall picture of the current medical system, there is an urgent need for a one-stop platform as a solution for the medical records management. The medical industry means different things to different people. For some it has become a way of collecting data, for some people it’s a way of progressing in their business, for some it is a small dental clinic or a big hospital but in reality, it is a combination of everything mentioned above. In the world of technology, people recognise this in different perspectives: for some it’s still like going to a doctor whose clinic maintains a medical record book for the patient’s entire life or even the patient maintains their own paper file. On the other side there are still some people who are willing to shift their work culture electronically.

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Today, every medical practice has different ways of keeping medical records. Not all medical records in a private medical practice are owned by them as ownership depends on the contracts created between the organisation and doctors in private. This is a huge problem with the patient data being lost from an organisation once the doctor leaves. Some practices didn’t even adopt the methodology of storing medical records electronically which again raises the issues of confidentiality and security. Although medical records are gaining more traction and would be the most straight forward way of solving such a big issue, if we rewind back about two decades ago, the 'eHealth readiness of Australia’s medical specialists report' which was announced from the Department of Health and Ageing published in May 2001 noted, ‘although computerised health records are gaining traction, relatively few specialists use an electronic recordkeeping system as a single repository for all relevant patient information. Only 41 percent of survey respondents used a computerised health record-keeping system, and of these just 37 percent relied solely on computerised records. Most of the specialists using computerised systems use them for administrative purposes and storing patient notes but, for data security and legal reasons, maintain separate hard-copy storage of communication to and from other providers (e.g. test results, diagnostic imaging and referral letters)’. It is only in the very recent times that the system has finally started to transition towards a centralised system. In the last twenty or so years, paper-based systems or as many as thirty different proprietary systems were used around Australia to keep track of medical records. Moreover, when audits are being conducted all these paper-based submissions are converted into electronic records in order to make records viable for the government to

HEALTHCARE MANAGEMENT

store and access. This creates a huge problem as when we look into data integrity, we literally cannot rely on the sources and no organisation will indulge in the audit reports which may contain errors that would harm the organisation as a whole. Therefore, we can say that the flaws and mistakes are never traced and eventually the government is at stake and not the individuals. Not only for paper-based record but this is also a common problem with the organisation with records stored electronically, after all they are software and that allows the deletion or removal of any record or data as per the user’s choice. Even in the Australian government’s My Health Record system, only up to two years of previous history will be uploaded. The problem here is that most people do not like their information to be uploaded and being known to others. Even with all the privacy and security assurances put in place, the instinctive nature of people to distrust government bodies remains. Finally, one last issue is the poor state of the health system when it comes to assuring that the practice is carried out legitimately. Fraudulent activities, including impostors impersonating medical professionals, claiming of false or unwanted procedures (over-servicing), illegal sales of pharmaceuticals, or even worse, fake medicines, have been appearing more often in the media. As much as 7 per cent of claims made in the private sector may account for frauds. Using blockchain, multiple aspects of the healthcare industry could be enhanced as being a complex system of interconnected entities under heavy regulatory boundaries, patient data is highly fragmented, and the cost of healthcare delivery is continuously rising due to inefficiencies in the system and dependence on several intermediaries. The healthcare industry is one of the world’s largest industries, consuming over 10 per cent of the gross

domestic product (GDP) of the most developed nations. Even though certain developments like efficient healthcare record keeping systems, wearable devices, and various artificial intelligence (AI) implementation have come up, there are certain problems pertaining in them. One of the major problems inhibiting them is cryptography due to which it’s not a preferable option. According to research, the only viable solution that pertained the attention is Blockchain. When we talk about blockchain, cryptography is just a one-stop-solution. Not only cryptography, it can also provide patients a comprehensive and immutable log platform where they can have easy access to their medical records no matter where they go and whom they refer. When we talk about the basic problems of the health industry, Especially Electronic Health Records (EHR), we think of security, efficiency, cost and ownership. Given this scenario, no other solution would be more useful than blockchain. In order to understand the opportunity ahead, we should start with trying to understand the problem(s) better. The first problem is about

Blockchain relies on established cryptographic techniques to allow each participant in a network to interact without preexisting trust between the parties.

data integrity, since we cannot rely completely on the way the individual records are being stored and recorded differently by different medical practices. And any alterations can harm the patients in the overall terms, and, moreover, if something was to happen, we wouldn't be able to track the current validator. At any given time, the data stored on a blockchain is always true. Smart contracts impose how executions happen and the consensus mechanism ensures that this is always true for all the participants. Data on the blockchain can never be altered, it can only be appended, this is incredibly important for one of the next problems. The next major problem is about data ownership, since even by Australian laws patients don’t have access to their own records, due to which sometimes in case of emergency their life becomes at a bigger risk. Blockchain allows for every participant to own their data, either anonymously, officially, or to a trusted third-party. This is an incredible step forward, as it implies that scandals such as the one involving Cambridge Analytica do not happen again. Data Traceability is the last major problem aligning within the current system as we are unable to track any alterations being made to the data due to the ownership issue i.e. in short no one could be held responsible. As previously mentioned, in a blockchain, data is always appended, never modified, it is almost impossible for this to happen (recall 51 per cent attack).Hence, we can trace all of the operations recorded from the beginning of the chain till the most current and observe exactly how things have happened. For such reasons, blockchain is vastly used in supply chain and logistics problems. We can summarise some of the opportunities here as follows: • Unchangeable audit methods • Ownership lies with the patients themselves

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HEALTHCARE MANAGEMENT

• One-stop solution for EHR • Creates a system of implicit trust • Ensure data safety • Allows data traceability and a higher level of data integrity • Integrity of medical clinical trials to be maintained • Ensures regulatory compliance • Verification of PHI integrity • Adequate tracking of medical claims • Drug traceability • Licensed pharmacy trace There are currently a number of companies working on healthrelated matters, leveraging blockchain technology. I will introduce three of them here, who use blockchain in different sectors. These are Nebula Genomics, DOC.AI, and IRYO. Nebula Genomics used blockchain technology to address the issue of genomic big data. Ultimately, it was a huge success for the company as it not only allowed buyers to efficiently acquire genomic data and protect themselves from the advancement, but the ownership was given completely towards the client side and it was highly protected. DOC.AI has developed a platform using AI, blockchain and natural language processing which helps the patients to interact about the certain

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health conditions they faced and how it could be prevented. Due to this high data security and immutable sharing, people could enter their symptoms and the platform can make predictive assumptions which can eventually give them an insight into their own data and how they can interact with the doctor. It was set as a great example of how to apply AI and Blockchain along with power of community to effectively achieve more précised treatment. IRYO, on the other hand, is working on the overall objective of building an effective platform for keeping health records unified. It ensures the safety of the data by making it utterly impervious to cyber security breaches which also protects the data from state-sponsored

attacks. Through this platform they promise that the patients can share their medical history anywhere in the world as they say that all the records would be stored in a single format. Hence, we can say that blockchain has a huge potential to enhance in medical industry. These are just a few examples, many more projects have been developed, and many more are being created every day. Blockchain technology has been the first system of record revolution since the invention of the ledger more than a thousand years ago. We can with great confidence say that blockchain has a full scope of enhancing the entire industry. All it needs is mass adoption, and once it is done it will set a new mark for medical innovation. I would like to conclude with my favourite project. It is called Openmined, and I invite all readers to visit the group’s website. Openmind is a platform which uses blockchain to anonymously train AI models using homomorphic encryption — meaning that the artificial intelligence is trained using encrypted data that is never decrypted. Potentially, one day we will all be able to contribute, safely, to the creation of a distributed AI that will help solve a huge number of problems that are now impossible to solve because of the lack of data. Our future is made up of data, it is only natural that we want to keep it secure.

AUTHOR BIO Alessio is a lecturer and innovation lead at Deakin University, with almost ten years of industry research and prototype development in world’s top firms. Among her experiences, she led the early application development of IBM Watson for Oncology and Blockchain logistic solutions for China’s One Belt One Road projects.

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TRANSFORMING CARE DELIVERY

Shaping the future of Healthcare

Elisabeth Staudinger President Asia Pacific Siemens Healthineers

troke is a serious problem world-wide and especially in Asia where the mortality rate is higher than in Europe or North America1. Access to care is especially crucial when it comes to stroke, as it greatly affects patient outcomes: the shorter the time the brain is deprived of oxygen, the less the permanent damage. However, in many parts of Asia, especially in rural parts, access to care remains limited. The Mekong Delta region in Vietnam was one such an example. Timely treatment for approximately 10000 stroke patients2 for the region with a population of 17 million wasn’t available for the longest time. Today, Stroke International Services (SIS) General Hospital in Can Tho city, Vietnam, is the first stroke hospital in the region and is playing a crucial role in providing timely treatment for stroke patients, thus helping to reduce the risk of disability and death, as well as improving the delivery and coordination of care in acute stroke. So called ‘Value Partnerships’ between Siemens Healthineers and a group of private investors in Vietnam played a major role in realising the vision to improve access to care in the region and thereby transform the way how care is delivered. What does it take to transform care delivery in Asia and improve outcomes? Let’s start with some major trends we see globally. The demand 1 Kim JS. Stroke in Asia: A global disaster. Int J Stroke 2014; 9(7): 856-7. 2 According to HCMC Society of Interventional Neuroradiology

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for healthcare is rising as people get older. At the same time there is a lack of qualified healthcare professionals as well as suitable infrastructure, especially here in Asia, which is home to more than 50 per cent of the world population. We need to find a way to cope with the growing demand and ensure access to care for as many people as we can. We firmly believe that digitalisation can and will play an important role in shaping the future of care delivery. I’ve addressed this opportunity of digitalisation in my previous interview last year. This time I would like to highlight the contribution that Value Partnerships can make. Can you elaborate more on the concept of Value Partnerships? How can they shape the future of care delivery? The main goal of a Value Partnership is to combine the strengths of the partners involved and jointly work towards a shared vision. The healthcare providers’ core strength of clinical expertise and a commitment to quality care can be paired with the global knowledge, strategic acumen, implementation capabilities, and innovative technology of Siemens Healthineers. Healthcare providers don’t just want a technology vendor. They want a true partner who can advise them on how to best serve patients’ needs now and in the future, and work along with them to bring their vision to life. Co-creation is the essence of a Value Partnership. Just like a marriage, no two Value Partnerships are the same. No two healthcare providers face the same mix of pressures and opportunities. Every Value Partnership is unique, built around the provider’s vision for delivering the best possible care to the patients that depend on them as well as the organisation’s requirements. What are some specific areas where Siemens Healthineers can provide value as a partner? Real value is created when the technology partner can offer competencies that can be combined to maximise benefit to the provider organisation and the patients it ultimately serves. Many Value Partnerships include technology management, which aims to reduce operational complexity and increase

technology availability through one single contact for all equipment related topics, providing additional budgetary security. Through our consulting and transformation services, we can optimise clinical operations as well as facilitate the introduction of innovation and digitalisation to improve efficiency. We also offer value-added services like education, staff training, workflow simulation, and design planning, which play a key role on our joint journey towards optimised care delivery. Last but not least, financing is a key enabler of our Value Partnerships. We have extensive experience with both public and private organisations around the world, and we understand the unique challenges and pressures that apply in each country where we are doing business. The wide range of offerings helps us to transform care delivery. What are some typical scenarios in Asia Pacific where Value Partnerships made a difference? The need for a partnership is typically triggered by certain events such as a new hospital construction or expansion, replacement of an aging technology fleet, financial uncertainty, performance issues, changes in reimbursement, changes in ownership/management, or when there is a recognised need for a change in quality and cost improvement. Although the specific challenges may differ from provider to provider, those are typical events that call for a partnership approach. Especially in this region, Value Partnerships are a means to increase access to care. When we talk about access, there are three dimensions: accessibility, affordability and availability. Accessibility means care is available ‘everywhere’ and, in particular, close to the patients. Affordability means that patients can pay for state-of-the-art diagnostics treatment, and finally, availability means there is limited waiting time. All three dimensions, accessibility, affordability and availability can be challenging in Asia. That’s a very comprehensive offering. Could you share some examples please? Let us take the previous example from Vietnam. Private investors who had a family member that suffered a stroke had the vision to provide timely treatment to patients in the Mekong Delta region. This was a huge ambition. The partnership we entered into included not only comprehensive diagnostic and interventional solutions but also an educational plan for the healthcare professionals in and around the region. As a result, the ‘SIS’s first Asian Stroke Summer School’ was born. The aim is to raise the skill levels of doctors on acute stroke management in the region including Laos, Cambodia and Indonesia. The concept is following the model of the European Stroke Winter School, which for the past five years has been held in Bern, Switzerland. The course format has turned out to be successful to spark interest in providing comprehensive endovascular stroke treatment services throughout Europe. With the first Asian Stroke Summer in SIS we have extended

this success by making the Winter School training accessible for interventionists and neurologists in the Asia Pacific region. Another, quite different example comes from Malaysia. The Laboratory Diagnostics (LD) team of Siemens Healthineers partners with our key account customers and regularly holds a series of LEAN workshops. The goal is to increase workforce productivity to address the continuous challenge of staff shortage and increased demand. The workshops typically focus on elimination of unnecessary steps that hinder or obstruct workflow and clinical excellence and also look for ways to create additional value for patients. True partnerships require strong commitments on both sides. How are value partnerships formed and how do you ensure success? As with any partnership, trust, understanding and the sharing of common goals and incentives are key ingredients. We make sure to gain an in-depth understanding of the unique challenges and opportunities our partner faces. We set common objectives and incentives to tackle those challenges together. This may or may not include a performance and risk sharing arrangement – such as a performance sharing model or pay per use model. Once we have an alignment on objectives and incentives, we plan on how we can jointly achieve those goals. Ultimately, by bringing together the competencies of a MedTech provider with those of a healthcare provider and thereby combining the unique strengths and expertise, we can have a great impact on the provision of healthcare in Asia. How can healthcare providers thrive in this ever-changing environment? Many healthcare providers aim at providing high-value care. High-value care simply means to provide both the best possible outcomes to the patients while investing as little money as possible. The key to providing high-value care is embracing four key themes, namely expanding precision medicine, transforming care delivery, improving the patient experience, and all enabled by digitalising healthcare. Our goal is to support our partners in realising their vision to deliver high-value care. With a successful track record in international management roles, Elisabeth Staudinger is a remarkable senior leader in the healthcare industry. She has worked in Asia Pacific since 2013 and is currently President of Asia Pacific at Siemens Healthineers. Leading a team of over 7000 people who are passionate about shaping the future of healthcare is her source of inspiration. She and her team share a common goal: to enable healthcare providers, particularly in Asia Pacific, to deliver highvalue care.

siemens-healthineers.com/value-partnerships

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MEDICAL SCIENCES

PCOS & OBESITY Obesity is a complex disorder and a major health risk factor linked to cardiovascular disease, stroke, cancer, hypertension, diabetes, and mortality. Polycystic ovary syndrome (PCOS) is an endocrinemetabolic disorder characterised by multiple hormonal imbalances, reflecting on a clinical presentation dominated by manifestations of hyperandrogenism, which generate short and long term consequences on female health. The obesity is a contributing factor in the development of PCOS. Lifestyle intervention is a non invasive form of therapy which is totally patient oriented and tailored to their abilities. Bariatric surgery has been an effective treatment for morbid obesity and with improvement of the metabolic syndrome. Bariatric surgery should be considered along with other medical and lifestyle alterations as first line therapy in PCOS women with obesity and metabolic abnormalities.. Pradeep Chowbey, Chairman, Max Institute of Minimal Access Metabolic & Bariatric Surgery, Max Super-Speciality Hospital

besity 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. Studies reveal obesity is killing three times as many as malnutrition.

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MEDICAL SCIENCES

Obesity is a global burden on society which has a potential to destroy Nations medically and economically. Disease has been defined in many numerous ways. The American Medical Association (AMA) 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. 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. The first description of linkage of Polycystic Ovary Syndrome (PCOS) and obesity was given in 1930. PCOS is an endocrine-metabolic disorder characterised by multiple hormonal imbalances, reflecting on a clinical presentation dominated by manifestations of hyperandrogenism, which generate short and long term

consequences on female health. PCOS being a complex disorder, infertility is the most morbid complication affecting approximately 48.5 million women aged 20–44 years, with PCOS accounting for 6–15 per cent of these cases, although up to 70 per cent of women with PCOS may be undiagnosed. The women afflicted by PCOS have a greater tendency to develop obesity, dyslipidemia, hypertension, metabolic syndrome, type 2 Diabetes Mellitus (DM2) compared to women without PCOS. Obesity worsens the condition of PCOS both reproductively and metabolically. The obesity should be addressed primarily in patients suffering from PCOS to avoid the sequelae of infertility, pregnancy complications, metabolic dysfunction. Insulin resistance is a major feature of PCOS and is particularly prevalent in those women who are obese with 70–80 per cent demonstrating insulin resistance and compensatory hyperinsulinemia. The Influence of Obesity on Metabolic Abnormalities in PCOS

A holistic approach to weight loss in adolescents is very important. Almost 20 per cent of adolescents are overweight by the age of 19 years

Obesity is a contributing factor in the development of PCOS. Body Mass Index (BMI) levels correlate with both body fat and concurrent health risks. Pre-diabetes, dyslipidemia, and metabolic syndrome are the metabolic abnormalities associated with PCOS in adult women. Women with PCOS tend to have more than two to four times metabolic disturbances compared to those without PCOS. Obesity poses increased risk of developing impaired glucose tolerance in overweight, obese woman with PCOS compared to a normal weighing woman with PCOS. The incidence of dyslipidemia and metabolic syndrome also increases with increasing obesity. There are numerous studies like multicentre trial of women with PCOS found no metabolic abnormalities in women with PCOS and BMI <27.

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MEDICAL SCIENCES

Symptoms of PCOS with Obesity

The following fig.1.1 describes the symptoms of PCOS with obesity. The Pathophysiology PCOS in Association with Obesity

The association of insulin resistance, hyperinsulinemia in association with obesity and PCOS is described in the following flow chart diagram (figure 1.2). The Influence of Obesity on Reproductive Abnormalities in PCOS

The diagnostic criteria for PCOS were revised at an International Expert Conference in Rotterdam in 2003. According to the Rotterdam criteria, diagnosis of PCOS requires at least two of the three following features: • Oligo-/anovulation; • Clinical and/or biochemical hyperandrogenism; • Polycystic ovaries on ultrasound. A major concern for women with

PCOS is decreased fertility, which is aggravated by obesity and metabolic aberrations. Menstrual irregularities and an ovulation are more prevalent in obese women with PCOS than in non-obese women. Studies have suggested improvement in their reproductive cycle with achievement of 5 per cent weight loss. Obese women with PCOS have difficulty for conception. In PCOS, normal physiology of folliculogenesis is disrupted in the ovarian cycle under the influence of increased androgen activity causing hyperandrogenemia. Treatment of Obesity in PCOS

Lifestyle therapy in PCOS Lifestyle therapy in PCOS is a daunting task. Lifestyle intervention is a non invasive form of therapy which is totally patient oriented and tailored to their abilities. Lifestyle changes include exercise regime and daily calorie restriction diet plan to improve PCOS. Although there are limited studies

INFERTILITY FATIGUE & MOOD SWINGS

INSULIN RESISTANCE

BODY - HAIR GROWTH

SYMPTOMS OF PCOS WITH OBESITY

OVARIAN CYSTS

TESTOSTERONE LEVELS

IRREGULAR MENSES

LOW SEX DRIVE

Figure.1.1

TROUBLE LOSING WEIGHT

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and are not consistent with results of improvement in PCOS with dietary modification. Medical Nutrition Therapy (MNT) helps women with PCOS for adopting the lifestyle changes to prevent complications. MNT is based on an assessment of lifestyle changes that would help a patient with PCOS achieve and maintain clinical goals. The Academy of Nutrition and Dietetics’ evidencebased nutrition practice guidelines recommend the following structure for the implementation of MNT for adults with PCOS: • Thorough nutrition assessment to help prioritise MNT • Nutrition diagnosis, which includes the presence of, risk of, or potential for developing a nutritional deficit that can be addressed by nutrition therapy • Nutrition interventions, which are specific actions to remedy the nutrition diagnosis; these can include clinical and behavioural goals collaboratively agreed upon with the patient, as well as specific nutrition interventions such as selecting a meal-planning strategy or education on controlling portion sizes or making healthy choices when dining out • Nutrition monitoring and evaluation with ongoing follow-up to support long-term lifestyle changes, evaluate outcomes, and modify interventions as needed The diet therapy approach is beneficial for these patients suffering from PCOS for improving insulin resistance, metabolic and reproductive functions. Effects of insulin-sensitising agents in PCOS Insulin sensitising is known to improve the symptoms of PCOS. The anti-diabetic drugs have been useful to treat the PCOS women with insulin resistance. The first study of metformin in women with PCOS was published in 1994; several studies have demonstrated a positive effect of metformin on both

MEDICAL SCIENCES

OBESITY

Abnormal Lipolysis

Insulin Resistance PCOS

Androgens

Ovarian Steriodogensis

Hyperinsulinemia

Ovarian cyst Formation Figure.1.2

reproductive and metabolic aspects of PCOS. Thiazolidinediones ( TZDs) accelerate the differentiation of adipose cells and improve insulin resistance. By improving insulin resistance and indirectly reducing androgen synthesis in the ovaries, also affects the reproductive system. The ovaries can also be directly targeted with TZDs to reduce hyperandrogenemia and to stimulate ovulation. Pioglitazone is a new TZD derivative which acts after insulin binding by insulin receptors to improve the action of insulin, reduces its resistance to hormones, and inhibits glucose production in the liver. Pioglitazone has been used to treat the insulin resistance, hyperandrogenism, and ovulatory dysfunction that are characteristic of PCOS.

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Effect of antiobesity drugs in PCOS There are currently very few studies which prove the efficacy of anorexiant agents in management of PCOS. There is one FDA-approved drug for the treatment of obesity: orlistat. Orlistat works through a d by inhibiting intestinal lipase activity and thus inhibiting fat absorption. Adverse effects include steatorrhea and flatulence that are reduced with adherence to a low-fat diet and, in rare cases, hepatic damage. Nevertheless, orlistat is available in prescription strength (120 mg/meal). A study on 101 PCOS women showed orlistat combined with lifestyle changes induces substantial weight loss in PCOS . However, emphasis on lifestyle changes when combined with antiobesity agents, exert beneficial effects

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on the endocrine abnormalities of obese patients with PCOS and improve metabolic parameters. The emphasis should be laid on lifestyle modification before initiation of pharmacological intervention. Bariatric surgery in PCOS Bariatric surgery has been an effective treatment for morbid obesity and with improvement of the metabolic syndrome. With modernisation globally and the current understanding of the metabolic changes occurring in bariatric patients postoperatively, bariatric surgery has emerged as successful modality of treatment for morbidly obese women with infertility secondary to PCOS. Epidemiological studies have suggested that weight loss post bariatric surgery may increase women's chance of conception with decrease incidence of PCOS after surgery, there are very few studies assessing fertility before and after bariatric operations. At present, there is no consensus on the role of such surgery in the management of infertility and whether surgery can also be beneficial in women who have a BMI of under 40â&#x20AC;&#x2030;kg/m2. There are very few studies conducted on PCOS patients. PCOS (n=17) patients with an average age of 30 years were followed prospectively for up to 26 months after bariatric surgery (biliopancreatic diversion or LAGB). Outcomes of this study were in favour of surgical intervention in PCOS. Twelve women regained normal menstrual function and most 10 had documented spontaneous ovulation. Average weight loss was 41KG. Patients showed significant improvement in hirsutism, androgen profiles. Bariatric surgery in reproductive age women has been shown to decrease menstrual irregularities. In another prospective 6-year study of patients undergoing LAGB (81 per cent of whom were women), 78 per cent of women saw improvement in metabolic syndrome and 48 per cent showed improvement in PCOS

MEDICAL SCIENCES

risk prevention of metabolic abnormalities. Bariatric surgery is a powerful tool that should not be overlooked simply because a woman is young or presents with PCOS and metabolic abnormalities. Bariatric surgery has both short and long term risks, the potential benefits may be greater in these PCOS women than in older women who are already more advanced with respect to vascular disease.

AUTHOR BIO

specifically with regards to menstrual cycles, fertility and/or hirsutism. PCOS is a challenge in the medical fraternity since many obese PCOS women are adolescents. The prevalence of diabetes mellitus before the age of 50 is exceptionally high and estimated at 3-4 times the general population prevalence. A holistic approach to weight loss in adolescents is very important. Almost 20 per cent of adolescents are overweight by the age of 19 years. It is very important for young women to initiate lifestyle changes through diet and exercise to prevent PCOS. Many PCOS women with obesity may develop coronary artery disease and glucose abnormalities at a very young age. Although women tend to seek medical care for menstrual irregularities and hirsutism, this is an opportunity for testing, education and

Discover a unique opportunity to learn, observe and work alongside leading world class clinicians. Guy’s and St Thomas’ NHS Foundation Trust offers overseas clinicians the opportunity to undertake an observership or hands-on clinical attachment at one of the best teaching hospitals in the UK, located in the heart of London. • Gain exclusive insight into one of the world’s most successful teaching hospitals

• Obtain direct exposure to clinics and ward rounds

• Be part of a unique development experience with full integration in a NHS department

Every woman with PCOS and metabolic abnormalities should be given appropriate counseling regarding the role of bariatric surgery in alleviating their burden of PCOS disease. Bariatric surgery should be considered along with other medical and lifestyle alterations as first line therapy in PCOS women with obesity and metabolic abnormalities. References are available at www.asianhhm.com

Pradeep Chowbey is Chairman - Minimal Access, Metabolic and BariatricSurgery, Max Super Specialty Hospital, Saket, New Delhi, India. He is Padmashri Awarded by The President of India, Doctor of Science (Honoris Causa), Surgeon to His Holiness Dalai Lama. Dr Chowbey. He is a pioneer laparoscopic surgeon in the Asian subcontinent. Prestigious positions held- Worldwide President - International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) (2012- 13) , Founder President- Asia Pacific Hernia Society (2004), President- Asia Pacific Hernia Society (APHS) (2004- 2009), President- Asia Pacific Metabolic & Bariatric Surgery Society (APMBSS) (2010-12).

Over 40 departments including: Cardiology Oncology Diabetes and Endocrinology Nursing

• Broaden and gain new skills for transfer back to the workplace

• Develop links for future working relations through peer mentorship • Share knowledge and expertise with doctors, consultants, nurses and AHPs

www.guysandstthomasevents.co.uk/AsianHHM

For more information or to contact us about a placement please quote AHHM19 to vpp@gstt.nhs.uk

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MEDICAL SCIENCES

Anticoagulation of Patients with Atrial Fibrillation and High Bleeding Risk In the era of new oral (non-vitamin K antagonists) anticoagulants

Patients with atrial fibrillation and high bleeding risk (i.e., very elderly, acute stroke, renal/liver impairment or thrombocytopenia) represent an expanding group of patients who are still not getting the correct decisions regarding proper anticoagulation management plan despite the great benefit derived from oral anticoagulants. Non-Vitamin K Antagonist Oral Anticoagulants could represent a new platform for easier handling and better anticoagulation strategy for this high risk group of patients with atrial fibrillation. Rami Riziq Yousef Abumuaileq, Palestinian Medical Services/Palestinian Ministry of Health- Gaza/Palestine

on-Valvular Atrial fibrillation (NVAF) is known to be the most common sustained cardiac arrhythmia worldwide and is recognised to increase the risk of major ischemic stroke by fivefold. Oral anticoagulants are used to reduce this risk. For several decades, Vitamin K Antagonists (VKAs) were the mainstay oral anticoagulants. In the last ten years, however, the introduction of non-vitamin K antagonists anticoagulants (NOACs) has revolutionised the anticoagulation therapy for NVAF. The NOACs outperformed VKAs and showed several important advantages like the improved benefit-risk ratio with less intracranial bleeding, more predictable effects without the need for routine monitoring,

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andfewer food and drug interactions compared with VKAs. Today, there are 4 NOACs approved and could be prescribed: apixaban, edoxaban and rivaroxaban (i.e., the factor Xa inhibitors) and dabigatran. (i.e., thrombin inhibitor). The clinical advantages of NOACs were confirmed many times in large randomised double blind clinical trials and in real world research studies. The European Society of Cardiology (ESC) guidelines have clearly expressed a preference for NOACs over VKAs for stroke prevention in NVAF patients, especially if newly initiated (Class I, level of evidence A). However, in some countries, NOAC therapy can only be prescribed (and/or are reimbursed) if the international normalised ratio (INR) control with VKAs has been shown to be suboptimal after a failed trial of VKAs (i.e., 3-6 months of VKAs). This strategy might be risky for many patients due to the expected instability of pro-thrombin time and INR control during the first few months of VKAs initiation. Thus, in accordance with current ESC guidelines NOACs (when available or affordable) need to be considered as the first choice anticoagulation for NVAF. Increasing awareness of guideline recommendations regarding anticoagulation of NVAF patients might not be a difficult target. However, dealing with NVAF patients who have high bleeding risk still represents a great challenge to anticoagulation in daily practice.

In the era of NOACs, cardiologists should have good knowledge along with updated strategies to reverse the NOACs’ effects in acute bleeding situations.

NOACs are at least partly eliminated by the kidneys. Cardiologists should know the renal elimination rate of the different NOACs. Dabigatran has the greatest extent of renal elimination (80 per cent), whereas edoxaban, rivaroxaban, and apixaban, cleared 50 per cent, 35 per cent, and 27 per cent respectively, via the kidneys as unchanged drug. The available NOACs showed consistent efficacy and safety in patients with mild to moderate CKD compared with non-CKD patients in the respective subgroup analyses of the major NOAC trials. In patients

Dosing of NOACs in chronic kidney disease based on estimated glomerular filtration rate (eGFR) NOACs

eGFR<15 ml/min or ESRD on dialysis

eGFR 15-29 ml/min

eGFR 30-49 ml/min

eGFR≥50 ml/min

Apixaban

5 mg b.i.d (FDA with caution) provided the patient is on regular uncomplicated hemodialysis

2.5 mg b.i.d

5 mg b.i.d

Dabigatran

Not use

75 mg b.i.d

110 mg b.i.d

150 mg b.i.d

Rivaroxaban

Not use

15 mg o.d

20 mg o.d

Edoxaban

Not use

30 mg o.d

60 mg o.d

Renal Impairment

Renal impairment and NVAF are closely related and the number of patients with both conditions is increasing. Patients with NVAF and chronic kidney disease (CKD) have an increased morbidity and mortality due to their excessive risk for both thromboembolic and severe bleeding events that could make risk stratification and treatment challenging. All four

with reduced glomerular filtration rate (eGFR) values, apixaban compared with warfar in was associated with significant reduction of bleeding event, and the stroke benefit reduction is maintained.[1,2] When dealing with NVAF patients who have renal dysfunction: 1. Cardiologists should know how to correctly evaluate the patient’s renal function before starting NOACs. 2. Cardiologists should follow the dose reduction algorithm ofNOACs according to the estimated eGFR. 3. Cardiologists should arrange the frequency of follow up according to the initial eGFR. 4. Cardiologists should be aware of the possible interaction between NOACs and other drugs that might be taken by the patients with CKD. Accurate evaluation of renal function is of utmost importance toward the best management strategy of cardiac patients. Before initiating NOACs, Cardiologists should estimate properly the renal function status/ eGFR of the patient and follow the dose reduction algorithm for those with renal dysfunction. Currently, no NOACs drug is recommended in patients with stage

Assess/modify reversible bleeding risk factors, maintain frequent follow up visits, regular accurate evalution of renal function and close check of the patient's drug list to avoid potential adverse drug interactions. Figure 1: Dose modification in CKD

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Patient with NVAF presented with acute ischemic stroke During the first 24 Hours Early and accurate assessment of the stroke severity according to NIHSS An initiation multidisciplinary team (i.e., neurologists, cardiologists, radiologists etc...) is advisable for proper decision making regarding resumption time of NOACs NIHSS < 16

TIA

NIHSS≥16

The patient clinical condition is stable

The patient's clinical condition is stable

The patient's clinical condition becomes stable

Blood pressure is controlled

By CT, no brain haemorrhage

By brain CT or MRI on day 6, no haemorrhagic transformation

By brain CT or MRI on day 12-14, no haemorrhagic transfoimation

No visible/detected contraindication to anticoagulation

NOACs can be started on the second day of event

NOACs might be initiated on day 6

NOACs might be started on day 12 -14

Factors support early NOACs:

Factors support delayed NOACs:

Young patient

Old age

Small infarct size

Large infarct size

Left ventricular thrombus by echo

Haemorthagic transfoimation

Severely depressed left ventricle ejection fraction/severely dilated cardiac chambers

Need major surgical intervention

Intracardiac devices need anticoagulation Left at thrombus or corrirast effect by echo

Clinically unstable Past history of spontaneous major bleeding

Figure 2: Managing of acute ischemic stroke

5CKD (i.e. eGFR of less than 15 mL/min). Rivaroxaban, apixaban, and edoxaban (but not dabigatran) are approved in Europe for the use in patients with stage 4 CKD (i.e. eGFR of 15–29mL/min) with the reduced dose regimen. With the dose reduction protocol, the use of either apixaban or edoxaban may be preferable in these patients. Apixaban is (27 per cent) renally cleared, and the dose is reduced by 50 per cent according to its doser eduction protocol which is2× 2.5mg daily for patients with stage 4 CKD. Edoxaban is 50 per cent renally cleared, but its dose reduction to 50 per cent is

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applied to be 1× 30mg daily in stage 4 CKD. Rivaroxaban has an intermediate renal clearance (35 per cent), and its dose is reduced in stage 4 CKD by 25 per cent to be 1× 15mg daily.[1,2] The role of NOACs in patients with end-stage renal dysfunction and on dialysis is unclear and subject to ongoing studies. The routine use of NOACs in patient with severe renal dysfunction (eGFR<15mL/min) as well as in patients on dialysis is best to be avoided. Also due to the lack of strong evidence for VKAs in this patient population (i.e. eGFR<15mL/min), the decision to oral anticoagulation

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should be very individualised, requiring a multidisciplinary approach and with respect to patients’ preferences. There are no data on the use of NOACs in NVAF patients after kidney transplantation. If NOACs are to be used in patients with NVAF after kidney transplantation, the dosing regimen should be selected according to the estimated eGFR, and caution should be applied to the possible drug– drug interactions between the NOACs and concomitant immunosuppressive drugs. The frequency of renal function monitoring depends on the stability of renal function. The monitoring interval (in months) can be calculated by dividing the eGFR (in ml/min) by 10; e.g.: if the eGFR is 50ml/min, 50/10= 5, therefore, the renal function should be monitored at least every 5 months, unless there were events potentially leading to an acute worsening of kidney function. Treatment for the very elderly

There is lack of randomised trials directed to investigate NOACs in very elderly with moderate renal impairment. However, there are specific recommendations for dose reduction of dabigatran and apixaban in NVAF patients ≥80 years, but not for rivaroxaban and edoxaban. Very elderly patients usually present with several co-morbidities and/or are on multiple pharma cotherapies. This reflects the need for closer follow up and implementations of particular measures. Frequent checks of the patient's list of medications to look for the possible adverse drug interactions are important and might be lifesaving for the elderly on NOACs. Patients ≥80 years who receive NOACs should be monitored more closely (i.e., to evaluate their blood counts and liver/renal function at least every 6 months). The use of oral anticoagulation in this group of very elderly patients

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must be decided on an individual basis. However, when assessing the net benefit for an individual patient, the higher risk of thromboembolic events should also be taken into account. Several NOAC labels include specific instructions for dose reductions for patients ≥80 years. For dabigatran, dosage should be reduced to 2× 110mg daily, if patients are ≥80 years. For NVAF, the apixaban dose should be reduced to 2× 2.5mg in patients ≥80 years, if one of the following two other criteria is met: body weight≤60kg or serum creatine ≥1.5mg/dl. For rivaroxaban and edoxaban, no dose adjustment is recommended for patients ≥80 years.[1,2] Thrombocytopenia

Coagulopathy and thrombocytopenia could mandate precautions or even contraindications to anticoagulation. With increasing prevalence of viral illnesses, liver disease, cancers, use of complex pharmacotherapy regimes, etc., finding various degrees of thrombocytopenia is not uncommon in daily practice. Studies on anticoagulation in NVAF patients with thrombocytopenia arescarce. Patients with high thromboembolic risk and a platelet count of >50,000 per mm3 is considered appropriate for therapeutic oral anticoagulation. This cut-off has also been used in recent studies. Full-dose anticoagulant treatment is usually considered unsafe for platelets <50,000per mm3. Those patients with platelet counts between 20,000 and 50,000 per mm3anticoagulation may be considered only in very specific situations on a case-by-case basis and prefer ablyprophylactic doses of heparins (i.e., 50 per cent of the therapeutic dose) should be used for those with high risk of ischemic stroke. In patients with platelet count of less than 20,000 per mm3, anticoagulation is contraindicated.[1,2] Patients with thrombocytopenia need frequent follow up of their

platelets profile.

counts

and

coagulation

In the setting of Acute Stroke

In the real world practice, a major challenge remains regarding how

long does the interval between acute stroke and restart of NOACs in NVAF patients? This question continues to be unasnwered as patients with acute/ recent stroke were excluded from the NOACs trials. Acute stroke in atrial fibrillation patients is associated with high rates of ischemic recurrence during the first 90 days. After a transient ischemic attack, if there is no bleeding and no ischemic lesion in the computed tomography of the brain, anticoagulation may be started immediately. After an acute stroke, if bleeding is excluded, and the score of the National Institutes of Health Stroke Scale (NIHSS) does not exceed16, oral anticoagulation can be initiated on day four. In more severe cases

Consideration on NOACs in patients with NVAF suffering intracranial bleeding. Early initiation of multidisciplinary team (i.e., neurologists, neurosurgeons, cardiologists, radiologists) Proper weighing of the risk benefit ratio of NOACs before patient discharge The patient or his family better to share in the decision after discussion with the team (i.e., choice informed)

Factors that might support the beneficial effects of NOACs Bleeding occurred in the setting of over dose oral anticoagulants Inducible bleeding (i.e., not spontaneous bleeding) Intracranial extra cerebral haemo rrhage (e.g., subdural, epidural) Younger age Reversible cause (e.g., uncontrolled hypertension) Surgically treatable bleeding (e,g., aneurysmal clipped) Left ventricular thrombus by echo Severely depressed left ventricle ejection fraction /severely dilated chambers Intracardiac devices need active anticoagulation Left atrium thrombus or contrast effect by echo

If the decision favours NOACs, so initiate/reinitiate NOACs after 4- 8 weeks of the event using a safer NOACs drug at lower dose (e.g., apixaban 25 mg bid). If the decision doesn't favour NOACs, left atrial appendage occlusion might be considered. Figure 3: AF_suffering_intracranial_bleeding

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Management of bleeding in patients while on NOACs • Prompt assessment of the degree of bleeding (i.e., mild, major, life threating bleeding). • Identify the site/sites of bleeding and apply compressions for external/accessible sites. • Ask about the NOACs drug used by the patient, its dose and the time of the last dose. • Assess the patient renal function and order coagulation test (i.e., the anticoagulation status).

Moderate / Significant bleeding

Minor bleeding

Consider interruption of NOACs for 1-2 days and manage reversible bleeding causes

Major/ Life threatening bleeding

Start symptomatic treatment:

Here the priorities will be for:

Fluid replacement / Blood transfusion

Fluid resuscitation measures

Treat bleeding site (Gastroscopy/ Colonoscopy)

Specific antidote (e.g., Idarucizumab for dabigatran or andexanet for factor X inhibitor), or PCC, activited PCC

Add oral charcoal if recent NOACs was taken within 2-4 hours If the bleeding continues, consider specific antidote or Prothrombin Complex Concentrate (PCC)

Hemodialysis for dabigatran if its antidote is not available

Figure 4: Managing bleeding while on NOACs

(NIHSS> 16), anticoagulation must be initiated after at least two weeks. In patients who develop intracranial bleeding during oral anticoagulation with NOACs, anticoagulation has to be stopped immediately. Many factors have to be taken into account in order to decide whether or not oral anticoagulation can be resumed after4–8 weeks. If intracranial bleeding on NOACs occurs pontaneously ( i.e. there are no further precipitating factors, like uncontrolled hypertension or trauma) there is a clear contraindication to resume NOACs after the bleeding event. In this case, occlusion of the left atrial appendage is a preferred therapeutic option. [1,2] In the setting of intracranial bleeding, the application of a shorter time

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period to resume NOACs may only be considered in life-threatening situations and compelling indications, such as symptomatic intra-cardiac thrombus formation or acute pulmonary embolism, and only after confirmation of haematoma stability by control imaging and strict blood pressure control. Liver Disease

The old belief that patients with liver disease are ‘auto-anticoagulated’ and are largely protected from thrombotic events has not been substantially assured by clinical data. The prevalence of liver disease is expected to increase with increasing prevalence of obesity, elderly, metabolic syndrome, dyslipidemia, diabetes mellitus, alcoholics, patients on multi-pharmacotherapies and

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autoimmune disease. Liver disease showed to increase risk of both bleeding and thrombosis. Before initiating NOACs, liver tests and INR should be evaluated. All NOACs are contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk including Child-TurcottePugh C cirrhosis. Rivaroxaban should alsonot be used in AF patients with Child-Turcotte-Pugh B liver cirrhosis due to the risk of more than two-fold increase in drug exposure. Dabigatran, apixaban and edoxaban may be used with caution in patients with ChildTurcotte-Pugh A and B cirrhosis. Careful attention should be paid to those with chronic liver disease, like chronic viral hepatitis and chronic autoimmune hepatitis who need closer follow up and precautions regarding adverse drug-drug interactions between NOACs and anti-viral or immunosuppressant drugs. [1,2]. Recognising patients at high risk of major variceal bleeding is of utmost importance before initiating NOACs. So, early collaboration among cardiologists, gastroenterologists/ haepatologists, and haematologists may help optimising the use of NOACs in patients with liver disease, who simultaneously face high risks of bleeding and thrombosis. Bleeding reduction strategy should be taken when it is necessary to prescribe NOAC to a patient with liver disease. This strategy should: measure baseline liver function tests, renal function, complete blood count, prothrombin time/INR, activated partial thromboplastin time, and screen for high-risk varices in cirrhosis for accurate estimate of bleeding risk;initiate proton-pump inhibitor therapy (especially if peptic ulcer disease), test for and eradicate Helicobacter pylori (as appropriate), provide alcohol cessation counselling; and minimise concomitant nonsteroidal anti-inflammatory drugs and antiplatelet use to reduce the

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incidence of bleeding event in such patients.

of factor Xa inhibitors in case of lifethreatening bleeding in Europe. [1,2]

Acute Bleeding Situation while on NOACs

References: 1.Steffel J, Verhamme P, Potpara TS, et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants

In the era of NOACs, cardiologists should have good knowledge along with updated strategies to reverse the NOACs’ effects in acute bleeding situations. This knowledge could be life saving for many patients presented with acute life threatening bleeding event while on NOACs. An antagonist for dabigatran, idarucizumab, is available and recommended. An antagonist for factor Xa inhibitors (i.e., apixaban, edoxaban and rivaroxaban) andexanet alpha, has only been approved for clinical use in patients in the USA. Therefore, prothrombin complex concentrates are still recommended for the reversal

in patients with atrial fibrillation. Eur Heart J. 2018;39(16):1330-1393. 2.Gremmel T, NiessnerA, Domanovits H. Non-vitamin K antagonist oral anticoagulants in patients with an increased risk of bleeding. Wien KlinWochenschr. 2018;130:722–734.

AUTHOR BIO Consultant Cardiologist (M.D., Ph.D)- Gaza- Palestine. Doctorate degree of Cardiology-University of Santiago de Compostela- Spain. Associate Editor in the European Heart Journal- Case Reports (official journal of the European Society of Cardiology). Accepted and soon will start a Post-Doctoral fellowship in Cardiac Electrophysiology- Queen’s University- Canada 2020- 2022. Expert in atrial fibrillation and anticoagulation management.

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Molecular Diagnostics Empowering patients for better outcomes, diagnosis, and treatment As healthcare shifts towards- personalization and digitization, diagnostics allow individuals to receive vital information with increased accuracy, specificity, and speed. In a bid to get closer to the end user, manufacturers are leveraging data and building intelligence into their products. This practice places prevention ahead of treatment and cure, thereby giving patients greater control over their care. Suresh Vazirani, Chairman and Managing Director, Transasia-Erba Group

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he most important aspect of In-vitro Diagnostics (IVDs) is the role they play in delivering patient care and improving outcomes. Innovations in IVDs are resulting in faster, accurate testing and are allowing clinicians to target treatment more precisely and effectively, improving patient pathways and enabling earlier intervention. Many studies have shown that about 70 per cent of treatment decisions rely on diagnostic test reports. Besides this, innovators in the IT industry are finding ways to transform data

DIAGNOSTICS

available from clinical laboratories into actionable medical knowledge. Moreover, people around the world are living longer, and have warmed up to the idea of DNA testing in health care. They also want to be able to track their conditions more closely and take control of when and where they receive diagnostic testing. A Revolution in the Making

Molecular diagnostics can be considered a revolution in clinical diagnostics, as it can detect a single bacterium, a single virus and a single gene change associated with the disease. A growing trend in molecular diagnostics is Nex-Gen Sequencing (NGS). Here, an analysis of the genetic information from the sample will help diagnose a disease well in advance, even before a patient actually starts presenting symptoms of a disease. It can thus be used to detect levels of TB, malaria and other diseases which all the other tests would miss. The sensitivity, speed and reduced cost per sample make it a highly attractive platform. In the near future, NGS will be considered by many laboratories for routine diagnostic use. However, new technologies like these need to be made accessible and affordable. Currently these tests are restricted to specialised laboratories and are priced exorbitantly. Applications with Molecular Diagnostics

Advanced molecular diagnostic solution scan consolidate, automate, increase throughput and provide versatility for multiple molecular diagnostic applications. Solutions can now handle multiple sample types concurrently, as well as utilising engineering innovations to amplify the advances in multiplexing. This helps laboratories in rapid sample processing and also aids them in expanding their testing menu to include laboratory-developed or external infectious disease, respiratory and gastro assays.

In India, let’s take the example of tuberculosis (TB). There are simply not enough people being tested and even for the ones who are tested, there is a high probability of false results. This is because the tests being used are not sensitive enough to detect the disease accurately. This is particularly the case in children. Febrile diseases such as malaria, dengue, and chikungunya are difficult to distinguish as the viruses causing these diseases closely resemble each other. This is where molecular diagnostics can play a crucial role in accurate diagnosis of these diseases. Here again, there is a need to make these tests accessible and easy to use so they can reach out to the interiors of the country. A Low-cost Automated Molecular TB Test

Erba Molecular is developing a cutting-edge, low cost TB system for small laboratories. This system offers flexibility, as it can be used for NGS sample preparation. Further, future HIV and other Blood Borne Virus (BBV) assays can be run on the same system. It is easy to use and comes with the following features: • Fully-automated pre-filled cartridgebased sample extraction • Wide throughput range of 1-80 tests per day with TAT <90 minutes • Eliminates need for centrifugation, filtration or cartridge autoclaving

• Low training and user skill requirements. It involves minimal user manipulation of challenging sputum samples and has an upfront heat-kill step for enhanced biosafety. Developed with a molecular technology using high-copy RNA and unique sample enrichment process, makes it highly sensitive for TBtests. The Impact on Patient Care

Currently, when a patient presents symptoms of fever, doctors prescribe them antibiotics. In the long run, extended use of antibiotics leads to drug resistance. Molecular diagnostics helps in detecting the disease accurately, early on. As a result, doctors will be in a better position to direct therapeutics, according to the patient’s need. Market Opportunity

The market opportunity is huge. Globally, the molecular diagnostics market has grown over 10per cent. However, it has hardly penetrated at all in India. Currently molecular diagnostics is available only in large reference labs and certainly not in medium or small labs. A lot more subsidies are required to promote the outreach of the molecular technologies and make them sustainable and thus profitable. A lot of companies are introducing molecular diagnostics, however, they are unable to contain the cost and

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Molecular diagnostics can be considered a revolution in clinical diagnostics, as it can detect a single bacterium, a single virus and a single gene change associated with the disease.

expand the reach. Erba Molecular (UK), a fully-owned subsidiary of Transasia Bio-Medicals is combining special technology that makes molecular diagnostics less complex with the infrastructure offered by Transasia, to introduce technologies that are customized to Indian needs. Thus, Erba Molecular can cater to the needs of affordable, Make in India products. So, with Nex-Gen sequencing and the future technologies, the hope here is that one can get more information from patients so that they can be better informed of their treatment needs. Overcoming Challenges

There is a lot of hype around molecular diagnostics and the expectations are high. People expect the tests to be excellent and our challenges are to get the clinical data, the review data and the confidence of the users so they recommend these tests. This is a genuine challenge and it relates to the regulatory framework.

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Having a regulatory framework in place will help protect patients. Erba Molecular (UK) is engaged with the regulatory bodies to make sure our tests are as accurate, as economical and as valuable as possible. It is now essential to get people to understand molecular diagnostics, the value it brings to them and how to use the equipment. This is precisely why it is it is very important that innovators should offer technologies that are easy to adopt, even in small setups. Another challenge is the optimum use of information. A simple molecular diagnostic test can provide a plethora of information, which can be quite overwhelming for the physician. To counter this, companies are now generating comprehensive and sophisticated databases, which will automatically give recommendations. For example, a person has disease X and needs to be treated with drug Y, and this is in progress at the moment. In this regard, there is a TB seek program

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which is collating all the different types of mutations associated with drug resistance and TB. Need for Regulatory Intervention

Like for any other segment of diagnostics, regulatory intervention are imperative for molecular too. This is in order to ensure high quality products. It is important that manufacturers follow processes within the regulatory framework and acquire the necessary accreditations. For the nex-gen sequencing, the regulatory framework is still emerging. Five years from now, molecular diagnostics will be as easily available as a common glucose test. This could be used as a preferred method of choice for detection of tuberculosis, dengue, malaria, chikungunya, etc. in India, so that these diseases can be treated faster. Today, the impact of technology on innovation is bigger than ever. We are witnessing an evolution in the field of medical technology â&#x20AC;&#x201D; one that is

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Riding the Wave of Surging Trends

An informed public and increased demand for rapid disease identification have helped the in vitro diagnostics industry to flourish in recent years. The markets in India, Brazil and China are

expected to grow at a rapid pace due to the high prevalence of infectious diseases in these countries. They are also witnessing an emerging trend for non-invasive prenatal testing, NextGeneration Sequencing (NGS), liquid biopsy, and circulating tumour cells test. These trends are pushing medical device manufacturers to expand the current base of IVD technologies as

AUTHOR BIO

making diagnosis and treatments more proactive and efficient. While this has added accuracy and convenience for both doctors and patients, the Indian population is becoming more conscious towards their healthcare upkeep. Right strategy and innovations in terms of diagnostic solutions will drive the growth in the future. Through our range of offerings, breadth of capabilities, reach, and an integrated network, we will continue to be the partner of choice for several diagnostic players.

well as to pursue work on developing new ones. The technologies that are most heavily influenced by these trends are point-of-care (POC), liquid biopsy, molecular diagnostics, and Artificial Intelligence (AI) and the Internet of Things (IoT) used in conjunction with in vitro diagnostics.

As Chairman & Managing Director, Suresh Vazirani has spearheaded the Transasia - Erba group to be renowned as Indiaâ&#x20AC;&#x2122;s leading In-vitro Diagnostic Company and a fast emerging player in the global IVD arena. He decided to set up Transasia BioMedicals Ltd., an In-vitro Diagnostic Company focused on meeting the needs of Doctors and in-turn their patients, with quality and affordable diagnostic solutions and a strong after-sales network.

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Appropriate Sterile Barrier Systems Oliver Healthcare

Dr. Aldin Velic, Director Market Development—Asia Pacific

Oliver Healthcare has achieved several milestones in sectors of Healthcare and Pharmaceuticals and a credible position. We would like you to share some views and ideas about your company, plans, future and your outlook on the industry? Oliver Healthcare is the only company in the world to offer two different coating technologies, this has put us in a strong position to help customers select application specific materials, that allows them to get their devices to market and ensure sterility during transportation and distribution. Oliver Healthcare plans to continue to expand its capabilities to serve the medical devices, pharmaceutical, drug delivery and diagnostic markets. We recently acquired CleanCut Technologies, based in Anaheim, California – and have as a result expanded our product portfolio, with an even higher emphasis on design engineering. Globally, the demand for effective and affordable healthcare continues to grow. In Asia-Pacific, we see access to healthcare improving, and the development of tighter and more stringent regulations driving the need for improved patient safety, more sophisticated device consumption, and thus more sophisticated supply chain partners, with expertise in global regulatory requirements and time tested material science and designs. Oliver Healthcare is one of the healthcare companies that drives innovation in packaging. Would you like to brief us about the upcoming innovations in Sterile Barrier Systems (SBS) and other products? Launching a new product in the market is a daunting task, and doing so using new materials is quite uncommon. The importance of using time tested materials is paramount, along with the material’s microbial barrier properties, and other variables such as puncture resistance, tear resistance and compatibility to various sterilisation modalities. The introduction of new materials is something most established companies will shy away from. Oliver’s innovations in Sterile Barrier Systems (SBS) stemmed from utilising time-tested materials, while altering the way they are converted into finished products. Over the past forty years, we have developed various adhesive coatings that have allowed those materials to work in high-heat (autoclave) sterilisation modalities, seal to silicone-PETG, and developed systems that allow customers to minimise the handling of

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devices, while increasing the chances for customers to pass performance and integrity testing during their validations. Most of our innovations come from design and development. We have technical engineers across the world that are subject matter experts in design, packaging, processes to chemistry – all working to design, and develop a system specific to a customer’s application and need. How can solutions from Oliver Healthcare help the sector embrace patient centricity to remain relevant, profitable, and to deliver better health outcomes? We work with thousands of medical device and pharmaceutical companies, with a focus on improving patient safety and health. In the drug-delivery segments, minimising particulate and endotoxins play a major in combating contamination and improving patient safety. Oliver recently conducted a study to compare particulate generation during the processing of these drugs, using Oliver’s specialty coatings, against our competitors’. The decrease in particulate generation when using our technology is one example in how we improve work to deliver better health outcomes. Today, majority of drug delivery systems utilise Oliver’s Xhale® coating when launching new drugs to market. Oliver Healthcare Packaging has been providing appropriate SBS for a broad range of medical devices. Do you have any plans to expand SBS facilities and come up with a new product line for consumers? In 2018, Oliver opened its newest facility in Suzhou, China. A state-of-the-art manufacturing site with ISO-7 cleanroom manufacturing. Over the past few years, we have invested millions in expanding and building out existing sites across the world. We are confident in our current capacity and customer growth – we are continually expanding existing sites, and ensuring customers demand and growth needs are met. What are the drivers, restraints, and opportunities that are influencing the growth of the global SBS market? Can you brief about the challenges faced by the company in becoming a trusted leader in packaging expertise? The main drivers of SBS market growth are the aging population, access to healthcare, growing middle-class in emerging economies and the need for better and safer products. Opportunities influencing this growth stem from customers

learning about the implications of under-engineered materials and their impact on patient safety. To be a trusted leader in packaging, we place a high emphasis on technical support early on in the design and material selection phase, ensuring the appropriate technology is given to the appropriate healthcare application and need. One of the biggest industry misconceptions in the packaging market is that HDPE cards are ‘dirty’. Can you please elaborate on this? I believe this notion that HDPE cards are dirty, might be the case for non-healthcare products. In healthcare, many customers today are using paper inserts, which could be considered dirty in the sense of particulate generation. As customers transit from paper inserts, we have seen a large increase in demand for our CleanCut cards, which are made of HDPE. The novel design and use in healthcare have helped customers’ lower costs, while improving the performance of the SBS. Oliver’s CleanCut cards are manufactured in ISO-7 cleanrooms. How can packaging help to combat counterfeiting and what has Oliver done to combat counterfeiting? The engineering knowhow to make Oliver’s coated products is very complex, and thus making the likelihood of other companies making and counterfeiting our products highly unlikely. Customers who use Oliver’s coated materials, especially our Xhale® coatings are at a lower risk of being counterfeited, since these materials and coatings are not readily available in the market. Healthcare counterfeiting has been a growing problem, and though it is prevalent in the industry with lower-end SBS materials, for high-end products using our coated products, it seems to be an effective way of combating counterfeiting. What do you think is the uniqueness of Oliver Healthcare that sets it apart from other companies? The high emphasis on custom engineered design and materials really seem to set us apart from our competitors. We observe customers approaching us with their own SBS solutions, and normally with a high emphasis on cost savings. When we involve our technical services team, we improve our customers cost position, not by lowering the cost of the materials, but by improving the overall processing as a result of better suited material offerings. What is the future of the medical devices industry and what according to you would be the shape of the health care packaging market in the future? We are seeing some pockets of the medical device industry mature, where products are seeing lower growth. Pressure from governments around the world to improve cost in the

healthcare segment is helping to drive innovative and new device launches that achieve better patient outcomes while lowering total procedure costs. As mature products focus on cost-outs, we will see the packaging market affected through cost-out efforts. There are risks to healthcare companies pursuing such strategies, as cost-outs can sometimes lead to under-engineered materials for products that should have had more protection. The risk-reward in a market where patient safety is paramount can lead to large product recalls. We see the medical device industry continuing to grow in new device introductions, and the emphasis on viable SBS solutions that are appropriately engineered driving longer-term growth, as those products reach mass market adoption. How much do you acknowledge science and strategy in Oliver's growth? Oliver’s growth stems from our commitment to providing best in class products to our customers. We co-design and develop the appropriate solutions based on our customers needs. This strategy has paid off in numerous ways. We see a high customer retention rate, tied to high customer satisfaction. Our growth is thus a byproduct of our customers’ success in the market. Overall what would you say are the most important things to consider when making effective healthcare packaging? Some of the most important things to consider when considering packaging for healthcare are your own products sterilisation requirements and processing needs. As customers move to more sustainable business models, considerations for raw material used and their compatibility with more traditional sterilisation methods might have changed. These changes can affect new sterilisation considerations, and the materials selected. In addition to this, moving a product from smallscale to large-scale production also has implications on the healthcare packaging materials considered. Partnering with the right company early on in your development process allows you to develop a good plan, from start to mass production, with an emphasis on material performance, sterility and patient safety. That’s what we help healthcare companies accomplish. Dr. Velic is the Director of Market Development for Oliver Healthcare Packaging in the Asia Pacific region. He is responsible for helping healthcare companies launch their medical devices to local and international markets by providing the right sterile barrier systems to protect their device while helping them navigate the changing regulatory environment.

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Can Thailand become a MedTech Innovator instead of a MedTech Customer?

hailand is well poised for building and sustaining a start-up culture, encouraged by the government’s Thailand 4.0 vision, which has seen entire sectors of the economy being rebuilt with new technology and overseas investment. A dedicated programme called ‘Startup Thailand’, set up by the National Innovation Agency (NIA), hopes to accomplish this by reforming government procurement, building innovation districts, and increasing international cooperation. As well as building the infrastructure of railways, airports and smart cities to support the new industries, the government is also investing heavily in its university system to boost research activity and train the thousands of

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The medical device market in ASEAN is predicted to be worth US$8.5 billion by 2021 according to Forbes magazine. Forbes also calculates the start-up ecosystem in Southeast Asia will be worth more than US$13 billion by 2020. But is Thailand doing enough to support healthcare industry start-ups and secure a leading position in those markets? John Battersby, Account Director, Bridges M&C Pte Ltd

engineers and scientists that will be needed for the planned expansions in targeted industries such as the biotech, biochemical, medtech and robotics The Thai government has progressive policies in place to help the country attain the position of “Thailand, a Hub of Wellness and Medical Services” within a ten-year

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timeframe (2016-2025). The plan focuses on four major areas: wellness, medical services, academic and medical centres, and health products. The government also provides additional technology-based incentives for investment in the development of core technologies — biotechnology, nanotechnology, advanced material

TECHNOLOGY, EQUIPMENT & DEVICES

technology, and digital technology — and enabling services that support targeted technology development. But will all this be enough? To find out, we spoke with Dr. Kakanand Srungboonmee, from the Centre of Data Mining and Biomedical Informatics, Faculty of Medical Technology, Mahidol University, in Bangkok Thailand. As well as being an academic, innovator and start-up founder herself, Dr. Srungboonmee is also key in curating the speakers and topics for the Start-up Podium which will take place at MEDICAL FAIR THAILAND 2019 from 11 to 13 September in Bangkok. 1. How would you describe the life sciences and medical/ health startup scene in Thailand?

The life sciences and medical/health start-up ecosystem in Thailand is in an early stage. We are comparatively new to the idea of innovating our own solutions to our own problems. We have been good customers for a long time, using products invented and manufactured elsewhere in the world. Thailand’s medical device market is the eighth largest in the Asia-Pacific region. Estimated in 2015 to be worth more than US$1.2 billion, it is expected to grow at a high single-digit rate (CAGR of 8.1 per cent during 2015 to 2020) to reach US$1.7 billion by 2020. Consumable devices and diagnostic imaging are among the products with large market share, followed by orthopaedics and prosthetics, dental products and patient aids. Local production is limited to consumables and basic medical devices. There are around 320 local manufacturers, mostly Small and Medium Enterprises (SMEs) producing products such as diagnostic kits, syringes, surgical gloves and catheters. Over 80 per cent of domestic

production is for export. Thailand continues to rely on import to supply most of the market, particularly highgrade and sophisticated medical devices. When those foreign products have not really met our needs, we have used our natural patient and adaptive tendencies to make them work for us or we have worked around their shortfalls. Now that is beginning to change and we are seeing more Thai start-ups innovating solutions for the local market. As Thailand’s medical device market continues to grow there will be great potential for local companies and innovators to develop products to meet demand in many areas including those related to surgical procedure equipment, implanted medical devices, respiratory devices and oxygen therapy, orthopaedic implant devices, heart valves, neurosurgical devices, rehabilitation equipment and accessories, and dermatological devices. One of the challenges we face at this stage is that the innovators/developers are often working at a distance from the healthcare environment without direct input from healthcare professionals. That can lead to the true needs of patients or healthcare professionals not really being met. We need more collaboration between healthcare

The Thai government has progressive policies in place to help the country attain the position of “Thailand, a Hub of Wellness and Medical Services” within a ten-year timeframe (2016-2025).

professionals and the innovators, and the IT and engineering professionals trying to develop solutions. At the beginning of the process we need the healthcare professionals to identify an unmet need and then we need them to be giving feedback to the development team throughout the process. Another challenge is that coaches and mentors for medical industry startups are difficult to find as the industry is still young in Thailand. Again, collaboration could be the answer. If entrepreneurs with start-up experience in other tech sectors, healthcare professionals, young MedTech innovators, established industry players, and the government sector can work together, we can build the necessary ecosystem to support MedTech startups. 2. Why is it important to innovate for the life sciences and medical/ health industry?

Innovation is important for the life sciences and medical/health industry because the current healthcare model is unsustainable. The traditional healthcare system has focused on treating people in hospital and then sending them home and the innovation has focused on looking for new treatments. But waiting for people to become acutely ill and then treating them is very expensive, and as our population grows older, that approach will become more and more unsustainable. Thailand is currently moving from an ageing society towards an aged society. By 2032, the proportion of ageing population is expected to reach 32.2 per cent of the population (from 16.5 per cent in 2016). Along with the reduced fertility rate, this will not only impact the country’s healthcare system but also its economic productivity. To cope with the impact of our ageing society, innovation in the life sciences and medical/health needs to focus more on promoting wellness and a healthier lifestyle. It needs to be looking for preventative treatments,

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earlier detection of disease and earlier interventions to treat or manage the disease before it becomes serious and requires hospitalisation. 3. What are the main challenges in innovating for the life sciences and medical/ health industry in Thailand?

We do not really have a co-working space specifically designed for life sciences and medical/health innovation. Developers and clinicians are not just figuratively working in their own silos and not talking and sharing ideas, they are actually physically separated from the clinicians and healthcare professionals. The innovators are working in offices over here, the engineers are in an industrial park over there and the clinicians and healthcare professionals are in a hospital somewhere else; they are not all part of the same ecosystem. So their true requirements are not really being met because they are not talking to, and working with, the innovators and developers. 4.How can these challenges be overcome?

We need to have co-working spaces that are especially designed for healthcare innovation. The co-working space

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should facilitate the development of the sort of ecosystem needed for medical industry innovation, with good coaching and mentoring systems from the clinical and industry sides. There should be start-up incubation spaces and engineering facilities on the campuses of the big research hospitals and collaboration and communication should be encouraged and facilitated.

to other industries, healthcare startups need opportunities to meet with investors who are familiar with the life sciences and medical/health industry and understand the challenges and time frames involved.

5. What are the main challenges in founding and sustaining a life sciences and medical/ health startups in Thailand?

The government, industry players, innovators all need to realise that life sciences and medical/ health innovation promotes sustainable wellness and wellbeing. It is this technology that directly helps us live healthier and better lives. An ecosystem suitable for life sciences and medical/health innovation should be created to help accelerate the innovations that will keep Thais living longer, healthier, happier, and economically more sustainable lives.

We do not have good coaches and mentors with experience in the medical business. Most of the start-up incubators do not really work with or have experience in medical industry. Start-ups have to find their own ways or share resources, including investor resources, with start-ups in other industries. We also need investors who understand the challenges faced by life sciences and medical/ health startups. General investors are interested in the healthcare industry but they are used to faster development times and seeing quicker returns on their investments in other industry sectors. So when they see the challenges faced by the life sciences and medical/ health sectors such as the longer time needed for development and clinical trials, stricter standards and more restrictive marketing regulations, they usually give up.

7. What can be done to make innovation a stronger priority for the life sciences and medical/ health industry in Thailand?

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6. How can these challenges be overcome?

We need incubators who are experienced in life sciences and medical/health industry. Longer term support is also needed in the life sciences and medical/ health industry; accelerators should work not just at the level of incubating the business but also in the various stages of development. Additionally, because investing in the healthcare industry costs more and takes longer to see returns compared

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John has twenty yearsâ&#x20AC;&#x2122; experience as a science and technical writer. Focused on medical and healthcare issues for the past decade he has written on many topics including dentistry, cardiology, immunology and pharmaceuticals. He has lived in Singapore and South East Asia for twenty years working as a freelance journalist and media adviser to the pharmaceutical industry.

MEDICAL MANUFACTURING ASIA 2020 Your strategic platform for medical technology solutions

Mark your calendar for the 5th Manufacturing Processes for Medical Technology Exhibition and Conference from 9 to 11 September 2020

The Asian medical market is booming. According to management consulting firm, McKinsey & Company, the company predicts that Asia will become the second highest medical technology market in the world by 2020, accounting for a third of global sales by 2025. In the ASEAN countries, with its population of over 600 million people and a GDP of 2.76 trillion US dollars, there is a rapid growth of the middle class and expansion in healthcare coverage. Both of which are factors driving the use of medical devices across

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Southeast Asia. Such products are likely to see growth of between 8 to 10 per cent in most markets, led by the consumables, diagnostic imaging and lab devices segments. As a specialist exhibition on manufacturing processes for medical technology, the 5th edition of MEDICAL MANUFACTURING ASIA makes a return to Singapore as the region's leading specialist trade fair for Asia's MedTech and medical manufacturing

processes sectors. Jointly organised by SPETA and Messe Düsseldorf Asia, MEDICAL MANUFACTURING ASIA 2020 will feature an extensive product range covering the upstream and downstream processes in MedTech sectors, including new materials, components, intermediate products, packaging and services, to micro and nanotechnology, testing systems and services, as well as materials, substance and components for medical technology. Industryfocused business forums will also headline the upcoming edition of the specialist trade fair.

Singapore: The heart of MedTech in Asia As Singapore continues to grow as a competitive economic hub for the region in terms of, ease of doing business, best labour force, strong IP protection and robust logistics infrastructure, it has also presented itself as a competitive MedTech manufacturing hub. The 3-day exhibition therefore strongly reflects Singapore’s focus on moving upstream to not just production but also value engineering. For companies keen on engaging global MedTech companies and see Singapore as an ideal base to develop products for the Asian region, MEDICAL MANUFACTURING ASIA 2020 provides a highly relevant springboard. This sentiment is also seen in Singapore’s continued growth in manufacturing, where MedTech output has grown annually by 11 per cent versus 6.3 per cent in general manufacturing for the past 5 years. Backing this is Singapore’s strong supplier base – with 6 of the world’s Top 10 EMS companies undertaking activities from the entire value chain, in medical imaging equipment, analytical lab instruments, medical consumables, patient care devices and diagnostics equipment in the Lion City and the government’s commitment to R&D capabilities, having set aside S$19 billion for Research, Innovation and Enterprise (RIE) activities until 2020. Singapore is also home to a growing community of start-ups thanks to the availability of public funding and a favourable infrastructure for early stage innovation. Against this industry landscape, MEDICAL MANUFACTURING ASIA 2020 continues to attract a highly international exhibitor base coming mainly from Asia and Europe and a trade visitor base that is predominantly represented by the medical devices and instruments, medical and healthcare, and electrical and electronic sectors from around the region.

MEDICAL MANUFACTURING ASIA 2020 is also synergistically co-located with the region’s leading medical and healthcare exhibition, MEDICAL FAIR ASIA – thus providing an end-to-end solutions and business sourcing platform across the entire value chain for the medical, healthcare, medical manufacturing and medtech sectors. Both MEDICAL FAIR ASIA and MEDICAL MANUFACTURING ASIA 2020 are part of the MEDICAlliance’s network of trade fairs—sharing the global expertise of MEDICA, REHACARE and COMPAMED—by the Messe Düsseldorf Group in Germany. For booth space booking and more information on MEDICAL MANUFACTURING ASIA 2020, please visit www.medmanufacturing-asia.com. www.asianhhm.com

FACILITIES & OPERATIONS MANAGEMENT

GREEN HOSPITALS Towards sustainability

Hospitals, being resource-intensive establishments, consume vast amounts of natural resources including electricity, water, food and construction materials to provide high-quality healthcare while ensuring hygiene. However, by deploying simple, smart and sustainable measures hospital can greatly reduce their carbon footprint. We call this concept Green Hospitals. The article talks about the various measures, challenges, and solutions to make greener and sustainable hospitals for the betterment of humanity. Hina Gupta, Operations Department, MG Cooling Solutions

he deteriorating health of our planet is an issue of international concern and has a direct impact on human health. Healthcare industry uses modern medications, equipment and sophisticated technologies for

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the treatment, but through resourceintensive processes. Healthcare sector consumes a large number of resources, energy-intensive equipment and generates an array of wastes which has a direct impact on

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human health. In India, it is estimated that the commercial sector, which includes the healthcare sector, consumes 7.58 per cent of the total electricity and generates approximately 1.48 million tons of healthcare waste per

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year according to the Central Pollution Control Board (CPCB) of India. According to an American journal,"The health sector is one of the most trusted and respected sections of society, and it is also one of the largest employers and consumers of energy. This presents both: a duty and a window of opportunity to achieve climate-neutrality, efficiency and cost reduction all at the same time". This vision can be achieved by improving the hospital design, minimising the waste and its disposal, using natural light and ventilation as much as possible, using inverter-based air conditioners and ventilation system (HVAC). Defining Green Hospital

The United States Environmental Protection Agency defines a green building as, "the practice of creating structures and using processes that are environmentally responsible and resource-efficient throughout a building's life-cycle from siting to design, construction, operation, maintenance, renovation, and deconstruction. This practice expands and complements the classical building design concerns of economy, utility, durability, and comfort. Green building is also known as a sustainable or highperformance building" According to the Indian Green Building Council, a green hospital building can be defined as one which enhances patient well being, aids the curative process, while utilising natural resources in an efficient, environmentfriendly manner. In India, we have a BEE (Bureau of Energy Efficiency) which works towards saving natural energy resources. The Confederation of Indian Industry (CII) established the Indian Green Building Council (IGBC) in the year 2001 to promote the concept of sustainable green buildings. The role of IGBC includes developing new rating systems,

certifications, conducting training programs. IGBC is licensed by US Green Building Council to provide LEED Certifications in India (Leadership in Energy and Environment Design) Similar to LEED, there are other building rating systems which have been developed globally and are followed in different countries • LEED- Leadership in Energy and Environmental Design (United States, Canada, China, and India), BREEAM-Building Research Establishment Environmental Assessment Methods (UK and Netherlands) • Green Star (Australia, New Zealand, and South Africa), • CASBEE -Comprehensive Assessment System for Building Environmental Efficiency (Japan) • Green Mark Scheme (Singapore) Talking about the one followed in India, Leadership in Energy and Environment Design or LEED ratings are classified into four categories: LEED-certified, Silver, Gold, and Platinum. Platinum is the highest rating and some of the factors behind this classifications are sustainable site development, water savings, energy efficiency, material selection, and indoor environment quality.

In the Indian context, Kohinoor Hospital in Mumbai is the first hospital in Asia and second in the world to achieve LEED platinum certification under Indian Green Building Council. Since Hospitals are required to run all the time, some of the factors are studied which pose complexities to change it to Green Hospitals like: • All-time back up required for emergencies • All hours are operational hours with no shutdown • Protocols to control infections counters sustainability. • High Air Changes per hours to prevent contamination • High requirement of Energy & water as compared to other buildings • High waste generated per bed • Constant renovations inside the building to upgrade machinery. Components of Green Hospital

Energy savings Since a hospital operates 365 days-ayear, 24/7, it needs heating, ventilation, and air conditioning (HVAC) systems to maintain the standards of care. This consumes 40 to 60 per cent of the total energy. Also, significant energy is used for heating water, temperature and humidity controls for indoor air, lighting, ventilation and numerous

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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

Since a hospital operates 365 days-a-year, 24/7, it needs heating, ventilation, and air conditioning (HVAC) systems to maintain the standards of care. This consumes 40 to60 per cent of the total energy.

transmission diseases to flourish which impacts the health of human beings. This can be resolved by minimising waste through composting, recycling, and disposing of it the right way. Here, we all need a behavioural change in better purchasing (minimising packaging, using reusable rather than disposable products, and buying recycled products). Also, plastic which is the main source of pollution, must be disinfected first before the landfill. A hospital in Asia has done wonderfully well by developing a compost system which will naturally create bio-methane and change it to bio-natural gas which is then used to power the hospital and water purification systems. Lighting Since hospitals run throughout the year, green hospitals work towards bringing the electricity load down. This is possible by using light sensors in the passage or washrooms and other AUTHOR BIO

medical processes which have greenhouse gas emissions. Without any compromise on the quality of care. Small steps such as switching to compact fluorescent and lightemitting diode (LED) light bulbs, using optimum temperature for the HVAC system, using energy-efficient products, reducing the stand-by time of the medical equipment, and certain retrofit measures as suggested by Energy Consultants can bring in positive change. Also, we all have observed slogans, posters on the walls which can also lead to a big impact. An energy audit can also help in saving millions by detecting leakages in HVAC Systems and checking the efficiency of motors and compressors of electrical equipment. Greener source for creating energy In India, most of the electricity is generated from coal, which has a direct impact on increasing carbon footprints, and the same goes for hospitals due to their heavy electricity requirement. Furnace oil, or liquified petroleum gas (LPG) is used to generate steam for processes such catering, and laundry. For backup, diesel-powered generators are used to get an uninterrupted supply of power. This can be resolved by using natural and renewable sources of such as solar, wind, and geo-thermal. Since it requires engineering, high construction and operating costs but in case of small sections, work can be done by solar energy like to sterilize medical equipment, sanitize the hospital's laundry, heat water for baths, Reduce waste management In India, most of the clinics, hospitals, and healthcare facilities do not have the infrastructure for waste management, and most of waste goes directly to the open, and then into ground water. This becomes even more critical as 10 to 15 per cent of the waste is toxic and harmful for all the handlers and environment. Releasing this waste openly in the environment allows

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areas which can detect occupancy and installing low-energy LED lights. Also, the architecture should work to bring in maximum natural daylight to reduce the load. Saving water Since hospitals have a huge water requirement, they must have a rain harvesting system in place and sewage treatment to recycle water for non-drinking use. The recycled water can be used for irrigation, cleaning activities, etc. In India, lots of healthcare facilities are using these approaches but we need to build at scale. Air quality This is one of the most vital components of any green building. Cities are suffering from poor quality air due to rising pollution, meaning a green hospital must have provision for better indoor air. This can be achieved by indoor plants, natural air purifiers, etc. Since the hospital area is exposed to so many pathogens and bacteria, it becomes vital to have a ventilation system and a well-designed cleanroom to continuously provide fresh and filtered air. Research has proved that a welldesigned green building can accelerate the healing process. Hence, consultants consultants and designers are working in the direction to employ green strategies to have a positive impact on patients. Due to this, a green hospital has various attributes such as better indoor air quality, 20-40 per cent energy saving, 35-40 per cent water saving, good day lightning, no sick building symptoms, comfortable temperature and humidity control for faster recovery.

Hina Gupta, she is working with MG Cooling Solutions spearheading the Operations Department. She has recently represented MG Cooling Solutions at IIM Bangalore and won the Best Business Growth Plan Competition held on May 2019. She has huge interest in making infrastructure Energy Efficient to reduce carbon footprints. She is also a member of the Technical Committee of ASHRAE ( American Society of Heating, Refrigeration &amp; Air Conditioning Engineers)

INFORMATION TECHNOLOGY

mHEALTH TECHNOLOGY Privacy & Control

The health sector is one of the most vulnerable sectors when it comes to data privacy. Blockchain technology, which is currently emerging as one of the most promising technology for healthcare systems is evaluated here from a privacy standpoint to ascertain if it will alleviate the concerns around data privacy especially in light of the GDPR. Karpurika Raychaudhuri University of New South Wales (UNSW) Pradeep Ray University of New South Wales (UNSW)

dvances in mHealth technologies, internet usage, and the uptake in the use of mobile devices across the globe have resulted in large quantities of medical data being collected which includes personal information as well as sensitive health data. mHealth solutions offer a cost-effective method to reach wider segments of national populations making it attractive for the purposes of public health management and as an enabler for meeting sustainable development goals in the global south. However, based on recent notable data breaches worldwide, the health sector has been identified as immensely data rich and yet one of the most vulnerable sectors when it comes to data privacy and cybersecurity. The health sector thus faces a unique challenge as it has

to perform a balancing act between privacy-preservation and accessibility of multiple parties to health data in the interest of individual and public health. The benefits of mHealth technology to improve healthcare quality and expand public access to services can be achieved only if individuals and service providers are confident in the privacy, security and data integrity of collected and stored health data. Blockchain technology is currently emerging as one of the most promising technology for healthcare systems, but it needs to be evaluated from a privacy standpoint to see if it will alleviate the concerns around data privacy. The concept of privacy today has been transformed from the historical “right to be left alone” to the ability and the right of users “to control and protect personal

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INFORMATION TECHNOLOGY

information” and in the cases of the General Data Protection Regulation (GDPR1) compliant countries, the “right to be forgotten”. The goal of this chapter is to review and analyse the academic as well as practice literature and report on the following: a. What are the major concerns about patient privacy related to mHealth data used for purposes other than primary patient care? b. How privacy legislation around the world is seeking to control concerns around data privacy? c. What are the implications for digital privacy in using blockchain technology for mHealth solutions? We will first briefly define privacy and why it is a concern for mHealth, we will then provide an overview of the major challenges for mHealth solutions. We then discuss how privacy legislation around the world is addressing data privacy challenges, followed by an evaluation of blockchain technology against one of the major privacy legislations, the EUGDPR. The Concern for Privacy in mHealth

The actual definition of privacy has not always been clear or comprehensive. Many researchers have suggested that privacy is the ability to control information about oneself (Bélanger&Crossler, 2011). From a traditional human rights viewpoint, “privacy is often thought of as a moral right or a legal right” (Clarke 1999) and in this tradition the right to privacy would also be a right that needs to be protected as is evidenced by the dominance of legal processes and mechanisms in existence to protect this right in societies. Privacy is held to be valuable because it is believed to protect individuals from all kinds of external threats such as defamation, harassment, manipulation, blackmail, theft, subordination and exclusion. Privacy is an articulation of the core value of ‘security’, meant to protect people from all 1 https://eugdpr.org/the-regulation/

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kinds of harm done by others (Moor, 1997). According to ALRC Report 108, 2008,information privacy involves rules that govern collection and handling of personal and sensitive data such as financial information and medical records while privacy of communications deals with the security and confidentiality of mail, telephones and other forms of private communications. In this chapter, our scope of privacy will be limited to information privacy pertaining to mHealth systems data and privacy of related communications over the internet. By control we mean controlling the unauthorised incursions from individuals, businesses and governments on data collected by combining technology, policy, and legislation in order to protect privacy (Landau, 2015). Privacy of mHealth data is a major concern of the population, particularly if there is stigma associated with the illness (e.g., HIV/AIDS). Although mHealth is being used widely in healthcare industry, there is a lack of robustness in these systems from the perspective of privacy management (Raychaudhuri & Ray, 2010).Healthcare data is a lucrative target for hackers and, therefore, securing protected health information is the primary motivation of healthcare providers. Healthcare has also become the primary target for cybercriminals. In Australia, the Office of the Australian Information Commissioner (OAIC) released its latest quarterly statistics report of Notifiable Data Breach (NDB) Scheme (1 April to 30 June 2019). The report shows trends and developments about notifications made under the NDB scheme and in this quarter, health sector recorded the highest number of data breaches. This year, a record number of 2.5 million Australians have also opted-out of the Australian online health record system, myHealthRecord. Governments globally have started tightening up their privacy legislation to combat the growing trend in data breaches. In this

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climate, the technologies underpinning mHealth must address data privacy seriously. Data Privacy Legislation

In the current digital world, mHealth data often flows across a borderless internet network. Borderless healthcare can enable treatments outside of national healthcare systems and sharing mHealth data can help to improve the accuracy of diagnosis and treatments and deliver positive benefits. However, governments around the world are imposing restrictions on cross-border data transfers in order to protect privacy, therefore organisations that deal with health data need to be aware of privacy legislation, standards and guidelines in each jurisdiction. EUGDPR The European Union(EU)General Data Protection Regulation (GDPR) is the new EU regulation about privacy and data protection which has become fully enforceable since 25 May 2018. GDPR essentially regulates the “personal data” of EU citizens through the entire life-cycle of collection, use, retention, transfer and deletion. GDPR has brought a new level of rigour and transparency into data collection, storage and use, resulting in heavy fines for organisations for non-compliance. The GDPR generally applies to the data processing activities of “data processors” and “data controllers”. Organisations that store data are “data controllers” and those that work with this data are called “data processors”. Processing in the GDPR context means any operations performed on personal data set(s) such as collection, recording, organisation, structuring, storage, adaption or alteration, retrieval, consultation, use, disclosure by transmission, dissemination or otherwise making available, alignment or combination, erasure or destruction. It is generally the responsibility of the data controller to comply with the GDPR. The controller decides why personal information is

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collected and processed while processors process personal information based on instructions from or under a contract with the controller. The GDPR clearly holds organisations accountable for any personal data that they hold, and there are substantial financial penalties on organizations for data breaches and non-compliance. Google has been the first tech giant to be penalised under GDPR in France, receiving a €50 million fine for privacy violation while in the UK, In the UK, the Information Commissioner’s Office (ICO) has for the first time used its new powers to punish companies (British Airways and Marriott hotel chains) that break laws protecting consumers’ data by handing them fines worth almost £300 million. The GDPR will be enforceable not only for EU companies, but also for companies that reside in other countries (for example, India), where the data of EU residents are monitored, or analysed as part of a service contract. Companies all over the world that operate internationally have therefore been ensuring that they comply with the GDPR and other new privacy regulation so that heavy penalties are not incurred for future data breaches. Outside EU regulation Privacy legislations around the globe are tightening up with the advent of GDPR.“The principles of the GDPR are also radiating beyond Europe. From Chile to Japan, from Brazil to South Korea, from Argentina to Kenya, we are seeing new privacy laws emerge”(Ansip & Jourova, 2019). Many countries around the world are amending their privacy legislations and countries that have not had data protection and privacy legislation have been introducing newones. The OECD guidelines on the protection of privacy and trans-border flows of personal data was developed in 1980 have been the basis for many national and international privacy regulations. The Austral-

ian Privacy Principles (APPs) outline how most Australian Government agencies, all private sector and notfor-profit organisations with an annual turnover of more than US$3 million, all private health service providers and some small businesses (collectively called ‘APP entities’) must handle, use and manage personal information. The Privacy Amendment (Notifiable Data Breaches) Act 2017 established the NDB scheme in Australia which sets out obligations for notifying affected individuals, and the Australian Information Commissioner, about a data breach which is likely to result in serious harm where examples of serious harm include identity theft, serious harm to an individual’s reputation. The GDPR and the Australian Privacy Act share many common requirements but there are some notable differences such as the ‘right to be forgotten’ under GDPR, which does not have an equivalent right under the Privacy Act. The GDPR also places obligationson the “controller” that are more onerous than the Australian Privacy Law. Other draft legislation and guidelines that are worth noting are India’s Personal Data Protection Bill,

which if passed will become effective in early 2020. In China, although the PRC CyberSecurity Law has been in effect to address cybersecurity and data protection, in May 2018, the National Information Security Standardisation Technical Committee (TC260) has issued a national standard, most similar to GDPR called the Personal Information Security Specification which covers the handling of personal information while Personal Data (Privacy ) Key Challenges for mHealth Technologies

Many mHealth technologies produce a large, long-term stream of data about a person’s health and healthrelated behaviours that, if aggregated, presents a huge opportunity for public health research. In order to do remote patient monitoring for the treatment and care of patients, healthcare professionals have been adopting Internet of Things (IoT)-based wearable technology which has witnessed billions of sensors, devices, and vehicles being connected through the Internet. In this section some of the key challenges are highlighted. mHealth applications and devices often collect a wide

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range of information for multiple uses. Challenge is to help individuals understand what data is being collected, where it is stored, who has access to which data at what granularity, what it will be used for and then notify users of any deviations from the agreed-upon protocol(Kotz et.al, 2016). Wearable sensors is a rapidly evolving field that is being used to monitor health states and infer behaviours but as is often the case with new and disruptive technologies, they raise some serious privacy challenges. Certain practices such as continuous audio recordings can capture private conversations with other non-consenting peoplein the house,which is unethical and could be illegal in certain countries. A survey on wearables has highlighted privacy challenges pertaining to ethical issues, data jurisdiction, inadequate privacy policies of devices, bystander privacy and re-identification risks(Datta et. al, 2018). The use of smartphones for mHealth apps raises privacy concerns as an average userâ&#x20AC;&#x2122;s smartphone has numerous apps and there is a possibility that one app could be gathering information about other apps on the device and use it in ways the user might not be aware of or approve of. A study reviewing data security and privacy policies of mobile apps for depression revealed that there is not much transparency around data handling as app developers have considerable latitude in their data security and privacy practices within health apps and how such practices are explained to users (Oâ&#x20AC;&#x2122;Loughlin, et al, 2019). According to(Kotz et.al, 2016), understanding the evolving range of relevant technologies by multiple stakeholders,involved in policy development and the enforcement of privacy legislation is crucial. This can be achieved by training and awareness. To realise the promise of mHealth devices and applications, every stakeholder in the system must understand and trust

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Other draft legislation and guidelines that are worth noting are Indiaâ&#x20AC;&#x2122;s Personal Data Protection Bill, which if passed will become effective in early 2020.

the system to provide high quality data and healthcare services while at the same time respecting patient privacy. The GDPR- Blockchain Paradox

There are massive opportunities for mHealth applications to leverage the blockchain technology ranging from electronic medical records and pharmaceutical supply chains to smart contracts for payment distribution. Blockchain lends itself to numerous solutions such as providing patients, the authority over their entire medical history or combatting the counterfeit drug market by tracking and verifying the authenticity of pharmaceutical product. Another significant area of blockchain use is the Genomic market where companies are building blockchain platforms to enable sharing of genomic data. However, there is still some regulatory uncertainty surrounding blockchain, especially in how the technology complies with GDPR. On one hand, GDPR and blockchain technology both aim to provide more security to personal data, are geared towards data transparency and individual rights and yet the paradox is that there are key differences as well. Some of the paradoxical challenges that blockchain technology faces when

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it comes to compliance with the GDPR are what constitutes personal data, immutable ledger, centralisation vs decentralisation (Bennett, 2018): What constitutes personal data? The GDPR applies to any personal data that is stored or transmitted using a blockchain network where personal data means any information relating to an identifiable natural person who can be identified directly or indirectly by identifiers such as name, location data, online identifier as wells as other data that relate to the physical, physiological, genetic, mental, economic, cultural or social identity of that person (Article 4 GDPR Definitions). Blockchain technology can hide the actual identity of individuals using the network by encrypting the data assigning them a unique identifier such as an encrypted key, however, the company holding the decryption key is the one who can actually do something with the data. but if someone holds the code to decrypt that key, then the encrypted key may still constitute personal data under the GDPR which essentially means that reversible encryption data can be considered personal data and therefore remains in the scope of the GDPR. Hashing or non reversible encryption is a way to overcome this challenge, however whether hashed personal data should be considered personal data is still unknown. Centralised legislation vs decentralised network Blockchain technology is essentially a decentralised network while the GDPR, is more suited towards centralised networks with a hierarchy of a data controller controlling data processors. It could be easier fora private and permissioned blockchain network to be GDPR compliant in this challenge because in a public blockchain it would be difficult for a regulator to determine who is liable when a network is in breach of the GDPR, potentially making everyone liable. In a permissioned blockchain, access and control of data

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and executed independently from their publisher(s) so there is a debate as to whether smart contracts are operated by the publisher or the network user or by both. Article 22 of GDPR gives people the right not to be subject to solely automated decisions and profiling under certain circumstances that have a “legal or similarly significant effect on individuals”. If smart contract developers have to allow for human intervention, then the trust that transaction participants have in smart contracts would be reduced. Finck (2019) evaluates and concludes that smart contracts do qualify as a form of solely automated data processing under Article 22 GDPR in certain cases, which means they will not be automatically compliant with GDPR, however they can be designed to be compatible with the GDPR requirements. The future of smart contracts will not be one of total automation. The challenges and provide scope for further research into privacypreserving blockchain technology. Ling & Zhang (2018) proposes a blockchain based secure and privacy preserving PHI sharing scheme using two kinds of blockchains - private and consortium blockchains. Fan (2018) proposes a consortium blockchain based solution called MedBlock with high information security combining the customised access control protocols and symmetric cryptography.

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is restricted to only few trusted parties and the right to restrict who can process the data (Art 18 of GDPR). However, a privately permissioned blockchain introduces a controlling authority and a need to trust this authority , which runs counter to the distributed nature of the blockchain. Immutable ledger The blockchain, whether public or permissioned is immutable, but GDPR gives people the right to erase, add or modify information. Blockchain’s main benefit is the immutability of data to ensure the security and accuracy of the record. A solution to the challenge is to avoid recording any personal data within the blockchain itself or to anonymise the data, although the robustness of anonymisation techniques is not always fool-proof. It should be noted that the GDPR does not specify what constitutes erasure. In this context, some encryption techniques, coupled with key destruction, could potentially be considered erasure even if it’s not erasure in the strictest sense. Destroying the decryption key would render the data as useless, however the counter-argument is that strong encryption is still reversible and can be broken as computers get faster in future and the personal data could be revealed at a future date. The personal data could be stored elsewhere, where one has read and write access, such as a secure server and a reference to that data can be stored in the blockchain as a hash function. The hash in this case is not reversible back to the data. Hash can be used to verify the integrity of the data in the central server. However, the hash itself may be classified as personal data as it links to the personal data. If the actual data is removed from the block chain then the hash becomes useless and is no longer considered personal data because it points towards nothing. Smart contracts and automation These are pieces of software that can be deployed to a blockchain network

Conclusion

While many challenges exist for blockchain technology to be compliant with privacy legislation, especially in the EU, it is equally important to understand that governments need to balance the right of safeguarding personal data with other fundamental rights. The right to data protection needs to be balanced with other equally important concerns around public health and innovation. European regulators have stated that while their goal is the protection of individual rights and personal data, they are equally committed to blockchain technology as a platform for innovation. Understanding the interplay between blockchain and the GDPR compliance should take place on a case-by-case basis, by analysing where the personal data appears, how it is processed and who is responsible for that processing. GDPR also stipulates that data protection should be designed into the platforms and by default, and not added on top. Blockchain technology is at a foundational stage and often developed by open source community, therefore, there is a lot of scope for data protection to be designed in blockchain based solutions. The purpose of GDPR and other privacy legislation is not to ban certain technologies but rather to ensure that adequate steps are taken to address risks to data privacy. References are available at www.asianhhm.com

Karpurika Raychaudhuri is an Australian management professional in ICT, part-time researcher at WHO Collaborating Centre for eHealth (UNSW) and an enthusiastic social business proponent.Karpurika manages her Sydney based IT consultancy, delivering ICT projects for blue chip clients and has research interests in emerging technologies and social entrepreneurship.

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

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INTELLIGENT HEALTHCARE

FROM VISION TO REALITY Riding the second wave of the digital revolution, the global healthcare industry is already intersecting across other sectors, witnessing a hike in investments for transformative technologies. A report by the PwC Health Research Institute estimates global healthcare to hit a spending of US$ 18.28 trillion by 2040, driven largely by ageing and growing populations, market expansion, clinical and technological advances. Nalin Amunugama, General Manager, Boge Kompressoren Asia Pacific Pte Ltd

ealthcare stakeholders are under constant pressure to deliver high quality care at the lowest cost. Faced with the potential shortage of 12.9 million healthcare professionals by 2035, the industry is struggling to cope with limited capital resources. The need to provide quality healthcare while ensuring a balanced ratio of patient to doctor is no longer a demand but a requirement. Over the past decade, huge sums have been spent on healthcare technology to improve the administrative efficiency of the health system, and to provide greater access and coverage. However, in keeping with the changing healthcare landscape, the primary focus has since shifted to providing innovative and costeffective ways to deliver patient-centric,

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technology-enabled healthcare - beyond the hospital setting. The advent of digital communication and portability of testing devices has made it easier for patients to connect and interact with physicians. Patients now have easy access to information about their conditions, and can benefit from the speed at which tests are conducted. These developments empower patients to have more influence over the course of treatments, and at the same time, provide doctors with new pathways to reach patients with pertinent information, monitoring and guidance. From robotics to smart hospitals, health record and data analysis, to decision-making optimisation, predictive tools and seamless operations continue to be unlocked

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by technological innovations to deliver better patient outcomes with greater efficiencies. A Holistic approach with EHRs

Electronic Health Records (EHRs) have revolutionised the practice of medicine, benefitting both clinicians and patients as society moves further into the digital era. Studies in Singapore have shown that one in five smartphone users have one or more health-related apps on their phone, highlighting the shift towards greater awareness and health consciousness among the general public. As consumers demonstrate greater interest and proactivity in their health, the switch to EHRs is the logical step forward as patients demand greater transparency and continuous updates on their health status. Epic, an America-based company,

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holds the largest electronic health record system in the US, with the use of their software in integrated care delivery networks, rehabilitation centres and hospitals across the country. Epic’s health records make it easier for doctors from various specialisations to have a holistic understanding of a patient when treating other non-related illnesses, especially in cases of emergencies where such records can provide critical life-saving information. This EHR software is used from the point a patient first steps into a medical facility to register at the administrative counter, to the nursing stations and into the patient room. Chronicling a patient’s healthcare over time, doctors and patients are presented with accurate, up-to-date, and complete information on a patient’s health at

the point of care, rather than a brief overview collected at every visit. EHRs enable greater accuracy, reduce medical errors, and encourage more in-depth analysis and evaluation. The system promotes coordinated and efficient care, removing the communication barrier between patient and doctor as more visuals are used to explain comorbidities. Assistive Care Robots

It is estimated that by 2050, one in six people in the world will be over 65 years old, and the number of people aged 80 and over will triple to 426 million. This growing population is going to require more care, which in turn, puts greater demands on healthcare resources. In view of global workforce shortages, it is critical for healthcare providers to

look into alternative sources to support patients and caregivers. At a hospital in Milan, a robot is already transforming patient care and hospital management, thanks to a collaboration between Konica Minolta and the scientific research centre, Istituto Italiano di Tecnologia. In the design of the assistive care robot, simply known as R1, designers and neuroscientists worked together to first understand types of shape and movement to make the robot more “human.” Another interesting feature is the LED-screen on the face of the robot which allows it to communicate more naturally with patients by altering its facial expressions. With the combination of Artificial Intelligence (AI) and 5G connectivity, R1 can read human body language and speech, and respond quickly. Interestingly, this humanoid robot is able to move and interact with people in a personalised way. For example, R1 can help patients and visitors with useful information on the hospital and its services, and provide directions to facilities, like the X-Ray department or cafeteria. R1 also makes for a remarkable companion. For long-staying patients, the robot can help by reading to them and taking food orders. With AI, R1 can use data such as food preferences to further streamline hospital processes and create better menus for patients. Looking to the future, AI is expected to play a more prominent role in hospitals. The technology could be deployed for a range of functions, from performing critical tasks such as interpreting various scan results for accurate diagnosis, to powering automation processes to take on repetitive tasks such as dispensing medications. Virtual and Augmented Reality

Virtual reality (VR) and augmented reality (AR) are already making inroads into the healthcare industry. The scope of VR and AR is wide as

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Intelligent Control System

the imagination as the technology has the ability to deliver convenient and effective healthcare services to patients. In addition, VR and AR can assist surgeons, doctors and nurses with diagnosis, treatment, surgery and longterm management of illnesses. For people travelling abroad, finding access to quality healthcare can be difficult, particularly in certain countries. However, wearable devices and mobile or web-based apps are helping individuals to monitor their health levels, including creating a direct line of communication with their doctors. Visual healthcare is especially useful in place of direct, face-to-face consultation. A video-link is an excellent platform for medical professionals to remotely manage and treat patients, and at the same time, reduce costs. One can also rely on virtual assistants like Siri for advice on a course of action, say, for a simple skin rash. And it is even possible to show the rash in a VR environment! For patients, the use of VR not only reduces unnecessary appointments to the doctor’s office but also makes it more convenient for those with minor ailments to get the appropriate medicine from a neighbourhood pharmacy instead. AR differs from the VR experience in that it augments and overlays the

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real clinical environment rather than stationing a surgeon in a virtual world. There are currently a range of technologies on the market, including mobile apps like Pokemon Go and holographic headset displays like HoloLens. In February, Philips demonstrated an AR concept for image-guided minimally invasive surgeries at MWC Barcelona, one of the largest mobile events in the world. Based on the company’s Azurion image-guided therapy platform and Microsoft’s HoloLens 2 holographic computing platform, the AR applications include those for imageguided minimally invasive therapies. Philips has also announced the development of an AR solution for spine, cranial and trauma procedures, a combination of 3D X-ray imaging and optical imaging to provide surgeons with an AR view of the inside and outside of a patient during surgical procedures. Another exciting development is the use of AR headsets during surgery which can collect video data from the operating room, with the assistance of machine learning. The data is used to make automated recommendations, identify critical structures to ensure they are not damaged, and help assess surgical skills during a procedure.

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According to the World Health Organization (WHO), 65 million people suffer from chronic obstructive pulmonary disease (COPD) with 3 million dying from it each year - making it the third leading cause of death worldwide. With the rise of chronic respiratory diseases, patients are dependent on a supply of medical-grade air. Medical air compressors play a vital role in aiding artificial respiration, and the operation of numerous surgical tools used within the various healthcare units. In day-to-day operations at hospitals and other primary care facilities, a reliable source is necessary to filter medical-grade air to sedated patients under anaesthesia or to those having difficulty with breathing. Contaminated, moisturised air, on the other hand, could potentially put patients at risk. For surgical instruments, medical air compressors provide functionality to tools used for puncturing, dissecting, and drilling. Tools can also be dried at constant intervals before, during and after surgical operations. In hospitals, an entire health system consisting of medical air compressors, receivers, dryers and filters is required for the production of air that is clean, dry and odourless. BOGE’s airtelligence provis 3 is already setting new standards for network control with its latest version of its intelligent control system. Nominated for the 2019 UX design awards (which recognises user experience as a key asset in connected life and work), the airtelligence provis 3 has the ability to control different compressed air networks. This is especially important to the healthcare sector where separately controlled networks need to operate alongside a sterile air network. Equipped with unique monitoring features, a simulations-software for comparing systems, a surveillance and alarm function that is userfriendly, the BOGE airtelligence provis 3 offers total control over the different compressed air networks. In addition,

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it provides web-based visualisation of all the operating systems via an intuitive touch display or remotely, from a mobile terminal. With the connection of holistic data from an unlimited number of compressors and components, including processes, status values, communication is directly condensed into a network that can be controlled and managed proactively, based on consumption. For healthcare facilities, BOGE’s compressed air systems offer optimal patient care in real time, from anywhere.

From robotics to smart hospitals, health record and data analysis, to decision-making optimisation, predictive tools and seamless operations continue to be unlocked by technological innovations to deliver better patient outcomes with greater efficiencies.

Digital Therapeutics

designed Glycoleap, a patient-facing application that monitors a user’s diet, weight, and glucose levels, as well as physical activity with an in-built pedometer. Serving as a “health coach”, Glycoleap is part of the company’s larger digital therapeutics platform that strives to actively and passively track, monitor and treat patients - making healthy choices a lifelong habit. With their signature one-to-one personalised coaching with certified dieticians, the mobile app is packed with other features, including real time feedback on daily food intake. By utilising evidence-based medicine, clinical practice is optimised with Glycoleap’s data contribution to the real-world efficacy evaluation of drugs prescribed to patients through a blend of AI and data analytics. Towards a Smarter Continuum of Care

Digitalisation of the medical industry works much like a continuous

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A new trend is emerging from the fastgrowing mobile or mHealth market for life sciences is digital therapeutics, where software products are used in the treatment of medical conditions. Digital therapeutics, as defined by Wikipedia, “is a health discipline and treatment option that utilises digital and online health technologies to treat a medical or psychological condition. The treatment relies on behavioural and lifestyle changes usually spurred by a collection of digital impetuses.” The field of digital therapeutics is starting to gain momentum across the healthcare sector, with an increase in innovative apps and digital solutions to provide at-home management of specific conditions. A number of start-ups and established technology companies have brought to market, innovative applications designed to enable patients to take better control of their care. While similar to other wellness apps, the difference is that digital therapeutics focus on delivering clinical outcomes. Besides addressing the different medical conditions, digital therapeutics can also track various stages of the patient’s healthcare journey the collection, integration and analyses of patient data. Such data allows clinicians to personalise treatment and work with the patient to avoid complications. Singapore company Holmusk

feedback mechanism, with the active and passive recording of patient data through electronic devices which are then uploaded onto electronic health databases. McKinsey and Company attributes US$2 trillion worth of healthcare costs are a result of poor health habits such as sleep deprivation, lack of exercise, consumption of alcohol, and other harmful substances. The overexpenditure on healthcare services can be reduced drastically with the use of wearable technology as they promote drug adherence with in-built timers, increase awareness of comorbidities, and encourage patient proactivity among its other features. It is a method of diagnosis that doctors and patients alike embrace and recognise as a need for better patient outcomes. With a better understanding of patient symptoms and disease trajectory, wearable technology evolves into a future with wearable healthcare as a solution for the delivery of better medical care. In the grand scheme of things, the healthcare industry has advanced, with efforts combined from both healthcare providers and healthcare seekers. With the growing awareness of health risks and the cautionary impact it brings, users of healthcare technology have turned proactive, encouraging healthier lifestyles as part of an effort to reduce the strain on global healthcare systems and promote independence in healthcare diagnosis. By harnessing the power of technology and the knowledge it brings to healthcare providers and consumers, patients are better able to understand their own conditions, and more importantly, empowered to take charge of their own health.

Nalin Amunugama is the General Manager of BOGE Kompressoren Asia Pacific with over 26 years of experience in the air compressor business, including its applications in digital healthcare, medical and pharmaceutical sectors. As a global leader in compressed air systems, BOGE’s focus is on creating seamless, cost-efficient and sustainable energy solutions to benefit customers and the planet.

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MENTAL HEALTH CHALLENGES IN THE ASIA-PACIFIC The figures for Mental Health around the world are staggering - any whichever way they are looked at. Governments, Healthcare institutions and employers have an obligation to reverse this trend. Best practices are emerging quickly but more can and should be done. Technology alone may not be enough but it can and will play an important role in this massive effort. Madhav Ragam, VP Government Industry, IBM Asia Pacific

ecently, after a 16-year old girl committed suicide in Malaysia following a survey on her Instagram account, the country’s minister for youth said, “I am genuinely worried about the state of our youth's mental health.” Infact, a study in Korea found that 75 per cent of those attempting suicide are living with more than one mental illness, while in Australia, the suicide rate among people with a mental illness is at least seven times higher than the general population. World Health Organization (WHO) estimates that globally, 264 million people suffer from depression, with many of these people also suffering from symptoms of anxiety. WHO also estimates that a total of 450 million people experience mental

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or neurological disorders around the world. Yet, mental health remains an issue largely unaddressed, almost neglected. As WHO points out, "health systems have not yet adequately responded to the burden of mental disorders.” National policies and programmes in mental health are urgently needed to change this situation, yet over 40 per cent of countries have no mental health policy, and over 30 per cent have no mental health programme. Talking about Asia-Pacific, in Australia and Singapore, under half of those with mental illness receive medical care, while in India and China, only around a tenth. This is even though mental health problems place huge health and economic burden on the country. For

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example, mental health problems are the second-biggest health issue in Asia Pacific on years lost to disability. Also, as per an EIU study, between now and 2030, they will reduce economic growth in India and China by USD 11 trillion. In Australia and New Zealand, the annual estimated total cost of mental illness is 3.5 per cent and 5 per cent of GDP respectively. Additionally, as per a recent WHO-led study, it is estimated that depression and anxiety disorders cost the global economy US$ 1 trillion each year in lost productivity. Even though, Dr. Brock Chisholm, the first Director-General of the WHO, had, in 1954,asserted that “without mental health there can be no true physical health,” progress in addressing mental health issues has been painfully limited.

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The Question is, why are Mental Illness Issues Overlooked?

To begin with, in most countries in AsiaPacific, there is a stigma associated with mental disorders, which prevents better community integration. While this can be attributed to culture and belief system, a lot of this is also due to lack of awareness and literacy surrounding mental health issues. This is followed by limited availability and access to medical help and health services to address the issue. It is estimated that mental health budget for most countries in Asia Pacific is less than 5 per cent of total health spending, the WHO’s recommended minimum. Governments (both local and central) will have to play a major role to address the issue. From improving outlay on mental health, to creating a politico-

legal policy framework, to driving awareness, to promoting emotional wellbeing and building resilience, to helping people understand, protect and sustain their mental health, to providing cost-effective public health strategies for promoting and restoring mental health. An example is the Manchester City Council’s Troubled Family Initiative using spatial and quantitative analytics to determine strategies that will work best for individual families. It used information to support planning and actions to reduce the drug and alcohol issues in families, which eventually resulted in fewer child removals. Another factor is lack of opportunities for people suffering from mental health disorders to find work, which not only helps them gain financial independence, but also societal

acceptance. As per a survey done by the Financial Times, which interviewed 450 respondents from 43 countries,“… majority felt unsupported, alienated or discriminated against on the basis of their mental health.” Two-thirds believed their work had “a somewhat to extremely negative effect on their health,” and 44 per cent said “they did not think mental health was taken seriously by their organisation.” Half said they either didn’t know where at work to go or had nowhere to go if they needed support. Employers will also be required to play a critical role, to accommodate employees with mental health issues, to provide vocational training support, and most importantly to ensure a workplace free of discrimination. An example is IBM Australia rolling out neuro diversity

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Also, as per an EIU study, between now and 2030, they will reduce economic growth in India and China by USD 11 trillion. In Australia and New Zealand, the annual estimated total cost of mental illness is 3.5 per cent and 5 per cent of GDP respectively.

individual needs. It is important to break down silos isolating social, legal and even behavioural health data, allowing integrated multi-disciplinary teams to glean insights developed from the full picture of patients’ information. With this level of access and visibility, duplicated efforts could be eliminated, and client needs could be met in intricately layered ways to lead to better outcomes. Solutions like the IBM Connect 360 leverage technology to harness cross-program data to support collaboration and provide actionable information at the point of care, by placing a unifying data management and coordination layer over existing systems. Care coordination: Coordinating care among care teams and providers are key factors in managing the health of the population. This requires unlocking and integrating the full breadth of information from multiple systems and care providers, automating care management workflows, and

AUTHOR BIO

programme, hiring people with autism to fill a variety of IT roles at its Client Innovation Centre in Ballarat. Equally important is to address mental health in the workplace, as several risk factors that affect mental health may be present in the working environment. According to the WHO, every dollar invested in improving access to treatment leads to a return of US$4 in better health and productivity. There are many effective actions that organisations can take to promote mental health in the workplace. An example is IBM working with HR services company Morneau Shepell in Canada on a solution to help people in distress. For this, IBM Canada launched Ava, a chatbot designed to guide people to mental wellness resources and services when they have questions about their own mental wellness. One of the key challenges while dealing with mental health — common to all Asia-Pacific countries — is that of data, or rather, the lack of it. In most developing countries, even basic information on prevalence of mental health issues is missing, more often than not. This not only limits adequate treatment and care options, but also has a limiting impact policy development. Sensitive data exists separately across different departments. It needs to be unified and made accessible to all team members. This is where technology can play a crucial role, by helping with solutions that can collect, integrate and analyse data, enabling and encouraging care providers and policymakers to act with information. Some examples: Unified patient views across silos: With so many individual case management systems, designing and deploying a data model that allows a comprehensive, collaborative view of patients proves to be difficult. Old, inefficient organisational silos prevent meaningful collaboration across departments, which make it impossible to synchronise efforts and direct a coordinated response to meet

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scaling to meet the demands of growing populations under management. There are AI-powered solutions that can help to do this, one of them is called Watson Care Manager. It can help coordinate care by unlocking the potential of structured and unstructured data with cognitive insights. Massive data sets from multiple programmes and organisations, including social determinants of mental health, can be combined with sophisticated analytics, natural language processing, and machine learning to help users synthesise findings and improve their decision-making. To summarise, mental illness is a widespread problem in AP, with anywhere between 4 per cent to 20 per cent of the population experiencing a diagnosable mental health problem. Most countries have a long way in bridging the treatment gap, as between 50 per cent - 90 per cent people do not receive treatment. It is government’s responsibility to ensure that mental health is an essential component of publichealth system, and policies and actions protect and promote the mental health and well-being of people. Mental health problems have serious economic repercussions, in the form of productivity lost and costs involved, even as countries struggle to collect data to support policy making and quality of treatment options. The solution to accelerate needed change is in an efficient use of technology, and the new opportunities brought by artificial intelligence (AI) and cognitive systems that can help to gain actionable insights from the data available. References are available at www.asianhhm.com

Madhav Ragam wants us all to live in safe, secure, well planned, healthy and thriving cities and nations. And in his role as Vice President - Government & Healthcare Industry Solutions, he works to find ways for Governments around Asia Pacific to better understand their citizens, businesses and work to deliver innovation and efficiency to the systems that support life on this planet, from social programs, defense, tax, customs & borders, transportation to healthcare.

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