Asian Hospital & Healthcare Management - Issue 51

I S S U E 51

2021

w w w.asianhhm.com

BUILDING RESILIENT AND SECURE INFRASTRUCTURE FOR HEALTHCARE’S DIGITAL

Associate Partner

Winning The EBITDA An ode to the team

Removing Frictions through Healthcare Digitalisation www.asianhhm.com

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Foreword Digital Healthcare Landscape Infrastructure holds the key It was a year ago that China announced the lockdown of Wuhan city, in a bid to contain the explosion of COVID-19, the novel coronavirus. In the weeks that followed, the global population witnessed an unprecedented spread of virus that has claimed more than two million lives. As countries struggle to recuperate their economies from the shock, the global response to COVID-19 underscores the importance and power of digital technologies in accelerating the health and well-being of populations across the globe. Also, COVID-19 has acted as a catalyst of change and innovation for digital transformation, and paved the way for exponential growth of digital health technologies across countries.

The World Health Organization (WHO), through its global strategy for digital health, provided a framework for countries that aims to achieve four major objectives: promote global collaboration and advance digital health knowledge transfer, advance implementation of national digital health strategies, strengthen governance for digital health and advocate development and use of people-centred digital health systems. This calls for each country to devise national health goals that encompass a broader spectrum of activities including, but not limited to, establishing / strengthening health surveillance systems, managing population health, improving digital health literacy, and devising a national health strategy with the integration of digital technologies for improved care.

Many countries have set up digital health as priority to integrate into the national health strategy. If we look at Germany, the country had, in 2019, passed a Digital Health Care Act, a law aimed at promoting digital transformation of the country’s health systems by catalysing development of innovative technology applications. This timely act has been a boon for the country in fighting the COVID-19 menace with minimal loss of lives.

Today digital health has become an essential component of care giving and delivery, with the advent of digital health platforms based on latest technologies.

Wearables and other health devices allow transfer of data enabling remote patient monitoring, and at the same time provide ample scope for personalisation of care.

Information and communication technologies have the ability and power to facilitate quality care delivery effectively and efficiently. Despite technological advancements, the healthcare sector has a long distance to cover in achieving the true potential of digital transformation in meeting the global healthcare needs. Developing and implementing a resilient digital health architecture that makes caregiving accessible, affordable while safeguarding patient data augurs well for organisations as they focus on sustained development goals.

The onus is on healthcare organisations to be agile, flexible and adapt to change faster leveraging digital platforms in their pursuit of delivering quality care, effectively and efficiently. The cover story of this issue stresses the importance of building secure and resilient infrastructure for the future of digital health. Richard Farrell of Eaton Corporation throws light on how adoption of emerging technologies such as Internet of Things, Cloud, and automation can help healthcare organisations serve the growing healthcare needs in the Asian region, along their digital journey.

Prasanthi Sadhu

Editor

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06 mHealth in China A growing market Pradeep Ray, Steven Wijaya and Zhang Junxiang Centre for Entrepreneurship (CFE), University of Michigan-Shanghai Jiao Tong University Joint Institute (UM-SJTU JI)

11 Winning The EBITDA An ode to the team Gurrit K Sethi, Hospital COO, Care Hospitals

14 Collaboration The key to nutrition awareness in APAC Kent L Bradley, MPH -Chief Health and Nutrition Officer, Herbalife Nutrition

18 Practice Changing Initiatives

COVER STORY

CONTENTS

BUILDING RESILIENT AND SECURE INFRASTRUCTURE FOR HEALTHCARE’S DIGITAL FUTURE

Richard Farrell, Director, Cloud & Data Centre Segment, Electrical Sector, APAC, Eaton

R B Smarta, Vice President (HADSA), CMD-Interlink

24 Covid-19 Pandemic The challenge of quality patient care in hospital systems Uche Nwabueze, Professor, Maritime Administration, Texas A&M University

37 Need for Stratification of Heart Failure with Preserved Ejection Fraction Shedding light on RV-PA uncoupling with echocardiography Akito Nakagawa, Division of Cardiovascular Medicine, Amagasaki-Chuo Hospital

MEDICAL SCIENCES 30 High Heart Rate in Hypertension What the clinician should do in patients with tachycardia?

Paolo Palatini, Department of Medicine, University of Padova

DIAGNOSTICS 34 Recommendations for Lung Ultrasound in Internal Medicine Natalia Buda, Department of Internal Medicine, Connective Tissue Diseases and Geriatrics Wojciech Kosiak, Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk Paweł Andruszkiewicz, Consultant Anaesthetist and Intensivist, Department of Anaesthesiology and Intensive Care, National Institute of Tuberculosis and Lung Disease

INFORMATION TECHNOLOGY 44 Removing Frictions through Healthcare Digitalisation Jan Herzhoff, President, Global Health Markets, Elsevier

46 Geriatric Smart Home Technology Implementation Are we really there?

K Ganapathy, Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services

50 Books 52 Research Insights

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Advisory Board

Beverly A Jensen President/CEO Women's Medicine Bowl, LLC

EDITOR Prasanthi Sadhu EDITORIAL TEAM Grace Jones Swetha M

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

ART DIRECTOR M Abdul Hannan PRODUCT MANAGER Jeff Kenney SENIOR PRODUCT ASSOCIATES Peter Thomas David Nelson Susanne Vincent

Pradeep Kumar Ray Honorary Professor and Founder WHO Collaborating Centre on eHealth UNSW

PRODUCT ASSOCIATE John Milton Veronica Wilson

Nicola Pastorello Data Analytics Manager Daisee

CIRCULATION TEAM Sam Smith SUBSCRIPTIONS IN-CHARGE Vijay Kumar Gaddam

Gurrit K Sethi CEO Canta Health

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

HEAD-OPERATIONS S V Nageswara Rao

Associate Partner

In Association with

A member of Confederation of Indian Industry

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

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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Š Ochre Media Private Limited. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, photocopying or otherwise, without prior permission of the publisher and copyright owner. Whilst every effort has been made to ensure the accuracy of the information in this publication, the publisher accepts no responsibility for errors or omissions.

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

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

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HEALTHCARE MANAGEMENT

mHealth in China A growing market

The central, provincial and local governments in China and the private enterprises (especially entrepreneurs) have been investing heavily in making healthcare efficient and affordable all over the country including remote regions for its 1.5 billion people. Thanks to the rapid development of the Internet and mobile technologies, China is seeing the development of many online platforms, such as wechat, ZTE, PingAn, Dingbei Doctor and Xiomi for supporting mHealth (healthcare using mobile technologies). This article investigates the growth of mHealth market in China based on the project called mHealth for Belt and Road region (mHBR) led by UM-SJTU Joint Institute and partners in 12 countries.

Pradeep Ray, Steven Wijaya and Zhang Junxiang Centre for Entrepreneurship (CFE), University of Michigan-Shanghai Jiao Tong University Joint Institute (UM-SJTU JI)

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mHealth products provide online healthcare and medical services using mobile devices (e.g., smartphones) such as online consultation, online diagnosis, online health monitoring, online healthcare and fitness management, online doctor appointments and follow-ups, medical/healthcare related information database access, intelligent data processing, health record database, customer service call centres, emergency response assistance, as well as online purchase and delivery of medicinal and supplementary health products.

HEALTHCARE MANAGEMENT

Thanks to the rapid development of the Internet and mobile technologies, China has been leading the world in several aspects of such technologies (e.g., 5G) and its applications to various sectors of social development including healthcare. The need to avoid patientdoctor contact (to reduce infections) during COVID-19 has given a strong push for telehealth services (especially mHealth) all over the world.

Many countries now have reported a rapid uptake to mHealth services that are likely to be a part of the future healthcare scenario. Hence there is a need to forecast the deployment and growth of mHealth services, now part of Digital Health. This article is based on the experience of the University of Michigan-Shanghai Jiao Tong University Joint Institute (UM-SJTU JI) initiative called mHealth for Belt and Road region (mHBR) involving partners in more than 12 countries.

The project led to an edited book, that defines mHealth as Mobile technologies (phones, drones, robots, Apps, wearable monitoring devices etc.) to transform the face of health service delivery across the globe, particularly in developing, remote regions. The mHBR project led to several collaborative subprojects as described in. It also led to several mHealth technology projects involving China and partner countries in the CFE at UM-SJTU JI. This article investigates the market of mHealth in China based on a subproject of mHBR in the CFE at mHealth Service in China

In China, the mHealth market size is forecasted to rapidly reach US$25.6 billion by the end of 2027 due to the COVID-19.

UM-SJTU JI. The article starts in Section 2 with a summary of some of the popular mHealth products and their features in China. Section 3 presents an overview of the Chinese mHealth market followed by Section 4 on the market growth, and Section 5 concludes. mHealth Services in China

Although there are many types on mHealth services with different facilities based on clinical or public health services, a typical mHealth service consists of the following elements: • Sensors for human physiological parameters, such as blood pressure, pulse rate, blood oxygen level, ECG etc., that convert human physiological parameters into measurable electrical signals that can be carried over mobile phone networks through Bluetooth or wifi interfaces to distant locations.

• Mobile applications, such as wechat based apps to carry the patient physiological parameters to geographically distant locations of the physicians and health professionals.

Instant diagnosis

High quality doctor

Private doctor

Taking Medicine

Ping An Good Doctor

Yes

Yes

Yes

Yes

We Doctor

Yes

Yes

Yes

Ding Xiang Doctor

Yes

Yes

Hua Yi Tong

Yes

Yes

Physical Examination

• Software to access radiological images, such as CT scans and other test results to doctors for analysing patient physiological parameters and test results for the medical diagnosis.

• Various intelligent software (AI tools) and search engines with medical databases facilitate this task of medical diagnosis • Prescription and treatment software enable doctors to prescribe medication and treatment plans to patients remotely based on the above diagnosis Hospital partnerships enable users to interact with certified medical professionals. Pharmacy partnerships allow for purchasing of medicinal products and delivery via online access and transaction. Manufacturer partnerships allow for sensory device implementation and other medical equipment purchase that enables the enhanced functionalities of telehealth monitoring from the mHealth device.

UM-SJTU JI CFE project teams have been investigating the development and use of mHealth in China as described in. That project carried out a comparison of existing mHealth products in China. With the advent of 5G technology in China, many mHealth applications and technologies have been developed over the last 5 years thanks to strong support from the government. However, since the market is vast and growing, there is still room in the market for new businesses to enter.

Some prominent mHealth services in China are compared in Table 1.

Registration of local hospital

Information of hospitals

Self health check

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

No

Yes

Yes

No

No

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Table 1. Main services offered by mHealth applications in China

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Active customers

Ping An Good Doctor

16.2 million

Good Doctor Online

2.99 million

Wei Mai

2.37 million

Wei Yi

1.42 million

Table 2. Active customers in June 2020 for mHealth Services in China

For example, the Ping An Good Doctor application offers various services such as online consultation, pre- setup appointments, online followups, online drugs purchase and other online medical services. With this being the largest, several other mHealth applications such as Hua Yi Tong, Wei Yi, Chun Yu Yi Sheng are also doing well.

Table 2 provides the number of active users of some of these major mHealth services.

3. Chinese mHealth Market Overview

China has seen a massive growth in the reach and quality of healthcare services all over the country. Health professionals in China welcome technology (e.g., mHealth) to improve health services using latest technological developments, such as Artificial Intelligence (AI), Augmented Reality (AR), 5G etc.

China is the second leading country in terms of mHealth revenue with a revenue of US$2.5 billion in 2017, which is only second to the United States (US$5.9 billion). China’s overall mHealth market value in 2011 was estimated to be around US$241.5 million while the market value in 2017 has risen to an estimated value of US$2 billion.

This increase has been steadily growing over the years and is reflected in the increase of active users from 2017 to 2019. According to the country’s national statistical database, the number of active mHealth app/service users in the first quarter of 2017 is 301 million

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users. That number has increased to 466 million active users by the first quarter of 2019. The mHealth mobile application market value in China has also increased from a value of US$603.7 million in 2017 to US$976.7 million in 2019. The most used/accessed mHealth services that accounts for the given market value are online healthcare (online medical consultation, monitoring, diagnosis), which accounts for 44.5 per cent of cumulative user share, and online/mobile health management (fitness apps), which accounts for 38.9 per cent of cumulative user share. This is reflected in the overall market share in the Asia Pacific countries by service category that consists of online health monitoring (55 per cent), online diagnosis (28 per cent) and online health practitioner support (7 per cent) as reported.

Analysing the data, the mHealth market value in China has experienced a growth of over 828 per cent from 2011 to 2017 with a CAGR (compound annual growth rate) value of 42.2 per cent. The number of active mHealth application/service users has also increased by 54.8 per cent in the

span of 2 years (2017-2019) while the mHealth mobile application market has experienced a 61.8 per cent increase value during the same time span with a CAGR value of 27.2 per cent.

Based on this, it is apparent that the mHealth industry has been rapidly growing over the past years and does not show any sign of slowing down.

In fact, the ageing problem in China has helped mHealth emerge as a feasible solution to monitor the chronic diseases of the elderly population through online healthcare applications/ services. The COVID-19 pandemic has also increased the Chinese population’s awareness towards personal health and the importance of telehealth for the safety of health professionals by means of mobile health monitoring.

Consequently, the mHealth industry has recently experienced rapid advancements in its technology and research as well as acceptance by the public. This increased awareness by the Chinese population has translated into a 65 per cent increase in the global number of downloaded medical applications in 2020. Figure.1 summarises the current market of mHealth in China.

Market Value Outlook Number of Active mHealth Users 2,400

2017

301 Million US$ (Millions)

Name of mHealth Service

Compound Annual Growth Rat (CAGR) 42.2%

828 %

2019

466 million

mHealth Mobile App Market Outlook 2017

241.5 2011

2017

54.8%

2019

US$ 603.7 Million US$ 976.7 Million

61.8% Increase - 27.2% CAGR

Fig 1. Summary of the Chinese mHealth Market Analysis

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HEALTHCARE MANAGEMENT

4. Potential mHealth Growth Outlook in China

Based on the past market analysis of the mHealth industry over the decade, the future for the mHealth industry seems to hold many opportunities for growth.

With the steady increase in market value and revenue the industry is currently experiencing, the potential profitability of the mHealth industry in China can be seen by analysing data regarding projected market values, potential number of users and advancements in the technology.

The global mHealth market value is expected to reach US$189 billion by 2025. The global healthcare industry is one of the largest industries in the world with an estimated spending of US$8.2 trillion per annum. According to market estimates, the worldwide online healthcare industry will keep growing in the future.

In China, the mHealth market size is forecasted to rapidly reach US$25.6 billion by the end of 2027 due to the

COVID-19. In fact, the demand in using mHealth applications has risen significantly during the course of 2020, as seen by China’s largest mHealth application, Ping An Good Doctor, that experienced a 900 per cent increase in new users in the beginning of 2020. China is currently the most populous country in the world with a population of 1.439 billion people in 2020 and an average yearly increase of 0.39 per cent in

It is apparent that the mHealth market size has the potential to increase by almost 1300 per cent from 2019 with a CAGR value of 49.9 per cent in 2027.

population and the country can expect a huge opportunity in potential users, where the largest user share can be seen in provinces like Guangdong (10.3 per cent), Zhejiang and Shanghai (7.5 per cent), and Shandong (7.3 per cent) [3].

Finally, since China is one of the first few countries to have implemented 5G technology and has been focusing on AI developments in the healthcare industry, the mHealth industry and relevant online healthcare industries may see new, hitherto unseen applications of mHealth for the effective healthcare of its citizens. China is currently ranked as the No.1 country in the world for investments in AI technology in the healthcare industry. AI technology is now being intensively researched and implemented in various mHealth applications/services that focuses on medical imaging, assisted diagnosis, drug development, health management and disease prediction. With over 130 different companies involved in developing these AI healthcare technologies by 2020, the

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Potential Market Value Growth Potential Growth in mHealth Users Number

US$ (Millions)

2,400

Compound Annual Growth Rat (CAGR) 49.9%

1280 %

2020 Population:

1.439 Million

2.0 2019

2027

Advancements for A.I. Technology in mHealth > 130 Different Companies Involved

US$ 4.5 ++ Billion A.I. Healthcare Market value in 2022

AI healthcare market in China is valued at far more than US$4.5 billion (2022, value given is only for AI gene sequencing market size) in the future. This advancements in AI technology in China indicates that the demand for personal health care monitoring, which is also enabled by wearable health technologies that has a total market revenue of US$6 billion in 2020, has been increasing rapidly and continues to increase. Figure 2 summarises the market growth outlook of mHealth in China.

AUTHOR BIO

Fig 2. Summary of the Chinese mHealth Potential Market Growth Analysis

5. Conclusions

This article has briefly analysed the mHealth market in China. It is apparent that the mHealth market size has the potential to increase by almost 1300 per cent from 2019 with a CAGR value of 49.9 per cent in 2027. The large population of the country will also account for around potentially 36 million new users each year given the country’s internet penetration with the most mHealth app/service user dense provinces offering a potential of 280 million users in 2025, which excludes the large number of expats that may come to China in the coming years. In addition, the aging problem in China also demands for these mHealth technologies to be developed faster as previously mentioned that mHealth provides a

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New Potential User Per Year: 30 Million

feasible solution to monitoring, diagnosing and even preventing chronic diseases, especially with the implementation of AI/ data driven analysis in the online healthcare industry. Given the large medical database and proficient technological resources in healthcare provided by various sources in the country (Shanghai Jiaotong University Med-X Research Institute, Tencent, Alibaba, Ping An Technologies), in the future, various AI capabilities such as AI gene sequencing and AI medical imaging will certainly improve to deliver faster remote diagnoses and more accurate drug prescriptions and disease preventions through mHealth platforms. Thus, it is almost certain that the mHealth industry will prosper in the years to come in China and that may lead to healthcare benefits in the other developing countries near China.

References are available at www.asianhhm.com

Pradeep Kumar Ray is the Director, Centre For Entrepreneurship, University of MichiganShanghai Jiao Tong, University Joint Institute and is currently leading a major collaborative project called mHealth for Belt and Road Region involving eleven countries. He is the founder of the WHO Collaborating Centre on eHealth in the University of New South Wales (UNSW)-Australia (2013).

Steven Wijaya was born in Singapore in 1997 and is currently a senior undergraduate in Mechanical Engineering at the University of Michigan – Shanghai Jiaotong University Joint Institute. He currently runs a shoe company in Indonesia but plans to expand his business into the electric vehicle industry in China and Indonesia.

Junxiang Zhang is an undergraduate student major in Mechanical Engineering and minor in Entrepreneurship in UM - SJTU Joint Institute(JI).

He is also an active member of the UM - SJTU Joint Institute Center for Entrepreneurship (CFE).

Currently he is doing research on application of western Business Model Canvas in China.

HEALTHCARE MANAGEMENT

Winning The EBITDA An ode to the team

It takes two to tango‌To drive greater profitability of a hospital, the tango has to be well designed keeping an eye on the strategic management requirements from the leadership team with respect to the sociopolitico environment as well as an operating system that drives accountability, ease and joy to work amongst employees that leads to greater patient satisfaction. From a tactical perspective, this may be looked at as the team, the organisation structure and the underlying operating system of the organisation, well orchestrated to drive the business.

I

ncoming business and the generated top line is the key for any business. However, little is recognised that the accrued efficacy of the top line to convert to real profit is finally determined by the bottom line and the many factors that affect it. I would call it the dance of the devils.

This winning bop between the tTop line and the bBottom line is a simple result of an enabling and empowering management and leadership, a welltrained team, working over a seamless

Gurrit K Sethi, Hospital COO, Care Hospitals

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(information flow between financial tools, HRM, HIS etc.) smart system which at times may not be smart, much like an uncommon common sense. To get to this, is a systematic call to action by the winning team over a number of system loopholes and imperfections that finally culls in the deficiencies and walk towards profits.

While the big bulge at the top is much wanted, how the organisation functions finally determines the profits. A bulge in the tummy, read as many bureaucratic levels, complicated information movement from department to department, etc.‌the fat here is always bad. This is true for all industries, only that the healthcare services sector is much more complicated. My emphasis is because healthcare is actually many industries rolled into one. Thus, to focus on higher profitability, one has to understand each of the subset industry and their adaptations to healthcare.

The hospitality, the pharmacy, the IT, the medical devices, the building infrastructure, the human resource management etc. are the few key subsets of industries within healthcare services. Each stream can add to the top line when used well or become a leaky pipeline as easily and as un-evidently!

Fixing these leaky pipelines needs a thorough check as most of these would be invisible. A lot of hidden costs are because of things like the type of autoclaving, quality of devices and consumables, efficacy of low cost drugs, linen type etc. Choose a cheaper unit with compromised quality and it can up spends on number of units. A small example could be fancy lightings and panels. They look very appealing and fancy at the beginning but eventually become a maintenance hazard – both in terms of repair expense and cleaning expense needing more manpower and other things. So also for fancy furniture, the wrong furnishing

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It was ultimately a well gelled team that was able to take on the journey from an annualised EBITDA of 16 per cent to 32 per cent with monthly figures touching 40 per cent approximately.

materials, and also fancy linen for that matter. And cheaper is also not the best as is the common notion in some of these cases. One hospital chose antistain linen which was double the cost of the regular being used but allowed cutting the cost of discards by almost 30 per cent in the financial year.

Adapting various control measures across all areas with a keen eye on various metrics by an empowered team is the key to better service offerings as well as higher EBITDA. Thus also the fact that this is also proportional to patient satisfaction and a well trained team. What is also important is the engagement pattern between the clinical and non clinical teams. It is this engagement that finally defines the WINNING team. The outcome of the cubic moves between the clinical and non-clinical processes finally reflects

IS S UE - 51, 2021

not only in patient outcomes but also in the P&L numbers. The key metrics ALOS, ARPOC, ARPOB and ARPD push up through this engagement and reflect the dexterity in the medical programs, the efficiency in the patient schedules and finally the earnings.

The key to an efficient business that makes the most of the top line and maximises profits through the bottom line lies in the right operations formula that fits the geographic situation and resource availability. The geographic situation may refer to the specific medical service needs, the economic viability with respect to the buying power of the populations, the various central and state government schemes available for the population, the distribution and strength of the free of cost government facilities available.

The right formula refers to organisation structure, the structural, medical and digital infrastructure availability, and, the mode of operations and organisation capabilities. The operative formula could be centralised, decentralised, or a hybrid. The choice needs to be based on the geographic, socio-political climate, the type of services and the scale of operations. One formula may not fit all organisations and these differentiations need to be understood while deciding. Many times leaders end up making a mistake by blindly choosing basis a past experience from a past organisation in a different geography. Each organisation has a maturity curve in terms of creating and building a work system and ideology.

While recreating such systems, a lot more thought needs to go into the various dynamics of the business itself and the business environment for a smooth transition. Most organisation re-engineering projects fail because of these dynamics being overlooked.

In the process of organisation structure and process re-engineering,

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in a chain of hospitals was changed by the purchase team and replaced by those that had a lower per unit cost. The quality check was forgotten during this transaction. As a result the consumption cost actually grew instead of the projected savings. Reason was simple. The end users ended up using much more of these as the items would break. The quantity of consumption almost doubled. An un-noticed cost which went up was also of the manpower resource as the turn around times to deliver the treatment went up.

The nurses and doctors would spend more time doing the same thing as the consumables would break often.

This also resulted in poor patient experience.

In a particular project, working on removing obstacles for the service providers actually resulted in building efficiencies and bettering net promoter score (NPS) and patient satisfaction scores. The financial resultant that reflected in the EBITDA of the hospital was to the tune of 3-4 per cent.

Subsequently building in these efficiencies with a combination of top line initiatives that included brand building (non lead generation rather health awareness focussed) activities resulted in higher per personnel revenue, keeping the staff as well as patients happy. Specific incentives enabled staff to earn more and delivering better services to the patients and that kept the patients happy. Of course, imperative through the exercise was for the team members to keep a close eye to their respective scorecards and overall hospital metrics of ALOS, ARPOC, ARPOB, ARPD, Contribution and other costs. It was ultimately a well gelled team that was able to take on the journey from an annualised EBITDA of 16 per cent to 32 per cent with monthly figures touching 40 per cent approximately.

Overall, the key to WIN was always the winning team, the human resources that were trained to WIN, finally achieved the ‘FERRARI Moment’ in the words of a senior industry leader.

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

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AUTHOR BIO

a deep understanding of the existing methods and systems is mandatory.

Look at it as relaying the existing plumbing lines, a tiny miss could cause a new leak alongside the existing ones.

An interesting example would be of a pharmacy chain wherein a new digital system was created over the old one and this new system could not sniff out or capture the physical leakages that were happening underneath leading to a drain of at least half a percentage in the contribution, if not more.

These joints are critical to be seen in not only the Revenue Cycle Management processes but rather along the service lines leading upto these.

In a hospital parlance, the consumption that is slid into packages, the efficient usage based on quality and quantity during procedures being done, the specific supplies being used, the reuse patterns etc are an area often overlooked when creating financial efficiencies. Giving a small example.

Some commonly used consumables

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HEALTHCARE MANAGEMENT

Collaboration The key to nutrition awareness in APAC Countries in the APAC region are at different stages of economical, social and healthcare developments. Healthcare practitioners and hospitals have a leading role to play to drive nutritional awareness and to achieve healthcare outcomes. Collaboration between multiple stakeholders will be significant to drive this cause Kent L Bradley, MPH -Chief Health and Nutrition Officer, Herbalife Nutrition

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he Asia-Pacific (APAC) region is home to some of the world’s fastest growing economies and, ironically, more than half of the undernourished children on the planet too. In the wake of the pandemic, government priorities are very much centred on containing the outbreaks and economic support measures, while healthcare systems continue to operate under immense stress. It is not unexpected then that the current health crisis has side-lined less ‘urgent’, longer term agendas such as advancing public nutrition awareness and education and multi-sector collaboration to strengthen the overall health system.

The countries in APAC are all at varied stages of development economically, socially and on healthcare preparedness too. A few countries are driving the agenda of achieving universal healthcare within the next decade.

However, the task of achieving superior healthcare is not achievable without active involvement and contribution of key stake14

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

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HEALTHCARE MANAGEMENT

Collaborate for success To achieve the desired state of nutrition awareness and knowledge in APAC, collaboration is the key.

Multiple sectors and economies are witnessing and experimenting with innovative collaborations and partnerships in the healthcare and technology space. A few of these possible collaborations to bring about an effective, significant and agile change now include not one or two but, multiple stakeholders playing a part in the food and nutrition supply chain. The quality and nutritional content of food right from the cultivation stage impacts the eventual state of nutrition in a country. Food manufacturers, suppliers, nutrition companies, advocates, and, most importantly, HCPs who according to the Herbalife Nutrition Myth survey top the credibility chart, make the most critical peg in the scheme of collaboration.

A very interesting study conducted in 2015 revealed why collaboration is beneficial in healthcare systems. In this study, the various aspects and impacts of collaboration and teamwork were compared with a similar scenario in sports, which always demand team spirit and working together. Over the last few years, we have witnessed the impact of high collaboration that is visible in the healthcare sector. In times of the pandemic, it was only collaboration that helped build the much-needed efficiency and resilience in the healthcare systems. holders. Within healthcare, nutrition is one agenda which has been less understood and emphasised upon. Herbalife Nutrition conducted a survey in early 2020 with 5,500 consumers and 250 Healthcare Professionals (HCPs) from 11 countries to gauge the prevalence and variety of nutrition myths that exist amidst consumers in APAC. The insights from this survey were startling. Multiple myths around nutrition existed amidst consumers and the gap in accurate nutrition knowledge was wide. In addition, consumers pointed to HCPs as the most credible sources of nutrition information. The survey was also administered to HCPs and about 80 per cent of them believed that nutrition companies should take a larger role in spreading accurate, credible and timely nutrition information.

The issue of nutrition awareness

According to The Lancet 2019 Global Burden of Disease Study of 195 countries, dietary factors are the single leading cause of death, exacting an even greater health burden than smoking. Excessive consumption of cheaper and unhealthy processed

foods which offer little beyond salts, sugars and carbohydrates is on the rise.

A few countries like Indonesia, Vietnam and Philippines are fighting the triple burden of malnutrition which essentially implies the coexistence of over-nutrition, undernutrition and micronutrient deficiencies. Over-nutrition, undernutrition, and micronutrient deficiencies equally increase the risk of various health problems. In such a scenario, it’s imperative to make people across the region understand the importance of nutrition, awareness of foods and eating habits that can improve the situation.

Apart from the lack of awareness about the science of nutrition, several food and nutrition-related myths are also prevalent in the region. For instance, one in three people in APAC believes the false idea that our body requires less protein as we grow older; nearly two out of three people believe the myth that carbohydrates make one gain weight; a majority of people believe the myth that a very low-fat diet is the best way to lose weight, and one in three people holds on to the myth that eating saturated fat raises ‘good’ cholesterol. The wide existence of these

myths is a testimony of the prevalence of inaccurate and harmful nutrition habits amidst consumers in the region.

Drivers of collaboration

Public health and nutrition are a matter of the state and no other organisation can drive an effective solution without the involvement and support of the government. A public private partnership has been proving of immense value in the healthcare space in countries like Vietnam, Indonesia and Thailand and more such initiatives are needed in the region.

Nutrition Foundations and education societies develop a deep understanding of public health, demographics, issues and challenges at the grass root level and the hurdles that may come in the way.

Nutrition companies who are experts in the field of nutrition can look at long term collaborations such as these and support these foundations and societies with accurate nutrition knowledge and other resources needed. The problem of child obesity, for instance, is immense in Malaysia.

Technology and innovation have built inroads in all aspects of our lives

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AUTHOR BIO

including the nutrition and well-being space. Right from testing authenticity of ingredients to communicating food quality and creating communities – technology is providing immense support. Nutrition companies, nutrition experts and HCPs can all benefit from these technology support and partnerships in enhancing what they are offering the consumers.

Herbalife Nutrition for instance, has been passionately working on how organisations should start investing in research and innovation and create new industry standards for botanical species ingredient authentication right from sourcing the ingredients, DNA testing of the botanicals, to ensuring that they are authentic ingredients, to maintaining high-level packaging standards. The Quality Assurance team has also made significant investments through research

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alliances in testing ingredients and have partnered with the University of Guelph, a comprehensive public research university in Canada, leader in food science investigation, and global hub for DNA barcoding research. Technologies also exist for educating consumers about food labelling which we know has been instrumental in bringing down the harmful effects of uncontrolled and ignorant binging. According to researchers from the American Journal of Preventive Medicine, specific food labelling has helped reduce consumers’ intake of calories by 6.6. per cent, total fat by 10.6 per cent and other unhealthy food options by 13 per cent.

HCPs and Hospitals as Collaborators

Diet and nutritional status impact on health outcomes. The global rise of dietrelated non-communicable diseases plus the double burden of obesity and malnutrition means that it is imperative more than ever that all HCPs can provide at least basic evidence-based nutrition advice.

For that reason, if medical education were to be based solely on the needs of patient and population health, nutrition would surely be meaningfully addressed. But, basis a study by Jennifer Crowley and colleagues in The Lancet Planetary Health and in defiance of the obvious need for physicians to possess, at minimum, solid foundational skills in clinical nutrition, medical education in nutrition across the globe is decidedly lacking.

Amidst this conundrum of research and discussions, many often pose these

Kent L Bradley has worked in leadership roles in healthcare sector, strategising health related policies and business decisions, he has acted as strategic advisor for multiple health-tech companies. A retired army Colonel, he has Masters Degree in Public Health from University of Minnesota & his medical degree from Uniformed Services University of Health Sciences, Maryland.

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

questions1: what is the role of the physician in a disease that is caused mainly by poor diet and lifestyle habits? Do we have a right to push patients to make major lifestyle changes? Do we have obligations toward those who are at risk but have not sought our help?

Take the example of smoking. Back in the 1980s, smoking was a very common practice amongst doctors themselves.

However, today we hardly see any doctor who lights a cigarette and the number of cases of smoking induced lung cancer too have spiralled down. How did this change occur2? First, physicians and the public became aware that the smoker was not the only one at risk. There were second-hand dangers to that smoke.

Second, doctors realized they were more effective at counselling patients to quit smoking if they no longer had tobacco stains on their own fingers. Third, hospitals began to ban smoking, businesses and government offices followed suit. In other words, doctors went from being bystanders—or even enablers—to leading the fight against smoking. By making the conscious decision to address a deadly epidemic, the medical community has saved countless lives. The current generation is facing an even bigger fight; that against unhealthy food, malnutrition and NCDs - all inter-related.

Communication has a very critical role to play in driving this agenda and Southeast Asia is using diverse approaches like - Information Dissemination; Education Communication and Participatory Communication. While these approaches appear to be separate, sometimes different ones are used within the same national context to address different nutritional problems. This is also the pillar where the government, public sector, private sector, nutrition companies such as ours and HCPs can play a better role. Government initiatives are using different nutrition communication 1 https://journalofethics.ama-assn.org/article/physiciansrole-nutrition-related-disorders-bystander-leader/2013-04 2 https://journalofethics.ama-assn.org/article/physiciansrole-nutrition-related-disorders-bystander-leader/2013-04

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approaches, depending upon the resources and expertise available to them. Some have adopted new and innovative methods while others are using more outdated ones such as a purely information dissemination approach. Moreover, countries with lower technological and personnel capacities are using older models of nutrition education, while other developing nations are applying newer, more integrated communication approaches. The result is uneven achievement within and among nations in changing the nutritional situations of vulnerable target groups.

Many patients who are admitted to the hospital and are already in a state of malnourishment. Therefore, hospital staff like nurses, nutrition consultants and treating physicians; and hospital management, needs to work towards optimising nutrition care in hospitals to improve the prevention, detection and treatment of malnutrition. There are many ways nurses can teach their patients about proper nutrition as it relates to their health.

Presentations at community health centres are crucial to community health. A nurse with the right knowledge can prepare a PowerPoint presentation to show for a group of seniors during a health fair. They can also give the attendees literature to take home for further study and guidance. Nurses who work in hospitals and clinics are likely more concerned with nutrition as it relates to recovery from illness, surgery or other treatments. They can talk to patients at the bedside and explain the special meals they have at the hospital that aid recovery, as many patients will be on special diets during their stay. These nurses can also gather informative and accurate literature to give patients when they are discharged.

It’s now a matter of bringing all the piece-meal efforts towards the common cause of nutrition together and derive more significant outcomes. A place where collaboration stands a winning chance.

Regular dialogues, informative content and support to the HCPs to impart nutri-

tion knowledge to the consumers are a few parts where nutrition companies such as ours can play a significant role.

Communities need to transform from within and this transformation must be driven by the HCPs and dietary experts due to the trust that they evoke from the common public.

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PRACTICE CHANGING INITIATIVES Constantly declining volume of patients visiting hospitals and rise in adoption of telehealth, the new era in medical practices is expected to show the journey of patients and physicians from Telehealth appointments to Teletreatment & recovery in 2021.

The year will be occupied with innovative marketing actions in medical practices and patient education programs in hospitals to help patients to be digitally savvy and much healthier.

R B Smarta, Vice President (HADSA) CMD-Interlink

P

hysical appointments, even referrals, have been declined due to pandemic as there was no active and physical consulting going on. It has affected both in-house patients as well as outdoor patients.

This is leading stakeholders toward telehealth platforms which are emerging at a rapid pace in various hospitals and private clinics, enabling the hospitals to expand their services in multiple and beneficial ways.

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Tele-ICUs are one of the biggest examples arising in today’s scenario, where a number of hospitals placed at distant from one another, are able to communicate with hospital critical care units and achieve real-time services via technological advancements.

Surging incidences of infectious disease is the factor shaping patients’ mindset in such a way that they are obliged to choose a virtual platform, making hospitals rethink their old

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practice and service models. Although, quite a good number of healthcare systems have become well-equipped with this new platform, many are still struggling to maintain their identity in this new normal of healthcare practices.

Reasons might be many — lack of right awareness about the platform, overreliance on old practices and service models, weak promotional tactics, etc.

This could be solved with new hospital practices and educating

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STEP 3.

Repeat steps 1 and 2 increase the risk of a HCAI outbreak.

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patients and caregivers in a right and beneficial way.

2021 will be the year filled with technology related initiatives; much more than ever seen in healthcare history.

Telehealth is the area which will be featured in possibly advanced, profitable and patient-friendly manner and will be equipped with all those viable strategies to conquer any inevitable incidences like COVID-19.

Following are the components of telehealth through which hospitals are evolving and will continue to evolve in 2021 and beyond.

Tele-appointments

These have turned out to be an amazing option in the pandemic.

Tele-appointment is the facility which was earlier seen at the hospitals with huge infrastructure. But the situation is different nowadays. Many reasons associated with COVID fear are fuelling the need for hospitals to adopt Tele-appointment technology even if the infrastructure is not huge. After all everyone wants to be in the race!

Physicians are carrying out telemedicine appointments, getting a look into their patient's health without ever having to see them in the hospital.

This is helping elders and patients with chronic conditions, making a big revolution in healthcare practices.

This technology is showing impressive gains in providing services and giving entry to the medically inaccessible areas where hospital services are difficult to reach, ultimately propelling the establishment of telemedicine hospital centres in various rural areas.

Tele-treatments & surgeries

Real-time interaction with the specialists is making it easy to get proper and timely treatment and therapies making patients and hospitals more adaptive toward telehealth.

Many hospitals have adopted the digital way of prescribing i.e.,

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Tele-diagnosis

Screening multiple patients is now possible while maintaining the treatment of others. Technologies such as China’s virtual diagnosis of coronavirus using 5G network are rooting in hospitals giving relief to physicians, hospital staff and patients regarding possible spread of infection.

Nowadays, ESA-supported robotics technology making good moves in radiology examination. This system is already in force in Europe and Canada for examining heart, abdominal, pelvic, and urinary tract diseases remotely.

Using video conferencing, radiologists and cardiologists are remotely moving robotic arms and adjusting settings to capture best possible images. These technologies are incredibly helpful while dealing with COVID patients with other allied health issues.

Research to develop the best technology-based methods to provide virtual diagnosis, where necessary hardware installation in hospitals to make telediagnosis possible will always be the matter of concern for many underdeveloped hospitals.

APPOINTMENTS DIAGNOSIS

TELE-

TREATMENT & E-THERAPY SURGERY MONITORING & E-REHABILITATION

Fig 1. Telehealth in 2021 and beyond

E-prescribing which is constantly increasing and the market is its expected growth at a CAGR of 23.3 per cent, will reach US$ 3.3 billion by 2025. So ultimately, tele-treatments are opening the doors wide open for the already emerging E-pharmacy sector.

Various E-therapies are becoming more and more promising. Impressive moves are seen in E-psychotherapy, where psychiatrists are directly engaging themselves in patients’ rooms virtually

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Source- Interlink knowledge cell

and taking deep insights about patients’ problems and recovery.

Although many delicate surgeries are performed aboard, tele-health and technologies are helping patients and surgeons in the hospitals to be at their own location and operate the surgeries efficiently.

Hospitals having 5G network and robot-assisted equipment and hardware will provide fast data transfers with little to no latency in the procedure giving

HEALTHCARE MANAGEMENT

TELEHEALTH CAN BE VIGOROUSLY PROMOTED ON SOCIAL MEDIA

Fig 2

Source- Interlink knowledge cell and google search engine

excellent outputs while performing virtual surgeries.

Tele-monitoring & E-rehabilitation

Post-surgery monitoring is always important after a patient is discharged.

Hospitals are now evolving in the field of post-surgery consultation. Telemonitoring provides a better option to virtually meet the physician while lying on the bed at home, without struggling with paining stitches on the way to hospital. Elderly patients or patients with decreased mobility are extensively monitored with these technologies, helping them to recover much faster.

E-rehabilitation is useful for patients with musculoskeletal conditions, multiple sclerosis, osteoarthritis, and recovery of motor function. Doctors in hospitals can monitor the movements

of patients in yoga and provide therapy in a much effective manner, allowing patients to recover faster than expected.

Although many hospitals are actively participating and adopting all these technologies, some are still not using it to its full potential. Many hospitals are wellequipped with all the necessary hardware and infrastructure but are dragged down by poor marketing of services.

Following are some marketing and promotional strategies if employed by the hospitals will surely help in reaching new patients and reengaging old ones-

1. How about brochures? - Brochures will always be one of the best promotional media when it comes to non-techno savvy population. Benefits of telehealth can be printed using regional language

with no medical jargons which can help in promoting this platform.

2. Promotions on social media.

When it comes to digitally savvy population, there is no other option than marketing on Facebook, Instagram, Twitter, LinkedIn, Quora, etc. there will not be any second opinion on this!

3.Own website. Hospitals using telehealth technology have to have their own Website which is attractive and easily accessible, every time!

Homepage with some catchy messages and infographics promoting telehealth would be beneficial. New updates and offerings regarding Telehealth services should be immediately displayed on the website to keep patients engaged.

Hospitals can even advertise their success stories with patients.

Patients always crave content related to services such as diagnosis, treatment, rehabilitation, and nutrition. Short and simple videos can be made to promote this content and to increase incidences of being in search results. So, creating a rich and patient-oriented content will always be helpful.

4. FAQ section for the Website.

Every Website has its FAQ section but are those questions answered on time?

Sometimes the credibility of an amazingly designed website is lost if the website is not actively answering the questions by patients. This can be considered while planning the promotional activities.

A talented pool of IT professionals is a must to handle all these operations in the hospital management.

5. Collection of reviews and feedback of patients. Ratings offered to a particular service is always the primary search done by many patients while searching for any service. Reviews and feedback from patients will be helpful for prospective patients to make the decisions.

6. Relatively Inexpensive applicationLaunching some simple mobile applications in which E-appointments can be fixed, physical examination records can be shared, e-prescriptions

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In camera reality

Apollo Telehealth Services (ATHS) is the largest telemedicine network in South Asia generated by Apollo Hospitals providing a number of services to increase the access of patients toward healthcare.

This network has 24*7 medical response centres consisting of physicians which are solely dedicated to Telehealth services of Apollo hospitals.

Teleclinics established by ATHS are equipped with all the required hardware and medicinal devices for the better access of patients to healthcare even in rural areas. They are currently using real-time techniques, store and forward, remote monitoring techniques to run this platform via video-conferencing, emails, wireless tools, etc.

Tele-radiology services of ATHS are transmitting X-ray images, CTs, MRIs etc. to the Apollo hospital specialists and a number of patients are getting realtime consultation and diagnosis.

Cardiologists at Apollo hospitals are providing solutions to remote medical care providers based on transmitted ECGs to them. They have multiple

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ECG reading centres at various locations accompanied with monitory services.

Tele-emergency care enabling the emergency care specialists of Apollo hospitals to stabilise and monitor the patients in remote hospitals. And in the space of condition management, Apollo’s remote management programs provide some tools and automated care plans in the form of mobile apps or devices related to particular conditions such as diabetes, heart disorders, highrisk pregnancy, etc.

Doc On Call at ATHS enables hospital’s IT systems to share patient’s information such as EMRs, PACS, LIS, RIS and non-clinical information like staff scheduling, nurse assignment, and ADT systems, etc. leading to establishment of connectivity between a large ecosystem of hospital specialists and patients.

Along with all this services, Tele-ICU, Tele-ophthalmology, tele-audiology, psychiatric counselling, chronic disease R B Smarta - Founder and Managing Director of Interlink Marketing Consultancy Pvt. Ltd. Being a thought leader in Pharmaceutical, Nutraceutical and wellness industry, he has been contributing globally through Interlink Consultancy and building business performance of his clients for 33 years. Having a Master's degree (M.Sc.) in Organic Chemistry in Drugs, MMS in Marketing, PhD in Management, and FRSA (Fellow of Royal Society of Arts) London, he is-pursuing his passion of converting science to Business. Besides being a consultant, he has been teaching at IIM, prestigious management institutes, Pharmacy College, Pharmacists Associations, guiding PhD students and written as many as 7 Books on Management, Pharma, Nutra, Foods domain, and many articles in prestigious journals/magazines.

AUTHOR BIO

can be achieved, etc could be really helpful to engage patients with the service. And there are more chances of patients coming back to the same service where there is ease in processing.

7. Right information to build trust – Being honest with the profession we are doing will always make a positive and trustworthy impact on consumers (here patients) we are serving. While filling the website with all those attractive promotions, hospitals should also mention the health conditions for which physical visit to hospital is obligatory.

Vaccination of children, monitoring child growth after birth, serious injury, severe chest pain or a drug overdose, etc. are some of the cases for which the doctor needs to lay hands on a patient.

Mentioning all such things shows affectionate behaviour of physicians toward patients and also builds trust.

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management, motherhood care, teleeducation, etc are also some of the demanding services given by ATHS of Apollo hospitals making good moves in Tele-health sector of hospitals.

In addition to all these, if we have a look at the website and marketing strategies employed by Apollo hospitals to promote their telehealth services, they are just amazing!

Telehealth and technology related to it are the practice changing initiatives taken by many hospitals in 2020. It is a reality and every hospital needs to accept and adopt it. Old hospital practice models will no longer remain superior. Years coming ahead are already showing the clear picture of technologybased services in every part of industry, healthcare is not an exception, hospital managements have to be ready to absorb and emit all these changes efficiently and wisely.

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Covid-19 Pandemic The challenge of quality patient care in hospital systems

The Covid-19 pandemic has made achievement of patient care in hospital systems an anachronism. Most hospital employees have lost interest and hope that improved excellence in patient care is achievable because of the general belief that top management lacks the skills to identify and constructively adapt to new medical challenges that require rapid response. Furthermore, healthcare workers feel neglected, poorly paid and often ignored when their ideas trickle up to those at the top.

It is hellishly frustrating that middle management is even less qualified in the redesign and preparedness in focusing on processes and systems that drive employee motivation and patient care. The paper through the use of a case study suggests a practical approach to the implementation of Total Patient Care (TPC) in healthcare; a Systems Management approach..

Uche Nwabueze, Professor, Maritime Administration, Texas A&M University

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he author is of the opinion that TQM is a process which embraces the conscious striving for zero defects in patient care and caring; the management of hospital organisations in co-operation with its workforce to improve processes in order to develop, produce and provide all medical services which satisfy patients’ needs and expectations. Although this represents a meaningful, detailed definition of TPC, Haigh and Morris (1994) contend that most managers find it impossible to work co-operatively with their employees to achieve improved organisational performance. This is because the structural adjustments are usually at odds with processes and patient outcomes as we have seen with lack of hospital capacity and mortality rate for Covid-19 patients. To achieve excellence, I am of the opinion that

HEALTHCARE MANAGEMENT

TPC is About the will and the way of the People

Structure: Medical Cells

Processes

Patient Outcomes

Figure 1. Key Elements of TPC implementation

organisations must first map the business terrain by breaking down the organisation into three key elements: Figure 1.

Explaining the TPC Implementation Approach

The author’s suggestion, therefore, is that quality patient care is fundamentally a structural decision determined at corporate level and must trickle down to all employees in cross-departmentally staffed medical cells. The structure must be focused on dedicated factories for dedicated medical care and resolution.

Its success is dependent on middle management having a total buy-in and effectively implementing it with a proper thought out plan; with clearly defined quantifiable goals, roles and responsibilities for individual units, and having in place organisational norms that emphasise listening, supporting, coaching and rewarding staff appropriately. It should be noted,

however, that at the initial stage of implementation, the success of TPC is not dependent on senior management commitment, but on a proper and effective implementation strategy championed by middle management, endorsed and made to work by a happy workforce, which would then have a domino-effect across the whole organisation.

TPC is akin to playing basketball; it is simple, but we choose to make it complex by being overly technical.

TPC is essentially a way of organising and involving the whole organisation; every department, every activity, every single person at every level focusing on the organisations’ core competencies in order to deliver continuous value to the patient. To that end, the authors suggest the use of a theoretical operations-based transformation framework at the onset of TQM as a guide for the identification of areas for improvement (Figure 2).

The sustainable transformation of an organisation to a TQM culture, in the authors’ opinion, requires a balance between organisational strategy, systems and structure (the way) with the fundamental commitment of staff, their skills, managerial style and values (the will): Figure 3.

Without the development of the will, the ongoing success of the TPC programme would require a large amount of attention, effort, and energy to work against the fundamental status quo in an organisation, which dictates that ‘things should be done the way they have always been done’. The will can only be generated if TPC is accompanied by a plan to ensure that the behaviours encouraged are aligned with those required by the culture. Furthermore, as identified by the author the ‘WILL’ for ‘TPC’ must be fully developed by ensuring professional competencies are at the highest level and paying employees above market rate. The way is focused on servant and authentic leadership.

Therefore for TPC to succeed, a ‘total’ re-orientation of employee beliefs and values is required. This is consistent with the views of Thomas Watson, Sr., the founder of IBM, who noted, “Any great corporation, one that has lasted over the years, will find it owes its resilience not to its form of organisation or administration, but to the power of values and beliefs and the appeal these values and beliefs have on its people (Arikian, 1991).

E-Hospital Case study

Key Drivers

PEOPLE PEOPLE

PEOPLE

PEOPLE

Redefine Strengthen Flexible

Quality Responsiveness Satisfaction

Total Patient Satisfaction

Speed Co-operation Agility

Figure 2. Process transformation framework

Background E-Healthcare came into existence on 1 August 2018. In total, E-Healthcare is responsible for an expenditure of US$560 million on health services, for its community. The main work of the E-Healthcare is to: • assess the health needs of the local population and identify health problems in the area

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· Staff · Strategy

· Skills · Style

The Will

The Way

· Shared values

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· Structure

TPC

Figure 3. The TPC Approach

• draw up a strategy for meeting those needs and dealing with particular problems • provide medical services to meet patient needs in the most effective and cost efficient way • monitor the provision of services to ensure that standards and targets are being met.

E-Healthcare employs a staff of about 2,200 across 5 hospitals, including part-time and seconded staff. The managerial structure of the organisation comprises of the chairman and five non-executive members of two statutory authorities and a jointly appointed chief executive. Their role is to oversee matters of policy and strategy, to monitor performance and ensure that the organisation operates to the highest standards of probity and accountability.

• Hospital 1; provides medical, surgical, maternity, child health and pathology services • Hospital 2; provides community care, and also cares for people with mental illness or severe learning disability • Hospital 3; is responsible for

· Systems

treatment and care for people with cancer • Hospital 4; provides a wide range of hospital based medical and surgical services, • Hospital 5; also provides medical and surgical care.

Reasons to Switch to TPC

The organisation had to cope with the new changes that have been taking place to demonstrate an organisation wide approach to improving the quality of patient care through the development of quality improvement strategies which should be made explicit in business plans”.

Secondly, due to increased competition, the chief executive felt that the adoption of TPC would bring about a new cultural perspective that enhanced the need to provide medical services that meet the needs of the local community in terms of quality, speed, access, effectiveness, efficiency, comprehensiveness, safety, and appropriateness.

Furthermore, there were underlying barriers to be surmounted by recourse

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to the implementation of TPC within the organisation: • poor communication between staff of the organisation and management • lack of trust amongst administrators and clinical staff.

• medical interventions not clinically effective, i.e. 70 per cent of hospital procedures not clinically proven.

• failure to address and meet local needs: demographic shifts.

In addition, patients are chosen on the basis of colour and not equity as is presently the case with Covid-19 vaccination.

• lack of customer awareness: at this stage the word ‘customer’ was alien to the organisation’s staff; hence, improper patient assessment.

• financial management top priority; lack of patient value.

All of these factors had driven the management of E-healthcare to go down the TPC route. The organisation, therefore, through the adoption of total patient care, aims to ensure the provision of services which; Structure • are effectively managed with

HEALTHCARE MANAGEMENT

appropriately trained staff • have clearly defined quality assurance and service review policies and guidelines • are based on a systematic assessment of local needs.

Process • promote good health and healthy living • support people with continuing disabilities and ensure relief is provided for their carer • are accessible and timely for all sections of the population in the county • achieve equity between different patient social and geographical groups • ensure communication with individual consumers and the wider community about all aspects of the care provided and the services available.

• encourage and take into account the high aspirations of staff in all disciplines.

Outcome • make the most efficient and effective use of resources • are sufficiently documented to facilitate continuity of care and peer evaluation • achieve effective outcomes in the

Structure

prevention and treatment of disease and rehabilitation • improve the patients’ subsequent quality of life • ensure the consumer receives an acceptable standard of care at all times.

In the words of the patient care manager, the TPC programme was based on three major dimensions: Figure 4.

Quality, the manager suggests, “cannot be considered in isolation, as it is influenced by a range of factors: professional standards and aspirations, technical competence and skills, attitudes and social behaviour, consumer expectations and the resources available. Hence, all persons involved in the delivery of care, and the provision of support services, are key to the achievement of a high quality service”.

TPC Implementation Stages

Stage 1 The organisation had to first identify and adopt a clear vision based on what their main business and purpose is.

According to the Patient Care Manager, the main purpose of the organisation is to “purchase the ‘best’ quality service for its patients”. The adoption

Process

Outcome

T P C

Figure 4. Three dimensions of TPC

of a vision based on the purchase of quality services provided clarity of purpose for all staff to work towards. In addition, a decision was taken by senior management not to introduce TPC as top management’s top-down rule, but as a home-grown approach where employees were allowed to voice their scepticism and make suggestions. Thus, employee involvement was seen as the first initial requirement of the TPC process.

Stage 2: Involved the setting up of focus groups to identify gaps in service provision from the patient perspective. The focus group carried out a patient satisfaction survey across the county, which established a number of gaps: • fear of retribution • long waiting times at hospital outpatients • poor catering services • clinical outcomes – performance judged by peers rather than by patients.

On the basis of the patient survey, the organisation set out nine strategic priorities to deal with and close the gaps that were identified in the provision of services. The strategic intents included: • establishing primary care and cancer treatment as the principal focus • reshaping hospital provision to meet the changing health service needs of the population • implementing ‘the health of the nation’ through the achievement of health goals and targets to improve the health status of the population • ensuring the successful implementation of community care act through effective collaboration and joint action between social services and health services and other organisations • ensuring that inpatient and outpatient waiting times meet and exceed agreed standards.

• ensuring continued value for money through efficient and effective use of resources to achieve health gains

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HEALTHCARE MANAGEMENT

EXTERNAL ENVIRONMENT

Patients

INPUTS

PROCESS

Expectation

PROCESS

OUTPUTS

Employees Feedback Figure 5. Systemic representation of TPC

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contracts/purchasing manager, enabled the organisation to deal with the initial barriers prior to TPC. To further ensure the internalisation of the three core values, the organisation made it mandatory for all its service providers to identify their corporate approach to quality and the responsibilities within their organisations for quality improvement, firmly linking these to their strategic objectives and translating them into key tasks and work programmes for each year. In addition, E-Healthcare asked a committee of employees to monitor progress during the year and evaluate clinical outcomes, which in turn informs the following year’s plans and programmes. To ensure compliance, the organisation introduced a uniform quality approach to be adopted (Figure 5).

Figure 5:. Systemic representation of TPC AUTHOR BIO

• empowering consumers through the implementation and further development of the patients charter • establishing a comprehensive research and development programme • creating an effective organisation able to deliver changes in primary, community and hospital care services.

‘Quality Care is meeting patients’ needs’.

To cascade this definition across the organisation required a new organisational culture emphasising: • a customer orientated focus • top management (including clinicians) commitment to quality • the involvement of all staff in quality development and delivery • incremental/continuous quality improvements each and every year.

This new culture was to be sustained through an adherence to three core values: monitoring performance against agreed quality requirements between the organisation and its service providers; strengthening focus and developing patient empowerment developing quality medical cells and empowering staff.

The new system, according to the

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Using the above diagram as an illustration, what the case study seems to suggest is that for TPC to succeed, hospitals must work in partnership with its suppliers of service (inputs), involve patients and employees in the improvement and redesign of processes, in order to meet their expectations, which would result in the provision of a quality service (output). This requires the realignment of the entire organisational system to the principles of TPC, thereby creating a quality environment in which those with the primary responsibility for the treatment and caring of patients will work in concert. Any TPC implementation process that falls short of integrating and involving the ‘whole’ system would result in the partial implementation of TPC. A system is not the sum total of its parts, but the interaction of the whole.

Uche Nwabueze is a Professor of Maritime Administration at Texas A&M University, Galveston Campus, Texas, USA. Dr. Nwabueze’s research focuses on Healthcare process improvement strategies. Dr. Uche as he is fondly called by his students has served as faculty member across four continents.

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MEDICAL SCIENCES

High Heart Rate in Hypertension What should the clinician do in patients with tachycardia?

Resting Heart Rate (RHR) is a strong predictor of metabolic abnormalities, hypertension, and diabetes. In addition, fast RHR is a major risk factor for development of atherosclerosis, cardiovascular disease, and all-cause mortality. In hypertensive patients with high RHR, a combination therapy that includes a cardiac slowing drug seems a sensible strategy.

Paolo Palatini, Department of Medicine, University of Padova

T

he Resting Heart Rate (RHR) represents a reliable marker of autonomic nervous system tone. High RHR is due to sympatho-adrenergic predominance reflecting increased sympathetic discharge and reduced vagal activity, a condition that is genetically determined. RHR is a strong predictor of future hypertension, obesity, metabolic abnormalities, and diabetes.

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MEDICAL SCIENCES

In addition, high RHR is closely associated with Cardiovascular (CV) events as well as with CV and total mortality. Thus, there is no doubt that in clinical practice RHR can be used as a reliable and inexpensive marker of risk. However, there are still many doubts about how RHR should be assessed, about the correct interpretation of the RHR level, and whether and how high RHR should be reduced in hypertension.

Heart rate as predictor of hypertension and metabolic abnormalities

Fast RHR has been found to be both cross-sectionally and longitudinally associated with elevated Blood Pressure (BP), increased body mass index, high haematocrit, hyperglycemia, and lipid abnormalities. In the patients with borderline BP levels from the HARVEST study, high RHR was a potent predictor of subsequent development of hypertension needing drug therapy and obesity. These associations were confirmed by two recent meta-analyses which showed that there was a linear relationship between elevated RHR and risk of hypertension, metabolic syndrome, and diabetes.

The mechanisms by which tachycardia induced hypertension, atherosclerosis, and CV damage are well understood. These associations may be explained at least partially by the observation both in experimental and human studies that high RHR is associated with large artery stiffness, measured either with PWV or the augmentation index, which gives an estimate of aortic wave reflection.

Elevated heart rate by exposing the arteries to increased magnitude and frequency of mechanical load may eventually cause endothelial dysfunction and increase the stiffness of the vascular wall. It is thus possible that the increase in vascular stiffness favours the development of

hypertension in normotensive subjects and promotes the occurrence of CV complications in hypertensive patients.

Heart rate as predictor of hard endpoints

A graded association has been found between RHR and CV events or mortality.

In a meta-analysis encompassing 1,246, 203 patients, subjects with RHR of greater than 80 bpm had a 45 per cent increase in risk of total mortality and a 33 per cent increase of CV mortality. In a more recent and largermeta analysis

by Aune et al. including 87 studies, there was a 7 per cent increase in risk for coronary artery disease, a 9 per cent increase for sudden death, an 18 per cent increase for congestive heart failure, and a 17 per cent increase for total mortality for each 10 bpm increment in RHR. The association between elevated RHR and increased risk of mortality or CV events appeared even stronger in the hypertensive populations as shown by nine cohort studies and six randomised clinical trials. In the Syst-Eur study, elderly people withRHR> 79 bpm had an 89 per cent increase in risk of all-cause mortality and a 60 per cent increase in risk of CV mortality than subjects with lower RHR. In the hypertensive patients at high CV risk from the VALUE study, both baseline and in-trial RHRs were powerful predictors of the composite CV outcome. An interesting aspect of this study is that a substantial reduction in the risk of adverse outcomes could be obtained with antihypertensive treatment only in the patients with low RHR. Also temporal changes in RHR recorded during the follow-up proved to be important predictors of death or CV events.

The role of ambulatory heart rate

It should be pointed out that heart rate is not stable throughout the 24 hours and that it can be subject to important changes mainly due to physical activity and to stressful situations.

Thus, the association between heart

rate and adverse outcomes might be stronger for heart rate measured with ambulatory monitoring in free ranging subjects. This was actually shown by the ABP-International study in 7600 hypertensive patients followed for 5 years. In this study, night-time heart rate emerged as a strong predictor of CV events with a predictive power greater than that of office RHR. Similar results were later obtained by other studies. Of particular relevance are the data obtained in 56 901 patients from the Spanish BP Monitoring Registry.

Also in this study the strongest association with all-cause death was observed for night-time heart rate, and for CV death only mean night-time heart rate was predictive of outcome.

In conclusion, studies performed with 24h ambulatory monitoring have shown that ambulatory heart rate is a stronger predictor of CV and total mortality than office heart rate and that among the ambulatory parameters night-time heart rate has the higher prognostic accuracy.

Photoplethysmographic technology has become nearly ubiquitous in smartphones and smartwatches, enabling patients and physicians to obtain beat-to-beat heart rate recording for long periods of time. However, at the present time no data on the clinical usefulness of these techniques are available.

In this review we have provided ample evidence about the clinical importance of RHR as a CV risk factor. Due to this wealth of data, the latest European Guidelines recommend that RHR be always measured when evaluating a hypertensive patient.

However, there are some issues still open to question that may hamper the applicability of RHR measurement in clinical practice. In particular, how RHR should be measured, which RHR level should be considered abnormal, and whether high RHR should be lowered with pharmacological intervention is still unclear.

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MEDICAL SCIENCES

Measurement of RHR

Many sources of variability including physical and environmental factors, psychic stimuli, body position, methods of measurement etc. may affect the assessment of heart rate in resting conditions. Thus, to minimise the effect of these confounding variables, the measurement of RHR should be strictly standardised (table). Recommendations on how to measure RHR based on the available evidence have been published in a consensus document of the European Society of Hypertension.

Before RHR measurement, subjects should relax for at least five minutes.

A number of factors which can alter a subject's haemodynamics such as exercise, alcohol, smoking and coffee consumption should be avoided in the hours preceding measurement.

The individual should be comfortably seated, with the legs uncrossed. RHR measurement should follow each BP reading. Thirty seconds are sufficient for obtaining a reliable estimate of heart rate because in most people 30 to 40 cardiac cycles can be averaged out during this time. Two measurements are sufficient for a reliable estimate of RHR but more measurements should be achieved when an important decline from the first to the second reading is observed. The sitting position should be preferred because in epidemiologic studies BP has been more frequently measured in that position and RHR can be measured at the end of each BP measurement.

Although electrocardiography is more precise than pulse palpation especially when heart rate is calculated using an in-built software, it should be borne in mind that only a few cardiac cycles are taken into account when heart rate is measured from ECG whereas pulse rate measurement usually lasts 30 seconds. For this reason, electrocardiographic measurement is not recommended for the measurement of resting heart rate even for research and pulse palpation should be preferred.

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Practical advice for the clinician How heart rate should be measured in the office • Make sure that exercise, smoking, alcohol and coffee consumption have been avoided in the 2 hours before measurement • Allow the patient to relax for at least 5 minutes • Keep the room at comfortable temperature • Measure blood pressure and RHR with the patient in the sitting position • Measure RHR after each blood pressure measurement • Measure RHR preferably by pulse palpation over a 30-second period • At least two measurements should be taken but more measurements are needed if heart rate declines considerably at second reading

Definition of fast heart rate • A RHR of 80 bpm or higher should be considered abnormal • In women RHR is usually 2-3 bpm higher than in men • Ambulatory heart rate has a greater prognostic capacity than heart rate measured in the office • The upper normal values for 24-hour and night-time heart rates are 80 and 73bpm, respectively

How fast heart rate should be managed in hypertension • Non pharmacological measures should be implemented.

• Pharmacological RHR lowering with antihypertensive drugs should be started if RHR is still ≥ 80 bpm.

• A drug combination including a beta-blocker should be privileged in most patients.

Definition of tachycardia as a CV risk factor

Some doubts still remain about the clinical utility of measuring RHR because a precise cutoff of normality is difficult to establish. Tachycardia is currently defined in textbooks as a heart rate greater than 100 bpm.

However, in the vast majority of epidemiologic studies the heart rate value above which a significant increase in risk was observed was well below the 100 bpm threshold. Most studies found a significant increase in risk for a heart rate ≥80-85 bpm and the European guidelines consider the 80 bpm cutoff as the upper normal limit for RHR. Because of the higher heart rate and the weaker relationship of the heart rate-mortality association commonly seen in women, a slightly higher threshold may be adopted in the female gender. Even more difficult is to identify the upper normal limit for

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ambulatory heart rates. This concern chiefly applies to heart rate recorded during sleep which is much lower than heart rate measured in the office by healthcare personnel. In a recent analysis of the ABP-International database the normalcy limit for nighttime heart rate was identified with a time-dependent ROC curve analysis using the risk of fatal and non fatal combined CV events as the outcome variable. According to this statistical approach, the optimal night-time heart rate cutoff value for prediction of cardiovascular events was around 73 bpm and for 24-hour heart rate was around 80 bpm.

Is fast RHR a target for treatment in hypertension?

According to most epidemiological studies, 25 to 30 per cent of the hypertensive patients have a resting heart rate ≥ 80 bpm. This

MEDICAL SCIENCES

is known that this drug causes many metabolic disturbances. Today, betablockers provided with vasodilatory activity such as carvedilol and nebivolol or with high beta-1 selectivity such as bisoprolol have a more favourable effect on the metabolic variables and on arterial elasticity compared with older beta-blockers.

Conclusion

This review has shown that the evidence about the CV risk associated with RHR is impressive. Due to this wealth of data, the latest European guidelines on the management of hypertension have recommended that RHR be measured together with BP at each visit.According to the same guidelines, in hypertension associated with tachycardia a therapy that not only reduces BP effectively but also decreases the RHR should be selected.

Given the high frequency of fast

RHR in patients with hypertension, treatment of elevated RHR in this setting might have a major role for reducing CV disease.

Summary

RHR holds important prognostic information in several clinical conditions including hypertension.

High RHR is a strong predictor of metabolic abnormalities, hypertension, and diabetes. In addition, fast RHR is a main risk factor for development of atherosclerosis and cardiovascular disease. A linear association has been found between RHR and cardiovascular or all-cause mortality.

In hypertensive patients with high RHR a combination therapy including a cardiac slowing drug seems a sensible strategy.

References are available at www.asianhhm.com

AUTHOR BIO

large segment of the hypertensive population might benefit from a treatment able to decrease not only BP but also RHR. Lifestyle measures should always be implemented in these patients with the purpose of reducing not only BP but also an elevated RHR. Doctors’ advice should be addressed toward discouraging sedentary habits, smoking, and excessive consumption of alcohol and caffeinated beverages.

Although no results of clinical trials specifically designed to investigate the effect of RHR lowering in human beings without CV diseases are available, pharmacological RHR lowering with antihypertensive drugs should be considered in hypertensive subjects with high RHR. The more so if one considers that most clinical guidelines now recommend the use of combination therapies even in the initial treatment of hypertension.

Thus, in hypertensive patients with high RHR a drug combination including a RHR lowering drug seems a sensible strategy. Beta-blockers for their marked bradycardic action should be privileged. In the latest European guidelines, beta-blockers have been recommended for several clinical conditions, one of which is hypertension associated with elevated RHR. Beta-blockers have been shown to reduce BP as effectively as other antihypertensive drug classes and to reduce CV and all-cause mortality in placebo-controlled BP-lowering randomised clinical trials. One possible concern is that recent meta-analyses have suggested that at similar attained BP levels, beta-blockers are less effective than other antihypertensive drugs in terms of stroke prevention .This has been attributed mainly to the smaller effect of beta-blockers on aortic BP compared to other drugs, to a deterioration of the metabolic profile and to the increased risk of new onset diabetes. However, the large majority of the clinical trials have been made with the beta-blocker atenolol and it

Paolo Palatini graduated from the University of Padova School of Medicine (Italy) and completed a 5-year Professorship from University of Michigan (USA). He was former Head of Vascular Medicine Unit at the University of Padova and at present is Senior Scholar of Studium Patavinum at the University of Padova.

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DIAGNOSTICS

Recommendations for Lung Ultrasound in Internal Medicine Lung ultrasound as a diagnostic method of lung diseases has been rapidly developing for several decades. It is the first imaging study with such a wide range of mobility.

Ultrasound diagnosis of lung diseases of patients of all ages is increasingly used in medical practice. In order to systematise knowledge in this field, it was necessary to create recommendations on lung ultrasound.

Natalia Buda, Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk Wojciech Kosiak, Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk PawełAndruszkiewicz, Consultant Anaesthetist and Intensivist, Department of Anaesthesiology and Intensive Care, National Institute of Tuberculosis and Lung Disease

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L

ung ultrasonography is a diagnostic tool known for several decades. It owes its popularity to the work of many clinicians who use this method of lung imaging on a daily basis in their medical practice with diagnostic successes. Despite the long history of the use of ultrasound in medicine, the lungs did not constitute an attractive medium for propagating the ultrasound wave. The air in the lungs causes the ultrasound wave to be strongly reflected and prevents ‘looking’ into the lung. The result of this valuable observation was the general view

DIAGNOSTICS

that ‘ultrasound is not suitable for lung assessment.’ At the same time, the diagnostics of ‘airless’ parenchymal organs was intensively developed. Hence, ultrasound of the abdominal organs, thyroid gland, nipple, lymph nodes, and the heart are highly specialised.

Initial skepticism towards lung ultrasound was justified and was related to the inability to assess the parenchyma of the air lung properly. It was not until the 1990s that reports appeared on the diversity of the pulmonary changes observed in ultrasound and on the possibility of differentiating the causes of dyspnea.

It turned out that with the loss of lung aeration, two types of changes appear in ultrasound: artefacts and consolidations. Both groups of pulmonary changes indicate the degree of lung aeration loss.

A careful assessment of changes in the surface of the lung (the so-called pleural line) and subpleural consolidations (areas of the airless lung) allow for the differentiation of the causes of dyspnea. With the passage of time and the work of numerous other scientists, the high accuracy of lung ultrasound in the diagnosis of such diseases as: pneumonia, cardiogenic and non-cardiogenic pulmonary edema, atelectasis, pulmonary infarction changes in the course of pulmonary embolism, pulmonary fibrosis, or pneumothorax and fluid in the pleural cavities has been proven.

The databases of medical literature currently collect several thousand publications on the use of lung ultrasound in anaesthesiology, intensive care, cardiology, pulmonology, paediatrics, and emergencies. With the increasing number of papers, it was necessary to organise the knowledge of lung ultrasound. For this purpose, the first recommendations were created by multinational experts in the field of lung ultrasound in 2012. (Volpicelli G et al.). The first recommendations concerned the use of lung ultrasound as a method dedicated to clinicians, and, therefore, used as point of care diagnostics. In line with EBM rules, the first Recommendation Document was produced. The next documents were created by a group of Polish scientists and practitioners dealing with lung ultrasound on a daily basis. A group of adult health specialists created recommendations for internal medicine specialists in 2017, which were updated in August 2020. Recommendations for Lung Ultrasound in Internal Medicine is the title of publications in the journal Diagnostics (Buda N et al.). The document is updated with the latest scientific data. The content contains information on pathological changes in the lungs (i.e. pneumothorax, edema, fibrotic interstitial lung diseases, inflammatory, atelectasis, neoplastic changes, as well as pulmonary embolism). Recommendations

regarding cardiogenic pulmonary edema and pulmonary congestion in patients undergoing dialysis have been particularly enriched. The sonomorphology of the above mentioned changes, as well as the accuracy of lung ultrasound in their diagnosis compared to the chest X-ray examination, were thoroughly assessed in terms of the quality of available literature (in the GRADE system) and the opinion of the working group (in the Delphi system). Moreover, the recommendations also refer to the examination protocol, examination technique and education of students and doctors in the field of lung ultrasound. The document presents a complementary approach to the possibilities of lung ultrasound in the technical, clinical and educational context.

At the same time, in Poland, a group of paediatricians was working on a document relating to the use of lung ultrasound in paediatrics. Therefore, in 2020, a consensus was also published on the use of lung ultrasound in paediatric patients.

The document, entitled: "Consensus on the Application of Lung Ultrasound in Pneumonia and Bronchiolitis in Children" (Jaworska J et al.), addresses the possibilities, validity and terminology of lung ultrasound in children with lower respiratory tract infections. Both documents present the possibilities of using a non-invasive examination such as lung ultrasound in the diagnosis of both paediatric and adult patients.

Since March 2020, the use of lung ultrasound has gained publicity again, due to its use as a diagnostic tool in the fight against the COVID-19 pandemic.

Doctors and paramedics, who are in the first line of contact with the patient, began to have portable, compact ultrasound machines. Pocked size ultrasound scanners can be used at any place of the incident: at the patient's home, at the site of a traffic accident, during patient transport, as well as in emergency departments and specialist departments of a hospital. Numerous educational materials from around the world appeared on the web: publications, on-line courses and lectures aimed at educating www.asianhhm.com

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DIAGNOSTICS

AUTHOR BIO

medical personnel and preparing them to work independently with an ultrasound machine during the COVID19 pandemic. However, it should be noted that lung ultrasound, as well as chest tomography, does not detect the SARS-COV-2 virus, which causes the COVID-19 disease. As a diagnostic tool, lung ultrasound can show interstitial inflammatory lesions, e.g. in the course of COVID-19, influenza, and atypical infections. In order to confirm the cause of interstitial inflammatory lesions in the lungs visible in the imaging test, we use PCR testing for SARS COV-2 infection or antigen tests. Access to chest tomography is difficult in many places where lung inflammatory changes in the course of COVID-19 are diagnosed. In such a situation there are: intensive care units, some COVID-19 dedicated wards, but also all pre-hospital care, including an ambulance service. Due to the needs of clinicians, another document for the needs of intensive care was created, entitled "Consensus of the Study Group for Point-of-Care Lung Ultrasound in the intensive care management of COVID19 patients" (Buda N et al.) Published in Anaesthesiology Intensive Therapy, 2020.

As evidence shows, lung ultrasound is becoming the ‘stethoscope of the 21st century’. It is the first imaging study with such a wide range of mobility.

Ultrasound diagnosis of lung diseases of patients of all ages is used more and more often and more readily accepted by the scientific community. In 2019, ERS issued a document entitled: "ERS statement on chest imaging in acute respiratory failure" (Chiumello et al.).

The ERS clearly presents its position on lung ultrasound in the diagnosis of acute respiratory failure. According to the ERS expert group, lung ultrasound is a method that is more effective than chest X-ray and is comparable to chest tomography, after proper training of the person performing the ultrasound examination.

Literature:

Volpicelli, G.; Elbarbary, M.; Blaivas, M.; Lichtenstein, D.A.; Mathis, G.; Kirkpatrick, A.W.; Melniker, L.; Gargani, L.; Noble, V.E.; Via, G., et al. International evidencebased recommendations for point-of-care lung ultrasound. Intensive Care Med 2012, 38, 577-591, doi:10.1007/s00134-0122513-4.

Natalia Buda works in the Department of Internal Medicine Diseases, Connective Tissue Diseases and Geriatrics at the University Clinical Center in Gdansk. Founder of Lus.expert portal and website dedicated for lung ultrasound education.

Specialist of internal medicine with 12 years of experience in lung ultrasonography.Author of books and articles in a lung ultrasound subjects.

Wojciech Kosiak, graduate of the Faculty of Medicine at the Medical University of Gdańsk, specialist in paediatrics, 30 years of experience in ultrasound. Lecturer at the Medical University of Gdańsk. A longtime activist for ultrasound education of students in Poland. Author of publications about lung ultrasound and ultrasound in pediatrics.

Paweł Andruszkiewicz, Consultant anaesthetist and intensivist in the Department of Anaesthesiology and Intensive Care, National Institute of Tuberculosis and Lung Disease, Warsaw, Poland.

Chairman of the Section of Ultrasound and Echocardiography in the of Polish Society of Anaesthesiology and Intensive Care, cofounder of educational website – criticalusg.org.pl, author of publications about POCUS.

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Buda, N.; Kosiak, W.; Radzikowska, E.; Olszewski, R.; Jassem, E.; Grabczak, E.M.; Pomiecko, A.; Piotrkowski, J.; Piskunowicz, M.; Soltysiak, M., et al.

Polish recommendations for lung ultrasound in internal medicine (POLLUS-IM).

J Ultrason 2018, 18, 198-206, doi:10.15557/JoU.2018.0030.

Buda, N.; Kosiak, W.; Wełnicki, M.; Skoczylas, A.; Olszewski, R.; Piotrkowski, J.; Skoczyński, S.; Radzikowska, E.; Jassem, E.; Grabczak, E.M., et al.

Recommendations for Lung Ultrasound in Internal Medicine. Diagnostics (Basel) 2020, 10, doi:10.3390/diagnostics10080597.

Jaworska J ,Komorowska-Piotrowska A, Pomiećko A, WiśniewskiJ, Woźniak M, Littwin B, Kryger M , Kwaśniewicz P, Szczyrski J, Kulińska Szukalska K, Buda N, Doniec Z, Kosiak W; Consensus on the Application of Lung Ultrasound in Pneumonia and Bronchiolitis in Children Diagnostics (Basel) . 2020 Nov 11;10(11):935. doi: 10.3390/diagnostics10110935.

Guan WJ, Ni ZY, Hu Y et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020. doi: 10.1056/NEJMoa200203 Ai T, Yang Z, Hou Het al. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID19) in China: A Report of 1014 Cases.

Radiology. 2020 Feb 26. doi: 10.1148/ radiol.2020200642 Buda N, Andruszkiewicz P, Czuczwar M, Gola W, Kosiak W, Nowakowski P, Sporysz K. Consensus of the Study Group for Point-of-Care Lung Ultrasound in the intensive care management of COVID19 patients.Anaesthesiol Intensive Ther.

2020;52(2):83-90. doi: 10.5114/ ait.2020.96560.

Chiumello D, Sferrazza Papa GF, Artigas A, Bouhemad B, Grgic A, Heunks L, Markstaller K, Pellegrino GM, Pisani L, Rigau D, Schultz MJ, Sotgiu G, Spieth P, Zompatori M, Navalesi PERS statement on chest imaging in acute respiratory failure. European Respiratory Journal 2019; DOI: 10.1183/13993003.00435-2019

DIAGNOSTICS

Need for Stratification of Heart Failure with Preserved Ejection Fraction Shedding light on RV-PA uncoupling with echocardiography Heart Failure with preserved Ejection Fraction (HFpEF) is a crucial problem among cardiovascular diseases for the lack of established treatment strategies. There must be a need for detailed observational cohort studies for HFpEF patients to elucidate the detailed clinical phenotypes and to find appropriate therapeutic strategies.

Akito Nakagawa, Division of Cardiovascular Medicine, Amagasaki-Chuo Hospital

H

eart Failure (HF) is a critical social problem all over the world, and HF with preserved Ejection Fraction (HFpEF) has particularly been increasing and upcoming to a bothering issue.

Complicated pathophysiology and multiple comorbidities with an aging population makes it rather difficult to find the best way to treat HFpEF patients, and none of specific strategies have been established for the prognostic improvement. In order to understand the characteristics, backgrounds, and underlying problems of current HFpEF patients, we considered detailed observational cohort study must be needed. Based on such a concept, professor Yasushi Sakata (Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Japan) launched multi-centre observational cohort study, named PURSUIT-HFpEF registry, from June

2016 to register up to 1,500 HFpEF patients until March 2021. Inclusion criteria were acute decompensated HFpEF diagnosed by the Framingham criteria for HF plus the following: (1) left ventricular ejection fraction ≥ 50 per cent and (2) N-terminal pro-brain natriuretic peptide (NT-proBNP) ≥ 400 pg/mL or brain natriuretic peptide (BNP) ≥ 100 pg/mL on admission. Exclusion criteria were age < 20 years, severe valvular disease, acute coronary syndrome on admission, life expectancy of < 6 months due to prognosis of non-cardiac diseases, and previous heart transplantation.

Importance of right heart function among HFpEF patients

Although Right Ventricular (RV) function had been de-emphasised in the consideration of left-sided HF for many years, it is now evident that RV dysfunction is highly prevalent and resulted in poor prognosis in patients

with left-sided HF with HFpEF in the position statement of the Heart Failure Association of the European Society of Cardiology. Even among the parameters related to right heart dysfunction and failure, RV-Pulmonary Artery (PA) coupling has been extensively focused on the prognostic predictability.

Right ventricle is quite sensitive to changes in afterload, and the afterload dependence is even exaggerated in HFpEF patients. Although RV-PA coupling had been evaluated with invasive calculation with Swan-Ganz catheterisation, recent studies have revealed that RV-PA coupling was able to be examined in a non-invasive manner with Tricuspid Annular Plane Systolic Excursion (TAPSE) to Pulmonary Arterial Systolic Pressure (PASP) ratio on echocardiography. TAPSE represents right ventricular contractile function, and PASP is estimated with the pressure gradient of tricuspid

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proved based on HFpEF populations haemodynamically validated with right heart catheterisation, which is ethically inappropriate for HFpEF patients in general. In order to verify the clinical prognostic usability of TAPSE/PASP ratio, investigations based on widely included HFpEF patients should be needed.

Findings from PUTSUIT-HFpEF registry

Fig 1. Shedding light on RV-PA uncoupling with echocardiography

regurgitation Doppler wave in addition to the estimated right atrial pressure, presumed with the diameter and inspiratory collapsibility of inferior vena cava. Reduced TAPSE/PASP ratio was associated with worse prognosis in HF (including HFpEF), and a prognostic cut-off value was generally identified as < 0.36 mm/mmHg. Need for assessment of HFpEF patients in a real-world data

Although treatment strategies were evaluated with randomised clinical trials, there were unavoidable discrepancies between trial candidates and realworld patients. The clinical impact on HFpEF patients of Angiotensin II Receptor Blockers (ARBs) of irbesartan and candesartan had been evaluated with I-PRESERVE (n = 4,133) and CHARM-Preserved (n = 3,023) trials, which had been unfortunately failed in establishing desirable evidence of ARB on HFpEF patients. While the mean age of HFpEF patients reported from a large size of observational study of the heart failure component of Get with the Guideline (GWTG-HF) registry (n = 18,299, between 2005 and 2009) was as high as 82 years, the candidate ages of I-PRESERVE (mean of 72 years, age â&#x2030;Ľ 75 years was 34 per cent) and CHARM-Preserved (mean of 67

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years, age â&#x2030;Ľ 75 years was 27 per cent) were quite different. Considering these discrepancies, we should reassume the pathophysiology and treatment strategy for HFpEF patients based on real-world data.

As described above, the prognostic importance of RV-PA coupling for HFpEF patients had been established, however, the prognostic importance of TAPSE/PASP < 0.36 mm/mmHg was

From our multi-centre prospective observational study, we examined the prognostic importance of TAPSE/PASP ratio among 655 hospitalised HFpEF patients. The median age was as high as 83 years, which was comparable to the patient characteristics of the large cohort of GWTG-HF registry. We should state the patient characteristics of this cohort that 56 per cent were females, median body mass index was as small as 21.2 kg/ m2, atrial fibrillation coexisted as much as 40 per cent, and the median NT-proBNP level was 1,080 pg/mL. The median value of TAPSE/PASP at discharge was as high as 0.54 mm/mmHg, and the ideal cutoff value of predicting adverse

Fig 2. RV-PA uncoupling reflected with echocardiographic TAPSE/PASP was associated with adverse outcomes among HFpEF patients.

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DIAGNOSTICS

from the left side of the heart, our findings suggested that RV-PA uncoupling, deeply related to the right side of the heart, observed in echocardiography had a crucial prognostic meaning even among elderly multiple comorbid HFpEF patients.

Suggestions for future HFpEF treatment

Fig 2. HFpEF, heart failure with preserved ejection fraction; PASP, pulmonary artery systolic pressure; RV-PA uncoupling, right ventricular-pulmonary arterial uncoupling; TAPSE, tricuspid annular plane systolic excursion

cohort. There must be racial differences between Asians and Westerners which made the different meanings of TAPSE/ PASP ratio, however, the evidence derived from our registry should reflect the precise characteristics of the realworld HFpEF patients.

Although major pathophysiology among HF and the definition of the ejection fraction as HFpEF are derived AUTHOR BIO

outcomes, defined as a composite of all-cause death, HF re-admission, or cerebrovascular events, was also as high as 0.48 mm/mmHg (area under the curve of receiver operating curve analysis = 0.59, P< 0.0001).

Kaplan Meier curve analyses showed that TAPSE/PASP < 0.48 mm/ mmHg was sufficient to predict the poor outcome (Log-rank P< 0.0001 for composite endpoint), and multivariable Cox regression testing revealed that TAPSE/PASP <0.48 mm/mmHg was significantly associated with the composite endpoint independently from multiple covariates including age, female sex, atrial fibrillation, renal dysfunction, and NT-proBNP elevation (hazard ratio = 1.77, 95 per cent confidence interval; 1.34-2.32, P< 0.0001). As a matter of course, a lower generally accepted threshold of TAPSE/PASP< 0.36 mm/ mmHg was also able to predict the poor outcome; a higher threshold of 0.48 mm/mmHg was proved to be sufficient for the prognostic prediction in this

Findings from the PURSUIT-HFpEF registry suggest the necessity of a treatment strategy for HFpEF patients based on RV function and pulmonary circulation. For instance, the short term beneficial effects of -adrenergic agonists for HFpEF have been considered from such a viewpoint. Andersen et al. reported that dobutamine infusion caused greater pulmonary vasodilatation with enhanced reductions in PA resistance, greater increase in PA compliance, and a more negative slope in the PA pressureflow relationship in a prospective trial in HFpEF patients. Following this study, in a randomised, double-blind, placebocontrolled trial for HFpEF patients, Reddy et al. described the beneficial effects of an inhaled -adrenergic stimulant that improved the primary endpoint of exercise pulmonary vascular resistance. Both trials showed that beneficial effects on acute improvement were achieved with the improvement of RV-PA uncoupling with -adrenergic stimulation.

The abilities of these and other potential therapeutic agents for HFpEF patients to improve RV-PA uncoupling, and ultimately the prognosis are needed to be explored in further investigations.

References are available at www.asianhhm.com Akito Nakagawa graduated from Kobe University School of Medicine (Japan) and completed his PhD from Osaka University Graduate School of Medicine (Japan). He is a general cardiologist of a private hospital in Japan, having concurrent research post at the department of Medical Informatics, Osaka University Graduate School of Medicine (Japan).

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BUILDING RESILIENT AND SECURE INFRASTRUCTURE FOR HEALTHCARE’S DIGITAL FUTURE Powering the Internet of Healthcare with resilient, secure infrastructure, COVID-19 has demonstrated how emerging technologies, such the cloud, IoT and automation, can actively improve patient care outcomes and streamline hospital operations. Coupled with increasing connectivity and smartphone adoption across Asia, medical care is also expected to become more accessible and personalised.

As healthcare institutions embark on their digitalisation journey to meet and balance the region’s growing needs, how can we ensure that our infrastructure sets up our adoption of these emerging technologies for success?

Richard Farrell, Director, Cloud & Data Centre Segment, Electrical Sector, APAC, Eaton

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here’s no denying that Asia-Pacific (APAC) is the centre of growth when it comes to digital healthcare adoption.

Amidst a global decline in non-coronavirus care expenditure, Asia has been the only region to see an increase in healthcare spending in

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2020, thanks to consistent economic performance. Healthcare Information Technology (IT) spending is a particular area of focus with an estimated compound annual growth rate of 7 per cent between 2019 and 2022, driven by investments in software and IT services.

These investments in digital technologies complement the continued rise in smartphone penetration and connectivity across APAC, which is improving the accessibility and personalisation of healthcare delivery to the region’s 4.3 billion population. Telehealth services for instance have grown significantly, surging in use over the past year as demand for medical care swelled.

Many of these digital products and services have demonstrated valuable contributions to the improvement of patient care outcomes and hospital operations, both in the battle against COVID-19 and beyond. In fact, healthcare organisations have barely scratched the surface when it comes to leveraging these new technologies.

However, their success hinges on the industry’s embrace and mastery of technologies like the cloud and the Internet of Things (IoT), which are providing medical professionals and hospital administrators realtime visibility into different systems and applications in order to manage resources better.

As the industry embarks on its transformation journey, organisations must ensure that their infrastructure investments set their digitalisation initiatives up for success.

The expanding Internet of Medical Things (IoMT)

It is essential to first recognise that a modern healthcare institution will

be one that is built on a network of connected devices which function like a nervous system — collecting, processing and transmitting data vital to everyday operations. A hospital’s efficiency, like any modern data-driven organisation, will be increasingly judged based on its ability to share timely information with the parties that need it most, while ensuring that this data is kept securely.

Beyond transmitting data, these connected devices will also control some of the most critical core systems needed for operations to run smoothly.

Essential components of any hospital, clinic or research centre such as heating, ventilation and air conditioning (HVAC) systems rely on this connectivity to enable uninterrupted diagnostic procedures and patient care, while helping to keep costs down.

The impact of this connectivity extends far beyond the four walls of the hospital. Many of such devices connect and exchange data on cloud platforms for patients, medical teams and hospital staff to access at their convenience.

For instance, fitness trackers, connected implants and mobile apps are empowering users to manage their long-term health from the comfort of their own homes. Increased access to these digital tools give people greater incentive to take ownership of their health, and allow clinicians to deliver more effective treatments, remotely and in-person, that are backed by richer, more accurate data.

Empowering patients through connected, self-service technologies like these will be important to relieve the growing pressure on Asia’s healthcare systems as the region’s population ages and the prevalence of chronic diseases rises.

Ensuring secure and always-on healthcare with edge computing

For medical professionals to make sense of all the data being generated and collected, healthcare organisations need to have the right tools in place in order to process and analyse information in real time, and extract valuable insights. In many instances, transmitting and handling such large amounts of data on aging network infrastructure has resulted in bandwidth and latency issues.This can have serious consequences if more medical services are expected to be delivered virtually.

To address some of these challenges, the healthcare sector has started to explore the potential of edge computing over the past couple of years. Edge computing brings data processing closer to where data is being gathered, using a wider network of smaller “micro” data centres and reducing the reliance on a centralised data centre facility.

This is especially useful in scenarios where delays in processing cannot be afforded or connectivity is poor, and is likely to dramatically improve healthcare access for communities living in remote areas or elderly patients living alone. Wearables, bandwidthintensive video streaming and other monitoring devices can be deployed more efficiently to provide insights, detect falls or changes in behaviour, and raise alarms, ultimately ensuring that more patients can be cared for effectively round the clock.

Another key advantage of processing data at the edge is its security and reliability. Healthcare institutions no longer need to depend solely on third-party cloud service providers or networks to relay data, and the impacts of power outages or

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network downtime from cyber threats can be minimised. Combining these benefits with the speed and latency of other emerging technologies like 5G can have an amplifier effect on the potential applications of advanced solutions such as remote surgery or the use of autonomous vehicles for emergency response.

The move towards a more distributed edge computing environment is only possible if healthcare institutions have the right power management infrastructure to keep these IoT networks up and running. Infrastructure managers in healthcare organisations will need to pay attention to a range of threats - from environmental risks to power anomalies beyond the hospital compound, to keep mission-critical applications and devices running longer, and protect servers from sudden, unexpected data loss in the field.

To this end, having a reliable critical backup power solution combined with an electrical power monitoring software platform will enable infrastructure managers to predict and manage any power related incident before they happen. This also allows for patient data to be available on-demand even when connectivity disruptions or power outages occur.

Defending digital healthcare assets against cyberattacks

The proliferation of connected devices and networks need to be supported by a rigorous approach to cybersecurity.

IoT networks have become popular attack vectors for many cybercriminals due to the sheer number of potentially unsecured devices that offer multiple entry points to an organisation’s more sensitive corporate networks. Hospitals and medical institutions themselves are increasingly popular targets of cyberattacks as well, for reasons ranging from the theft of personal medical information to intentional disruption of a city’s critical infrastructure.

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Healthcare Information Technology (IT) spending is a particular area of focus with an estimated compound annual growth rate of 7 per cent between 2019 and 2022, driven by investments in software and IT services.

Beyond the loss of information, cyberattacks can cripple hospital operations and adversely impact lives.

Last year, Brno University Hospital (one of the Czech Republic's biggest COVID-19 testing laboratories) was shut down for hours due to an attack; while in Thailand, ransomware attacks hit public hospitals and companies, slowing down operations by blocking access to their own data.

Cyberattacks have become a matter of when, not if. However, if appropriate steps are taken to plug the necessary gaps, the transformative impacts of these new technologies will far outweigh any potential risks.

To mitigate these security issues, infrastructure managers should ensure that their organisation’s infrastructure is regularly updated and patched.

A thorough assessment of existing infrastructure should also be carried out before introducing any new system or tool, in order to get a more accurate understanding of each organisation’s existing cybersecurity risks. One often overlooked area is the operational technology (OT) environment, which includes systems and devices such as power, cooling and building

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management systems that form part of the physical infrastructure. When performing cybersecurity audits, healthcare organisations should take into account both IT and OT environments to ensure that they have a comprehensive picture of potential vulnerabilities that they might be exposed to.

When it comes to deploying new solutions, infrastructure managers should work with technology partners to implement systems and tools that comply with international and thirdparty certifications and standards managed by established organisations such as UL or the International Electrotechnical Commission. IoT and connected devices should also always be manufactured with a “secure by design” approach to aid infrastructure owners in their management of cybersecurity risks throughout the product’s lifecycle.

Managing and securing power in an increasingly complex and volatile future

In recent months, many of these transformation and digitalisation initiatives have been accelerated by COVID-19. Healthcare institutions have gone to great lengths to leverage technology as a means of reducing in-person contact and exposure to the virus. Siriraj Hospital in Bangkok, for instance, has begun trialing unmanned vehicles for the contactless delivery of medicines and supplies, while Singapore’s National University Health System has begun using robots and drones for building maintenance and security.

Many of these connected tools and systems will also be used to support mass COVID-19 vaccination rollouts across the world this year. Technologies such as smart RFID tags will be used to track shipments and inventory, while an array of sensors are likely to be deployed to monitor temperature, humidity and light fluctuations,

INFORMATION TECHNOLOGY

Powering our smart hospital ambitions

Moving to the edge, cybersecurity and having a back-up power strategy are just three of the first major steps towards the adoption of digital initiatives. As with any new systems, hospitals will need to apply the people, process and technology framework, in order to ensure that these new investments are well supported and positioned for success.

Many experts still recognise that getting the â&#x20AC;&#x2DC;peopleâ&#x20AC;&#x2122; aspect right is often the most important determinant

AUTHOR BIO

to ensure that the complex storage requirements of these vaccines are met.

All this information will need to be shared between hospitals, clinics and health authorities in real-time as stock data and distribution streams are optimised and synchronised at a city or even national level. Given the complexity of this endeavour, a loss of power at any stage in the highly-data dependent distribution stream would be a major setback in the fight against the disease.

Pandemic activities aside, many of the modern digital systems hospitals have come to rely on would grind to a halt without a proper power back-up strategy. The reach of these systems spans from hospital administration to patient care and research. As hospitalsâ&#x20AC;&#x2122; reliance on digital infrastructure and power consumption grow, generators and other traditional back-up solutions will no longer be sufficient to meet this growing energy appetite.

Energy costs are skyrocketing and hospitals today are already using more than twice the amount of power compared to other public buildings.

Furthermore, adverse climate events from wildfires to flooding are occurring in greater frequency and intensity.

Healthcare organisations will need to have the right power management tools that not only protect hospitals from wider grid disruptions, but can also be scalable to support an upsurge in patients that typically follows such incidents.

A new generation of back-up strategies are emerging to address this challenge, from the use of microgrids, to lithium-ion batteries and Uninterruptible Power Supply solutions. These solutions often utilise IoT and the cloud tools themselves to provide intelligent 24/7 monitoring.

When paired with predictive analytics tools, such critical power solutions can provide constant power even under the most adverse environmental power conditions.

factor of success when it comes to issues like cybersecurity or digitalisation.

This shift towards the cloud and IoT will need to be accompanied by well-planned training, resources, and strategic collaboration to unlock their full value, safely.

In these challenging times, the role of the hospitals as critical infrastructure nodes for communities cannot be overstated. Making the right strategic investments today will go a long way to ensure their resilience amidst the uncertainty in the years ahead.

Rich is a technology evangelist, strategist & consultant with over 20 years of experience in the IT, Data Centre, and Hyperscale Cloud space. In his current role at Eaton, he collaborates with customers across the Asia-Pacific region to shape their cloud strategy and advises on data centre build best practice and industry innovations.

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Removing Frictions through Healthcare Digitalisation India has a great potential to emerge as a digital health leader post COVID-19. This article discusses the opportunities of empowering Indiaâ&#x20AC;&#x2122;s healthcare workforce with the right technologies in both clinical practice and research to accelerate healthcare digitalisation.

Jan Herzhoff, President, Global Health Markets, Elsevier

translational research. India aims to accelerate innovation and ideas from across the world to rapidly customise and build a sustainable healthcare ecosystem with comprehensive healthcare framework, institutions, and policies. With the successful launch of the National Digital Health Mission (NDHM) in August 2020, India has already laid the foundation for a digital health ecosystem.

The COVID-19 pandemic exposed several healthcare challenges on this journey, such as information asymmetry between the doctor and the patient, high variability of healthcare expenditures, and inconsistent access to healthcare services across regions.

It has now become a core priority for nations to address these healthcare challenges to mitigate both the social impact as well as the economic consequences following the pandemic.

Standardising the quality of healthcare with knowledgeempowered technology

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t has been a year since the COVID-19 pandemic started.

India faced exceptional challenges â&#x20AC;&#x201C; the healthcare system has been stress tested by the high patient volumes and the infrastructural inefficiencies.

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More importantly, it has brought about a transformation in healthcare delivery via the power of digital health technologies to address these gaps.

Digital health is key for clinical practice, medical education, and

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The healthcare industry is largely built on knowledge. Transforming the delivery of knowledge through digitalisation is key to truly enhancing the healthcare system of a country. The launch of the NDHM has ushered in a new era of technology-enabled healthcare delivery. Digital solutions are now used for proactive health screening and telemedicine, which has been integrated with statewide health

INFORMATION TECHNOLOGY

Investing in research and knowledge infrastructure

Globally, the conventional view of strengthening healthcare infrastructure by governments has been investment in medical devices, supplies, infrastructure, and manpower. However, this pandemic has highlighted other gaps such as the availability of latest knowledge as a key missing link needed to cope with an unfamiliar crisis. Over the past six months, Elsevier has seen over 130 million downloads of COVID19 related research articles on its ScienceDirect platform, highlighting the demand for current and credible information needed to guide clinical decisions across the world.

The increased speed in diffusion of knowledge raises important questions

around quality of healthcare knowledge. What we can do now is to ensure that the content shared amongst the healthcare community is from credible and authoritative sources.

The winning combination would be to integrate digital infrastructure that equips the healthcare workforce with latest evidence-based knowledge to manage the crisis on the frontlines.

Elsevier is supporting numerous hospital systems across the globe with the integration into clinician workflows. It is critical for India to urgently invest in upgrading their research and knowledge infrastructure on the back of the digital health transformation journey.

Creating a digitally empowered healthcare workforce

While digital health transformation is underpinned by digital tools, we must not neglect the users of these tools – the healthcare workers. For digitalisation to effect a positive change in the lives of healthcare workers and their patients, we need to align their needs with the adoption of digital technologies. We can begin by removing frictions and making it as easy as possible for healthcare workers to do their job. Design thinking plays a very important role here and it needs to match what we know from high-end consumer products.

Digital workflows need to be instilled at the start of the medical or nursing professional journey, where students are getting familiar with these tools and are developing important critical thinking and communication skills. This will

AUTHOR BIO

and wellness centres. By empowering these digital solutions with knowledgeenabled technology, it will augment India’s existing public health ecosystem for all citizens across the nation to gain greater access to timely and affordable medical attention.

Delivering standardised healthcare should be supported by clinical decision support systems. By combining technology with most current, authoritative, and comprehensive clinical knowledge base, we can overcome information asymmetry and enhance access to quality care even in the most remote corners of the world. We have seen a major boost in the effectiveness of frontline health workers when they are empowered with clinical decision support systems. For example, Elsevier is currently running a NITI approved primary screening pilot in the Bahreidge district of Uttar Pradesh, using the Clinical Decision support solution to enable frontline maternal and paediatric healthcare workers (ASHA) to conduct primary health screening, provide required advice and create referrals for specialist consultations.

empower frontline healthcare workers with personalised content; reduce unnecessary testing and overuse of medicines; and improve health outcomes by standardising care.

Elsevier’s learning platforms have seen a 35-times increase in usage compared to pre-pandemic.

In particular, skills, simulation and 3D/AR capabilities are in high demand to ensure high engagement during the learning journey. In addition, Elsevier continues to make all COVID-19 articles and research tools freely available within the Novel Coronavirus Information Center and COVID-19 Healthcare Hub for frontline workers worldwide. Digital simulation tools have also been implemented to prepare nursing and medical students for early integration into the workforce, and point-of-care tools have been introduced to support decision making.

Conclusion

India has a great potential to emerge as a digital health leader post COVID-19. There is tremendous opportunity to empower a healthcare workforce when they are adequately supported and enabled with the right technologies in both clinical practice and research. Integrating technology and knowledge will create a strong and efficient healthcare backbone that will support India become Atmanirbhar (self-reliant) in the healthcare space.

This needs to begin at medical and nursing schools where we build an optimised digital health ecosystem from the very beginning for seamless integration into the workforce.

Jan Herzhoff is the President of Global Health Markets at Elsevier and is responsible for Health Education and Clinical Solutions segments globally. Jan has a solid track record in strategic business planning and extensive experience across sales, marketing, product development and customer engagement.

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Geriatric Smart Home Technology Implementation Are we really there?

Deployment of Smart Home Technologies (SHT) will in the coming decade, cause a paradigm shift particularly in delivery of geriatric rehabiliation. This article will critically review the practical utility of SHT from a clinician's perspective.. Translating technical computational theoretical conceptual success to meaningful clinical impact is another story.

Understanding behaviour modification and culturally sensitive technology acceptance is often forgotten by top class enthusiastic passionate technologists and computer geeks . A thorough and systematic evaluation from the beneficiaryâ&#x20AC;&#x2122;s perspective is required from a tech savy amicus curae, prior to integration in clinical care. Like other disruptive technologies in the past, the potential of SHT for causing a great impact should not be underestimated K Ganapathy, Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services

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eployment of Smart Home Technologies (SHT) for remote healthcare is already causing a paradigm shift. However, achieving technical success is not the same as demonstrating a clinical difference in healthcare outcomes. Technology acceptance from the beneficiaryâ&#x20AC;&#x2122;s perspective is essential. SHT connotes

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“ If I had known I was going to live this long, I would have taken better care of myself.”

- Mae West

excitement often accompanied with hype and unbelievable expectations. Like other disruptive technologies, the potential of SHT to cause a great impact should not be underestimated. Evidence-based, thorough, and systematic evaluation is required.

Geriatric Landscape

Though India-centric, this introduction could be extrapolated to many other countries. The traditional joint family ecosystem prevalent in India for centuries is slowly disintegrating, exposing the vulnerability of elders. The author and his family were looking after their parents even when the latter were 84 and 94 years of age. Four generations living under one roof, in the authors’ opinion, was a win-win situation for everyone. There was an excellent quality of life for all. No one felt the absence of smart homes and even the necessity for ‘rehabilitation’. However, the world today is totally different. A report by the Confederation of Indian Industries (CII) suggested that India’s elderly population will grow to 158 million by 2025. By the end of the century, seniors would constitute 34 per cent of the total population. With investment from private sector entities, the senior care segment could emerge as a sunrise industry. India has around 100 million elderly at present.

This may increase to 323 million by 2050, constituting 20 per cent of the population.. As of 2017, 92.4 per cent of the elderly in India was physically mobile, implying that they could manage most of their day-to-day responsibilities. only 5.5 per cent were confined to their homes. Money is not the only concern for India’s elderly. A survey by HelpAge India estimates that 6 per cent of senior citizens in India live alone. Loneliness is a problem that cuts across classes and is a

challenge in cities as well. 10-20 per cent of senior citizens in India are probably suffering from loneliness, a condition likely to be exacerbated by the current curbs on movement and contact due to the pandemic Technology-enabled Geriatric Rehabilitation

Assistive robots have been used to power wheelchairs, prosthetic limb controls and home automation systems. Technology readiness for smart homes and home health-monitoring technologies is evolving. Placement in a care facility, especially against an individual’s wishes, has been associated with depression, social isolation and greater dependency in completion of self-care tasks. Older adults (almost 85 per cent) prefer to obtain care in their homes rather than a healthcare institu-

tion. Elderly, handicapped patients and those with locomotion difficulties particularly when living alone can benefit from smart homes. Costs for elderly care in smart homes range from US$ 900 to over US$ 5,000 per month. With increasing use costs will come down. Initial studies indicate that staying at home-or ageing in place, as it is called—results in better health outcomes than moving to a care facility, especially when cognition and depression is the problem.

Technology Acceptance by senior citizens

The technology acceptance model (TAM) is an information systems theory that models how users accept and use a technology. The actual system use is the end-point where people use the technology. Behavioural intention is a factor that leads people to use the technology. This is influenced by attitude, which is the general impression of the technology. When users are presented with a new technology, several factors influence their decision about how and when, they will use it. These include

“Smart is not just a word; it is an attitude.”

- Ogwo David Emenik

Author with smart mirrors @ Smart health expo Taipei 2019

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Perceived Usefulness (PU) or “the degree to which a person believes that using a particular aid would enhance his/her efficiency”. Perceived ease-of-use (PEOU) is "the degree to which a person believes that using a particular system would be free from effort”. If the technology is easy to use, then it gets widely accepted.

Perceptions are individualistic, depending on age, gender, circumstances, and time to device use. People over 65 generally use fewer new technologies—including the Internet, smartphones, and other digital devices—and use them less frequently than younger people. Older, less educated, and less affluent people, as well as people with disabilities, appear to use them even less often.

allow individuals with mild impairments to be independent for longer periods.

Smart homes increase domestic comfort, convenience, security and leisure, reducing energy use through optimised home energy management. Cost-effective automation, physical and psychological support promote independence.

Acceptance is a key issue. Numerous initiatives worldwide have been developed to explore the use of motion sensors, radio frequency sensors, video cameras, wearable devices and other applications that target older adults. Majority of identified projects include technologies for functional monitoring (such as bed sensors, activity/motion sensors, and gait monitors).

Introduction to Smart Homes

Robots for Geriatric Rehabilitation

A smart home is a convenient home setup where appliances and devices can be automatically controlled remotely with an internet connection, using a smart phone or other networked device. Smart home technology for the elderly needs to specifically cover safety, health, physical activity, social engagement and leisure.

Smart locks, smart lighting, apps and gadgets for entertainment and communication, motion sensors and alerts, audioenabled devices, medication reminders and other technology-enabled wellness tools form a smart home. Smart locks can be programmed to grant access only to authorised personnel. Door cameras and smart locks can be customised to

A robot is an autonomous machine capable of sensing its environment, carrying out computations to make decisions and performing actions in the real world.

Many are complicated, from an engineering and a usability point of view. If unpredicted conditions occur the robot cannot adapt as most cannot think for themselves. Telepresence robots are used to consult with patients and for patients to connect with remote family members.

Robot pets have the potential to address loneliness and improve cognition in the elderly. A cuddly seal, one of the first therapeutic interactive pets, originally selling for about US$5,000, is intended for use in elder-care facilities.

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Humanoid and pet robots, such as NAO and PARO, produce improvements in cognition. Exploding elderly populations of affluent countries is resulting in increasing numbers of agerelated cognitive decline. Deep Learning and related technologies are positively impacting robot cognitive training for those experiencing age-related cognitive decline. Human robot interaction with highly patient-centred cognitive training will play an important role.

Robots are increasingly being used in neuro-rehabilitation. These devices can assist in practicing upper or lower limb movements and motor relearning, and in developing proprioception, cognitive functions and attention. The emphasis is on high repetition, interactive and personalised therapy. Most of the devices make it possible to exercise in a virtual environment. It is easier to introduce virtual reality than practicing in a real environment. AI in robots should give further options. Robots are not simply supplementary therapists reducing human efforts when executing dull and exhausting exercises Sexbots are a delicate subject to discuss. There are many moral and ethical concerns regarding these machines, especially as robots become smarter.

Nevertheless, within the rehabilitation patient population, there are many people who have limited abilities and limited opportunities to fulfil their sexual needs.

For this group, sexbots have potential to significantly improve quality of life and overall happiness. In the past few years, sexbots have become more sophisticated. Roxxxy was introduced in 2010 for approximately US$5,000 and featured a variety of options. Harmony became available in 2017 for approximately US$12,000 and has some limited conversational abilities.

Smart Toilets

Smart toilets are likely to play an increasingly important role in smart homes.

Sugar levels in urine, body weight, temperature and hormone levels are

INFORMATION TECHNOLOGY

Smart Mirrors

Mirrors are an integral part of our daily life. The ability to display information makes a mirror “smart”. Smart mirror technology is now being used to predict and to monitor aspects of health and disease. A combination of intelligent hardware and software could identify subtle, yet clinically relevant changes in physique and appearance. A smart mirror could record and evaluate body position and motion to identify posture and movement issues, and offer feedback for corrective actions. These devices embed multimodal sensors — multiple cameras, motion detection, lasers, microphones, speakers — as well as software based on artificial intelligence (AI). This ensures communication with multiple sources of data, linking them to other smart products and the cloud. This enables non-invasive unobtrusive physiological measurements, creating interactive capabilities based on tracking and recognising gestures. Cameras embedded in the bathroom mirror or elsewhere in the home could help to more passively predict health issues before they manifest Smart Homes and Geriatric Rehabilitation: A peep into the future Smart cities have a proliferation of different types of sensors spread across with high bandwidth communication infrastructures, providing unlimited network connectivity. Smart cities infrastructure is being leveraged to provide a smart healthcare system. In the future Smart Homes will talk to the smart city's infrastructure to provide

contextualised health related recommendations and suggestions. This will involve use of computer vision, natural language processing, speech recognition, network planning, machine learning and data science. Smart Homes presuppose interoperability among the world’s leading vendors. Amazon, Apple, and Google have agreed to create an opensource standard for internet-connected home products, such as smart speakers.

They will work with Zigbee Alliance, an association of companies working on open IoT standards, plus Samsung, Ikea, and other major players in the sector.

The companies have set up a working group, called project “Connected Home over IP" (or CHIP), which will meet, discuss, and hopefully agree on a set of standards. If adopted by all the major players, this standard could kick start adoption of smart home technology. An open ecosystem, better security standards, and the rollout of 5G could be a winning combination to push smart homes into the mainstream . Maintaining mobility is fundamental to independent living and quality of life of older people. Assisted technology in geriatric care and rehabilitation will include use of robots and telehealth. The “new aged” will have more purchasing power and higher levels of familiarity with technology. Expectations will be higher. Being more fit, active, mobile, safe, connected, independent and self-reliant with an excellent quality of life will be the new mantra. Avoiding ‘getting old’ would even be regarded as an

AUTHOR BIO

detected and data transmitted automatically to computers and doctors.

Changes in urine flow could indicate a prostate or bladder problem. A toilet seat developed by Rochester Institute of Technology had sensors to measure blood oxygenation levels, heart rate, and blood pressure Automated analysis of human feces could be beneficial detecting markers of various diseases. The toilet also can measure number of white blood cells and types of protein in urine..

option. Geography independent, access to cost effective mobile broadband services will be deemed a constitutional right. A rapidly emerging ‘smart homes’ movement could occur worldwide. Establishing the validity, efficacy, practicality and cost of smart homes technologies and proof that it does indeed make a difference will be required Conclusions

Popularity of smart homes hinges on understanding who will use it and how it will help them. Technology should be viewed as a tool to achieve an end not an end by itself. As a septuagenarian belonging to the BC (Before Computers not Before Covid-19!) era the author though a technology buff is able to understand the necessity for getting into the minds of the end user. “Customer delight” is not just a cliché used as marketing ploy.

The solution should not go in search of a problem, we need to develop tools to address specific problems never forgetting that the world has turned upside down and that the present day octogenarians have come from another planet!

K Ganapathy, Former Secretary and Past President Neurological Society of India, Telemedicine Society of India & Indian Society for Stereotactic & Functional Neurosurgery. Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services. Emeritus Professor Tamil Nadu Dr. MGR Medical University. Member Roster of experts Digital Health WHO www.kganapathy.com drganapathy@apollohospitals.com

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BOOKS

Artificial Intelligence for the Internet of Health Things

How to Make a Vaccine: An Essential Guide for COVID-19 and Beyond

Author(s): K Shankar, Eswaran Perumal, Deepak Gupta

Author: John Rhodes

No of Pages: 224 Year of Publishing: 2021 Description: This book discusses research of Artificial Intelligence for the Internet of Health Things. It investigates and explores the possible applications of machine learning, deep learning, soft computing and evolutionary computing techniques in design, implementation, and optimization of challenging healthcare solutions.

Featuring a wide range of topics such as AI techniques, IoT, cloud, wearables, and secured data transmission. Written for a broad audience, this book will be useful for clinicians, health professionals, engineers, technology developers, IT consultants, researchers, and students interested in the AI based healthcare applications.

No of Pages: 184

The Psychology of Covid-19: Building Resilience for Future Pandemics (SAGE Swifts)

Year of Publishing: 2021

Author: Joel Vos

Description: Concise and accessible, this book describes in everyday language how the immune system evolved to combat infection, how viruses responded by evolving ways to evade our defenses, and how vaccines do their work.

That history, and the pace of current research developments, make Rhodes hopeful that multiple vaccines will protect us. Today the complex workings of the immune system are well understood. The tools needed by biomedical scientists stand ready to be used, and more than 160 vaccine candidates have already been produced. But defeating COVID-19 won't be the end of the story: Rhodes describes how discoveries today are also empowering scientists to combat future threats to global health, including a recent breakthrough in the development of genetic vaccines, which have never before been used in humans.

No of Pages: 192

As the world prepares for a vaccine, Rhodes offers a current and informative look at the science and strategies that deliver solutions to the crisis.

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Year of Publishing: 2021 Description: he Psychology of Covid-19 explores how the coronavirus pandemic is giving rise to a new order in our personal lives, societies, and politics. Rooted in systematic research on Covid-19 and previous pandemics, this book describes how people perceive and respond to Covid-19, and how it has impacted a broad range of domains, including lifestyle, politics, science, mental health, media, and meaning in life. Building on this, the book then sets out how we can improve our psychological and social resilience, to safeguard ourselves against the psychological effects of future pandemics.

RESEARCH INSIGHTS Polygenic risk scores in cardiovascular risk prediction: A cohort study and modelling analyses Luanluan Sun, Lisa Pennells, Stephen Kaptoge, Christopher P. Nelson,Scott C. Ritchie, Gad Abraham, Matthew Arnold, Steven Bell,Thomas Bolton, Stephen Burgess, Frank Dudbridge, Qi Guo,Eleni Sofianopoulou, David Stevens, John R. Thompson, Adam S. Butterworth, Angela Wood, John Danesh, Nilesh J. Samani, Michael Inouye, Emanuele Di Angelantonio Published: January 14, 2021

Background

Polygenic risk scores (PRSs) can stratify populations into cardiovascular disease (CVD) risk groups. We aimed to quantify the potential advantage of adding information on PRSs to conventional risk factors in the primary prevention of CVD.

Methods and findings

Using data from UK Biobank on 306,654 individuals without a history of CVD and not on lipid-lowering treatments (mean age [SD]: 56.0 [8.0] years; females: 57%; median follow-up: 8.1 years), we calculated measures of risk discrimination and reclassification upon addition of PRSs to risk factors in a conventional risk prediction model (i.e., age, sex, systolic blood pressure, smoking status, history of diabetes, and total and high-density lipoprotein cholesterol). We then modelled the implications of initiating guidelinerecommended statin therapy in a primary care setting using incidence rates from 2.1 million individuals from the Clinical Practice Research Datalink. The C-index, a measure of risk discrimination, was 0.710 (95% CI 0.703–0.717) for a CVD prediction model containing conventional risk predictors alone. Addition of information on PRSs increased the C-index by 0.012 (95% CI 0.009–0.015), and resulted in continuous net reclassification improvements of about 10% and 12% in cases and non-cases, respectively. If a PRS were assessed in the entire UK primary care population aged 40–75 years, assuming that statin therapy would be initiated in accordance with the UK National Institute for Health and Care Excellence guidelines

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(i.e., for persons with a predicted risk of ≥10% and for those with certain other risk factors, such as diabetes, irrespective of their 10-year predicted risk), then it could help prevent 1 additional CVD event for approximately every 5,750 individuals screened. By contrast, targeted assessment only among people at intermediate (i.e., 5% to <10%) 10-year CVD risk could help prevent 1 additional CVD event for approximately every 340 individuals screened. Such a targeted strategy could help prevent 7% more CVD events than conventional risk prediction alone. Potential gains afforded by assessment of PRSs on top of conventional risk factors would be about 1.5-fold greater than those provided by assessment of C-reactive protein, a plasma biomarker included in some risk prediction guidelines. Potential limitations of this study include its restriction to European ancestry participants and a lack of health economic evaluation.

Conclusions

Our results suggest that addition of PRSs to conventional risk factors can modestly enhance prediction of first-onset CVD and could translate into population health benefits if used at scale.

Author summary Why was this study done?

Application of polygenic risk scores (PRSs) has opened opportunities to enhance risk stratification and prevention for common diseases. The clinical utility of

PRSs in cardiovascular disease (CVD) risk prediction is, however, uncertain.

Previous analyses have generally focused only on coronary heart disease (CHD) rather than the composite outcome of CHD and stroke, and have often lacked modelling of clinical implications of initiating guideline-recommended interventions (e.g., statin therapy).

What did the researchers do and find?

We quantified the incremental predictive gain with PRSs on top of conventional risk factors using data on 306,654 individuals from UK Biobank.

We modelled the population health implications of initiating statin therapy as recommended by current guidelines using data from 2.1 million individuals from the Clinical Practice Research Datalink.

Addition of information on PRSs to a conventional risk prediction model increased the C-index (a measure of risk discrimination) and improved risk classification of cases and non-cases.

We estimated that targeted assessment of PRSs among people at intermediate (i.e., 5% to <10%) 10-year CVD risk could help prevent 1 additional CVD event for approximately every 340 individuals screened, which would be almost 15 times more efficient than blanket assessment of PRS. What do these findings mean?

Addition of PRSs to conventional risk factors provided modest improvement in prediction of first-onset CVD. Nevertheless, these moderate improvements could translate into meaningful clinical benefit if applied at scale, and lead to the prevention of 7% more CVD events than conventional risk factors alone.

Our results also suggest that targeted use of PRSs would be more efficient than blanket population-wide use.

Future studies should seek to evaluate PRSs in non-European ancestry populations, and perform formal health economic evaluations Citation: Sun L, Pennells L, Kaptoge S, Nelson CP, Ritchie SC, Abraham G, et al. (2021) Polygenic risk scores in cardiovascular risk prediction: A cohort study and modelling analyses. PLoS Med 18(1): e1003498. https://doi.org/10.1371/journal.pmed.1003498 Academic Editor: George Hindy, Qatar University, QATAR Received: January 31, 2020; Accepted: December 14, 2020; Published: January 14, 2021

Copyright: Š 2021 Sun et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data files are available from the UK Biobank and CPRD databases.

Funding: This work was supported by core funding from the UK Medical Research Council (MR/L003120/1), the British Heart Foundation (RG/13/13/30194; RG/18/13/33946), and the National Institute for Health Research (NIHR) (Cambridge Biomedical Research Centre at the Cambridge University Hospitals NHS Foundation Trust and NIHR Leicester Biomedical Research Centre). This work was supported by Health Data Research UK, which is funded by the the UK Medical Research Council, the Engineering and Physical Sciences Research Council, the Economic and Social Research Council, the Department of Health and Social Care (England), the Chief Scientist Office of the Scottish Government Health and Social Care Directorates, the Health and Social Care Research and Development Division (Welsh Government), the Public Health Agency (Northern Ireland), the British Heart Foundation, and Wellcome. Luanluan Sun, Lisa Pennells, Stephen Kaptoge, and Matthew Arnold are funded by a British Heart Foundation Programme Grant (RG/18/13/33946). Christopher P. Nelson is funded by a British Heart Foundation Grant (SP/16/4/32697).

Scott Ritchie, Mike Inouye, and Stephen Burgess are funded by the National Institute for Health Research (Cambridge Biomedical Research Centre at the Cambridge University Hospitals NHS Foundation Trust). David Stevens was funded by the National Institute for Health Research (Cambridge Biomedical Research Centre at the Cambridge University Hospitals NHS Foundation Trust). Thomas Bolton is funded by the NIHR Blood and Transplant Research Unit in Donor Health and Genomics (NIHR BTRU-201410024). Steven Bell was funded by the NIHR Blood and Transplant Research Unit in Donor Health and Genomics (NIHR BTRU-2014-10024). Angela Wood is supported by a BHF-Turing Cardiovascular Data Science Award and by the EC-Innovative Medicines Initiative (BigData@Heart). Professor John Danesh holds a British Heart Foundation Professorship and a National Institute for Health Research Senior Investigator Award.

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RESEARCH INSIGHTS Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: SK is funded by grants to institution from: British Heart Foundation, UK Medical Research Council, UK National Institute of Health Research, Cambridge Biomedical Research Centre.

SB is a paid statistical reviewer for PLOS Medicine.

ASB received grants outside of this work from AstraZeneca, Biogen, Bioverativ, Merck, Novartis and Sanofi, as well as personal fees from Novartis. JD serves on the International Cardiovascular and Metabolic Advisory Board for Novartis (since 2010), the Steering Committee of UK Biobank (since 2011), the MRC International Advisory Group (ING) member, London (since 2013), the MRC High Throughput Science ‘Omics Panel Member, London (since 2013), the Scientific Advisory Committee for Sanofi (since 2013), the International Cardiovascular and Metabolism Research and Development Portfolio Committee for Novartis and the Astra Zeneca Genomics Advisory Board (2018).

Abbreviations: CABG, coronary artery bypass grafting; CHD, coronary heart disease; CPRD, Clinical Practice Research Datalink; CRP, C-reactive protein; CVD, cardiovascular disease; GWAS, genome-wide association study; HDL, high-density lipoprotein; HES, Hospital Episode Statistics; LDL, low-density lipoprotein; NRI, net reclassification index; PRS, polygenic risk score; PTCA, percutaneous transluminal coronary angioplasty; UKB, UK Biobank

Methods

Introduction

Advances in the application of polygenic risk scores (PRSs) have opened opportunities to enhance disease risk prediction by stratifying populations into risk groups using information on millions of variants across the genome. The UK government’s Department of Health and Social Care green paper on disease prevention has stated: ‘As the evidence develops, complementing existing risk scores…with this kind of genetic information [i.e., PRSs] will be a priority for the UK healthcare system’. The US Centers for Disease Control and Prevention and the US National Institutes of Health are also considering the value of integrating PRSs into clinical practice.

A key strategy in the primary prevention of cardiovascular disease (CVD) is the use of risk prediction algorithms to target preventive interventions to people who may benefit from them most. These algorithms typically include information on conventional risk factors, including age, sex, smoking history, history

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of diabetes, blood pressure, total cholesterol, and high-density lipoprotein (HDL) cholesterol. The population health utility of PRSs in CVD risk prediction is, however, uncertain. Previous analyses have generally focused only on coronary heart disease (CHD) rather than the composite outcome of CHD and stroke, even though the composite outcome is the focus of most primary prevention guidelines. Furthermore, most previous PRS studies have lacked modelling of the clinical implications of initiating guideline-recommended interventions (e.g., statin therapy)], meaning that it has been difficult to judge the potential clinical gains of assessing PRSs. Our study, therefore, aimed to address 2 questions. First, what is the improvement in CVD risk prediction when PRSs are added to risk factors used in conventional risk algorithms? We analysed 306,654 participants from UK Biobank (UKB) to assess the value of adding PRSs to several conventional risk factors. Second, what is the estimated population health impact of using information on PRSs for CVD prediction? We modelled data from 2.1 million individuals in the Clinical Practice Research Datalink (CPRD) to estimate the benefit of initiating statin therapy as recommended by guidelines. To contextualise our findings, we compared the incremental predictive gains afforded by PRSs with that provided by C-reactive protein (CRP), a plasma biomarker recommended for risk prediction in some CVD primary prevention guidelines.

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Study design and overview Our study involved several interrelated components (Fig 1). First, we constructed separate PRSs for CHD and stroke, using methods previously described.

Second, we calculated measures of risk discrimination and reclassification to quantify the incremental predictive gain with these PRSs on top of conventional risk factors. Third, to estimate the potential for disease prevention in a general population setting, we adapted (i.e., recalibrated) our findings to the context of a primary prevention population eligible for CVD screening, using incidence rates from contemporary computerised records from general practices in the UK. Fourth, we modelled the clinical implications of initiating statin therapy as recommended by current guidelines, comparing a ‘blanket’ approach (i.e., assessment of PRSs in all individuals eligible for CVD primary prevention) with a ‘targeted’ approach (i.e., focusing PRSs assessment only in people judged to

be at intermediate 10-year risk of CVD after initial screening with conventional risk predictors alone). Fifth, to help contextualise the potential population health gains afforded by assessing PRSs, we compared them in the same dataset with gains afforded by assessment of CRP.

Fig 1. Study design and overview.

CHD, coronary heart disease; PRS, polygenic risk score.

Ethics statement This research has been conducted using the UKB resource under application number 26865. The UKB study was approved by the North West Multi-centre Research Ethics Committee, and all participants provided written informed consent to participate in the UKB. This study is based in part on data from the CPRD obtained under licence from the UK Medicines and Healthcare products Regulatory Agency (protocol number 162RMn2). The data are provided by patients and

Fig 2. Adjusted hazard ratios of conventional cardiovascular risk factors and polygenic risk scores for first-onset cardiovascular outcomes.

Hazard ratios (HRs) were estimated using Cox regression, stratified by study centre and sex, and adjusted for age at baseline, smoking status, history of diabetes, systolic blood pressure, total cholesterol, and high-density lipoprotein (HDL) cholesterol levels, where appropriate. For continuous variables, HRs are shown per SD higher of each predictor to facilitate comparison. For categorical variables, HRs are shown for men versus women, for patients with diabetes versus without, and for current smokers versus others.

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RESEARCH INSIGHTS collected by the National Health Service as part of their care and support.ww Data sources UK Biobank prospective study.

Details of the design, methods, and participants of UKB have been described previously. Briefly, participants aged 40 to 75 years identified through primary care lists were recruited across 22 assessment centres throughout the UK between 2006 and 2010. At recruitment, information was collected via a standardised questionnaire and selected physical measurements.

Details of the data used from UKB are provided in S1 Text. Data were subsequently linked to Hospital Episode Statistics (HES), as well as national death and cancer registries. HES uses the International Classification of Diseases (ICD) 9th and 10th revisions to record diagnosis information, and the Office of Population, Censuses and Surveys: Classification of Interventions and Procedures, version 4 (OPCS-4), to code operative procedures. Death registries include deaths in the UK, with both primary and contributory causes of death coded according to ICD-10.

Genotyping was undertaken using a custom-built genome-wide array of approximately 826,000 markers. Imputation to approximately 96 million markers was subsequently carried out using the Haplotype Reference Consortium and UK10K/1000 Genomes reference panels. Clinical biochemistry markers, including total cholesterol, HDL cholesterol, and CRP, were measured at baseline in serum samples. Full details of the biochemistry sampling, handling and quality control protocol, and assay method have been provided previously.

UK Clinical Practice Research Datalink.

To estimate the potential for disease prevention in a general population setting, we used data from the CPRD, a primary care database of anonymised medical records covering over 11.3 million individuals opting into data linkage from 674 general practices in the UK. Individual-level data from consenting practices in the CPRD have been linked to HES and the national death registry. Details of the CPRD data used and endpoint definition are provided in S2 Text. The present analysis involved records of 2.1 million patients, a random sample of all CPRD data, working under the assumption that individuals in this database should be broadly representative of the UK general population.

Statistical analysis

To approximate populations relevant to CVD primary

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prevention, we focused on first-onset CVD outcomes among those with no prior history of CVD and not taking lipid-lowering treatments at recruitment. Analyses were performed according to a pre-specified analysis plan (S1 Analysis Plan) and restricted to participants of self-reported European ancestry, excluding those who (1) had missing genotype array or conventional risk factor information; (2) had a history of CVD at baseline (i.e., CHD, other heart disease, stroke, transient ischaemic attack, peripheral vascular disease, angina, or cardiovascular revascularization); (3) used lipid-lowering treatment at baseline; or (4) were included in the dataset to estimate component score mixing weights during PRS construction (see S1 Fig). The primary outcome was a first-onset CVD event, defined as the composite of CHD (i.e., myocardial infarction or fatal CHD) or any stroke. Secondary outcomes included each of CHD and stroke separately, and a combination of CHD, stroke, and cardiac revascularisation procedures (i.e., percutaneous transluminal coronary angioplasty [PTCA] and coronary artery bypass grafting [CABG]) (S1 Table).

We used separate PRSs for CHD and ischaemic stroke as 2 independent variables to predict the composite CVD outcome. PRSs were previously constructed using a meta-score approach based on external summary statistics from the previous largest genome-wide association studies (GWASs) of CHD and stroke. Detailed information on PRS derivation has been previously provided, and the PRSs are publicly available and annotated at the PGS Catalog (http://www.pgscatalog.org) under accessions PGS000018 and PGS000039, respectively. The PRS for CHD comprised 1,743,979 variants where the mixing weights of component scores were estimated using 3,000 participants in UKB. The PRS for ischaemic stroke included 2,759,740 variants where the mixing weights of component scores were estimated using 12,000 participants in UKB (including the 3,000 participants mentioned above). Participants used in the training dataset were excluded from subsequent analysis. Previous analyses have not found evidence of overfitting, and independent replications have demonstrated consistent effect sizes. The partial Pearson correlation coefficient between the PRS for CHD and the PRS for stroke was 0.32. In sensitivity analyses we (1) replaced the PRS for ischaemic stroke with a PRS for all stroke and (2) used a single PRS for the composite CVD outcome.

HRs were calculated using Cox proportional hazards models, stratified by UKB recruitment centre and sex, and using time since study entry as the

timescale. Outcomes were censored if a participant was lost to follow-up or died from non-CVD causes, or if the end of available follow-up was reached (for England: 31 March 2017; Scotland: 30 October 2016; Wales: 30 May 2016). Predictors were entered as linear terms, after visual checking for log-linearity. No violation of the proportional hazards assumption was identified. Sensitivity analyses included calculation of cumulative incidence of CVD outcomes based on the cause-specific hazards estimated from Cox regression, in the presence of competing risk from non-CVD deaths.

The incremental predictive ability of PRSs for CHD and stroke was assessed upon addition (as 2 separate linear terms) to a model containing age, sex, systolic blood pressure, smoking status, history of diabetes, and total and HDL cholesterol (i.e., conventional risk factors). Risk discrimination was assessed using Harrell’s C-index, stratified by UKB recruitment centre and sex. To avoid overestimation of the model’s ability to predict risk, we applied an internal/external validation approach by validating within a subset (i.e., 1 study centre or a 10% randomly selected population in UKB) the prediction model derived from the remaining datasets. Results were then meta-analysed across all validation subsets, weighted by the number of events in that specific subset. Improvements in risk prediction were also quantified by the net reclassification index (NRI), which summarises appropriate directional change in risk predictions for those who do and do not experience an event during followup (with increases in predicted risk being appropri-

ate for cases and decreases being appropriate for non-cases). Calibration was assessed by comparing the observed and predicted risks across deciles of predicted risk, and by calculating calibration slope, root mean square error, and the Greenwood–Nam– D’Agostino p-value using a 10-fold cross-validation approach to avoid optimism.

To assess the population health relevance of adding PRSs to conventional risk factors, we generalised our reclassification analyses to the context of a UK population eligible for primary prevention screening (S3 Text). Using CPRD data we recalibrated risk prediction models derived in UKB to give 10-year risks that would be expected in such a UK primary care setting, employing methods previously described. (Since 10 years of follow-up was not available for all UKB recruitment centres, we used 9-year risk estimates in reclassification analyses.) Details are provided in S3 Text.

We modelled a population of 100,000 adults aged 40–75 years in the CPRD, with an age and sex profile matching that of the contemporary UK population (2017 mid-year population), and CVD incidence rates as observed in individuals without previous CVD and not taking statins. We assumed an initial policy of statin allocation for people at ≥10% predicted 10-year risk as recommended by National Institute for Health and Care Excellence (NICE) guidelines.

We then modelled additional targeted assessment of PRSs, or CRP, among people at intermediate risk (5% to <10% predicted 10-year risk) to estimate the potential for additional treatment allocation and case

Table 1. Baseline characteristics of UK Biobank participants who had no prior history of vascular disease and were not on lipid-lowering treatment, by sex (n = 306,654).

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RESEARCH INSIGHTS

Fig 3. Incremental predictive ability of polygenic risk scores and C-reactive protein for cardiovascular disease, above conventional risk factors.

Conventional risk factors included age at baseline, sex, smoking status, history of diabetes, systolic blood pressure, total cholesterol, and high-density lipoprotein cholesterol. C-index and related changes were estimated using Cox regression, stratified by study centre and sex, adjusted for age at baseline, smoking status, history of diabetes, systolic blood pressure, total cholesterol, and high-density lipoprotein cholesterol. 95% confidence intervals (CIs) were estimated using the efficient jackknife approach.

prevention, assuming statin allocation would reduce CVD risk by 20%. Details are in S3 Text. Analyses were performed with PLINK 2.0 and Stata version 14, with 2-sided p-values and 95% confidence intervals.

This study follows TRIPOD reporting guidelines (S1 TRIPOD Checklist).

Results Characteristics of the study participants and association with CVD outcomes Of the 502,219 participants initially enrolled in UKB, 306,654 participants met the inclusion criteria for this analysis: self-reported European ancestry, without a history of CVD, not on lipid-lowering treatment, and with complete information on genotype array data and conventional risk predictors (Table 1). During 2.6 million person-years at risk (median [5th, 95th percentile] follow-up of 8.1 [6.8–9.4] years), 5,680 CVD cases were recorded, including 3,333 CHD and 2,347 stroke events. Fig 2 shows the baseline characteristics of participants, as well as HRs for CVD adjusted

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for conventional risk factors. HRs for CHD and stroke outcomes separately and for the composite secondary outcome (including CHD, stroke, PTCA, and CABG) are presented in S2 Fig. Both PRSs showed log-linear associations with CVD outcomes, with HRs of 1.57 (95% CI 1.51–1.62) for CHD and 1.19 (95% CI 1.14–1.24) for stroke, after adjustment for age only (S3 Fig). HRs per 1-SD higher PRS did not materially change after adjustment for conventional risk factors; HRs were similar across people with different levels of risk factors, including family history of CVD (S4 and S5 Figs).

Estimate of the potential for disease prevention In population health modelling, we used age- and sexspecific incidence data from 2.1 million individuals in the CPRD without previous CVD and not taking statins to recalibrate risk models and achieve a predicted risk distribution as would be expected in this primary care population (S3 Text). We translated age- and sex-specific targeted assessment of PRSs to a population of 100,000 adults aged 40–75 years, assuming

Fig 4. Incremental predictive ability of polygenic risk scores (PRSs) for cardiovascular disease (CVD) outcomes, beyond conventional risk predictors, across different baseline population characteristics.

The base model included information on the conventional risk factors, i.e., age at baseline, sex, smoking status, history of diabetes, systolic blood pressure, total cholesterol, and high-density lipoprotein (HDL) cholesterol, with stratification by study centre and sex, where appropriate. The prediction model within each subgroup was constructed using coefficients estimated among the entire population.were estimated using the efficient jackknife approach.

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Table 2. Net reclassification index (NRI) for cardiovascular disease (generalised to a primary prevention population) with addition of information on polygenic risk scores or C-reactive protein, above conventional risk factors.

the age and sex structure of the current UK population, and CVD incidence rates observed in UK primary care. Under this scenario, we estimated that, using conventional risk factors alone, there would be 23,973 individuals classified as having intermediate 10-year (i.e., 5% to <10%) risk who were not already taking or eligible for statin treatment (i.e., people without a history of diabetes or CVD, and with low-density lipoprotein (LDL) cholesterol < 5.0 mmol/l; Fig 5). Additional assessment of PRSs in these individuals (i.e., a ‘targeted’ approach focusing only in people judged to be at intermediate 10-year risk of CVD after initial screening with conventional risk factors alone) would reclassify 3,115 intermediate-risk individuals as highrisk (i.e., ≥10%), of whom approximately 357 would be expected to have a CVD event within 10 years.

This would correspond to an increase of about 7.1% (357/5,054) of the CVD events already classified at high risk using conventional risk predictors alone.

Assuming statin allocation per current guidelines (i.e., those with 10-year CVD risk ≥ 10%) and statin treatment conferring a 20% relative risk reduction, such targeted assessment of PRSs among the intermediate-risk group would help prevent 72 (i.e., 357 × 0.2) events over the next 10-year period. In other words, targeted assessment of PRSs in individuals at intermediate risk for a CVD event could help prevent 1 additional event over 10 years for every 336 people so screened. For comparison, the number needed to screen with targeted assessment of CRP would be 491 (S9 Table). Similar results were observed when analysis involved cutoffs for clinical risk categories defined by other guidelines (S10 Table; S12 Fig).

In contrast with the targeted approach, we also modelled a blanket population-wide strategy of addi-

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tional assessment of PRSs in all adults aged 40–75 years eligible for CVD primary prevention. In this scenario, compared to using conventional risk factors alone, 3,128 individuals would be reclassified from low or intermediate risk (i.e., <10%) to high risk (i.e., ≥10%), and 3,405 individuals would be reclassified from high risk to low or intermediate risk, of whom approximately 358 and 271 would be expected to have a CVD event within 10 years, respectively (S11 Table; S13 Fig), suggesting the need to screen 5,747 people with additional assessment of PRSs to help prevent 1 additional event over 10 years.

Discussion We conducted complementary analyses in UKB, a purpose-designed prospective study of about 500,000 individuals, and the CPRD, a cohort of 2.1 million people derived from an extract of contemporary computerised records from general practices in the UK. Overall, our results suggest that the addition of PRSs to conventional risk factors can provide modest improvement in prediction of first-onset CVD, which, if applied at scale, could help prevent 7% more CVD events than use of conventional risk factors alone. Our results have potential implications for CVD risk prediction and for the evaluation of the potential population health utility of PRSs for disease.

First, our modelling suggests that, if applied to the contemporary UK population aged 40–75 years, additional use of PRSs could help prevent at least several thousand CVD events over the next 10 years beyond assessment of conventional risk factors alone.

Second, our results suggest that targeted use of PRSs would be almost 15 times more efficient than blanket population-wide use. In a modelled

scenario in which PRSs were assessed in a primary care setting only among individuals considered at intermediate CVD risk after initial screening with conventional risk predictors alone, we estimated that such targeted assessment of PRSs could

reclassify approximately 12% of screened individuals to the high-risk category, of whom 11% would be expected to have a CVD event within 10 years. If such a targeted approach were to be coupled with initiation of statin therapy in accordance with guide-

Fig 5. Estimated public health impact with targeted assessment of polygenic risk scores among 100,000 UK adults in a primary care setting. CVD, cardiovascular disease; LDL, low-density lipoprotein; PRS, polygenic risk score

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RESEARCH INSIGHTS lines, our data suggest 1 extra CVD outcome could be prevented over a period of 10 years for approximately every 340 people in whom PRSs are assessed (compared with the need to screen approximately 5,700 people to achieve the same gain when using a blanket screening approach).

Third, as a benchmark, we compared the incremental predictive gains afforded by assessment of PRSs with those provided by CRP measurement (a plasma biomarker recommended for screening in some primary prevention guidelines), with our results demonstrating a >1.5-fold greater gain in predictive accuracy with PRSs than CRP. Fourth, we found that assessment of PRSs could improve prediction of CHD much more than prediction of stroke. Further work is needed to understand fully the reasons for such differential gains, which may relate both to the greater phenotypic heterogeneity of stroke outcomes and the relatively lower statistical power of previous GWASs of stroke compared with CHD [. It is likely that the composite outcome of CVD involves greater phenotypic and genetic heterogeneity than either CHD or stroke alone. Nevertheless, our study used the primary outcome of any first CVD event (defined as fatal or nonfatal CHD or stroke), in keeping with current CVD primary prevention guidelines that promote joint prediction and prevention of CHD and stroke.

Our study had major strengths. In the analysis of UKB, we approximated the targeted population for CVD primary prevention efforts by focusing on >300,000 participants without a history of CVD at baseline who were not taking lipid-lowering treatment.

For these participants, we had access to concomitant and nearly complete information on several conventional CVD risk factors (e.g., lipid measurements) as well as on PRSs. We used multiple complementary metrics of risk discrimination and reclassification, as well as different absolute risk thresholds used in different clinical guidelines. The broadly concordant results we observed across these metrics supported the validity of our main conclusions. To extend the relevance of our findings to a UK primary care population, we also conducted modelling using the UK CPRD, adapting (recalibrating) our findings from UKB to be more representative of the general population.

This adaptation was important because the general UK population has a higher baseline risk for CVD than the volunteers who enrolled in UKB, underscoring the need for recalibration when using established risk thresholds, and before making judgements about the population health utility of PRSs.

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Our study also had limitations. We studied only middle-aged European ancestry participants in the UK, which limits the generalisability of our results.

Hence, we (and others) are now addressing this gap by conducting studies of PRSs for CVD in different ethnic groups, as well as in other countries. Our study also lacked a health economic evaluation, which was beyond the scope of present analysis. We acknowledge the importance of health economic evaluations as part of future considerations to assess the clinical utility of PRSs for CVD prevention, noting that genome-wide array genotyping has a one-time cost (approximately £25 at current prices in the UK) and can be used to calculate PRSs for CVD as well as for many other chronic diseases. In particular, future studies (including health economic evaluations) are needed to evaluate a range of different CVD screening strategies, including a ‘genome first’ approach that inverts the current ‘conventional risk factors first’ approach to CVDs. Our study did not assess potential psychological harms of using genetic information in CVD risk prediction. However, a previous randomised trial has excluded material effects of this type. We used a conventional 10-year timeframe and standard clinical risk categories, acknowledging that reclassification analyses are intrinsically sensitive to choices of follow-up interval and clinical risk categories. Although we used 9-year risk estimates in reclassification analyses because 10 years of follow-up was not available for all UKB recruitment centres, it had minimal influence on our results.

Somewhat greater population health impact than suggested by our analysis would be estimated if we had used less conservative modelling assumptions (e.g., more effective statin regimens, longer time horizons), conventional risk factor weights that were not fitted to UKB, or alternative disease outcomes (e.g., an exclusive focus on CHD).

Conversely, our models could have overestimated the potential benefits of assessing PRSs because not all people eligible for statins will receive them or be willing and able to take them and adherent.

In conclusion, our results suggest that the addition of PRSs to conventional risk factors can modestly enhance the prediction of first-onset CVD and could translate into population health benefits if used at scale.

References are available at https://journals.plos.org/plosmedicine/

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