Asian Healthcare Management - Issue 40

I S S U E 40

2018

w w w.asianhhm.com

PAIN AND THE PATIENT ENVIRONMENT A US PERSPECTIVE

PRIMARY CARE The challenges of a changing world DIGITAL TRANSFORMATION Healthcare in disruptive times

Foreword Pain Management Time to shift gears!

According to the Institute of Medicine of The National Academies, 100 million Americans suffer from chronic pain. Pain is a critical public health issue in the United States costing the society US$560-635 billion, equivalent to $2,000 per individual, every year. However, it is not just an American epidemic; chronic pain affects the lives of 1.5 billion across the world.

effectiveness of non-opioid pain management strategies. This has only resulted in a dilemma for healthcare providers who are expected to relieve suffering in today’s “Fifth Vital Sign” era. Healthcare providers will be continually challenged as chronic pain assessment and treatment becomes an integral part of their approach.

During the early 90s, it was increasingly recognised that patients living through their last days were in agonising pain. Soon after this, the American Pain Society (APS) began a campaign named “Pain, The Fifth Vital Sign,” to increase awareness among health professionals of pain assessment and management. The campaign led to increased pain research, awareness and most importantly focus on pain relief. The campaign was seemingly successful with regulatory bodies such as the Joint Commission declaring pain as the fifth vital sign and it was mandatory for healthcare organisations to assess, monitor and document patient’s pain. On the other side, there has been an unnoticed and unwarranted overreliance on opioids to treat chronic non-malignant pain. This over dependence only resulted in rampant and uncontrolled use of opioids. While opioid prescription and usage became prevalent, there was no clear evidence that opioid treatment was effective for chronic pain relief or improving function.

The key objective of chronic pain management is to discover the cause, lessen suffering, and restore function. There are numerous factors such as Biologic, psychological, and social that play a crucial role in achieving this. Some of the common pain management strategies that have proven to be effective include a multidisciplinary pain treatment, prescription of non-opioid medications (anti-depressants and anti-epileptic drugs), physical therapy, psychological and behavioural therapies, and complementary and alternative medicine such as Acupuncture etc.

Acute or chronic pain has been so affecting billions across geographies but pain management as a practice and pain research are relatively new fields in comparison with the rest of medicine. Opioid-based approach has deterred organisations from contributing to or investing in research and clinical attention to the

Assessing and treating pain has become an ethical and legal obligation for clinicians. This calls for research to widen the scope of evidence based treatment, which results in effective pain management outcomes and functionality for patients. It is time for the healthcare organisations to shift gears and start focusing on non-opioid chronic pain management strategies on a consistent basis.

Prasanthi Sadhu

Editor

CONTENTS 06

COVER STORY

PAIN AND THE PATIENT ENVIRONMENT A US PERSPECTIVE Susan E Mazer, President, CEO, & Co-Founder Healing HealthCare Systems, Inc

HEALTHCARE MANAGEMENT 14 High Reliability in Healthcare Creating the culture and mindset for patient safety AJ Hobbs, Healthcare Planning + Strategies Consultant, Perkins+Will Robin Guenther, Principal + Sustainable Healthcare Design Leader, Perkins+Will

21 Less is More Your brand plan isn’t fit for purpose. Here’s how to fix it, easily Brian D Smith, Principal Advisor, PragMedic

26 Primary Care The challenges of a changing world Md Moshiur Rahman, Associate Professor, Graduate School of Biomedical & Health Sciences, Hiroshima University Sajeda Chowdhury, Graduate School of Biomedical & Health Sciences Hiroshima University

FACILITIES & OPERATIONS MANAGEMENT 34 High Reliability in Healthcare Creating the culture and mindset for patient safety R B Smarta, Managing Director, Interlink Marketing Consultancy Pvt. Ltd.

26

38 Discharge Begins at Intake Communication tactics that help patients transition and shorten stays and reduce readmissions Nancy Michaels, President, NancyMichaels

INFORMATION TECHNOLOGY 42 Digital Transformation Healthcare in disruptive times

50

UshaManjunath, Director, IIHMR (Institute of Health Management & Research)

46 Modern Technology Is it helping or hindering health?

Behsad Zomorodi, Founder and CEO, Phamax

50 Electronic Health Record System from the Perspective of Data Privacy SB Bhattacharyya, Health Informatics Expert, Founder & CEO, Bhattacharyyas Clinical Records Research & Informatics LLP

56 BOOKS

2

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

IS S UE - 40 2018

Advisory Board

EDITOR Prasanthi Sadhu EDITORIAL TEAM Debi Jones Grace Jones ART DIRECTOR M Abdul Hannan PRODUCT MANAGER Jeff Kenney

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

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

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

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

Gabe Rijpma Sr. Director Health & Social Services for Asia

HEAD-OPERATIONS S V Nageswara Rao

Microsoft, New Zealand

Peter Gross Chair, Board of Managers HackensackAlliance ACO, USA

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

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

In Association with

A member of Confederation of Indian Industry

Ochre Media Private Limited Media Resource Centre, #9-1-129/1,201, 2nd Floor, Oxford Plaza, S.D Road, Secunderabad - 500003, Telangana, INDIA, Phone: +91 40 4961 4567, Fax: +91 40 4961 4555 Email: info@ochre-media.com www.asianhhm.com | www.ochre-media.com

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.

Stiegelmeyer – your partner for high-quality hospital beds Beds and furniture for a successful recovery and a pleasant daily care routine – that’s what the Stiegelmeyer-Group stands for. The family-owned business with head quarters in Germany furnishes hospitals, senior residences and homes with products that support both patients and staff, and enable economic actions. We are setting tomorrow’s trends in hygiene, easy operation and design.

•118 years tradition and experience •production locations in Germany and Europe •own development centre •thorough quality control

www.stiegelmeyer.com

•more than 125,000 manufactured beds per year •technical advance in machine washable beds •modular systems for individual requirements •comfort beds for private customers

HEALTHCARE MANAGEMENT

Pain and the Patient Environment A US perspective

Pain management has been relegated to those who prescribe and administer medications. With need to minimise the use of opioids and interest in use of non pharmacological methods to provide comfort, pain management has become part of the patient experience. The good news is that there are many ways to positively engage patients to manage their pain.

Susan E Mazer, President, CEO, & Co-Founder, Healing Healthcare Systems, Inc

F

rom the earliest beliefs in death being divine, to the use of prayer and rituals to ward off evil spirits, to the beginnings of science and medicine being codified by research, scientific discovery, and, now, to evidence-based practice, pain remains difficult to comprehend and manage.

6

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

For hundreds of years, the medical community believed 17th Century French philosopher Rene Descartes’ theory that the mind had no influence on the body. In1967, the breakthrough work of Ronald Melzack and Patrick Wall finally opened the door to pain management being multi-disciplinary.

IS S UE - 40 2018

HEALTHCARE MANAGEMENT

That the mind could and does influence the experience of pain has created a plethora of studies that look at all aspects of the human experience.

And despite this, pain management has yet to be implemented successfully in the United States and other countries around the world. For years, patients were under-treated and pain was underreported. Then, in 1990, The Joint Commission shifted its regulations, calling for pain to be the fifth vital sign, that every patient be assessed for pain and provide a self-report. Since then, the epidemic in the use of opioids prescribed by physicians for patients in and out of the hospital has become an epidmic.

So now the focus is on non-opioid pain treatment. This might include other drugs and non-pharmacologic pain management strategies such as acupuncture, massage therapy, relaxation therapy, etc. But the physical environment also informs patients’ experience of pain. And there are many ways that the micro-environment of

patients can be effectively manipulated as part of pain management strategies.

For some perspective on this concept, let’s begin with Florence Nightingale.

The Comfort of the Patient

In the mid 19th Century when Florence Nightingale began observing the poor, the disabled, and the sick in the streets of London, she questioned the way the whole British healthcare system operated.

At that time European hospitals were either run by the local government or the Church. The system was paternalistic, with patients and families seeking and following the advice of physicians in all aspects of care or following religious leaders, holy men who claimed to know what to do.

Nightingale found that the comfort of the patient to be ignored by the system that was supposedly dedicated to the relief of suffering. She considered the standard circumstances in which the ill were to recover, untenable. She wrote, “the thing which strikes the experienced observer most forcibly is this, that the symptoms or the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all, but of something quite different–of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administration of diet, of each or of all of these.” (Nightingale, 1860) She also wrote once that “when you have done away with all that pain and suffering, which in patients are the symptoms not of their disease, … we shall then know what are the symptoms of and the sufferings inseparable from the disease.”

The patient environment for Nightingale was primary care. It is where they spent all the many hours without having access to the distractions and activities of daily life. Physicians had already adopted a mechanistic view of medicine, and while they diagnosed and

performed surgeries, they knew little about the subjective lived experience of the patient and left the suffering to be handled by the nurses. That is actually true to this day.

For Nightingale, changing linens, ensuring ample sunlight, tending to cleanliness, and providing fresh air, beauty and comfort were restorative.

These were also steps to avoid infection, which was almost always fatal. Those were her toolbox. And, her theory, while at that time as yet untested in London, was fully and successfully implemented in the Scutari Military Hospital, resulting in a drop in the mortality rates from 42 per cent to two per cent within six months.

The Meaning of Pain

The being-ness of a patient has always been about illness, regardless of where the patient is. And, the primary complaint, concern, fear, and anxiety, was and remains about pain. But, 'pain' remains complex and ambiguous in what it means.

Theoretically, Melzack and Wall’s Gate Control theory of pain has endured correction, but has not been proved wrong. The Specificity Theory, which said that each pain has its own specific trigger and response, has been proven wrong. (Massieh Moayedi, 2013) Opium was the original drug of choice for pain relief, offering not only freedom from physical pain, but also a kind of euphoria that created the first dependency (Brownstein, 1993).

Opium, however, creates an addiction that is detrimental to patient health and has extensive social and economic implications.

Since the development of pharmaceutical analgesics, patients have become increasingly dependent on their physicians to prescribe pain medications, direct their dosage, and keep them protected from undue suffering. In the US, the co-dependence between patient and clinician regarding

www.asianhhm.com

7

HEALTHCARE MANAGEMENT

pain has been and remains unhealthy, if only because patients require a physician to diagnose and prescribe and physicians need to be paid, which does not happen without a diagnosis.

When the Joint Commission declared pain as the fifth vital sign in 1990, all healthcare organisations were compelled to assess and document the patient’s pain through a universal

instrument for self-report. Further, the patient satisfaction surveys developed by the US government asked patients whether the clinical staff did ‘everything possible’ to control their pain. The responses were included in the final tabulation on which reimbursement was based.

The subsequent increased pressure on clinicians, the ongoing marketing

of pain medications which set patients up to expect zero pain, and the deceit of US pharmaceutical companies who hid the known addictive risks of their products, have together brought patients to the point of having little understanding of their own role in managing their pain. All of which has led to the current Opioid Epidemic in America.

The Impact of the Physical Environment

Other than pharmaceutical, pain management tools currently recommended for use in the US involve acupuncture, massage, and other physical interventions.

However, the ways of the mind and body extend beyond their own immediacy. It is the process of meaningmaking and of spontaneous involuntary responses to environmental stimuli that informs the effectiveness of these interventions.

The environmental interface between human beings and their surroundings are the five senses, plus cognitive skills that make sense of what is happening. There are voluntary responses, which occur following a perception and define what is happening. However, the involuntary responses, such as the startle-reflex reaction to a loud noise, closing one’s eyes in the face of bright lights, and anxiety in response to crowding, are well documented and become patients’ experiences of where they are.

Environmental stressors, then, are defined by both voluntary and involuntary responses to sensory stimuli.

Stressors do not adapt to the capacities or acuity of the individual, but confront patients on an ongoing basis.

Thus, if the individual is unable to compensate or otherwise accommodate the environmental stimuli— whether noise that is too loud, lights that are too bright, or temperatures too cold or hot—stress is the automatic response.

There are studies that have reviewed environmental stressors and their impact on pain management that offer insights into what kind of flexibility is needed to provide comfort for a patient.

Walch et al. (2005) found the patients who had undergone spinal surgery that were placed in rooms with bright sunlight (more than 46 per cent) used 22 per cent less pain medication than those in dimly lit rooms. This is specific to natural sunlight, not overhead,

8

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

IS S UE - 40 2018

fluorescent lights. These patients also experienced less stress and slightly less pain.

Other studies also looked at the benefits of exposure to sunlight, which provides Vitamin D to the patient.

However, considering older patients, it is not uncommon for light-sensitivity and overall depressive moods and result in room with the shades closed and patients not venturing outside.

ISQua’s 35th International Conference

KUALA LUMPUR

2018

23rd – 26th SEPTEMBER

KUALA LUMPUR CONVENTION CENTER

Heads, Hearts and Hands “Weaving the Fabric of Quality and Safety”

SUPPORTED BY

Dr Pawan Agrawal

Prof Jeffrey Braithwaite

Dr. Uma Raman Kotagal

International Motivational Speaker, Author, Educationist, Business Consultant & Successful Entrepreneur, India

President-Elect Of ISQua; Foundation Director, Australian Institute of Health Innovation, Australia

Executive Leader, Population and Community Health; Senior Fellow, Cincinnati Children’s Hospital Medical Center, USA

#ISQua2018

Rushika Fernandopulle MD, MPP, Co-Founder and CEO of Iora Health, USA

https://isqua.org/Events/malaysia-2018

HEALTHCARE MANAGEMENT

Environmental Stressors

Studies have shown that distracting noises, whether loud or not, are stressful and cause patients anxiety.

(Mazer, 2010) Auditory processing is compromised for older patients and even more under the effects of medication (Patricia, 2006).

Therefore, sounds coming from talk television, from beyond the line of sight, and those that are irrelevant to the patient’s experience should be minimised, if not totally avoided.

Patients who are confined to a bed in a hospital room can also experience crowding by clutter that impinges upon the space available to them. Keeping the room tidy, removing meal trays and other elements whose usefulness has ceased, will expand the space.

The intrinsic attractiveness of an environment would be characterised as its pleasantness or unpleasantness as perceived by the user. And, from studies that look at the impact of positive valence on everything from waiting time to pain relief, feeling good is better than obsessing the bad.

And, being positive, not optimistic in the usual sense, but positive rather than negative in the moment is decidedly better. (Finan and Garland, 2016; Andreatta, Mühlberger, et. al., 2010).

10

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

If the environment is stressful, represents negative feelings, or has no sunlight or beauty, it will make patients’ pain worse and challenge all pain management efforts.

Besides creating a pleasant environment for patients, it is also important to provide positive distractions. Nature in many forms— whether potted plants, photographs, access to the outdoors, or nature and music programming on different media platforms—has been found to effective in reducing stress and moving patients focus away from their pain.

Finlay and Anil (2016) found that music could alter the perception of time, with music perceived as happy resulting in a positive valence and shortening the perceived time spent in pain.

The use of virtual reality as a positive distraction for patients is also gaining traction in the US Recent studies at Cedars Sinai Medical Center in Los Angeles have shown that virtual reality can calm and distract patients, relieving the sensation of pain and easing the stress of being in the hospital. Researchers believe that immersive distraction may also help lower blood pressure, improve depression, reduce agitation for those with dementia, and be supportive for women enduring long labours while giving birth (Tashjian, Mosadeghi, Howard, et. al, 2017).

IS S UE - 40 2018

Roger Ulrich’s Theory of Supportive Design addresses environmental characteristics that support or facilitate coping and restoration with respect to the stress that accompanies illness and hospitalisation. By having restorative and buffering effects on stress, and by enhancing coping and other healthful resources, supportively designed healthcare environments can foster gains in numerous patient health outcomes (Ulrich, 1997). His three areas of focus address many elements identified in Melzack and Wall’s Gate Control Theory of pain. They are: 1. Foster control, including respecting the patient’s privacy according to their needs. Control in this case is in accordance to the capacity of the patient. And, in the process of recovery, it must be re-evaluated in order to continue to restore the autonomy and self-management capacities that will be required to be fully restore health.‘Control’ takes many forms.

It may mean patients ask for a fresh pillow or call for help for toileting. It may mean that they may choose their own music or television programmes.

It may also mean that they have the right to not listen to what they do not want to hear, such as other people’s conversations, music, or programmes.

Having lighting choices also helps

P46354OCHRE

HEALTHCARE MANAGEMENT

Conclusion

Pain is experienced through many filters, including cultural and social norms that are different around the world. The unique nature of each

12

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

patient and the culture with which he or she identifies, his or hervalues and preferences, and the history of the patient’s relationship to pain must all be considered. Given that pain is not only complex, but is also impacted by the immediacy of the circumstances of the patient, there are many tools that can be used to mitigate environmental stressors and provide relief.

The Opioid Epidemic now plaguing the United States is not limited to Western cultures. Reasons have been attributed to greater supply and a health system that has encourages ongoing medication for chronic pain.

However, regardless of the reasons, the

main path of addiction begins inside the healthcare system.

There are many reasons to ensure good pain management by mediating pain relief with both pharmaceutical and non-pharmaceutical methods.

Education, close monitoring, and an authentic relationship between patients and their clinicians is critical. Also, providing a broad range of options for relieving pain that empowers patients in safe and healthy methods is the optimal way to ensure healthier longterm outcomes.

References are available at www.asianhhm.com AUTHOR BIO

foster control. Patients should be able to close the blinds to avoid glare, open them to bring in sunlight. They should also be able to turn off overhead lights and turn on closer bed lamps.

2. Provide for social support, including not only the family, but also friends who are important to the patient. Pain can cause a specific kind of isolation that reduces the patient’s own coping capacity, which can increase fear, and also lead to ruminations - the repeating of fears and anxieties regardless of whether they are based in reality. Social support requires adequate space and seating arrangements. It also requires prioritising the needs of the patient over those of the family by modelling the kind of environment that will be appropriate for optimal recovery at home. Today, with digital capabilities, patients may have access to their family members through their smart phones. Also, messaging and emails are now commonly used to keep family and friends up to date. With these technologies, however, privacy must be addressed for the sake of patients and the other patients around them.

3. Provide opportunities for restoration, including exposure to nature and other positive distractions. The value of positive distractions for pain relief cannot be overestimated. For patients to only focus on themselves, their pain, and their concerns over their future, only makes it worse, and the suffering becomes unbearable. Providing access to nature is one solution, but it isn’t the only one.

Artwork, virtual reality programmes, labyrinths (for those patients who are mobile) have also been found to be effective. And the same thing won’t work for every patient. It all depends on their age, preferences, capacities, and acuity.

Susan Mazer is President and CEO of Healing HealthCare Systems. A thought leader and knowledge expert on how the environment of care impacts the patient experience, Dr. Mazer is a well-published author and frequent speaker at healthcare industry conferences. She earned her Ph.D. in Human and Organizational Development from Fielding Graduate University.

IS S UE - 40 2018

THE INTERNATIONAL EXHIBITION ON MEDICAL TECHNOLOGY, DEVICES, SERVICES AND GENERAL HEALTHCARE

BUILDING THE FUTURE OF HEALTHCARE

Medical instruments and consumables Medical laboratory Orthopaedic / rehabilitation IT in healthcare Surgery Diagnostic imaging (radiology)

Pre-register now!

Explore new technologies, learn the best practices and enrich your knowledge at any of our seminars and CME-accredited conferences!

info@medicaldevicesasean.com

HEALTHCARE MANAGEMENT

14

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

IS S UE - 40 2018

HEALTHCARE MANAGEMENT

High Reliability in Healthcare Creating the culture and mindset for patient safety While patient care delivery reliability is more nuanced than mechanical industries, healthcare can improve by adopting characteristics of other industries that have achieved high reliability. Creating the culture for patient safety begins with a preoccupation with failure and commitment to resiliency.

These characteristics must be adapted at all levels of the organisation.

AJ Hobbs, Healthcare Planning + Strategies Consultant, Perkins+Will Robin Guenther, Principal + Sustainable Healthcare Design Leader, Perkins+Will

A

s the world moved into 2018, the safety record of commercial aviation in 2017 was big news.

2017 was the safest year for commercial flight ever, with one fatal accident for every 16 million flights. While 2017 may have been a bit of an outlier, there is a clear trend of decreasing fatality in commercial aviation; fatality risk dropped 83 per cent from 1998 to 2008. This safety record is all the more impressive given the global trend toward increasing extreme weather, which can certainly impact aviation safety. The annual average number of US extreme weather events costing over USD 1 billion in the most recent five years (2012-16) is 11.6 events. In 2017, there were 16, which set a new record.

From Hurricane Sandy to Typhoon Haiyan, healthcare infrastructure is vulnerable to damage and disruption at a moment when the community need for health services peaks.

In part due to these great strides, aviation is among the industries known for their high reliability. High reliability industries do an exceptional job reducing errors and protecting the humans that interface with their systems, even in the face of dangerous and complex tasks and external influences. While aviation is praised for its high reliability,

www.asianhhm.com

15

HEALTHCARE MANAGEMENT

healthcare lags behind. Healthcare produces errors and deaths that have made their own headlines; in the United States, some estimates have put healthcare errors as the third leading cause of death, behind only heart disease and cancer. Healthcare infrastructure continues to fail in extreme weather, leading to costly evacuations, care disruption, and in some instances, loss of life. In many instances, long-term disruption to healthcare delivery can hamper community economic recovery.

How can this continue to happen?

How can healthcare contribute to the problem it’s here to solve? Can healthcare reliability be improved?

Arguably, the ‘input’ and ‘output’ in healthcare, human beings, are much more complex than planes, and thus achieving high reliability is even more elusive in healthcare. Still, healthcare organisations can adopt characteristics

16

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

of other industries that have achieved high reliability in order to improve patient safety and system performance.

Healthcare has to continually challenge itself to work toward high reliability – that is, ‘doing no harm’. This begins with culture and mindset.

Researchers Karl Weick and Kathleen Sutcliffe focused on

A failure-obsessed culture and a systems thinking mindset is necessary for healthcare to move toward high reliability.

IS S UE - 40 2018

high reliability have identified five characteristics of highly-reliable organisations. Weick and Sutcliffe have noted that these characteristics are ‘responsible for the mindfulness’ that keeps the system functioning well, even in unanticipated conditions.

These characteristics are: preoccupation with failure, reluctance to simplify, sensitivity to operations, deference to expertise, and commitment to resilience. Two characteristics in particular that create the culture and mindset for patient safety and high reliability are preoccupation with failure and commitment to resilience.

Commitment to Resilience

While healthcare should make failure increasingly visible, they must also respond appropriately to failure by committing to resilience. Resilience thinking, which can look different at the many levels of our complex healthcare delivery systems, helps organisations reach high reliability. It is a culture and mindset that must be supported by tangible system techniques to prevent and recover from patient safety failure in both daily clinical operations and in infrastructure. Commitment to resilience can come in the form of physical and operational design and implementations.

Architect Thomas Fisher, in Designing to Avoid Disaster, notes that “…centralised infrastructure, from power grids to hospitals, are larger, more complex, increasingly dependent upon massive amounts of increasing ongoing maintenance, and often vulnerable to failure of a single element.” He goes on to suggest that going forward, good design and planning will be based on the understanding that nothing will work as planned, or even at all.

A commitment to resilience means imagining, and accounting for, the worst. There are a host of tools and resources emerging globally to assist healthcare organisations in developing a commitment to resilient infrastructure.

HEALTHCARE MANAGEMENT

Preoccupation with Failure

A preoccupation with failure requires transparency and a shared responsibility for outcomes. Organisations and their people with high reliability mindsets are consistently seeking out where errors are occurring – errors that reach the end user and errors that get caught and corrected. In healthcare, we often call these errors that are caught before reaching the patient “near misses.”

This preoccupation with failure spans both direct patient care and the physical infrastructure that supports it.

A Highly Reliable Organisation (HRO) is not satisfied with correcting individual failures, satisfied with near misses, but rather thinks in terms of the system. A HRO questions how their system is designed to allow a near miss to happen and knows that one mistake can turn a near miss into a patient safety error or a critical infrastructure failure. In a high-reliability, patientsafety focused culture, it is everyone’s responsibility to constantly seek to expose and correct systematic vulnerabilities and failures, whether in patient care protocols or physical infrastructure and equipment.

Searching out failure requires both experts in systems and those on the front-line caring for patients, all supported by leadership. Experts trained in system design and human factors can utilise specific tools to proactively identify potential patient safety errors. One such tool, Failure Modes and Effects Analysis (FMEA), is a step-by-step approach to identifying possible failure in a system’s design. FMEA practitioners follow through by recommending actions to reduce opportunity for failure. Systems engineers can also implement systems to making failures on the front line more visible to the healthcare improvement professionals who can dedicate time to investigating and fixing them. The concept of ‘and on’—a system to notify management, maintenance, or other quality and safety staff of a quality or safety failure—could be adopted in healthcare to move towards high reliability.

Operationally, one way to commit to resilience is to appropriately respond to every incident report brought forward by front line staff. It is not enough to collect information about

In a high reliability organisation, those on the front line delivering patient care share the responsibility of identifying and remediating failures. Front line staff will encounter patient safety failures more organically as they directly deliver care to patients. A basic step hospitals and ambulatory sites should take is to create a structure for reporting patient safety incidents (patient safety lapses, near misses, errors, etc.)

As this incident reporting avenue is made available, leadership must support the psychological safety of the front line staff who do report failure. One approach to supporting the front line in reporting incidents is the ‘Just Culture’ system. Just culture includes cultural guidelines and incident response tools, developed based on engineering principles to enhance patient safety by respecting and protecting those who report incidents.

Historically, safety issues in healthcare have been too often hidden because of fears that those reporting patient safety incidents may result in individually punishment or even termination. This is unjust for the healthcare workforce which is, by and large, comprised of caring, well-intentioned, and smart individuals. On the other hand, HROs support their front-line staff when they report failure. Their culture believes that failure is almost always a consequence of system error rather than individual negligence. Actively seeking out failure and responding appropriately in the face of system failures will move healthcare toward high reliability.

system failure and make it more visible.

A highly reliable organisation responds with resilience by redesigning systems in response to patient safety failures and properly communicates the outcomes

of the improvements to the appropriate stakeholders.

When it comes to increasing incidents of extreme weather, it is critical to design systems that can

www.asianhhm.com

17

HEALTHCARE MANAGEMENT

respond to future weather conditions, from the gradual stresses of sea level rise to the immediate increases in maximum wind speeds or rainfall totals. Designing redundant systems, such as operable windows for natural ventilation and daylighting when mechanical infrastructure fails, is one key strategy for resilient design.

United Nations Office of Disaster Risk Reduction (UNIDSR 2012) notes: “Paying attention to protection and resilience will improve environmental, social and economic conditions, including combating the future variables of climate change, and leave the community more prosperous and secure than before.� Perkins+Will, a design firm, collaborates with clients to implement tangible facility design tactics that can demonstrate and support commitment to resilience.

For example, designing clean and / or redundant energy systems allows for patients and the healthcare professional serving them to operate in a stable, safe environment. Spaulding Rehabilitation

18

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

IS S UE - 40 2018

3rd Healthcare Asia Pacific Summit 2018

June 6-8 , 2018 · Four Points by Sheraton Singapore, Riverview

HIGHLIGHTS More than 100 Delegates interpre�ng healthcare regula�ons in Singapore, Japan, China, Australia, Malaysia, Thailand, India, Vietnam, and other major jurisdic�ons

Firsthand informa�on from regional government officials and industry leaders on healthcare policy in the APAC region and around the world, and future market trends

Insights into market access strategies and the registra�on process for healthcare products

The latest informa�on on quality assurance and regulatory compliance for medical devices and pharmaceu�cals

In-depth analysis of product development and clinical trial requirements in the Asia Pacific region

Challenges and opportuni�es for medical device supply chains and distributors

Exchange between company representa�ves and government regulators, in the interest of developing the industry

For further information about this event, please contact: Miss. Cindy Cui Tel: +86 21 5580 0330 Ext. 8253 Email: cindy.cui@duxes.cn

h�p://www.duxes-events.com/hap

www.asianhhm.com

19

HEALTHCARE MANAGEMENT

AUTHOR BIO AJ Hobbs is an industrial

engineer and Healthcare Planning + Strategies Consultant at Perkins+Will.

AJ partners with healthcare clients to plan for their future through a systems engineering and quality improvement lens. AJ designs operations and facilities in tandem to improve health and the experience of care while reducing costs.

of healthcare organisations to improve patient safety. These characteristics include a preoccupation with failure and a commitment to resilience. To do no harm, healthcare must actively seek out understanding its potential to cause harm and encounter system failures and design systems that both prevent harm and quickly recover from harm wherever possible.

Sources Fisher, Thomas (2013). Designing to avoid disaster: The nature of fracture-critical design.

New York and London: Routledge.

Makary, Martin A.; Daniel, Michael (2016). Medical error-the third leading cause of death in the US. BMJ. pp. 353.

Hospital, on the Boston waterfront, is designed with all the critical infrastructure on the roof, well above flood elevation. All critical services are located out of harm’s way. The building generates its own thermal energy and electricity, so it can operate indefinitely when municipal grid power is lost.

Additionally, a high reliability organization fosters resiliency in its individuals. At Perkins+Will, the healthcare design teams design spaces in hospitals that aim to reduce fatigue and interruptions. For example, carpeting the interior of support cores on nursing floors has reduced sound transmission which can wear on the staff delivering healthcare and cause distraction and fatigue. Designing space for staff that are restorative also demonstrates a commitment to resilience. Staff members having quiet areas with access to natural light and natural views can improve their mood, make them more resilient in the face of failure, and ultimately improve patient safety.

Conclusion

A failure-obsessed culture and a systems thinking mindset is necessary for healthcare to move toward high

20

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

reliability. The imperative is clear: a focus on improved patient safety and improved performance in extremely complex care and extreme externalities, like weather, is necessary. Healthcare as an industry has much to learn from other high reliability industries, like aviation, in terms of ensuring safety for its customers. Characteristics of high reliability organisations, as defined by Weick and Sutcliffe, must be adopted across the levels of the complex structure

AUTHOR BIO Robin Guenther designs and advocates at the intersection of healthcare architecture and sustainable policy. She is Senior Advisor to Health Care Without Harm and co-authored Sustainable Healthcare Architecture and Primary Protection: Enhancing Health Care Resilience for a Changing Climate available from US Department of Health and Human Services at toolkit. climate. gov.

IS S UE - 40 2018

Weick, Karl E.; Kathleen M. Sutcliffe (2001). Managing the Unexpected - Assuring High Performance in an Age of Complexity.

San Francisco, CA, USA: Jossey-Bass. pp.

10–17.

Boysen, Philip G. (2013). “Just Culture: A Foundation for Balanced Accountability and Patient Safety.” The Ochsner Journal. pp.

400–406.

United Nations Office for Disaster Risk Reduction [UNISDR]. (2012). How to make cities more resilient: a handbook for local government leaders. Retrieved from http:// www.unisdr.org/campaign/resilientcities/ toolkit/handbook

HEALTHCARE MANAGEMENT

Less is More

Your brand plan isn’t fit for purpose.

Here’s how to fix it, easily.

In most life science companies, the brand plan document is not fit for purpose. Intended to communicate the plan and gain commitment, It is typically a timeconsuming tome that is rarely read and often ridiculed. The problem lies not in the content but in the way that it is structured.

In this article, I describe the way that brand plans are evolving into something better adapted to the 21st century life science industry..

Brian D Smith, Principal Advisor, PragMedic

I

n life science companies, the brand plan is ubiquitous, important and expensive. Every brand has one, it drives success (or causes failure) and brand teams invest huge amounts of time and money in the annual ritual of writing and executing this essential document.

And yet the brand plan itself if often an object of ridicule. Once written, it rarely becomes the well-used, oftenconsulted guide to implementation that it should be. More often, it sits on a shelf until, next year, it is dusted off and used as a template for the next plan. This isn’t how it is supposed to be and, in this article, I’ll explain why this happens and how your brand plan can become a useful, working document.

What’s more, my remedy will cost you nothing and require no more work than your existing process for writing the brand plan.

Falling between three stools

Why are dust-collecting, ignored brand plans are so common in pharma and medtech companies? After all, the people who write them are intelligent and hardworking. My research indicates that, to adapt an English idiom, the problem is that brand plans fall between three stools. In other words, they try to do three things at once and, as a result, fail at all of them.

Firstly, brand plans try to be a comprehensive repository of all the analysis and thinking that the brand team have done. This is a useful thing to have because it helps brand teams maintain continuity. Secondly, brand plans try to be a rallying call, communicating the brand strategy clearly to motivate those who must implement it. Since brand strategy is executed cross-functionally, this is also an important purpose of a good

brand plan. Thirdly, brand plans try to enable approval from senior colleagues, which is essential given their costs and importance to the business.

All three goals are important, of course. But they require very different documents. A good repository would be extensive and detailed. By contrast, a plan that tries to communicate and motivate needs to be succinct and to the point. And an approval document needs to both focus on the strategic issues but also provide enough detailed information to explain and justify strategic choices.

For one document to fulfil all do those three things is a big ask. It is like asking for a glamorous, highperformance car that holds a large family’s holiday luggage and is very cheap to buy and run. The typical result of these conflicting demands is a compromise: a brand plan that

www.asianhhm.com

21

HEALTHCARE MANAGEMENT

doe none of these three things very well. Such compromise plans fall between the three stools of repository, communication and approval. That’s why, in practice, they sit on the shelf between planning cycles.

The Wedge Solution

This description of a compromise, ineffective brand plan seems to resonate with most life science brand leaders, but not all. In my research, a tiny minority have solved this problem. What is more, they have done so little effort and at no additional cost.

The leading companies I studied use a Wedge brand plan structure, meaning a very short plan (usually 5 or 6 pages) supported by an extensive set of appendices. The short plan does the job of both communicating the strategic issues and communicating the strategy. The appendices provide the necessary detail to act as repository and to explain strategic choices.

Importantly, Wedge brand plans usually contain the same information as more traditional plan structures.

It is only the organisation of that information that is different.

The strength of the Wedge structure is that everyone can easily read the short plan whilst the appendices can be read selectively when the reader has a particular interest or has a question about something in the short plan.

In practice, the key to making a Wedge plan structure work is to put the right information in the right place. The short plan must contain a few key things and no more. The appendices must contain everything necessary to support those few essential elements.

The executive summary should be a paragraph of less than 200 words. It must describe the scope of the plan, give a distillation of the brand strategy statement, summarise new activities that will contribute significantly to achieving customer preference and provide a quantified statement of both resources to be expended and returns expected.

The critical success factors section should state the 6 to 10 critical success factors that the brand strategy must address. This should typically occupy about half a page but this section is closely cross-referenced to the various supporting appendices which analyse the market situation.

The brand strategy statement must make clear what value will be offered to which market segments and, just as importantly, the parts of the market from which resources will be withdrawn or with-held. This is usually no more than a paragraph.

The activity plan consists of a brief description of those activities most important to the brand strategy or that require large shifts in resource allocation. This section is typically one or two pages but cross references

to various appendices that describe the detailed activity, their costs and their intended outcomes.

The metrics section must contain the headlines of three kinds of metrics: lag, lead, and learning. This section is typically one or two pages but again is cross-referenced to various appendices, such as sales targets, measures of activity outcome and measures that test any assumptions inherent in the plan.

This 5-section structure of the short plan should be the same for any brand and any market because this allows senior leadership to compare easily between brands and businesses.

Importantly, it is important to resist the temptation to “just add in this section”. If the short plan exceeds 5-6 well-spaced pages, it will no longer do its job.

What Should the Appendices Include?

The appendices should include anything that’s needed to support the statements made in the short plan. In most cases, most of the content needed for the appendices will already be written but currently be included in the main part

What Should the Short Plan Include?

To be effective, the short plan must contain 5 short sections, as shown in figure 1.

22

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

figure 1.

IS S UE - 40 2018

www.asianhhm.com

23

HEALTHCARE MANAGEMENT

Useful Brand Plan Appendices TITLE

An Easy Solution to an Important Issue

PURPOSE

Emergent Properties Analysis

To identify the opportunities and threats arising from the social and technological environment

Competitive Pressure Analysis

To identify the opportunities and threats arising from the competitive environment

Contextual Segmentation Analysis

To identify the opportunities and threats arising from heterogeneity of needs in the payer, patient and professional environments

Product Category Life Cycle Analysis

To identify the opportunities and threats arising from innovative and imitative activity in the market

Hypothesis Loop

To identify new market insights by testing assumptions inherent in the plan

Value Chain Comparison

To identify the strengths and weaknesses arising from differences between competitors’ value-adding activity

Reality Filters

To objectively test and validate, clarify or remove strengths, weaknesses, opportunities and threats arising from other analyses

SWOT Alignment

To identify critical success factors arising from the alignment of strengths to opportunities and weaknesses to threats

Focus Matrix

To identify the type and level of resource allocation appropriate to each contextual market segmentation

Brand Strategy Formulation

To state the brand strategy in the form of value offered and resource allocation to contextual segments

Brand Strategy Diagnostics

To test and validate the brand strategy statement against objective criteria

Concentric Value Proposition

To identify a complete and costed set of activities, consistent with strategy and internally coherent, that flow from the brand strategy

3L Metrics

To identify appropriate lag, lead and learning metrics for each significant activity in the concentric value proposition

Almost all business problems are either trivial and easy to solve or provide big benefits but are fiendishly complicated.

Almost never does an easy solution have a big impact on the business. But the effectiveness, or otherwise, of brand plans is something that can profoundly influence the success of the firm and the Wedge brand plan structure, currently used by only a tiny minority of firms, is a solution that can be easily adopted by any brand team.

The Wedge structure works because it addresses all three goals of a brand plan—repository, approval and communication—and it does so by the simple expedient of restructuring much the same content contained in traditional plans. No extra content is needed, although the newly-clear structure may illuminate the need for some new analyses, such as those in table 1.

In practice, the biggest challenge to implementing a Wedge brand plan structure is not technical but cultural.

After decades of reading brand plans that are hundreds of pages long, some firms struggle to accept a document of 5 pages, even when supported by a mass of appendices. But, as leading firms have no recognised, when it comes to brand plans it is often true that less is more.

of the plan. Although the short plan structure can and should stay the same across brands, the choice of appendices can and should vary widely depending on the situation.

That said, there are certain analyses that are almost always valuable and should be in the appendices of any brand plan. These are summarised in table 1, which acts as a guide, but not a constraint, to the structuring of

24

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

this second, much larger section of the document.

One beneficial side-effect of using this set of usually-necessary appendices is that, in practice, it often illuminates gaps or weaknesses in the thinking behind the brand plan. Space does not allow me to explain each of these methods in this article, but full details are in my book Brand Therapy.

IS S UE - 40 2018

AUTHOR BIO

Table 1

Brian D Smith works at the University of Hertfordshire in the UK and Bocconi University in Milan, Italy. This article is based on his latest book “Brand Therapy: 15 Techniques for Creating Brand Strategy in Pharma and Medtech”, which is available from Amazon.

www.asianhhm.com

25

HEALTHCARE MANAGEMENT

PRIMARY CARE

The challenges of a changing world Primary care is the day-to-day healthcare by a healthcare provider in comprehensive first contact. In this changing world, we are facing unprecedented demographic and epidemiologic transitions. Urbanisation, aging and globalised lifestyle changes lead to increase noncommunicable diseases with multimorbidity. The ultimate aim of primary care is better health for all.

Md Moshiur Rahman, Associate Professor, Graduate School of Biomedical & Health Sciences, Hiroshima University SajedaChowdhury,Graduate School of Biomedical & Health Sciences Hiroshima University

P

rimary healthcare is the first level of contact of individuals and communities with the healthcare system. The Alma-Ata Declaration ‘Health For All’ is broadly accepted to be a precise statement of the principles of primary healthcare. With a few exceptions, it was observed that a number of countries adopted targets and expressed their commitments to primary health in order to improve the health services. This commitment has been assimilated into practice in various ways such as ‘Healthy People 2000’ in the USA, 'Targets for Health for all’ in the European countries, the ‘New Perspectives on the Health of Canadians’, and the ‘African Health Development Framework’ in the African countries. Regrettably many countries, particularly the poor ones have given marginal importance to the safety aspect of food production and

26

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

supply chain, although the declaration of Alma-Ata recognised that the provision of food and proper nutrition are essential elements of primary healthcare. It has been observed that a number of issues like the environment, urban growth and rapid population growth that were not appropriately dealt with have since received considerable attention by the Alma-Ata Conference in 1978. Other relevant concerns are unmet needs of water supply and basic sanitation, and special needs of women and elderly people. However, 2.5 billion men, women, and children still lack access to basic sanitation services around the world. About 1 billion people continue to perform open defecation. An additional 748 million people do not have ready access to an improved source of drinking water, and hundreds of millions of people live without clean water and sanitisers that

IS S UE - 40 2018

could facilitate the spread of diarrheal disease, the second leading cause of death among children under five. The major problem is inequality between and within countries in ensuring the uniform healthcare practices.

This article explains the challenges and changing nature of primary healthcare due to the changing global context. The world population trend is changing and increasing ageing rapidly. At present, the aged population is at the highest level in the human history. The proportion of the world's population over 60 years will be nearly double from 12 per cent to 22 per cent between 2015 and 2050. Ageing is the major cause of mortality in the developed world. In 2050, 80 per cent of older people will be living in low- and middle-income countries. A compounding factor of poverty will be the highest prevalence of disability

HEALTHCARE MANAGEMENT

among elderly in a population. The increase in the number of people with multi-morbidity is being recognised as a greater risk of adverse health outcomes with two or more chronic conditions.

Countries facing these major challenges need to ensure that their health and social systems are capable of addressing this demographic shift. The growing urbanissation of this world’s population is projected to accelerate following increase in city slums and degradation of the environment. Therefore, special attention is needed to several critical issues, such as population growth, ageing, urbanisation, and the environment changes.

Undoubtedly, globalisation can be termed as an important factor in disease transmission around the world.

Among infectious diseases, Human Immunodeficiency Virus (HIV) remains as the world's most significant

public health challenge, particularly in low- and middle-income countries.

Globally, an estimated 36.7 million people were living with HIV in 2015 with the vast majority in low- and middle-income countries. Although we are fighting for a Tuberculosis (TB)-free world, it is still one of the top 10 causes of worldwide death while HIV poses the greatest risk for developing active TB. Thus, TB is a leading killer of HIV-positive people causing a 40 per cent mortality in 2016. The alarming emergence of multidrug-resistant TB may ultimately advance toward the threat of an incurable epidemic. The current challenge is to end the TB epidemic by 2030, which is one of the health targets of the Sustainable Development Goals. In 2016, nearly half of the world population was at risk of malaria, causing huge burden and death, mostly in sub-Saharan

Africa. The malaria situation has been stagnant in many countries; however, drug resistance of parasites and vectors to insecticides is becoming a major challenge. An increasing tension remains in developing countries between the promotion of primary healthcare and vertical diseaseorientation programs focusing on HIV, TB, and malaria.

Following the continued epidemiological transition, Noncommunicable Diseases (NCDs) are progressively replacing infectious and communicable diseases. Every year globally, 70 per cent deaths are caused by NCDs where Cardiovascular Diseases (CVDs) and Cancer remain as the number one and second cause of death, respectively. Most CVDs can be prevented by addressing risky behavioural attributes such as tobacco use, unhealthy diet and obesity, physical inactivity and harmful use of alcohol by utilising robust strategies. To reduce the significant disability, suffering and deaths caused by cancer worldwide, effective and affordable programmes in early diagnosis, screening, treatment, and palliative care are prerequisites.

NCDs are being recognised as an increasingly important problem for public health both in developing and developed countries. The prevalence of Diabetes Mellitus (DM) is known to be highest in some developing countries and among disadvantaged population groups and minorities in developed countries. As the treatment and management of DM cases are costly, the developing countries have to assess the feasibility of national control programmes seriously.

Alcohol-borne diseases, mental illness, and drug addiction have also become a major concern. Early detection and management could reduce the risk and cost by providing primary healthcare.

Prevention being better than cure, the emphasis should urge communities to promote healthy lifestyles and behaviour.

www.asianhhm.com

27

HEALTHCARE MANAGEMENT

The proportion of the world's population over 60 years will be nearly double from 12 per cent to 22 per cent between 2015 and 2050.

Lower literacy rate among women folks is another serious obstacle to health development. Numerous studies have reported the clear relationship between literacy, family planning, and falling infant mortality. The global average of immunisation coverage has remained stalled at 86 per cent with no significant changes during the past year. Widespread activities are needed to accelerate coverage to 95 per cent, such as availability of vaccines, weekend management of vaccination programs, and strongly motivating the health workers. Maternal, neonatal and child health is facing various challenges in many developing countries. Pneumonia and diarrhoea are still the leading causes of death among children under-five.

A failure to breastfeed, malnutrition, measles, and HIV are related risk factors for frequent, severe or prolong episodes.

Most of the maternal and under-five child mortality and morbidity could be prevented through the access of firstlevel care including immunisation, good nutrition, provision of safe water supplies and sanitation facilities. In industrial countries over the last three decades, the fall in the prevalence of breastfeeding, especially after three months has been becoming a threatening issue for child health as well as maternal health. Genital mutilation is traditional and cultural practices harmful to the health of women and children remain an important problem in a number of developing countries. A need for more integration between healthcare programs has been

28

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

recognised, however, incorporating primary healthcare into development programs has never been easy.

Moreover, inequalities in health and healthcare between different ethnic, gender, social, and occupational groups remain a serious problem.

Unemployment is increasing in most of the countries. Injury, violence, and crime are also increasing in some areas.

War and conflicts in many parts of the world have spurred up migration and mobility, causing excessive suffering, disease induction, disability, and death.

The threat of natural and man-made disasters such as floods, tsunamis, earthquakes, droughts, and the outbreak of new diseases also possess devastating effects on health. All of these factors contribute to the increasing social insecurity and stress around the world. Global attention to occupational health safety is also needed to mitigate the risk of diseases and injuries in the vulnerable and high-risk groups.

Another challenge for primary healthcare is resource allocation. A large portion of health budget with few exceptions goes to staff salaries, very little money remaining for medicine and operating costs. The cost of firstlevel care in Africa is nearly double in comparison to Asia, as well as hospital care is also higher. The maldistribution of health staffs and disproportions between various types of health staffs is the main problem in human resources.

Huge variation in the ratio of nurses to doctors is striking in different countries.

IS S UE - 40 2018

There is a great involvement of traditional health practitioners in the health system in many countries. Community health workers and volunteers are also engaged in primary healthcare services in several countries. The role of health personnel needs to be more precisely defined.

There are limited funding, limited capacity and capability of healthcare providers ultimately leading to inadequate services. Training, incentive, motivation, improved remuneration demand necessary attention. More attention to teamwork, collaboration, and appropriate manpower mix can bring higher achievement.

Access to medical technology varies greatly; therefore, availability of qualified and reliable laboratory services is essential for diagnosis and treatment.

One of the greatest challenges is to invent rapid diagnosis facilities in health centres of developing countries for lifethreatening diseases like AIDS, malaria, typhoid, Ebola, etc. Approximately more than half of people lack access to the basic radiological diagnostic services, although radiotherapy and nuclear medicine exist in many developing countries. There is still limited access to diagnostic techniques of Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) scanners compared to developed countries. Many countries need to develop the institutional bodies for technology assessment.

The social determinants of increased health risk, such as poverty,

www.asianhhm.com

29

HEALTHCARE MANAGEMENT

30

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

behaviour. However, health promotion strategies are still very challenging to implement, especially during crisis or disaster period such as Ebola outbreak or any form of natural disaster.

At the international level, primary healthcare is inevitably linked with concerns of economic equity, balanced world development, and international peace. Four basic principles are underlying the primary healthcare: 1) universal accessibility and coverage on the basis of need; 2) community and individual involvement and selfreliance; 3) intersectoral action for health, and; 4) appropriate technology and cost-effectiveness in relation to the available resources. Efficient and effective primary healthcare provides the best contribution to greater social justice and equity by reducing the gap between people with and without access to an appropriate level of healthcare.

The appropriate level of information dissemination and motivation is the key to enhance community involvement in primary healthcare, for greater self-reliance. Health workers must be trained to acquire a better understanding of approaches that promote community participation.

As per the practical implication of the primary healthcare approach, the healthcare system must be enabled to coordinate actions with other sectors at the appropriate level. The primary healthcare approach recognizes the value of technology, particularly when it can contribute cost-effective

AUTHOR BIO

unemployment, landlessness, remoteness, and urban slum environments, have been largely neglected. Health improvement for vulnerable and high-risk groups requires the approaches that designed to tackle the complex web of economic and political marginality.

An integrated multi-sectoral approach is a prerequisite to obtaining access to health services, clean water and food for the empowerment of mass populations.

Many projects have been reported with considerable success in this direction, supported by nongovernmental organisations. Technical cooperation in primary healthcare is a continued effort among developing countries that need seamless supports from multilateral and bilateral agencies.

Behavioural and health system research remains relatively weak in terms of investment in developing countries, which reflected in the poor planning and management. There are enormous problems in logistics management for health services.

Along with haphazard operations, weak communications impose an additional constraint on logistics in the developing world. People in hardto-reach areas, have limited access to healthcare and often suffer from lack of resources, including trained health personnel. Quality assurance remains a major problem in many developing countries because of malpractice in disobedience and non-compliance with the standard operating procedures, poor commitment and inadequate capacity ultimately causing huge death and disability tolls. The future challenge will be to develop applied methods for solving with real problems and for improving health.

The term ‘health promotion’ has been used since the 1920s that incorporates both individual and societal action to ensure improved health. Health education is an essential element of primary healthcare and to comply with the promotion of healthy

IS S UE - 40 2018

solutions to common problems (such as the cold chain temperature indicators).

Increasing the cost-effectiveness and efficiency of health services is also required to make a positive transition in public resource allocation. The primary healthcare approach, which calls for greater community involvement, intersectoral collaboration, and the application of alternative technologies, will need more flexibility and a certain degree of decentralisation through new institutional arrangements.

Substantial progress has been created in the accomplishment of a number of the elements of primary healthcare. Globally as a whole, ageing population, increasing urbanisation, and the emergence of diseases and technologies are creating new demand on the healthcare system. The growing economies are impacting the rising cost of healthcare expenditure, which ultimately increases the concern of national economic competitiveness.

Strong political commitment, community-participation, skilled providers, evidence-based medicine, and sound research are needed to tackle these challenges of the changing world through accessible, affordable, comprehensive and quality primary healthcare. It is high time to get prepared for systematic and scientific addressing of the upcoming primary healthcare challenges.

References are available at www.asianhhm.com

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

SajedaChowdhury is a multidisciplinary Researcher at Hiroshima University, Japan. She has research experiences both in molecular biology and epidemiological field. Formerly, she worked as Lecturer of undergraduate medical students and Trainer of nursing students in Bangladesh. Her research interest included Hepatitis-B virus and antiviral candidates along with public health issues.

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

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

www.asianhhm.com www.asianhhm.com

31

The Importance of Good Capillary Blood Sampling Katja Lemburg, EKF Diagnostics

Capillary blood (fingerstick) sampling is increasingly being used worldwide due to the growing availability of point-of-care (POC) testing (Figure 1). With anaemia affecting approximately 25 per cent of the global population, and a high prevalence in developing countries, haemoglobin (Hb) is the most frequently performed test in POC haematology.1 POC haemoglobin testing can deliver accurate results in settings where a benchtop laboratory haematology analyser is not practical. Such locations include field settings where mobility and simplicity are essential, or resource-poor locations where dedicated laboratories are not available. Notably, pharmacies are increasingly offering Hb POCT in such situations.

However, Hb values are prone to being affected by pre-analytical errors, with incorrect capillary blood sampling being the most common reason leading to inaccurate POC haemoglobin results.2 Therefore, personnel drawing blood must adhere to strict and standardised blood sampling techniques to ensure accurate and consistent POCT results that are comparable to laboratory techniques.

For this reason, detailed capillary sampling guidelines have been published by both the Clinical and Laboratory Standards Institute and the World Health Organization.3,4 This article provides an overview of capillary sampling best practice.

Figure 1 Simple, bubble-free capillary blood sampling using specifically designed reagent free cuvettes such as the DiaSpect Tm microcuvette (EKF Diagnostics, Cardiff, UK).

32

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

IS S UE - 40 2018

Understanding Common Causes of Pre-analytical Errors It is important to understand the common causes of pre-analytical errors and reduce their impact on the haemoglobin result. Variability in reported haemoglobin values can be caused by a number of physiological factors,such as: gender, body position, dehydration, smoking, or altitude. As previously discussed, it can also be significantly affected by pre-analytical errors arising through incorrect capillary blood sampling technique.

Detailed below are some of the most common sources of error that healthcare workers should be aware of in order to appreciate the importance of adhering to standardised best practice capillary sampling procedures: • Choice of lancet – This must make a sufficiently deep puncture to ensure an adequate flow of blood. 1.85 to 2.25mm is recommended for adults, depending on the thickness of the skin. For children aged below 8 years, the penetration depth should not exceed 1.5 mm.2 • Puncture site - Selecting the correct finger and puncture site will ensure best chance of good consistent blood flow and minimise pain for the patient. The middle or ring finger should be used, ideally of the non-dominant hand, as they are generally less calloused and less sensitive to pain compared to the index finger or thumb. The thumb should also be avoided due to its pulse (arterial presence). In the fifth finger the distance between the skin surface and the bone is too small.4 The puncture should be slightly off centre from the central, fleshy portion of the fingertip – near the side where the skin is thinner with fewer nerve endings and less pain sensation, but not on the very side of the finger.

• Cleaning, disinfection and drying - Cleaning and disinfection of the puncture site is essential to remove any potential contaminants that could affect the reading or jeopardise patient safety. The puncture site must also be dried

Figure 2 The effect of time and capillary blood flow on haemoglobin results.

completely, after cleaning, to remove any remnants of alcohol solution that will dilute the blood sample and cause false low readings.

• Applying too much pressure around the puncture site - The finger can be massaged gently before and after the puncture to stimulate blood circulation, but not going beyond the first knuckle. Maintaining a light pressure at the moment of puncture ensures effective penetration. However, the finger should not be pressed too hard as this will push fluid from the tissue into the blood and cause false low readings.

Good Operator Training and Practice

The Importance of Time and Blood Flow

In conclusion, with good operator training and best practice procedures in place, as well as physiological factors considered with the correct reference ranges applied, then Hb testing can be very reliably undertaken in a wide variety of POC settings.

Another key factor that influences Hb measurement is capillary flow. Typically for haemoglobin, the first 1-3 drops after puncture show a higher degree of variability of the Hb concentration, independent of the analytical device used for the test. It is for this reason that these first few drops of blood should be wiped away.

The highest accuracy is generally reached from the 4th drop after puncture, with good capillary flow occurring for a period of 30-45 seconds. After this time, coagulation will occur where blood clotting would lead to inaccurate Hb results if blood is sampled then. Figure 2 demonstrates the ideal capillary blood sampling window.

The most important factor to reduce pre-analytical errors is the presence of a free spontaneous blood flow, especially as neither the size of the drop nor the time of collection following the puncture is well defined and manufacturers’ recommendations on this subject vary.

Best practice for capillary sampling can avoid the majority of pre-analytical errors.2Therefore, in addition to following a standardised documented procedure, it is essential to ensure that all personnel taking blood samples are properly trained. Effective and continuous operator training and practice must be in place to eliminate pre-analytical errors and to obtain correct results for Hb testing, especially from capillary sampling.

References 1. Briggs C et al, Where are we at with point- of- care testing in haematology? British Journal of Haematology, 2012, 158, 679–690 2. Massimo Daves et al, Evaluation of capillary haemoglobin determination for anaemia screening in blood donation settings Blood Transfus. 2016 Sep; 14(5): 387–390.

3. Ernst DJ, Balance LO, Calam RR, McCall R, Szamosi DI, Tyndall L. Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens. 6th ed. Approved Standard GP42-A6. Wayne, Pa: Clinical and Laboratory Standards Institute, 2008. Available at: https://clsi.org/standards/ products/general-laboratory/documents/gp42/. Accessed July 6, 2017.

4. Dhingra N, Diepart M, Dziekan G, et al. “Capillary Sampling,” in WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy. Geneva, Switzerland: World Health Organization, 2010. Available at: www.ncbi.nlm.nih.gov/ books/NBK138654. Accessed July 6, 2017.

Advertorial www.asianhhm.com

33

FACILITIES & OPERATIONS MANAGEMENT

HIGH RELIABILITY IN HEALTHCARE

Creating the culture and mindset for patient safety High reliable organisations system ensures and manages resilience by focusing on safety of customers over other performances. Their intention is to provide trust worthy services and create environment where by potential problems are foreseen, recognised priory, and basically is always respondent to prevent tragic.

Staff should be aware of the culture to be followed with patients and organisation should orient their mindset with help of quality culture programmes and put down model and strategies accordingly in benefit of patient. Often patients are unaware of their rights and care provided, thus empowering them is essential.

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

C

ulture of a healthcare organisation impacts the mindset of employees and surrounding environment.

Considering organisations culture there are various aspects which should be assessed. It starts from how the staff value the decision of senior, new innovations and technologies that are applied in organisations, risk taking capability, alertness towards minute details, contribution towards needs of the patients apart from treatment, and behaviour in conflict situation. All those things matter and contribute to build a reliable organisation. The most important aspect of quality culture is accountability. Many of them get confused between the two terms responsibility and accountability. In short and sweet words, responsibility tends to share your duty and the credit is shared amongst the team members responsible for that job role. Whereas accountability is a

34

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

IS S UE - 40 2018

FACILITIES & OPERATIONS MANAGEMENT

liability which can’t be shared and only you are creditable for it. Accountability is very important in healthcare culture, as it improves doctor-patient trust, reduces the misuse of resources, and helps organisations provide better quality care.

In many healthcare organisations the tendency of measuring the patient safety, is by evaluating the incident reports. The head officers of the healthcare organisations should realise the fact that not all patients and relatives are vocal and have guts to complaint or raise their voice. Instead what they follow is change the center of treatment. This is indeed not right, nd leads to increase in cost and declined value of the hospital.

Safety can be distressed in variable ways and system can fail to address and rationalise the process. The logic behind failures may be familiar and predictable, but sometimes the system fails to address and responds inadequately and in unpredictable ways. Some of the safety parameters are achieved by staying alert and acknowledging them at right instant to keep things on track. Normally, in top healthcare organisations, doctors, nurses, and managers follow similar ways to ensure patient safety. These efforts though are not showcased; have to be realised by the assessor person and those minutes things should be acknowledged by the senior team members. This encourages the staff to keep going and motivates to seed the culture of safety parameters. This also concludes that to assess the culture of safety the assessor has to observe beyond the set of metrics and parameters to monitor functioning of the healthcare system.

Right from commencement, organisation should encourage performance measurement involving collecting, reporting and benchmarking data. Assessing scientific as well as operational performance generates buy-in for improvement and allows an organisation to track its improvements over time. This data further can be used to recognise and prioritise goals and

to track growth toward establishment of high-reliable organisational goals.

While setting the goals several key factors are considered. Before you start, ensure that you understand the systems that are already in place and then plan, execute and maintain services for other safety declined services which are critical in setting goals and achieving error-free performance and operation.

The application of soft intelligence skills for monitoring and prospecting the issues receives smaller attention.

Quality culture in High-Reliable Organisations (HRO)

The culture of a HRO is such that they encourage the staff and strong safety parameters are followed that permits learning from errors and are observed as opportunities. In any event related to safety, feedback plays a major role.

Especially a human or organisational error can be overcome by analysing

Analysing the issues and attending to it immediately ensures safety

Identify flaws and gaps in the system that can be discharged

the communication gaps between the staff and forthcoming by various ways and methods to ensure appropriate feedback system.

“The secret weapon towards building efficient & high-reliable organisation is Quality culture” 4C-Critical Essentials HROs often identify strategy through pilot study whereby initially training, planning and practice are carried on small group. The aim is to assimilate three significant practices into the groundwork: • Commitment entails person to stay motivated and follow work ethics towards their job roles. This provides company modest benefits like developed productivity and lower employee turnover.

• Communication entails person to express straight forwardly and use standardised protocol ways to send and receive data

Staff understanding regarding accidents will increase and they will be aware and alert of accidental factors

Reporting the issues

Cultivates an understanding

Idenyifying gaps in the system

Smooth communication & feedback system

Communicate the concern about accident to ensure the errors are prohibited and culture of safety is maintained

www.asianhhm.com

35

FACILITIES & OPERATIONS MANAGEMENT

Assess current status of culture of safety Team-based training focusing on safety culture

STEP TO PROMOTE CULTURE & MINDSET OF SAFETY

Keep safety policies in place

Leaders should play positive role model

• Coordination entails person to provide and obtain support for the team effort and under take duties and responsibilities as per team expectations • Collaboration entails person to believe and admire teammates, monitor awareness at all times, and cooperatively resolve the problems and adopt to conflict management techniques.

8 Step approach for patient safety:

The issues arising in healthcare system are perceived as carelessness of some

36

Analyze data

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

Use adverse events as opportunities

Distinguish between deliberate unsafe actions & human errors

human responsibility but fundamentally entire system is responsible. Single person may be authorised and made accountable for duty but system should be aware that safety of patient is the responsibility of the entire organisation.

Staff should realise that major of time is spent at job and independent of job role we should be proactive and do it appropriately as per ethics.

1.Assessing status of safety culture: The organisation should follow certain assessment tools as per their services to ensure safety. Assessment is the only way to measure the overall compliance

IS S UE - 40 2018

Apply improvements on single-unit

with safety and can highlight the changes, which will engage employees in creating long-term adjustments to your safety culture.

2.Analyse data to make improvements: Analysing the assessment parameters will help in pointing out the current status of safety culture. This will guide the way to come up with precise improvements that take your organisations unique characteristics into account.

3.Apply improvement on single-unit: A pilot study should be carried out

FACILITIES & OPERATIONS MANAGEMENT

6.Leaders should play positive role model:

8.Team-based training focusing on safety culture:

Executives, managers, and the top head staff should act as the model for all interactions between staff at various levels in a hospital. This helps people feel less over whelmed encountering issues when necessary, and it helps to encourage mutual spirit of respect.

Leaders should keenly contribute to all initiatives and programmes designed to improve safety culture. Leaders play an accountable role and are point of source for learning for juniors.

7.Keep safety policies in place to support culture of safety and reporting: Facility wise safety policies and protocols should be elaborated to each employee and clear plans should be designed for supervising the responsibility and accountability to enhance patient safety. To make reporting process transparent, design definite policies addressing the protocol for reporting adverse events. Assure that all staff is aware of the policies, giving them periodic reminders if necessary.

Organisations having low incidence ratio train their employees to recognise and respond to a variety of problems.

Staff is trained in safety applications and education is provided to create awareness and anticipate them to all possible adverse incidents to take right actions. Training for initiatives dedicated to refine quality and safety parameters must include a team-based approach.

Cooperative teamwork surges communication, permits team members to recognise possible errors beforehand, and ensures both patient safety and employee satisfaction.

AUTHOR

BIO

on a single department to examine the feasibility of an approach that is proposed to be used in other departments of organisations. Testing on a small-scale provides assurance of long-lasting changes towards building a more positive safety culture.

4.Use adverse events as opportunities for improvement: One of the top ways to promote a patient safety culture is to give doctors and nurses the freedom to openly report any mistakes or problems they notice. Treating every mistake as a learning experience helps keep them from causing harm to patients down the line.

5.Distinguish between deliberate unsafe actions & human errors: Nowadays in many organisations the issue arises not because of a simple mistake, but because of someone’s flagrant, risky action. Authorised employees should follow certain protocols that will help out to differentiate between these cases and handle the situations accordingly. It’s not about being observed. It’s about what you realise, what you ask, what you say, and what you do.

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

Way Forward:

Adopting approaches to high-reliable strategy must confirm that the strategy is allied to their organisational goals and are way forward to accomplish goals and sustainability toward zero harm. One of the best known strategies is Evidence-Based Leadership (EBL).

It helps in designing the framework that ensures building of sustainable culture. That’s because it is based on operating system, accountability parameters that acts as the foundation for orientation and is the critical factor of high-reliable strategy.

Putting together, performing as intended plays a major role in each activity. Safety focus in addition to performance as intended leads to zero harm services. Evidence-based processes plus performance as anticipated results into clinical excellence and last but not the least patient-centric approach and performance as intended leads to positive results for patient engagement.

Risk is a function of probability and consequences. By declining the probability of misfortune, high-reliable organisations alter a high-risk initiative to a high-consequence method; they operate to make system ultra-safe.

References are available at www.asianhhm.com

www.asianhhm.com

37

FACILITIES & OPERATIONS MANAGEMENT

Discharge Begins at Intake

Communication tactics that help patients transition and shorten stays and reduce readmissions Keeping the patient and family members at the forefront by pro-actively communicating with them will automatically allow for more satisfied, engaged and an overall more positive experience for patients and their families.

Nancy Michaels, President, NancyMichaels

W

henever I work with a hospital or healthcare system to help them with communication processes, I introduce this concept created by business guru and author, Steven Covey, that states “begin with the end in mind.”

This approach of reaching effective outcomes works with establishing and reaching most project management goals and objectives.

With patients and their family members, the idea of discharge beginning at intake makes sense so as to not offer up any unexpected surprises, but to clearly articulate what a patient and family member(s) should expect starting with the intake process.

Share the procedure's timeline, the expected length of the stay, what to expect at discharge (to the best of our abilities) with your patient ahead of time, not in real time, as things are happening.

38

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

When this is done effectively, patients have a better understanding of what to do prior to a hospitalisation (assuming there’s time for an intake; if that’s not the case, then the ‘intake’ could be explained to a family member or friend on behalf of the patient) and are not upset when it’s the expected time for them to return home. Most of us are compliant and want to be when we know what to expect.

Here are a few suggestions to help prepare a patient and their caregivers with their course of treatment, preparation prior to entering the hospital and discharge plan that can be ideally delivered prior to their hospital stay or to family members in emergency situations.

1.Preview Expectations with Patients & Family Members

I learned the concept of previewing expectations from my son’s behaviourist when he was only four years old. I had a

IS S UE - 40 2018

suspicion that Noah was on the autism spectrum from only a few months of age. As a toddler, Noah’s speech delays caused him (and the rest of us) much frustration and resulted in behavioural issues that needed to be addressed.

He would often hit, spit or go into uncontrollable temper tantrums.

Loud noises like police sirens or toilets flushing caused him pain or discomfort and he would cover his ears. Crowds also bothered Noah, and we noticed his ‘behaviours’ increasing. When Noah was four, we were able to have him evaluated by a renowned neuropsychologist, who diagnosed Noah’s symptoms as presenting like Asperger’s Syndrome – on the autism spectrum.

We sought out the help of a child behaviourist, named Janice, to assist us with Noah at home and at school.

We did and it was life-changing for me. Janice came to our house very early one morning at 6:30am just in time to

FACILITIES & OPERATIONS MANAGEMENT

systems in the art and craft of practicing the theory of ‘previewing expectations’ with patients and family members.

2.Decreasing Fear through ProActive Communication

witness me serving Noah his breakfast.

As most mornings went, I placed Noah’s scrambled eggs on the table in front of him and he’d take his hand and throw the plate off the table leaving eggs strewn throughout the kitchen. I was at my wits end. And by this time had learned to use plastic plates!

Janice witnessed what happened and simply whispered to me, “Nancy, make him the eggs again and tell him that you’re going to give them to him, before you put it in front of him.” I made the eggs again and before I placed the dish in front of him, I said, “Noah, mommy made you eggs for breakfast, here you go.” He lifted his fork and began eating.

What? Impossible I thought. How did this happen? What had I been missing all this time?

Janice explained that the breakfast scenario was a very short-term example of ‘previewing expectations.’ In other words, by letting Noah know that

breakfast was about to be served – as opposed to simply placing his breakfast in front of him – he was able to prepare himself for the meal he was about to receive. She told me that the concept of ‘previewing expectations’ would work with everyone in my life. For example, when going to the grocery store with your three children give them a preview in the parking lot by saying “if everyone behaves and doesn’t throw things into the cart – when we get to the checkout line, I will allow you each to get one candy.” It worked like a charm with all three of my children.

I was a critically ill patient a few years after working with Janice when I was diagnosed with organ failure and had an emergency liver transplant within one week of going to my local ER and being transferred to the critical care unit of a major Boston hospital. I now know first-hand the benefit of this approach and train healthcare professionals and

As a long-term patient there were many hours, days, weeks, and months that I had time to think – a lot. I often felt that I was in a continuing state of not knowing. Not knowing about what the next procedure might be. Not knowing when I’d be able to breath on my own when I was coming off the ventilator (super scary). Not knowing when my family or friends might be visiting? Not knowing when my doctor would do his or her rounds and not knowing if they’d share any good news that day. The list was endless.

What made things worse, is that there were times when I’d be told something was going to happen (i.e.

CT scan, MRI, biopsy, etc.) – but it was hours or days later when it actually did occur. The worst was when I was told I’d be taken off the ventilator the next day (after being on it for about 30 days) and it was four days later when that happened. That’s very unnerving to a patient who hasn’t spoken a word in the three terrifying months as an ICU patient.

Knowing what to expect and what may be needed – a family member or friend to be with the discharged patient, medical appointments that need to be kept, open lines of communication with a doctor or nurse practitioner with a direct phone number that someone will answer the call to answer your questions, are all helpful in easing patients and family member’s level of anxiety that can’t help but shorten stays, increase satisfaction and decrease recurring admissions.

3.The Case for Over Communicating

More communication – even repetitive communication – helps patients and family members better understand

www.asianhhm.com

39

FACILITIES & OPERATIONS MANAGEMENT

The approach of reaching effective outcomes works with establishing and reaching most project management goals and objectives.

what your expectations are, and can prepare them mentally and physically for what’s to come. Taking the time to communicate what they can expect allows for more positive outcomes.

I realise that healthcare providers want to provide consistent communication throughout the process and it may be the ultimate goal of healthcare, but I also know first-hand that doesn’t always happen. For me, my anxiety increased primarily after my family left and I was experiencing pure panic about my physical and mental state. Would more consistent communication have made things less stressful for me? Would it be for my family? Would it work for other patients?

I firmly believe it would and have heard from others that it goes a long way in calming nerves.

4.Breakdown Silos between Departments

One of the greatest fears of patients and family members is that their medical team is not in communication with one another. Our idea oftentimes is that there are too many cooks in the kitchen and does anyone really know what the other division is doing?

Chances are that you are all speaking regularly and very much aware of what

40

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

needs to be addressed with each unique patient you care for. As crucial as it is for departments/physicians treating the same patient to communicate with one another, this dynamic interaction needs to be communicated to the patient as well to ease doubts, fears and discomfort.

We simply don’t know what if anything is being addressed between a team unless that is clearly articulated to us.

Please share what the ‘collective’ course of treatment is working towards. We so appreciate the effort of anticipating our anxieties and keeping us aware of what is happening.

5.Be Present and Aware of the Situation You are in and that Your Patients are Experiencing

Time management is important for everyone in a medical setting; however, if you feel rushed, your patients will sense that. If they are not comfortable asking questions because it would take extra time, it will lead to confusion and discontent later on for everyone.

6.Truly Listen

You’re already doing that with each interaction you have with a patient. The best way for your patients or a family member to know you heard them is to paraphrase, repeat important question

IS S UE - 40 2018

or key concepts back to them to ensure you've heard their concerns correctly.

When responding to your patients or family members, start by saying, "what I hear you saying is . . ., is that correct?"

We remember more of a conversation when we paraphrase and repeat back.

It also allows for misinformation or understandings to be cleared up on the spot and not escalate with missed assumptions.

During intake or early on in a patient’s hospital stay, it’s wise to revisit what the plan is so there are clear expectations of what will happen should everything go according to plan.

7.Practice being Empathetic

The ability to put yourself in the bed of your patient or the mindset of a family member and deliver messages in the way you would want someone to tell you or a loved one news about your health is a good start to being empathic.

When people know you care, the level of trust increases and improves the overall situations tenfold. If a patient or family member is resisting a discharge, hearing them out with an empathetic tone shows a level of compassion and understanding that is helpful when it’s your turn to explain the benefits to the patient of being able to leave the hospital and to feel positive about that.

8.Take it From the Top — Leadership can Instill Compassion

Compassion and human understanding needs to come from within the top of the organisation and shared with everyone

FACILITIES & OPERATIONS MANAGEMENT

9.Remember: First Impressions are Made within Seven Seconds . . . or Less

Always try to make the best possible first impression always. Clean clothing, well-groomed nails, hands, hair all go into making a positive (or not-sopositive) first impression. In healthcare especially, these first impressions matter most. They also add to the credibility and believability of what you say. Non-verbal presence and

communication are critical in winning people over and your ability to speak with credibility.

10.Put Conversations and Questions In Context

Many conversations with patients and their families can be difficult or uncomfortable. Attempt to normalise situations by asking permission to share results of tests with them, or get answers to questions that you need to know and could potentially be frightening to a patient or family member. By saying, "we have to ask all patients these questions when they enter the hospital, so I hope you don't mind me asking a few questions now, is that ok?" This reduces fear and allows patients to feel that they have more control in situations where they have very little.

Imagine if – in the healthcare market – every patient and their family members had expectations previewed

for them so they had a good idea of what to expect – at the very beginning – during intake – or even pre-admission?

What if the previewing of expectations continued during their (hopefully short) stay and prior to discharge?

When people know what to expect their anxiety levels decrease – their stress goes down. When stress diminishes, so do anxious conversations, demands and complaints to and about medical and non-medical staff. Money is saved and patients are more content across the continuum of healthcare. It’s a win-win-win scenario. Stays may be shorter and readmissions decrease. Isn’t that what value-based healthcare is all about? Keeping the patient and family members at the forefront by pro-actively communicating with them will automatically allow for more satisfied, engaged and an overall more positive experience for patients and their families with these points in mind.

AUTHOR BIO

in the health continuum. To doctors, nurses, technicians to maintenance people, the culture of compassion begins within and throughout the leadership and permeates throughout an organisation and is delivered to the end user — the patient and their family or caregivers. We feel it and appreciate the kind gestures, tone of voice, words of encouragement and pro-active communication.

Nancy Michaels speaks and consults with hospitals and healthcare systems who want to more fully engage and make the patient experience a better one through more effective communication.

www.asianhhm.com

41

INFORMATION TECHNOLOGY

DIGITAL TRANSFORMATION HEALTHCARE IN DISRUPTIVE TIMES

I

The integration of IT in healthcare has opened doors for various innovations in the technological frontier.

India unlike countries like UK or US has a lot of pitfalls in the healthcare sector and technology is very crucial to address the growing menace. This article explores how the digital transformation in healthcare is shaping the Indian healthcare system.

UshaManjunath, Director, IIHMR (Institute of Health Management & Research)

42

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

IS S UE - 40 2018

ndia’s healthcare market is one of the fastest growing, witnessing an overwhelming growth of nearly 25 per cent in the recent years and rightly so. The market value of Health Information Technology is pegged at US%1 billion and expected to grow one and half times by 2020. The disruption in the sector is driven by technology innovations including IT, biomedical research, healthcare delivery models, population health, financing of healthcare, people and provider knowledge and expectations in addition to the epidemiological spectrum.

INFORMATION TECHNOLOGY

The Stage for Transformation is Already Set:

India which has been taking notable steps towards digital proliferation in different sectors has also seen affirmative growth in the healthcare industry.

Though not swift, a steady growth has been witnessed. Now with the availability of well-equipped medical devices and telemedicine, the phase of digitisation in healthcare has taken a new dimension. Subsidising to this factor, the ‘Universal Health Coverage’ themed policy of the union budget has been a great boost. In fact, a sole factor cannot be termed as the pioneer to digitisation of healthcare. Several factors have contributed for the digital transformation in healthcare which has been saving millions of lives every day.

Technology, digital literacy, and internet penetration in India is becoming more pervasive and very impressive We have more than 460 million internet users in 2017, and by 2021, the number is expected to reach 635.8 million users which indicates that digital healthcare is increasingly becoming feasible.

Digital connectivity growth of about 15 per cent in 2014 is expected to grow to 80 per cent access in 2034, with rural internet users increasing by 58 per cent annually. Smart phone users with 299.24 million going up to 340 million by the end of 2018 would soon surpass the number of users in the US. Nearly 1 billion subscribers for mobile phones are reported from the country’s telecom regulator and soon they will all become smart phone users. With 2G/3G/4G technology and broadband internet, the healthcare users will look for multiple channel experience from provider companies.

Startups and entrepreneurship India’s Global Innovation Index is improving, and it is ranked 3rd among the middle-income countries.

Despite the protracted profit interval, approximately 300 start-ups entered healthcare information market in

2015. The technological developments in healthcare applications have transformed the lives of people.

Health apps have been instrumental in performing various functions like oversee personal vitals to making the treatment easier, real time data capture, telemedicine, point of care devices and trackers. These developments attracted huge funds in 2010-15 for healthcare sectors like Medical Health apps, appointment booking, wearables, telemedicine, data analytics, practice management, wellness and clinical decision systems in that order.

In fact, telemedicine industry has been witnessing exponential growth and is expected to be worth US%32 million by 2020. Furthermore, even artificial intelligence; augmented reality

and virtual reality are changing the landscape of healthcare industry.

Digital India It is not only that private healthcare is investing in technologies but the Government’s e-health initiatives in line with ‘Digital India’ campaign are giving a fillip to the sector’s growth.

Domestic market growth will give a boost to healthcare domain, medical devices, digital applications, and Health IT. Top pharma companies have had 63 per cent unique apps in 2014 compared to 2013. Digital India, Skill India and Start-up India campaigns are bearing fruits and will pitch India for a better ‘Digital Healthcare’.

Reducing rural and urban divide The technological innovations are modifying the healthcare industry

www.asianhhm.com

43

INFORMATION TECHNOLOGY

and will loosen the rigid division of urban and rural gradually. Urban areas have much sophisticated healthcare infrastructure while rural areas are lacking basic amenities and access to it, despite having major population residing there. Technology can definitely play a great role in bridging this gap. The use of mobile phones for medical consultations by using videos, image and conference has been a great help to people residing in rural area; who have to strive to seek medical care.

Telecare, better patient engagement, health education and public health innovations are already underway.

Health financing Investments and healthcare funding will be the most critical area that needs attention. Major transformation in Universal Health Coverage must be technology enhanced for transparency, governance, and access to high quality care for all. Healthcare is now at the centre of Central and State budgets: India cannot afford to miss the opportunity for demographic dividend. Commitments in increasing

44

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

public spending in National Health Policy 2017 to nearly 2.5 per cent of GDP cannot be back tracked. In the private sector, IBEF has highlighted the critical investments in India: Max Healthcare (US$48 million in Cancer care hospital), Practo Technologies (raised US%55 million), Gamma Group (investing US%449.68 million in health infrastructure and education sectors). This is an indication of growth in the sector and gives a big boost to technology based care, technology adoptions and transformations.

Transformation is Underway:

The dynamic digital transformation that is being spoken of is not something in vogue. In fact, India has always been a steady adopter of technology in healthcare. Today, when integration of IT in healthcare or telemedicine is a proves this reality.

Patient care and safety Dr. Nandakumar Jairam, CEO, Columbia Asia, in CAHO Tech 2017 reiterated that transformation is evident: Stethoscope in 1970s has given way to today’s healthcare as

IS S UE - 40 2018

‘frontier science’. IVF and fetal medicine and many others are already a reality. Technology and automation in diagnostics and laboratory services are already being adopted in the Indian scenario. From better Turn Around Time (TAT), improved accuracy and report delivery to patients, the transformations are evident. Medanta – The Medicity has implemented innovations in lab automation successfully. Majority of the emergency physicians, hospital lab head and internists agree that TAT of lab results enhances trust and sense of well-being and enhances patient safety.

Manipal Hospitals, being the first hospital chain to adopt robotics for surgery and operations, deployed IBM’s AI cognitive computing platform ‘WATSON’ for treatment of cancer patients. AIIMS, New Delhi has a state of the art ‘robotic surgery unit’. Hospitals like NH and others have already successfully implemented innovations in ICU monitoring using high tech and many interfaces.

Technologies for ‘data visualisation’ and hence improving accuracies in diagnostics and treatment options is of high value. Hospitals like Amrita Institute of Medical Sciences are using 3-D Printing for facilitating difficult cardiac care decisions.

Applications of telecare in ophthalmology, radiology and cardiac care consultations have already been proven to be very effective in improving access and reducing costs. Applications of point of care devices, wearables, IT and digital education/empowerment in geriatric/chronic care and home healthcare are making inroads at a faster pace.

Training and skilling of providers Simulation-based medical and nursing education from use of lifelike manikins to present synthetic models to hi-fi simulation suites have enabled dissemination of knowledge, skills, and attitudes. It is common for e-learning platforms and certification to eliminate cost

INFORMATION TECHNOLOGY

Digital connectivity growth of about 15 per cent in 2014 is expected to grow to 80 per cent access in 2034, with rural internet users increasing by 58 per cent annually.

from health will make Public Health data for evidence-based applications of various health programmes. For e.g. Programmes for ‘TB Free’ India and ‘Stop TB Strategy’ needs many digital applications for programme implementation and monitoring.

Emergency and ambulance services This is one area in which technology and IT applications has already transformed emergency and ambulance services since its large-scale innovations

by EMRI in 2005. 108 Ambulance Services have very positively impacted maternal care in India. Technology and process standardisations have been highly possible in a short span of time.

Research and innovations Technological advancements in bio-medical research, drug delivery, clinical research, evidence-based medicine and medical device innovations (low cost, m-health, e-health, app-based etc.) have all entered the vocabulary of research and innovations in healthcare in India.

Personalised medicine in the age of robotics and impersonalisation is AUTHOR BIO

and geographic challenges in skilling.

SMAC - (Social, Mobile, Analytics and Cloud) based technologies have given newer opportunities for learning and teaching. A case in point is the successful implementation Simulation in Training of ‘Healthcare Workers’ in Father Muller Hospitals, Mangalore and others. Digital education in not only empowering providers but also patients.

Health informatics and data management The integration of IT in healthcare has revolutionised the process of medical treatments, management of data, electronic prescription, scheduling appointments, pathology lab management, case analysis etc. In fact, there is no doubt that other function of hospitals like HR, administration and marketing will receive a good boost with its applications in information system of hospital management and enterprise resources planning software.

The public-private partnerships are all set to get a hold to leverage the CSR and power of technology. The programmes, which are CSR-based in technology have been very successful in appealing to companies who are big players in the market. However, the growing integration of IT in healthcare has not made everything easy for the organisations. Now the biggest task lies in front of them is to find a meticulous way to build capacity by acquainting the right skill sets among zealous health and hospital management professionals.

Outpatient, in-patient, emergency/ ambulance, ICUs, critical care, home healthcare services etc. will be impacted positively by cloud computing for data access and management, Electronic Medical/Health Records and mobile and the internet of things. Electronic Personal Health Records (EPHR) at population level will transform data management. Right now, patients using private labs can download reports and soon that could become common in public health too. Big data

the reality (!). Embedding of sensors (vs wearables like band-aids) like ‘nanosensors’ in blood stream could detect cancer, an impending heart attack or a forthcoming autoimmune attack with improved precision and early. Continuum of care, ‘womb to tomb’ dissection, decoding and defining granularity at the molecular level for DNA sequencing will all be possible.

Cochlear implants for hearing loss and a trachea transplant are already here. Concept of Cyborgs ‘fusion of artificial and biological parts’ in humans is science fiction. Futuristic possibilities could be a ‘sensors’ to transfer thoughts and call (& talk) via body area networks (or brain area networks)!

From the dawn of civilisation until 2003, the world had accumulated I billion gigabytes, now the data richness is generated in multiple zettabytes (each zettabyte=1 trillion gigabytes each year)! Healthcare providers must leverage BIG DATA for making ‘health-and-wellness’ for population a reality. Life science, Technology and Medical Industry must come together with governments for transformations to be harnessed. Many social, moral, ethical, and existential dilemmas must be tackled with sensitivities in this exciting odyssey.

Equally important for India is a ‘Healthy India’, health as a right for every citizen. We already saw ‘Humanoid Sophia’ meet the press, we could have ‘Humanoid Doctors’ in remote areas! The ‘Dr. McCoy from Star Trek’ moment for healthcare with robotic arms that perform surgery to nanorobots delivering drugs through the bloodstream is already here!

Usha Manjunath, a Healthcare Management Academician and currently the Director of IIHMR, did her M.Sc. (Speech & Hearing) from AIISH, Mysore and M.Phil (Hospital & Health Systems Management) and PhD in Quality Management from BITS, Pilani, and Rajasthan, India. She has completed a Certification Program in Strategic Leadership and Management in Healthcare in December 2012 by IIHMR, Delhi and Johns Hopkins Bloomberg School of Public Health.

www.asianhhm.com

45

INFORMATION TECHNOLOGY

Modern Technology Is it helping or hindering health?

W

e live in an exciting technological time. Every day, technology accelerates and evolves, changing the way we live and interact. Such advances have affected the way we communicate, work, and travel. Technology is also having a huge impact on the healthcare industry1 .

1. http://phamax.ch/blog/?p=917?utm_ source=pharmafocusasia.com&utm_ medium=article&utm_campaign=enoutreach

46

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

As the years go by, we are faced with more and more breakthroughs in the way of information gathering, treatments and communications, which affect patient experience, reduce costs, and improve quality of care.

Despite the many advantages offered by modern technology, a number of concerns remain. Technology can, in fact, encourage patient-centred care2 2. https://www.healthitoutcomes.com/doc/ways-technologyimproving-patient-safety-0001

IS S UE - 40 2018

and reduce potential medical errors, but it has also been blamed for a rise in obesity, mental health issues, and insomnia.

We will explore the ways in which technology has helped and hindered health, healthcare, and the patient experience in the following paragraphs.

Clinical Wearables Provide Doctors with More Data

In the first half of 2017 alone, the health

INFORMATION TECHNOLOGY

Article covers how health technology is advancing and how it is being used to treat a range of diseases and conditions, greatly improving patient care whilst also allowing patients to stay at home for longer without hospital intervention. On top of this, technology is benefiting us in terms of data and knowledge about certain conditions.

Behsad Zomorodi, Founder and CEO, Phamax

technology sector brought in more than US$3.5 billion in ventures3. The health technology market is booming, and a large part of this is due to clinical wearable devices.

Wearable devices allow medical professionals to collect data remotely, which helps them to monitor and assess the health of the wearer without

interference. This means doctors can be informed and knowledgeable about an individual’s condition, without seriously changing their way of life.

Sufferers of Alzheimer’s are able to continue living at home for much longer4 due to wearable devices and sensors being placed around their homes. Such sensors send out alerts

3. https://www.cnbc.com/2017/11/19/nixon-peabody3-shady-things-that-digital-health-start-ups-do.html

4. https://www.telegraph.co.uk/business/social-innovation/ smart-health-technology/

and notifications if meals are missed, or if they fail to get out of bed that day.

This gives everyone involved peace of mind, but it also gives doctors a clearer picture of the patient’s health, which influences their medical decisions and recommendations.

Clinical wearables are being used for a range of other diseases and conditions, including anxiety, depression, asthma, Chronic Obstructive Pulmonary Disease (COPD), and diabetes. They

www.asianhhm.com

47

INFORMATION TECHNOLOGY

are even being used to predict the onset of strokes. In essence, technology is allowing us to be forewarned, which is allowing us to be forearmed.

Technology is Vastly Improving Patient Care

Technology and big data have made patient care much more safe and reliable over the years. Doctors and nurses can now use tablets or handheld computers to record a patient’s medical history and ensure they are being given the right treatment. Such electrical equipment and databases also store results of vital signs and lab tests, which means patients have much easier access to their own information. They are also able to develop a greater understanding of their own treatment and care.

Social Media is Impacting Mental Health

Of course, technological advancements aren’t all positive. The rapid growth in

48

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

Technology can, in fact, encourage patient-centred care and reduce potential medical errors, but it has also been blamed for a rise in obesity, mental health issues, and insomnia.

being the worst social media network for mental health and wellbeing5. This is a result of a ‘compare and despair’ response, as young people are able to constantly see their peers having a good time that they, seemingly, aren’t having. Despite the negative feelings brought about by social media, people are unable to stay away; in fact, it has been shown that the draw of such platforms can be as addictive as cigarettes and alcohol6.

Technology is Making us More Active

the popularity of social media has led to the speculation that such constant connectivity and social sharing has led to problems related to mental health.

According to a recent survey by the Royal Society for Public Health, social media can be linked to high levels of anxiety, depression, and Fear of Missing Out (FOMO), with Instagram

IS S UE - 40 2018

While technology might be taking its toll on our mental health, there is evidence to suggest that it is pushing us to be more active. As evidence, we can look to tools such as Fitbit7 and other 5. http://time.com/4793331/instagram-social-mediamental-health/ 6. https://www.irishtimes.com/business/technology/socialmedia-use-linked-to-anxiety-and-depression-1.3097776 7. https://www.fitbit.com/uk/home

INFORMATION TECHNOLOGY

apps that track our steps and general activity. All these apps encourage us to hit our daily targets, either through walking, running, or various home workouts. This is all designed to increase the amount of exercise we do every day, but some apps even count calories burned, track heart rate, and monitor sleep. This improves the overall lifestyle, giving patients a more fulfilling life.

Technology is Informing and Empowering Patients

More and more people are making use of the internet to research upon their medical issues and conditions.

Individuals are taking the time to look up symptoms, become educated on treatments, and research medicines.

Ultimately, this means that people are more knowledgeable and informed, which gives them greater peace of mind and empowers them to have a say over their own patient care.

Of course, access to information is not necessarily always beneficial.

Patients might research symptoms and convince themselves they have a particular condition. They might fight tooth and nail against a doctor’s recommendations based on logic that isn’t entirely sound, or on information from an unreputable medical website.

Though this can be frustrating for medical professionals, it is offset by the fact that patients are generally more confident and they are able to get in touch with other people with the same condition, to compare notes, and discuss their patient experiences.

Technology has Improved Our Treatments, Machines, and Medicines

There is one obvious way in which technology has changed the healthcare industry for the better. It has given us new machines, medicines, and treatments that have saved countless lives and improved the quality of life of thousands of patients worldwide. From MRI scanners to X-Ray machines, technology has enhanced the diagnosis of various conditions and, ultimately, treatment.

One condition that has seen remarkable new advances due to health technology is that of haemophilia.

Gene therapy has recently been used to treat haemophilia8, an inherited blood disorder. In one trial, researchers studied ten men with haemophilia, who received a single intravenous infusion of a virus carrying a gene for factor IX, a blood-clotting protein.

Eighteen months later, nine out of the ten patients had no bleeding episodes, as reported in the New England Journal of Medicine9. On top of that, eight out of the ten patients no longer needed a factor IX injection every few days, seriously improving the overall quality of life.

Another study carried out by clinical researchers at the Barts Health NHS Trust and Queen Mary University of London10 found that 12 months on from a single treatment 8. http://www.sciencemag.org/news/2017/12/gene-therapystops-bleeding-episodes-hemophilia-trial

with a gene therapy drug, patients with haemophilia A were showing normal blood protein levels, which effectively means a cure for haemophilia is now a very real possibility.

Technology and Melatonin Production

You can’t mention health and technology in the same vein without addressing how it impacts our quality of sleep. After all, sleep has a huge impact on our overall health11. The lack of sleep can cause memory issues, problems with concentration, mood swings, and high blood pressure. It can also cause weakened immunity and weight gain.

Technology such as tablets, laptops, and smartphones can affect your sleep because they suppress melatonin production12. The blue light emitted by these screens reduces melatonin, making it harder to not only sleep, but to stay asleep. This is a problem, given that many people check their gadgets just before they head to bed.

As with any tool, technology can be a help or a hindrance, depending on the situation. What is clear is that it has a huge impact on the quality of life, the overall care of patients worldwide, and on healthcare in general. This influence is likely to become greater as the years go by and technology continues to evolve. It’s exciting to consider the ways in which technology will change the way we live, how we detect certain conditions, and how we battle disease.

9. http://www.nejm.org/ 10. https://www.bartshealth.nhs.uk/news/groundbreakinggene-therapy-trial-set-to-cure-haemophilia-a-2529

11. https://www.healthline.com/health/sleep-deprivation/ effects-on-body#1 12. https://sleep.org/articles/ways-technology-affects-sleep/

AUTHOR BIO Behsad Zomorodi is the Founder and CEO of phamax , a Swiss pharmaceutical consultancy that is passionate about simplifying healthcare market access complexities. Behsad has over two decades of industry and consulting experience in the healthcare sector. At phamax, Behsad heads long-term strategic planning, business development, and investor relations.

www.asianhhm.com

49

INFORMATION TECHNOLOGY

Electronic Health Record System from the Perspective of Data Privacy

Electronic health record systems handle health-related ultra-sensitive data of a person throughout his life, along with all personal information that accurately identifies him. This makes it imperative to protect the data from cyber-threats and consequent untold damages. This article discusses the various issues involved and the different mitigation methods.

SB Bhattacharyya, Health Informatics Expert, Founder & CEO Bhattacharyyas Clinical Records Research & Informatics LLP

50

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

IS S UE - 40 2018

D

uring the course of any clinical encounter a person discloses ultra-sensitive healthrelated information to his provider to enable the latter to address his health-related problems better, faster, and hopefully, cheaper.

Information that he would otherwise rather keep well under wraps. Ethics demands all providers treat all information that their patients disclose to them with the greatest of care and keep them secreted away from everyone, even the spouse, unless explicitly released from this obligation by the patient. The confidentiality of the private information needs to be maintained at the highest possible levels of security by medical professionals at all times— unless there are extenuating circumstances to disclose them, like for the public good, compliance to the law, etc.

INFORMATION TECHNOLOGY

When the information is recorded electronically, the onus of maintaining the secrecy continues to wrest on the provider and he needs to ensure that it is indeed maintained at all times, else he would be liable for all consequences thereof. The fear of compromises due to lack of adequate control of the cybersecurity from threats has made the public to naturally be very wary of having their information maintained there.

The digital health industry is aware of all this and already have in place a number of appropriate processes and enabling tools that are able to effectively address them to robustly.

The following sections discusses some of the commonly-used ones in brief and simply.

EHR

An Electronic Health Record (EHR) is a life-long record of all the different health-related encounters that a particular person has throughout life.

All of these encounter documents need to be lined up and merged together into a single continuous document to help provide that person’s journey through life with respect to health.

This life-long record contains every single health-related detail of a person, many of which are sensitive enough to merit special considerations be given to the data privacy and confidentiality issues so that the person whose data is being handled and his provider are able to feel reasonably confident about permitting their location in an electronic format in the cyberspace.

Privacy

Privacy is the claim of individuals, groups or institutions to determine for themselves when, how and to what extent any information about them is communicated to others .

It also refers to the ability of individuals to manage the collection, retention and distribution of private information and has been variously

Data integrity is a fundamental component of information security and generally refers to the accuracy and consistency of data stored anywhere.

defined as the control of access to private information while avoiding certain kinds of embarrassment and ensuring what all can be shared, or not, with others .

In short, privacy is ensuring that others do not get to know all that one does not wish to tell.

Confidentiality

Confidentiality is the protection of personal information and entails keeping certain information strictly limited to a selected few and usually is a set of rules or promise that ensures it.

Confidentiality in healthcare requires healthcare providers to keep a person’s personal health information private unless consent to release the information has been provided by the patient.

Patients routinely share personal information with health care providers.

If the confidentiality of this information were not protected, trust in the physician-patient relationship would consequently be diminished. Persons would then be less likely to share sensitive information, which could negatively impact their care.

Creating a trusting environment by respecting a person's privacy encourages the patient to seek care and to be as honest as possible during the course of

a health care visit. It may also increase the person’s willingness to seek care. For conditions that might be stigmatising, such as reproductive, sexual, public health, and psychiatric health concerns, confidentiality assures that private information will not be disclosed to anyone including partners, family, friends, employers or any other third party without their explicit consent.

Due to ethical and legal reasons, breaching confidentiality is justified, but only in certain special circumstances.

1. Concern for the safety, both of self and of other specific persons: access to medical information and records by third parties is legally restricted. Yet, at the same time, clinicians have a duty to protect identifiable individuals from any serious, credible threat of harm if they have information that could prevent it. The determining factor is whether there is good reason to believe specific individuals (or groups) are placed in serious danger depending on the medical information at hand.

2. Legal requirements to report certain conditions or circumstances: applicable laws usually require the reporting of certain communicable/ infectious diseases to the public health authorities. In these cases, the duty to protect public health outweighs the duty to maintain a patient's confidence.

From a legal perspective, the state has an interest in protecting public health that outweighs individual liberties in certain cases.

3. Ethical considerations make it indefensible not to use information that may save the life and limb of another, where the data of one may help not only alleviate the pain and suffering of another but perhaps even save the life that would otherwise be lost. For example, if a person has a lifethreatening condition and information about someone else also having suffered a similar condition who was successfully treated of the condition exists, then it would be morally indefensible not to use that knowledge and save a life.

www.asianhhm.com

51

INFORMATION TECHNOLOGY

Security

In a healthcare context, security is the method and technique to protect privacy and is a defence mechanism from any type of attack. Studies have showed that the slow adoption of EHR is mostly due to privacy concerns. People need to be in control of the collection, dissemination, and storage of their health information.

If they feel out of control, their feeling of vulnerability and general mistrust of healthcare information systems and the information that they have disclosed with the expectation of it being held in trust increases manifold. Digital health systems are used in medical applications for delivery, efficiency and effectiveness of healthcare and the users have the right to know about the various security measures that are in place in order to feel secure about their privacy.

Functional Challenges

The various functional challenges to the successful establishment and use of an EHR are as follows.

Centralised availability There is a need to ensure that all records of a person are available at a central place so that they may be accessed and processed together in real-time.

Privacy issues There is a need to ensure that private things are indeed kept private.

Confidentiality issues There is a need to ensure that confidentiality of information is maintained as well as the information is available to those who need it for safety, legal or ethical reasons.

Security issues There is a need to ensure that both of the above are successfully addressed in a meaningful and demonstrable manner to the satisfaction of care receivers (persons and patients) and their care providers (medical professionals).

Technological Solutions

The various functional challenges detailed above are addressed in this section.

52

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

Cloud-based solutions The ‘Cloud’ is actually a group of interconnected computer servers that is accessible through the Internet by a broad group of authorised users across enterprises, geographical locations and operating platforms.

A person visits a number of healthcare professionals to receive services over his lifetime. These services could be for routine attention like immunisation, health check-up, etc., or special like a doctor visit for consultation due to illness or a facility visit for undergoing procedures like surgery or emergency due to some accident – minor or major.

Each of these healthcare encounters leads to the creation of a record. Creating one single life-long record from all of these individual encounter-based records requires all of the latter to be serially collated from the very first to the very latest and then processed together.

Consequently, the availability of all the records at a central place is crucial.

IS S UE - 40 2018

Either using a Cloud-based solution or storing a copy of each and every encounter in the Cloud makes this very practical.

Cyberspace, security, and threats Cyberspace is a notional space created by networking various digital devices including computers. Basically, it is the electronic ecosystem where not all of rules of the natural laws of physics and chemistry apply. The ‘Cloud’ essentially exists in the cyberspace.

Cyber security refers to the techniques of protecting computers, networks, programs and data from unauthorised access or attacks that are essentially malicious.

Cyberthreat is the possibility of malicious attempts to damage or disrupt a computer network or system.

Achieving EHR security There are a number of methods by which adequate levels of security can be achieved in any EHR system that would be sufficient to allay the various security-related concerns of the stakeholders.

INFORMATION TECHNOLOGY

Technical Solutions – using various security techniques as follows : • Encryption • Authentication • Role based access control (RBAC) Human Solution • Privacy Awareness • Privacy Education Information system designer and developers need to ensure that privacy requirements are included in the design and development phases itself. This is an extremely issue that all EHR vendors must pay particular attention to and failure to do so would in all likelihood result in serious legal consequences, which would mean one definite thing —business failure.

Security anywhere is as weak as it is at its weakest point. This unfortunately happens to be the users themselves.

Using passwords that can easily be guessed, making them available from where even a toddler can access, sharing them with all and sundry, etc. are all extremely dangerous practises that many users, unknowingly and knowingly continue to indulge in for a variety of reasons, mostly due to matters of convenience.

Encryption Encryption is the process of using an algorithm to transform readable data into an unreadable encoded one in order to make it incomprehensible to unauthorised users. The encoded data can only be decrypted to make it readable with a security ‘key’.

This end-to-end data protection process, which falls under the science of cryptography, is essential for to ensure a trusted delivery of sensitive information, including those over such open networks like the Internet.

Advanced Encryption Standard (AES) is an example of symmetric-key encryption process that uses a 128-bit, a 192-bit or a 256-bit key is considered pretty reliable as breaking them is virtually impossible at the currently available computing power. The Pretty Good Privacy (PGP) is an example of

asymmetric-key encryption and is a public-key encryption process that uses private and public keys in tandem.

Authentication and authorisation Authentication is the process of determining whether someone or something is, in fact, who or what it is declared to be. This is accomplished by identifying an individual through the person's unique user identifier and a password (or passphrase, biometric, OTP challenge, etc.). It is distinct from authorisation, which is the process of giving individuals access to system objects based on their identity. Once a person has been authenticated, he is permitted access to the system based on his access rights. This is authorisation. Both are accomplished through the log-in functionality.

Role-based access control Aka RBAC, this is a process by which system access to users is granted based on the roles they are authorised to perform. By tagging the roles to access, a user is permitted, or not, to execute a certain set of functions based on the roles they perform. This provides the flexibility to deny any unauthorised user, including those unknown, who are trying to gain access with malicious intent, from carrying out task or tasks that they are not permitted to.

Consent management Any person whose data is being managed using a system needs to provide as explicit a consent as is practical to permit anyone who uses the system to access the data, or not. Taking such a consent in as transparent a manner as possible provides the necessary legal protection to all those who use the system and access the data contained therein while ensuring that the person who has provided the consent has done so with sufficient clarity as to what all he has consented to and not.

Audit trail The genesis of audit trail belongs to the world of accountancy and is basically a system that traces the detailed transactions relating to any item in a record.

In the context of EHR, it is a tracing record of detailed transactions of all activities performed on it. Such a record is able to keep track of everything that has occurred with respect to the EHR and is able to provide details of all activities, thereby making it easier to detect most, if not all, malicious activities. Any compromise to the data integrity or the performance of any nefarious activity can not only be traced but the culprits identified so that necessary action can be undertaken, often in real-time.

Through the use of audit trail in digital health documenting systems, any person or entity, including a court of law, can be provided with sufficient information with a better-than-acceptable levels of confidence that the health records maintained in the electronic format is safe and secure.

Data integrity Data integrity is a fundamental component of information security and generally refers to the accuracy and consistency of data stored anywhere, whether in a database or data warehouse or data mart or something else. For data to be complete, all of its characteristics including business rules, relations, dates, definitions and lineage need to be correct. Data integrity is maintained through the ongoing use of error checking and validation routines, like ensuring that numeric columns/cells do not accept alphabetic data.

As a process, it verifies that the data has remained unaltered in transit from creation to reception. As a state or condition, it is a measure of the validity and fidelity of a data object.

Database security professionals employ any number of practices to assure data integrity, including data encryption that locks data by cipher, data backup that stores a copy of data in an alternate location, having in place appropriate access controls, including assignment of read-write privileges, input validation, to prevent incorrect data entry, and data validation, in order to certify uncorrupted transmission.

www.asianhhm.com

53

INFORMATION TECHNOLOGY

54

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

A blockchain is a continuously growing list of records that are linked and secured using cryptography containing a cryptographic hash of the previous block, a timestamp and transaction data. By design, it is inherently resistant to modification of the data. They are secure by design and exemplify a distributed computing system with high fault tolerance.

This makes these types of database potentially suitable for the recording of events, medical records, and other records management activities, such as identity management, transaction processing, documenting provenance, food traceability, voting, etc.

Sadly, what prevents it from being the answer to all EHR-related problems is its inherent latency in data retrieval.

While this is not a serious enough issue in the non-critical care settings like outpatients or routine inpatients where the patient is well-settled, it is definitely a problem that cannot be mitigated using high-end technological solutions in critical care settings including accidents and emergencies.

Privacy awareness & education Painful as it is, there is no recourse other than to admit that awareness about privacy and rights related to confidentiality is practically non-existent amongst the publicat-large. Too often a person will not think twice before sharing their intimate details on the social network, but mention of someone entering information into a health information system makes that very person

AUTHOR BIO

This ensures that the data, as intended to be captured, is not only captured in that state but also stored, retrieved, or exchanged, is exactly the same from the time of entry forever.

Hashing Hashing is the transformation of a string of characters into a fixed-length value or key that represents the original string and is used in many encryption algorithms apart from its use in indexing data in databases to make data location and retrieval quick.

This technique makes it possible to generate and store a hash key of a particular record and subsequently to re-generate the hash key of the same record and check the re-generated key with the original key. A match means that the original record is being preserved. Else it points to compromise of the record’s integrity. This is a red flag indicating breach of security that may have privacy and confidentiality issues.

Safeguards Physical These are safeguards put in place to ensure that all computer hardware including servers, networking equipment including routers, continuity of power supply and temperature maintenance are in a safe place free from any physical harm due to elements of nature, acts by animals or breaking and entering by humans. Various guidelines are drawn up and rigorously followed to ensure that all threats are adequately dealt and mitigated.

Administrative Safeguards These are basically a set of standard operating procedures related to how security is to be handled, the rules that govern the personnel who deal with or handle sensitive data, how risks are to be managed, methodology for oversight, etc.

Blockchain technology As of 2018, this is ‘the new kid on the block’ as far as cyber-security is concerned and appears to be on the up and up on the hype cycle of the type popularised by Gartner.

IS S UE - 40 2018

extremely concerned that assumes the hue of outright paranoia. Such a situation is, sadly, all too common for one’s comfort.

This results in the requirement of appropriate raising of awareness and educating the stakeholders using simple and easy-to-follow techniques so that their concerns are adequately allayed and their knowledge regarding the various related do’s and don’ts are suitably augmented. Public messages in the media, private emails and messages, availability of capacity building videos and other educational documents, appropriate postings in the various discussion forum, etc. are some of the various methods that can be adopted in this regard.

Concluding Observations

As is evident from the various functionalities, techniques and tools mentioned and discussed above, robust safeguards are well-known and extensively used by the Information Technology industry to ensure that the privacy and confidentiality of any data can be securely handled with reasonable care.

By using them in EHR systems the data they contain can be well-protected in a reasonably secure manner.

Stakeholders can consequently rest easy, confident in the knowledge that the sensitive health-related data contained in EHRs are sufficiently safe in the cyberspace.

References are available at www.asianhhm.com

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

We are online too!

Direct Marketing

e-newsletter

Banner aDvertising

In addition to advertising in AHHM magazine, our clients benefit from cost-effective online options for branding and promotion campaigns through www. asianhhm.com. With large number of visitors and huge database that we built over the years, we help you to devise and execute targeted promotion campaigns.

For more details: Email: advertise@asianhhm.com Tel: +91 40 4961 4567 Fax +91 40 4961 4555

www.asianhhm.com www.asianhhm.com

55

Books

Innovations in Healthcare Management

Actionable Intelligence in Healthcare

Author(s): Vijai K Singh, Paul Lillrank No of Pages: 456 pages Year of Publishing: 27 March 2015 Book Description: Innovations in Healthcare Management: Cost-Effective and Sustainable Solutions explores recent innovations in healthcare from a global and Indian perspective. Emphasizing the importance of Lean healthcare and innovation, it presents low-cost, high-volume solutions that improve access to care.

Author(s): Jay Liebowitz, Amanda Dawson No of Pages: 293 pages Year of Publishing: 15 May 2017 Book Description: This book examines the structure for turning data into actionable knowledge and discusses: •The importance of establishing research questions •Data collection policies and data governance •Principle-centered data analytics to transform data into information •Understanding the "why" of classified causes and effects •Narratives and visualizations to inform all interested parties

Providing concrete examples of the five levels of innovation present in healthcare, the book presents new concepts, methods, and tools for advancing processes and operational flow. It includes case studies of actual results in healthcare innovation from three continents that highlight emerging global trends in healthcare system innovation.

The book maintains a focus on key issues across the healthcare industry—such as access to care, demand creation, patient experiences, and data—to help readers implement new ideas and new models of delivery of affordable care in healthcare systems around the world.

56

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

Actionable Intelligence in Healthcare is an important examination of how proper healthcare-related questions should be formulated, how relevant data must be transformed to associated information, and how the processing of information relates to knowledge. It indicates to clinicians and researchers why this relative knowledge is meaningful and how best to apply such newfound understanding for the betterment of all.

IS S UE - 40 2018

The Digital Doctor Author(s): Robert Wachter No of Pages: 352 pages Year of Publishing: 16 April 2017 Book Description: Written with a rare combination of compelling stories and hard-hitting analysis by one of the nation’s most thoughtful physicians, The Digital Doctor examines healthcare at the dawn of its computer age. It tackles the hard questions, from how technology is changing care at the bedside to whether government intervention has been useful or destructive. And it does so with clarity, insight, humor, and compassion. Ultimately, it is a hopeful story.

"We need to recognize that computers in healthcare don’t simply replace my doctor’s scrawl with Helvetica 12," writes the author Dr. Robert Wachter.

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

Informatics Education in Healthcare Author(s): Eta S Berner No of Pages: 243 pages Year of Publishing: 23 August 2016 Book Description: This book reviews and defines the current state of the art for informatics education in medicine and health care.

This field has undergone considerable change as the field of informatics itself has evolved. Twenty years ago almost the only individuals involved in health care who had even heard the term “informatics� were those who identified themselves as medical or nursing informaticians.

The book addresses the broad range of informatics education programs available today. The Editor and experienced internationally recognized informatics educators who have contributed to this work have made the tacit knowledge explicit and shared some of the lessons they have learned.

This book therefore represents the key reference for all involved in the informatics education whether they be trainers or trainees.

Rethinking Lean in Healthcare Author(s): Tom Zidel No of Pages: 198 pages Year of Publishing: 2016 Book Description: This book deals with a hospital's struggle to secure and maintain financial stability. In the story, the leadership team of a fictional hospital adopts the tools and principles associated with the Toyota Production System or Lean.

The story takes the reader through leadership's arduous journey from rejecting the methodology to embracing it, to successful implementation.

This book is important because many of our nation's hospitals are besieged with financial difficulties with declining reimbursement and the public is losing confidence in our hospital's ability to provide quality care without error. Lean can provide relief from these issues but only if it is properly implemented. of pages: This book deals with a hospital's struggle to secure and maintain financial stability. In the story, the leadership team of a fictional hospital adopts the tools and principles associated with the Toyota Production System or Lean. The story takes the reader through leadership's arduous journey from rejecting the methodology to embracing it, to successful implementation.

Organisation Development in Health Care Author(s): Huw T O Davies, Mo Malek, Rosemary K Rushmer No of Pages: 208 pages Year of Publishing: 2017 Book Description: Health systems across the globe face similar problems: controlling costs while maintaining or improving health care quality and access. Drawing on experts from Europe and America this eclectic collection of leading edge research examines the impact of organizational development on improving quality and efficiency in health care. A series of chapters provide accounts of organizational reconfiguration in the UK and elsewhere. The contributors examine how structural and procedural changes must be matched by the development of human resource services if increases in efficiency and effectiveness are to be achieved. The book will be of interest to health care academics, policy makers, managers and practitioners who are interested in keeping abreast of the latest developments in health care research.

www.asianhhm.com

57

Books

58

Cardiology Clinical Methods

Clinical Pearls in Cardiology

Author(s): V Jacob Jose, S Ramakrishnan No of Pages: 278 pages Year of Publishing: 2017 Book Description: • A brief and simple text.

• Presents various clinical methods in cardiology.

• Divided into nine compact chapters.

• Deal with History Taking and Physical Examination, Arterial and Jugular Venous Pulses, Blood Pressure, Precordial Examination, Various types of Heart Sounds, etc.

• Useful for the undergraduate students of cardiology, Board examgoing students of cardiology, as well as the students pursuing DM or DNB in cardiology.

Author(s): Hemanth IK, Shafeeq Mattummal No of Pages: 200 pages Year of Publishing: 2017 Book Description: Clinical Pearls in Cardiology is a concise collection of vital information on the signs and symptoms of heart diseases. This pocket-sized, quick reference guide is comprised of more than 200 questions and answers on clinical cardiology. The book is divided into 10 chapters, covering history taking and general examination, pulse and blood pressure, the precordium, heart diseases and radiology. The book features analysis of the common symptoms of heart diseases, with pathophysiological explanations and differential diagnoses for each symptom. Symptoms covered include chest pain, shortness of breath, palpitations, dizziness and leg swelling.

Clinical Pearls in Cardiology covers the essentials of cardiology in a simple, compact style.Key Points More than 200 questions and answers on clinical cardiology Features analysis of a range of heart disease symptoms 36 illustrations.

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

IS S UE - 40 2018

Essentials of Clinical Radiation Oncology Author(s): Matthew C, MD Ward, Rahul D, MD Tendulkar, Gregory M M, MD, CM, FRCPC Videtic No of Pages: 671 pages Year of Publishing: 2017 Book Description: Essentials of Clinical Radiation Oncology is a comprehensive, user-friendly clinical review that summarizes up-todate cancer care in an easy-to-read format.

Essentials of Clinical Radiation Oncology has been designed to replicate a "house manual" created and used by residents in training and is a "onestop" resource for practicing radiation oncologists, related practitioners, and radiation oncology residents entering the field.

Key Features: •Offers digestible information as a learning guide for general practice •Examines essential clinical questions which are answered with evidencebased data from important clinical studies •Places clinical trials and data into historical context and points out relevance in current practice •Provides quick reference tables on treatment options and patient selection, workup, and prognostic factors by disease site.

Bedside Clinics in Surgery Author(s): Makhan Lal Saha No of Pages: 1286 pages Year of Publishing: 2018 Book Description: • The concept of exact measurement of a swelling has been incorporated by using a Vernier caliper instead of a tape measurement.

• A new long case on management of diabetic foot has been added in the long case section.

• In X-ray section interpretation of mammography has been added.

• In surgical anatomy section, lower leg compartments and cervical fascia have been added.

• About 30-40 new figures added as per the requirement of the main text.

• The TNM classification of all the malignant tumors has been updated.

• Surgical anatomy section discussed exclusive hand drawn illustrations and tried to correlate the anatomy portion with short and long cases.

Planning and Designing Healthcare Facilities Author(s): Vijai K Singh, Paul Lillrank No of Pages: 278 pages Year of Publishing: 2017 Book Description: Planning and Designing Healthcare Facilities: A Lean, Innovative, and Evidence-Based Approach explores recent developments in hospital design. Medical facilities have been adapted to the requirements of clinical functions. Recently, the needs of patients and clinical pathways have been recognized. With the patient at the center of the process, the flow of tasks becomes the guiding principle as hospital design must employ evidence-based thinking, and process management methods such as Lean become central.

The authors explain new concepts to reduce healthcare delivery cost, but keep quality the primary consideration. Concepts such as sustainability (i.e., Green Hospitals) and the use of new tools and technologies, such as information and communication technology (ICT), Lean, and evidencebased planning and innovations are fully explained.

The Patient Revolution Author(s): Krisa Tailor No of Pages: 224 pages Year of Publishing: 2016 Book Description: In The Patient Revolution, author Krisa Tailor a noted expert in health care innovation and management explores, through the lens of design thinking, how information technology will take health care into the experience economy. In the experience economy, patients will shift to being empowered consumers who are active participants in their own care. Tailor explores this shift by creating a vision for a newly designed health care system that—s focused on both sickness and wellness, and is driven by data and analytics. The new system seamlessly integrates health into our daily lives, and delivers care so uniquely personalized that no two people are provided identical treatments.

The patient revolution has just begun and an exciting journey awaits us.

www.asianhhm.com

59

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

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

HEALTHCARE MANAGEMENT

DIAGNOSTICS

Asia Healthcare Summit.......................................................... 11

EKF Diagnostics............................................................ 03, 32-33

GES India................................................................................. 25

TECHNOLOGY, EQUIPMENT & DEVICES

HAPS 2018............................................................................... 19

Cantel Medical........................................................................ IFC

ISQua 2018.............................................................................. 09

Fotona d.d...............................................................................IBC

MDA 2018................................................................................ 13

Stiegelmeyer............................................................................ 05

MEDEX'18................................................................................ 29

FACILITIES & OPERATIONS MANAGEMENT

Radiology UAE......................................................................... 23

Cantel Medical........................................................................ IFC

Turkish Cargo.........................................................................OBC

Stiegelmeyer............................................................................ 05

SUPPLIERS GUIDE Company............................................... Page No. Asia Healthcare Summit.......................................................... 11

Company............................................... Page No. ISQua 2018.............................................................................. 09

www.asiahealthcaresummit.com

https://isqua.org/Events/malaysia-2018

Cantel Medical........................................................................ IFC

MDA 2018................................................................................ 13

www.medivators.com

www.medicaldevicesasean.com

EKF Diagnostics............................................................ 03, 32-33

MEDEX'18................................................................................ 29

ekfdiagnistics.com

www.medicasia.org

Fotona d.d...............................................................................IBC

Radiology UAE......................................................................... 23

www.fotona.com

http://radiologyuae.com/

GES India................................................................................. 25

Stiegelmeyer............................................................................ 05

www.gesindia.in

www.stiegelmeyer.com

HAPS 2018............................................................................... 19

Turkish Cargo.........................................................................OBC

http://www.duxes-events.com/hap

www.turkishcargo.com

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

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

60

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

IS S UE - 40 2018

The medical power of light SP Dynamis High-Performance, Minimally Invasive Laser Treatments By combining two complementary laser wavelengths (Nd:YAG and Er:YAG) the SP Dynamis functions as a highly versatile laser system that can perform an exceptionally wide range of applications in aesthetics and gynecology. An additional high-performance surgical QCW Nd:YAG laser wavelength ensures safe, minimallyinvasive and effective surgical treatments.

Laser treatments include: • • • • • • • • • •

Laser-assisted lipolysis Endovenous laser ablation Hyperhidrosis treatment TightSculpting® – non-invasive laser lipolysis Vascular lesion & unsightly vein treatments Pigmented lesions removal Fotona4D® – non-invasive face lifting Scar revision Acute acne treatments Laser hair removal

87927/3

The SP Dynamis ensures safe and effective treatments with reduced recovery times.

Visit www.fotona.com to find out more.

Committed to Engineering:

The Highest Performance, Best Made Laser Systems in the World

THE THING THAT WEIGHS ON US THE MOST IS YOUR HEALTH TURKISH CARGO FLIES TO MORE COUNTRIES THAN ANY OTHER CARGO AIRLINE. OUR EXPERTISE IN TRANSPORTING PHARMACEUTICALS BRINGS H E A LT H A N D H A P P I N E SS TO M I L L I O N S A R O U N D T H E WO R L D.