Asian Hospital & Healthcare Management - Issue 49

ISSUE 49

2020

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FIGHTING THE COVID-19 PANDEMIC Siemens Healthineers responds Elisabeth Staudinger President Asia-Pacific Siemens Healthineers

Associate Partner

Managing Cultural Diversity in Hospital Systems in The Era of Covid-19

Cash Management in Emerging Asia-Pacific Hospitals The king is back! www.asianhhm.com

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Foreword Promoting Cultural Diversity for Improved Healthcare “We may have different religions, different languages, different coloured skin, but we all belong to one human race."

Kofi Annan, Former Secretary General, United Nations At a time when several countries across the world have been fighting the COVID-19 pandemic, another issue garnered attention: the killing of George Floyd at the hands of the police. While debate over the ensuring protests continues, the incident has brought to attention the racism and bias that exist in the society. Some similarities could be drawn to the healthcare sector with regard to serving patients from different backgrounds.

“Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane” said Dr Martin Luther King Jr. five decades ago.

Even today, disparities in healthcare—access, coverage and quality care—remain a challenge in achieving health equity for the global population.

Affordable care is still a distant dream for economically weaker communities across the world. On the other side, there have been several incidents where care givers face issues of racism and bias. We continue to hear or read about patients denying care because the care giver belongs to a certain race, religion, community, or ethnic group.

Diversity and inclusion come from understanding and acknowledging the fact that no two individuals are the same. It becomes more important in a healthcare environment as understanding patient needs and cultural concerns, if any, can help provide effective care.

Respecting cultural diversity and building cultural competence enables hospitals and healthcare organisations in better serving the needs of patients irrespective of their race, region or ethnic origin. Healthcare organisations can become better providers of care by building a culturally competent workforce, engaging public through community-based programmes, and developing customised health management programmes that address needs of patients with diverse

backgrounds. Most importantly, making diversity and inclusion an organisational priority and aligning with the strategic plan can help healthcare systems achieve health equity.

American Health Association (AHA) launched the #123forEquity pledge campaign with the objective of eliminating health disparity and ensuring every individual, irrespective of his/her community receives high quality, equitable care.

Another example is COVID-19 Bias and Anti-Racism Training Act, a new legislation that aims to train health providers and other individuals involved in COVID-19 testing, treatment, vaccine distribution, and response. On July 15,the California senator announced a legislation that authorisesa grant of US$100 million grant for FY20 and FY21 for hospitals and other healthcare providers to organise training programs, in the district. Efforts have been underway to increase diversity and cultural competence in the healthcare institutions and also bring down health disparities. The key to is to execute these campaigns as planned and expand such programs beyond geographical and political boundaries.

This issue features an article that talks about managing cultural diversity in hospital systems, specifically in the current global health landscape affected by Covid-19. The author brings to fore the importance of raising awareness of cultural differences in a diverse world and adopt ways to overcome challenges caused due to lack of people integration.

Prasanthi Sadhu

Editor

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CONTENTS HEALTHCARE MANAGEMENT

COVER STORY

06 Covid-19 & Change-20+ Critical future factors for the next normal David A Shore, Former Associate Dean and Current Faculty Member, Harvard University; Former Distinguished Professor of Innovation and Change, Tianjin University of Finance and Economics

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FIGHTING THE COVID-19 PANDEMIC Siemens Healthineers responds

12 Prevention Of Covid-19 Technologies Involved M S Minu, Assistant Professor, Dept of Computer Science & Engineering, SRM Institute of Science and Technology

Elisabeth Staudinger, President Asia-Pacific, Siemens Healthineers

Bharath S B, SRM Institute of Science and Technology Deepanjali, SRM Institute of Science and Technology

16 Managing Cultural Diversity in Hospital Systems in The Era of Covid-19 Uche Nwabueze, Professor, Maritime Administration, Texas A&M University

24 Trends in Healthcare Delivery Jeong Jae Youn, Country Manager, Singapore & Emerging ASEAN, GE Healthcare

Ian Chuang, Chief Medical Officer, Elsevier

27 Food Safety and Regulations Emerging role of technology Kent L Bradley, Chief Health and Nutrition Officer, Herbalife Nutrition

32 Cash Management in Emerging Asia-Pacific Hospitals The king is back!

Aditya Agarwal, Principal, Roland Berger

Kent L Bradley, Chief Health and Nutrition Officer, Herbalife Nutrition

INFORMATION TECHNOLOGY 48 Virtual Health Gurrit K Sethi, Hospital Chief Operating Officer, Care Hospitals Strategic Advisor for Global Health Services, Global Strategic Analysis

50 Telehealth in the Before Covid-19 and After Covid-19 era A story from India K Ganapathy Krishnan, Director, Apollo Telemedicine Networking Foundation; Director Apollo Tele Health Services

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

57 Mental Health in COVID-19 An e-health service to provide tele-mental health support in pandemic Nazia Akter, General Manager & Head of Business Solution, Synesis IT Ltd. Rupayan Chowdhury, Group CEO, Synesis IT Ltd. Tanjir Soron, Head of Mental Health, Synesis IT Ltd.

37 Support Beyond Medication Doctor-patient relationship in the times of a pandemic

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54 Digital Healthcare Transformation and Innovation Optimising knowledge flow

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62 Artificial Intelligence Enabled Patient Experience R B Smarta, Chairman & Managing Director, Interlink Marketing Consultancy Pvt. Ltd

In a world of competition.

Stand out.

In an increasingly globalised world it is astonishing how many solutions seem the same.

We all know that challenges vary depending on cultures and countries. Standing out is not just about processes but having passionate people with the right local knowledge, experience and the independence to think freely.

That is why we exist and excel.

International Assistance Group has been federating assistance companies since 1992. We have grown from a small non-profit association into the world’s largest alliance of independent assistance companies and accredited providers.

We make global world-class solutions a reality. That’s because we vet and select companies with local expertise, skills and knowledge delivering quality services 24/7.

Local partners. Global solutions. www.international-assistance-group.com + 33 1 55 30 09 10 netiag@netiag.com M E D I C A L & T R AV E L A S S I S TA N C E • R O A D S I D E A S S I S TA N C E • C O S T C O N TA I N M E N T • T PA • S E C U R I T Y S E R V I C E S

Advisory Board

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

EDITOR Prasanthi Sadhu EDITORIAL TEAM Debi Jones Grace Jones

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

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

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

PRODUCT ASSOCIATE John Milton Veronica Wilson

Nicola Pastorello Data Analytics Manager Daisee

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

Gurrit K Sethi CEO Canta Health

HEAD-OPERATIONS S V Nageswara Rao

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

Associate Partner

In Association with

A member of Confederation of Indian Industry

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

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

Peter Gross Chair, Board of Managers HackensackAlliance ACO

Malcom J Underwood Chief, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital 4

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COVID-19 & CHANGE-20+ Critical future factors for the next normal This article explores critical future factors that need to be ingrained in the fabric of organisations on a going-forward basis.

David A Shore, Former Associate Dean and Current Faculty Member, Harvard University; Former Distinguished Professor of Innovation and Change, Tianjin University of Finance and Economics

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e have certainly seen examples of both the successes and failures intrinsic in the management of the coronavirus crisis. When history books are written, the headlines will include the fact that COVID-19 was the disruption few adequately planned for.

While this has proven tragic, it is not wholly unexpected. As a rule of thumb, we embark upon change initiatives knowing only about 20 per cent of the equation. The remaining 80 per cent is discovery. After all, change is an experiment.

We don’t know what we don’t know, and for most people, the greatest fear is fear of the unknown.

This is not a new nor unique phenomenon. People are people. Carbon and water. It has been more than two centuries since the Buddha spoke of this trauma which he called ‘the suffering of change.’

The Buddha observed that people suffer change for one primary reason – fear. The world is in fear of the invisible killer known as COVID-19.

While the central theme of After Action Reviews (AAR) will likely be the seemingly capricious and occasionally Rube Goldberg-esque emergency management of coronavirus, one inspirational chapter will be devoted to the emerging art of saying ‘thank you.’

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Canary in the coal mine

Gratitude is a win-win

As medical and political leaders contemplate how and when we should exit the shutdown and migrate to a slowdown, this MedPol chicken and egg debate is replete with meltdown protagonists and antagonists. However, a common characteristic of successful change agents is that they learn for the future, they plan for the future, and they work toward making that future a reality.

While the off-boarding strategy is more conflicted, there is far more consensus regarding the preliminary retrospective review of the global onboarding response. ICYMI — bad news doesn’t get better with time!

After the first alarms sounded in early January 2020 that an outbreak of a novel coronavirus in China might ignite a global pandemic, much of the world squandered nearly two months that could have been used to bolster stockpiles of critically needed medical supplies and equipment. A case in point is a memo

by President Trump’s trade advisor Peter Navarro, in which he warned in late January that failing to mitigate the risk of a coronavirus outbreak could cost the U S trillions of dollars and place millions of Americans at risk of illness or death. The memo advised, “The lack of immune protection or an existing cure or vaccine would leave Americans defenseless in the case of a full-blown coronavirus outbreak on US soil.” The memo, dated Jan. 29, was the highest-level early alert known to have circulated in the West Wing (Haberman, 2020). It came as the administration was taking its first substantive steps to confront the crisis while the president was simultaneously downplaying the risks.

Whether it be with signs, in song, in neon lights, or with parades, we have witnessed gestures of appreciation and admiration for the army of health care workers, first responders, and the multitude of other essential workers who have both saved lives and allowed life to be sustained. A pharmacy technician named Alyssa who valiantly worked 60 hours per week without adequate PPE is now my heroine.

While many leaders are keen to position themselves as ‘change agents,’ it is important to punctuate that there is nothing inherently good in change. Change simply means making something different, while positive change means making something better. Likewise, an ‘innovation’ is not an innovation unless it is perceived to add value over the existing it erations.

One can only hope that conspicuous displays of gratitude have a longer shelf life than COVID-19 and live on as a meaningful legacy of this pandemic.

It is not only the objects of our appreciation that benefit. Gratitude is a win-win. Gratitude is proven to make one healthier and happier.

Research indicates that gratitude in the workplace can also motivate, strengthen work cultures, and improve resilience (Grant & Gino, June 2010; Miller, MC, Posted 11/21/2012, updated 10/29/2015).

While such grand public displays of appreciation will wane over time, the lesson should not be lost. If kind gestures are to strengthen an organisation’s culture, they will need to become a habit. One way to start this new tradition is to have each

employee commit to engaging in one act of kindness each day (e.g.: text someone on your team and tell them why you are grateful to them; better yet try an old fashioned handwritten note).Arguably, the most effective way to automate a habit is to make it part of a larger ritual. To set an actionable goal, try practicing gratitude at the same time every day. As we begin this new gratitude hackaday, it might also be helpful to leverage an app such as 365 Gratitude, which provides daily prompts. In my own work on strategic planning and guided implementation, I encourage organisations to embrace ‘gratitude’ as one of their core values.

In light of the pandemic, I suggested to one organisation that they consider taking it one step further and embed gratitude into their KPIs. Gratitude is the quality of being thankful and represents a readiness to show appreciation for and to return kindness.

It helps people refocus on what they have rather than what they lack. In times of crisis this awareness often allows us to feel a little less helpless and hopeless. To the contrary, in the field of positive psychology research, gratitude is strongly and consistently associated with greater happiness.

Harvey V Fineberg a former president of the National Academy of Medicine predicts, “We face a doleful future” (McNeil Jr, 4/18/2020). In times of tumult, both giving and receiving gratitude will be a welcomed component of the treatment plan for an unhappy population experiencing at best months of cabin fever or more protracted periods of isolation for the most vulnerable among us.

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has fundamentally unsettled most every aspect of the organisation. During disruptive times, people find great solace in, and indeed crave stability. One might consider these as Type S or Static organisations. Type S organisations are reluctant to change established business practices, particularly in the midst of a crisis. The refrain is often, “we made a plan and we need to work the plan.”As one health care colleague wrote to the author, “given all that has transpired and needs to happen to make things normal, most healthcare organisations will not

be thinking progressively. It truly is the time to reinvent and shape the future but this will require some very bold moves.

Given the financial status of 99.9 per cent of hospitals, these moves require leaders who are not faint of heart.”

There are other leaders who see the possibilities that COVID-19 provides. They recognise that the greatest success is earned by those who are most adaptable. These business units and organisations look for first mover advantage. Type A or Agile organisations perhaps

Change-20+

What if we asked the question, “Who led the change initiatives in your organisation in 2020?A) CEO, B) CTO, C) CFO, D) Board, E) COVID-19.

Some would argue the virus won’t transform their organisation, leaders will.

However, a preliminary survey by the author finds the most frequent answer would inevitably be E) COVID-19. The novel coronavirus is instigating and accelerating change, innovation, and disruption in ways that were previously unheard of, and certainly were not captured in the organisation’s strategic plan. As one respondent put it, “a crisis is a terrible thing to waste and option “E” is serving as the enabler.” We know that often it takes a crisis to realign people’s mindsets and dampen their natural inclination to resist change, even when it is change for the good. What if COVID-19 emerges as one of the most impactful things to ever happen to your organisation? What if a virus turns out to be the breakthrough catalyst for enterprise-wide transformation?

Every crisis has an end. How will your industry and your organisation be reshaped by the crisis, and what strategies should you pursue to emerge as a leader during the reconstruction phase?

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counterintuitively argue that you build greater organisational resilience by foregoing stability. Type A teams and organisations pivot current strategies to better reflect the new conditions.

This pandemic has demonstrated just how brittle our society and many organisations are. A microscopic virus has profoundly changed our lives, our economies, and our societies. This is when resilience – the capacity to adapt and bounce back – will be one of the most predictive characteristics that help organisations recover, if not renew. Perhaps organisations would be well-served by reinventing themselves as Type R, with a Resilientblended approach to change. A Type R-blended approach would include change initiatives designed to allow an organisation both bounce back and bounce forward.

The new post-acute phase critical future factor

This pandemic has demonstrated that no enterprise is immune from disruption and signifies just how brittle many aspects of civilisation are. A tiny virus has drastically upset every aspect of our lives. In a time like this, resilience — the ability to adapt, bounce back, and move forward at scale — will be one of the most important characteristics to aid organisations in recovery and renewal.

The goal with crisis-instigated change is to shift from a reactive response to proactive planning. The coronavirus pandemic punctuates the need for an updated, heavily fortified and dramatically expanded dimension that is absent in all but a few strategic plans – emergency management planning. This Critical Future Factor (CFF) is developing a comprehensive plan to maintain business continuity. It is anchored by a PlanAhead Team (PAT).PAT is focused on forward-looking intelligence, developing scenarios, and identifying the options needed to act strategically and tactically across all relevant time zones – days, weeks, quarters, years. Along with PAT

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Beyond strategic planning

At its core, the fundamental purpose of strategic planning is to transition a department or organisation from its current state to a future desired state. Among the guiding principles of Shore’s Beyond Strategic Planning model is a deep appreciation for the fact that change takes place across three time zones.

Change initiatives benefit from being bookended on the front end by a retrospective review. Studying the antecedents allows the change team to have context and anticipate what might be.

On the back end is the often-neglected phase of sustainment.

The author’s Beyond Strategic Planning model includes a place of pride for the sustainment phase (Shore, 2020).

As the coronavirus maintains its grip on the globe, organisations need to triage their change initiatives, least they divert urgently needed resources. Preliminary questions include: • What should we stop doing?

• What should we keep doing?

• What should we start doing?

Keeping the ‘tude going all project long

We have also found that gratitude warrants a place of pride in successfully leading change. Change initiatives are all about dependencies – in order for one team member to do what they need to do another needs to do what they need to do. Expressing appreciation for good work can be a great motivator.

On more than one occasion the author has witnessed frustrated and tired team members receive substantial solace from gazing at their change initiative’s gratitude wall. Beyond the core working team whose initiative is in one way or another driving the future, there are always a wide range of stakeholders who impact or will be impacted by the change. To ensure we thank everyone, I recommend change agent keeps a gratitude journal and thank every single person and department that played a role in launching, leading, and realizing value from each change initiative.

Change = Resistance

Another guiding principle is that inherent in change is resistance. This is clearly

on display with the anti-quarantine rallies in which protestors decry that the US coronavirus lockdown is causing an economic and social meltdown.

With any quantum change, the unit of measurement is the people. If you can’t change people, you cannot change anything. If you can’t break through long-standing resistance and silos, you cannot change anything. Further, walking among us are a remarkably high percentage of CAVE dwellers – people who are Constantly Against, Virtually Everything. You suggest a change, and before you can even finish, the CAVE people inform you of all the reasons why it is not a good idea in their organisation, municipality, state, province or country (Shore, 2014). To counteract those who are prone to reciting their ABC’s (Anything But Change), the author has developed an approach to managing change anchored by another set of ABCs – Applied Behavioral Change. As challenging as the medical and economic response to COVID-19 is, conspicuous by its absence is the fact that we did not mind our ABCs, which requires getting people and communities ready, willing

and able to respond to change (Shore, et al, 2019, Shore, et al, 2019).

Type S vs type A organisations

With the coronavirus crisis dominating lives and livelihoods, important change initiatives are often relegated to a secondtier position. However, in times of crisis, perhaps change should be anything but second-tier. The differential response to the much-anticipated post-acute world has divided leaders and organisations into two very distinct realities.T here are leaders and organisations around the globe who are trying to ascertain how to move forward with “business as usual.”Like all good leaders, change agents understand a basic tenet of crisis communication which is that the first step in developing a message is to understand the moment. These leaders communicate with their workforce by promising a plan to ‘reboot’ programs, products and services that have been disrupted and to get things ‘back to normal.’Some place many decisions on hold preferring to play a wait and see game. These are perfectly understandable positions. The pandemic

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there must also be a RAT (Rapid Action Team) ready to jump into action on a nanosecond’s notice.

Successful leaders understand that while the virus may now be in the air, change must permeate their organisation long after the virus dissipates. While an organisation’s Mission, Values and Vision (MV²) will remain the North Star for most, strategic plans should be reviewed, reprioritised and rewritten.

The scenario planning component of the Beyond Strategic Planning model should become an anchor of all strat plans.

Further, scenario planning must include a healthy dose of business continuity, contingency, and succession planning, as well as other future-looking factors.

To be sure, the coronavirus has spotlighted the need for succession planning, which is often absent or a weak link in strat plans. All critical positions must have backups. Cross-training and redundancies are not optional. While higher performing organisations typically have contingency plans for the C-suite, what is often missing are backups for other key positions beyond the executive team. What happens if the virus attacks your payroll, benefits, compensation, or project managers? The succession planning section of the strategic plan needs to have a plan for people in these and other key roles deemed as organisational ‘essential workers.’ This work might begin by identifying critical roles and the employees necessary to keep your business solvent. Next, begin the process of naming and preparing an understudy. What needs to happen to ensure that the understudy is ready for prime time? In developing the emergency management succession plan, I often recommend looking outside the organisation. Consider retirees or former employees who may be ready, willing, and able to step back into their old shoes temporarily. Organisations may also be well-served by considering subject matter experts or Board talent as possible ‘swing positions. ’Regardless of the option(s) an organisation selects, some

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The novel coronavirus is instigating and accelerating change, innovation, and disruption in ways that were previously unheard of, and certainly were not captured in the organisation’s strategic plan.

reskilling or upskilling will invariably be required. When stress testing the plan, it is important to run through realistic and black swan business scenarios.

During these stress tests we often find that the battle-tested veterans are lower maintenance and perform particularly well.

Purple squirrels During this pandemic, businesses are both dying and surging at the same time. How will businesses reinvent themselves and pivot to post-crisis

mode? How will they retain their commitment to clarity of purpose while remaining united in their MV²— their true north? How does an organisation’s response to this crisis prepare for the next crisis? As much as good should not be the enemy of great, even in times of crisis, urgent must not usurp important. A crucial lesson is that organisations need leaders who are ambidextrous. Leaders must be able to simultaneously manage the urgent along with the important. We need leaders who on one hand can lead change; while on the other hand can lead through change. We can refer to such leaders as ‘purple squirrels.’The challenge even for purple squirrels is substantial. Human beings reflexively migrate to what is urgent, foregoing what is important. As organisations prepare for round two of COVID19 or an entirely new black swan event, applied strategic planning must transition from important to urgent.

Although a rare phenomenon in nature and in organisations, purple squirrels do exist in both settings and are worth cultivating.

AUTHOR BIO

David A Shore is a former Associate Dean at Harvard University where he continues to teach and lead professional development seminars. He is on the External Advisory Board of McKinsey & Company focused on the implementation of innovations. Shore is Adjunct Professor of Organisational Development and Change, School of Business, University of Monterrey (Mexico) and the former Distinguished Professor of Innovation and Change, Tianjin University of Finance and Economics (China).

Address correspondence to David A Shore dshore@fas. harvard.edu

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Our response to the COVID-19 pandemic We are fully committed to supporting our partners throughout the healthcare system to provide the best possible care for patients. Siemens Healthineers supports healthcare providers at each stage of COVID-19 patient care: diagnosis, prognosis, therapy and follow-up.

Clinical

Our medical imaging, laboratory diagnostics and point-of-care testing solutions can support physicians to make a prognosis about the severity of a COVID-19 case, help treat the patient, and assist in the follow-up to find out when the patient has recovered.

Operational

At the same time our digital health solutions, services and consulting can support healthcare providers in protecting healthcare workers and increasing healthcare delivery capacity. For example, our digital services enable medical personnel to operate systems regardless of their location and thus with a potentially lower risk of infection.

To see parts of the portfolio from Siemens Healthineers that can support healthcare providers at each stage of COVID-19 patient care please visit: https://www.corporate.siemens-healthineers.com/covid-19

COVID-19 patient pathway

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PREVENTION OF COVID-19 T E C H N O LO G I E S I N V O LV E D

Coronavirus which started in Wuhan, China on 31 December is a world pandemic disease in which the wholeworld is at stake. As we know, the disease is spreading rapidly it is important to foresee the disease and to contain it. There are many casualties due to this disease and for the safety and the security of the people, various government and private institutions and people have made so many technologies to make the lives easier at this time. We know prevention is better than cure; it's better to stay safe rather than curing the disease after suffering from the disease. Various countries are working to find a drug for this disease so that this.

M S Minu, Assistant Professor, Dept of Computer Science & Engineering, SRM Institute of Science and Technology Bharath S B, SRM Institute of Science and Technology Deepanjali, SRM Institute of Science and Technology

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1. Artificial intelligence (AI)

Artificial intelligence is playing a major role in the development of various new kinds of products to help the people in the pandemic. It is being used for tracking the outbreak of the virus, developing vaccines, and also in various gadgets like in CCTVs, etc for monitoring the people's temperature and social distancing.

2. Pact bluetooth chip

PACT-Private automatic contact tracing is a developing project by the MIT experts using the short-range Bluetooth signals in the mobile phones to trace the people whom the infected person had contact within the last 14 days. In this project a phone sends arbitrary signals to

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various products such as chatbots and online tools by which we can collect the data, visualize and analyse the spread.

7. Gene editing:

the nearby phones and the other phones, collects the signals and re-sends it, these data are stored in the databases and if a person is infected by the virus then it would be easy to locate the people the person have been in contact with within the 14-day period.

In this pandemic period drones are also used for delivering food and groceries etc. In Rwanda and South Africa, a medical organisation called Zipline has been using drones to deliver blood and blood products.

3. 3D printing

Big-Data plays a major role in the present situation. They provide an effective way of analysing the data and helps to provide a visualisation of the analysed data by which we can foresee the spread. People have also developed

Nowadays there is an increase in the need for medical equipment and gadgets like masks, ventilators, breathing filters, etc, and these are done by the help of 3D printing devices. These devices produce products much faster and efficient than the traditional method.

4. Delivery drones

Drones may be called the future delivery vehicle. Because of the speed and efficiency of drones, they can be used for delivering products much faster, and thus major companies like Amazon, Dominos pizza, etc. are working on this.

6. Big-data analytics

Gene editing technology is the technique in which RISPR-Cas9 ((Clustered Regularly Interspaced Short Palindromic Repeats--associated protein 9) is used to edit the genetic code in a person. They have been used to treat muscular dystrophy, Alzheimer's in mice, fight drug-resistant bacteria. As this is an efficient way of curing the disease but there are so many obstacles in executing this procedure. One on the main problem is the lack of modern technology, if any incomplete or change in gene edition to the undirected location happens then they might have various kind of unpredictable future consequences. presently Mammoth Bioscience the co-founder of RISPRCas9 are working on this gene editing for covid-19 in University of California, San Francisco. As this technique is an efficient way of treating the pathogen this is an indispensable technique. Maybe in the future we glimpse on it.

5. Robots

Robots have always been a fascination to the world. Scientists have been working for years to make a fully developed robot. Currently, they are used in various countries for purposes like cleaning the floor, hospital reception, medical assistance, etc. In China, they are used for checking temperature, spraying disinfectants, dispense hand sanitiser; and in providence, regional medical centre doctors use robots to treat the COVID-19 patients sitting outside the glasses and utilising the robot cameras.

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8. Nano technology

Nanotechnology can be defined as the use of nano-sized particles and devices to diagnosing, target medicine delivery, etc. Nano-technology is an antiviral drug delivery system that helps the cells by reacting with the virus and binding with them and eliminating the chances of a virus entering the cell.

Nano-particles or gold and silver are used in medical nanotechnology. This technology helps to create vaccines that can affect a particular location and thus they are really important.

RNA based vaccines do not have licenses to be released but a USA based medical company has used an RNA based vaccine called mRNA-1273 in testing for developing the vaccine for COVID-19 and has entered the 1-phase of the test.

9. Super computer

Supercomputers are computers that can process a large amount of data at a specific time. Today, they are used by major tech companies such as Huawei, to develop vaccines by analysing data at a much faster rate and also used for making large calculations and models for the infected virus. Governments and healthcare institutions are also using satellite imaging and positioning to find the infected people and to provide them with effective care. These are a few of the technologies used by people during this pandemic period to reduce the spread and contain it.

Changes in technology 1. Digital payment

In digital payments, the payer and the payee both use digital modes to send and receive money. It is also called electronic payment. Cash might carry the virus, so some banks in various countries like China, USA and South Korea have set up several techniques to make sure that notes are clean before they go into the market.

Digital payments, either in the form

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AUTHOR BIO

HEALTHCARE MANAGEMENT

Minu is currently working as an Assistant professor in the department of Computer Science and Engineering at SRM Institute of Science and Technology. She had published many papers in scopus indexed journal and web of science. Her research expertise involves big data analytics, IOT and Network Security.

Bharath is currently pursuing his B-Tech degree in computer science in Big Data Analytics at SRM Institute of Science and Technology, Ramapuram. He is an enthusiastic content writer and passionate towards article writing. He is interested in updating and learning new technology.

Deepanjali is a software engineering student currently pursuing her B-tech degree at SRM Institute of Science and Technology, Ramapuram. She is a hardworking and a proactive person.

She possesses good relationship qualities. She is interested in designing works.

of cards or e-wallets, are the prescribed payment method to avoid the spread of COVID-19.

2. Remote work

Many companies have asked their employees to work from home. Remote work is based on the technologies such as virtual private networks (VPNs), voice over internet protocols (VOIPs), and virtual meetings using cloud technology, work collaboration tools and even facial recognition technologies that permit a person to appear before a virtual background to preserve the privacy.

3. Distance learning

Educational institutions like colleges and schools have started online education. This helps ensure that the education is not been disrupted by the lockdown. Technologies involved in this learning are similar to those for remote work and also include virtual reality, augmented reality and AI-enabled robot teachers.

4. Telehealth

Telehealth is the distribution of healthrelated services and information

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via electronic information and telecommunication technologies.

Telehealth is an effectual way to fighting against the spread of COVID. Although quarantine measures have turn down the person to person interactions significantly, human innovation has brought the parties online. With the help of these technologies doctor consultations made easier through virtual contact.

5. Online entertainment

Online entertainment blends entertaining interactive functionality and content including live video streaming, video chat communications, multi-player gaming, music and videos streaming, with social networking service such as social graph management, forums, reviews, ratings, and geo-location options. Due to the lockdown and the spread of COVID19 all the malls and the theatres are shut. As a result, some of the movies are being released in online entertainment site like Amazon prime, Netflix and so on. These online entertainment apps are helpful to compensate the economic loss which the countries are facing during this pandemic.

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MANAGING CULTURAL DIVERSITY IN HOSPITAL SYSTEMS IN THE ERA OF COVID-19 Uche Nwabueze, Professor, Maritime Administration, Texas A&M University

For hospital systems to compete effectively in the global market place, to serve patients and to sustain medical success, all hospitals must become as diverse as the market it is trying to reach and serve. In financial planning most financial consultants preach the necessity of a diverse financial portfolio, but the same ad vocation is not made when it comes to hiring people in the workplace. What you find is a corporate landscape of ignorance and indifference to the benefits of a diverse workforce.

In most organisations, diversity at the lower inhuman levels rather than at middle to senior managerial positions is the norm. This tendency seems to suggest that excellent organisations are defined by the homogeneity of management.

However, I have found the reverse to be the case. Great organisations in my opinion should be environments where gender, ethnic, race, and spiritual differences are respected — a culture of social inclusion and integration. Top management should be heterogeneous in composition.

This paper suggests that hospital organisations that are serious about achieving success in the provision of care and caring for patients and, as a result increase market share must embrace the opportunities cultural diversity offers. The paper offers a plan to make cultural diversity work better in hospital systems.

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I

n an increasingly diverse world, hospital systems must be fundamentally aware of cultural differences and strategise ways to overcome challenges posed by the lack of people integration and respect of cultural differences, and appreciate that the “melting-pot� era is over. However, in the workplace there still exists racism, discriminatory hiring and promotion policies personal and managerial behaviour based on perception of what reality is and not on reality itself. Thus, the reality is organisational situations where career progression and development is defined absolutely by the colour of your skin. In spite of some progress by some hospital systems to embrace diversity, global diversity initiatives at best is a failure.

What is diversity?

The author is of the view that diversity represents a highly integrated work environment where the children of the world come together in fulfilment of a common, meaningful purpose. By children of the world, the author posits a representation of Women, Gays, Lesbians, Asians, Latinos, Blacks, Whites,

HEALTHCARE MANAGEMENT

etc. — that is people of all races, gender, religion and ethnic background. The ado vacation is an organisational family unit that prohibits discrimination. Diversity therefore calls for an open, honest, harmonious and inclusive environment where people are treated with respect and dignity –an equivalent of the United Nations.

Be it as it may, a reality check of true diversity in the workplace is inclusiveness and togetherness — how open-minded are people in forming relationships. Or do we gravitate towards colleagues who are similar in gender and color characteristics; does management treat everyone equally regardless of race?

How conflicts between two individuals from different cultures are resolve? It is author’s suggestion that winning hospital systems of the future would resemble a league of nation of highly valued, highly involved, highly engaged, highly rewarded, and highly appreciated people who often times agree to disagree, but are united in their quest to win in the market-place by providing extraordinary medical service. This would require the development of an organisational character strengthened by cultural differences. However, top management of organisations must have the courage to prevent cultural homogeneity and opt in favour of cultural heterogeneitythat is a culture of social inclusiveness.

The most effective way to achieve this is through conversation; helping people to confront their underlying assumptions and beliefs of minorities (Women, Gays, Lesbians, Blacks, Latinos, Asians, Jews and Muslims).

Assumptions and beliefs

The assumptions and beliefs that we hold of people that do not look and act like us, has a lot to do with upbringing.

I believe that a child’s behaviour reflects the manner in which he or she is raised.

If she is raised with love, she becomes loving; if she is raised with hate; she becomes cruel and spiteful. Furthermore, if a child is raised in an all white suburban

area, attended all white schools and had all white friends that child comes to accept that as the social norm and have little or no understanding of differences in the social composition of the workplace. It therefore becomes very difficult to socialise into a system that suddenly has a group composition of Blacks, Asians, Latinos, Gays etc, people you have nothing in common with. Most do not even speak like you and have never had similar vacations or watch the same TV shows and all of a sudden they are colleagues at work.

Moreover, you heard at history classes in high school and at home that blacks are only good in music and athletics, and are not predisposed to rules and responsibility. In fact, your parents may have suggested that Blacks are meant to be inarticulate and lazy; Hispanics are strong-headed, un-educated, and only useful in menial jobs; Asians are conniving and cannot be trusted; Gays are sinners and must not be tolerated and women are supposed to be at home tending to the kitchen and children - necessary evils. To confront our ignorance to differences in culture, to gender and to sexuality, management must help employees change the internal pictures – the mental model that impacts their relationship with others.

We, either as managers or employees, must realise that our mental models are not fixed truths, but temporary, wrong

Sustaining workforce diversity comprises four crucial components that companies should adhere to: commitment, monitoring, accountability, and celebrating milestones.

assumptions and learn through training and mentoring programs that people should be taken for who they are. This requires the need for each of us to have a fundamental understanding of our inner-most self, of our purpose in life and develop the strength of character to challenge our assumptions and beliefs, only then can we find inner peace- a requirement for building an emotional connection to other people.

Addressing people Issues in hospital systems

A cross-mentoring programme is important in overcoming childhoodbased belief systems. I am against mentoring programmes based on White/White; Black/Black; Woman/ Woman etc. They are divisive and do not encourage understanding, building bridges based on integration and oneness. If hospitals believe that hiring a token Black, Latino, Asian, Gay, or Woman is what diversity represents, they need to rethink. In ensuring that mentoring programs work there must be a spirited effort at desegregating middle and upper levels of the organisational hierarchy. A change in people’s behaviour and attitude is also required.

For example, most women believe that their case is about untapped potential, the expectation of them by management to assimilate by becoming one of the boys. Thus, management has to remove all gender-based hurdles to women and other protected class career progression and development.

For other minority workers, management must emerge from its blissful ignorance and realise that diversity is not affirmative action. My understanding of affirmative action in the American context is amusing; wherever there is a minority worker, he or she is assumed by white colleagues to be less qualified. This assumption is not representative of the true situation in most industries. In higher education for example, most minority faculty members are terminally degreed (Ph.Ds) and in

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healthcare, minority staff members are often over qualified and yet hold lower level positions.

Furthermore, they face the daily challenge of having to prove themselves to colleagues and patients, and would have to work four times as hard to gain credibility and acceptance. It becomes painful to come to the reality that for the minority worker the issue of respect, acceptance, status, belongingness and recognition is wishful thinking. Another key challenge for management is having the courage to focus on equality of opportunity- a process of affirming talent, drive and merit. For example, Ann Compton who many regard as one of the finest ABC news reporters was one of the very first women to be hired

by ABC Corporation. At the time of her interview, Anne Compton was not more qualified than the male candidates, but the organisation chose to give her the opportunity to serve and the rest is history. According to Sam Donaldson a colleague of Ms Compton; diversity is not affirmative action, but a process of creating out of the box thinking, which

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is only tenable in a culturally rich work environment (Personal Communication, 2005).

In addition, Barbara Walters was discriminated against because it was suggested that she had a pronunciation problem with ‘r’, which was interpreted as she having a Brooklyn accent. Ms. Walters was later given the opportunity and today she is a television legend.

The suggestion is for organisations’ to give the so called B and C players the opportunity to serve alongside the so called A players. Management must therefore eliminate internal cultures that ignore great ideas from the minority worker, perceives assertiveness as aggression; perceives a questioning mind as insubordination and destroys souls through destructive comments rather than enhancing the mind, heart and spirit of the wholeness of the individual regardless of cultural differences.

Diversity as a competitive weapon

It is claimed by most writers (Thomas and Ely, 2000) that a diverse workforce is a factor for competitive advantage.

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However, Thomas and Ely contend that the poor application of both assimilation and differentiation models of diversity have hindered the value of a diverse workforce. In the assimilation model, Thomas and Ely claim that the mistake that management makes is the tendency to treat ‘everyone’ the same by blending minorities into a majority monoculture.

Whilst in using the differentiation model, organisations tend to pigeonhole employees into niche jobs and markets based on their background. For example, blacks are hired and assigned to promote products designed for the black market.

Whatever, the model used; the real issue is the failure of management to conceive of how best to utilise a heterogeneous workforce. It is my opinion that the failure of most healthcare systems to adequately address implicit bias in the recruitment and hiring process continue to negatively impact non-whites.

A diverse workforce I believe has great potential as a source of competitive advantage only if the socialisation, assimilation, training, social recognition, responsibility, career development and

HEALTHCARE MANAGEMENT

achievement are accorded minority workers. More fundamental is the need to listen to them and facilitate an environment where their attitude is moved from a passive to effective role and from trying to survive to a partnering role. (Figure 1).

The real environment of most hospitals is that of the minority worker arriving the workplace full of enthusiasm about his or her role only to be ‘knocked back’ by a general attitude that says: “we hired you, but please keep away from us”.

Efforts directed at mutual friendship and acceptance is rebuffed; suggestions are ignored; assertiveness seen as aggression; politeness construed as laziness and critical thinking seen as obstinacy.

When white employees fail to acknowledge minority colleagues because they assume an air of superiority or that their way is the only way, the collective value of individual contributions is greatly diminished.

In such an environment, employees become either passively uncritical; mere survivors or just conformist rather than effective, critically involved human beings. (Figure 2).

The minority worker from my experience and research has the motto: ‘live and let’s live’. He or she seeks an environment that would challenge them to their maximum capability and to attain a higher level of personal achievement based on their God given talent. However, from figure 2, it is my opinion that the immediate need of minority employees is not physiological nor is the second level safety, but justice – fair play, trust and genuineness followed by recognition. The minority worker like mainstream whites also has a fundamental need for recognition, appreciation and acceptance of his or her contribution towards the attainment of company goals. Minorities have a need to be one of the boys or girls; a need to be involved and a higher need for challenge and achievement. When the minority worker feels that her words and actions go un-noticed, serious

Critical Involvement

Passive

Effective

Survivor

Partner/Conformist

Uncritical Involvement

Figure 1

emotional problems is likely to ensue.

Therefore, top management should also create working conditions and methods of operation and assessment where people regardless of colour, sexuality, race or gender can maximise their strengths. Hospital systems should stop the tendency of putting square pegs in round holes or focusing on overcoming people’s weaknesses rather than maximising their strengths. The focus must shift to personality-to-jobfit and personality-to-culture fit that would allow for integration rather than the continued segregation of workers by poor managerial policies.

Winning with diversity

Hospitals that really care about diversity can learn from the most successful coach in the NBA - Phil Jackson of LA Lakers.

Mr. Jackson has become the most successful coach in the NBA not only because he has coached some of the best players in the NBA – Rick Fox, Michael Jordan, Shaquille O’Neal, Scottie Pippen, Kobe Bryant, and Dennis Rodman, but the fact that coach Jackson

To increase organisational effectiveness, I suggest a new hierarchy of needs:

JUSTICE RECOGNITION RESPECT FREEDOM SECURITY Figure 2

recognises that a winning team is not only built around superstars, but also with lesser talent- all working together for a common goal.

In fact, it is the coach’s and therefore management’s ultimate responsibility to integrate disparate elements of unequal abilities into a smoothly running unit, while overcoming obstacles such as hatred, jealously, resentment, un-equal pay, overblown egos, race and gender issues. Success in sport or business is all about managing and enhancing human relationships within a corporate culture that encourages constructive disagreement. Therefore, managers must put in place a code of conduct that ensures that everyone is treated with respect, dignity and honor; a prima donna mentality must not be allowed. Without respect and an open environment where people feel free to share thoughts and feelings, an organisation’s creative energy and ingenuity can wane and this is usually the case in cultures lacking in people integration.

How can a hospital system get the most out of its diverse workforce?

How can it ensure that these individuals interact effectively with each other?

And what can a company do when races clash? Make no mistake, it’s a delicate balance, and one that requires in my opinion, moral leadership- the capacity to distinguish right from wrong and doing right; seeking the just, the honest, the good and right conduct.

Moral leadership gives life to people and enhances the chance of diversity succeeding by treating everyone fairly, eliminating barriers to equal opportunity and emotionally connecting every employee to a common, meaningful purpose. Rethinking Diversity-Lessons from History Lance Armstrong won the Tour de France as a member of the U S Postal Team; his team mates were not selected to be just like Lance Armstrong, but were chosen to complement Lance’s strengths.

The result was a team composed of

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riders from Spain, Columbia, Norway, Czechoslovakia, Luxembourg and Belgium. The team’s security chief was a veteran Texas department of public safety officer. The lesson is supposedly obvious; when you seek the best for your organisation you will end up with a diverse team. However, it is suggested that organisations populated with people who think alike, look alike, with similar social and educational have severe disadvantages: • Tendency to recruit friends • Manufacture products for friends • Sell to friends • Advertise to friends • Market research with friends • Assume values and needs are the same for everyone.

Unfortunately, our friends make up only a small percentage of the marketplace. The global market place is

made up of diverse customers who are no longer white guys. Thus customeracquisition strategies derived from whit male dominated environment just would not cut it any longer. For example, Golden Sachs the investment banking firm headlines some of its advertising with: “The great news is that great minds do not think alike”. The implication is that successful organisations, are not environments of conformity of opinions, but hold varying perspectives to global issues.

Workforce demographics

The change in the workforce demographics is another important factor that organisations must address.

According to the U S department of labor statistics, the workforce will soon be dominated by women, senior citizens and minority ethnic groups.

Immigration will also be a major factor for a diverse workforce. The foreign-born share of the population has more than doubled between 1970 and 1997. In the past, most Americans emigrated from Europe; the majority of the working population now comes from Asia and Latin America (Hattiangadi 1997). This diverse group also brings with them issues of group differences and an increased emphasis on trainability. To be effective management must focus on what would determine the future –trends and demographic changes and forget about what has worked in the past. They have no choice but to better coordinate the make-up of their workforce.

Ultimately, management must redesign their approach to the selection process. Major change is required in the selection process- to select individuals to join the organisation or on to teams

Making it Work in Hospital Systems: Diversity Initiatives One of the primary focuses that should be implemented to combat corporate diversity opportunities is to create employee-networking groups such as International Week ceremony and a diversity recognition program.

These programs will support the organisation’s goal of increasing corporate wide diversity initiatives.

Commitment from leadership will be the key to the success of a corporate diversity plan. It is unlikely that division managers, middle managers, supervisors and others in positions of authority will become champions of diversity unless they believe that the chief executive officer (CEO) and those reporting to the CEO are totally committed to valuing diversity.

To begin with I offer a few suggestions. First organisations must initiate several networking groups.

The networking groups should not be exclusively for Black, Hispanic, Asia, Gay or Lesbian, but cross cultural in order to encourage exposure. This would facilitate learning, understanding and appreciation of differences.

The networking groups would also provide a structured environment for colleagues to participate in mentoring, networking and corporate-wide hiring initiatives. In addition, the group will enhance the better positioning

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and delivery of the company’s products and services to the global community.

Another initiative is to institute an international week as an annual event. During this event, employees are put in to teams representing different countries. Each team will present a display that describes the culture of the country. For example, artifacts can be displayed and samples of food from the featured country will be cooked and distributed. Top management would then sponsor these teams on trips to the assigned countries. For example, regardless of your origin, if you are assigned to team Nigeria you would travel to Nigeria for a few days and awards presented to team members on their return by the Chief Executive Officer.

This type of exercise will further facilitate the breaking down the of walls of diverse cultures, values, beliefs and perceptions and would open the pathway for communication and sharing of ideas for business growth.

Furthermore, a diversity Champion’s Presidential Award should be established to recognise those colleagues whose accomplishments, efforts and behaviours support and advance diversity objectives established by the organisation.

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rather than into a specific job. Selecting someone on the basis of his or her knowledge of a specific word-processing program for example may appear to be short sighted. Consider the changes in jobs, technologies, and business directions, they all change rapidly and job requirements will also change.

Alternatively, selecting someone who can become an important part of a growing company seems a smarter investment.

Globalisation of diversity- a set of Benefits

In the 21st century, an organisation that embraces a diverse workforce will attain benefits that could increase its business opportunities and their quest to maintain a competitive edge. This view is supported by Chapman (2002) who argued in his article “Discomforting route to diversity”, that increased diversity is not merely inevitable in the workplace; it is positively a beneficial change for the best. He eludes to the

fact that if the population where most corporations serve is diversified, it makes good business sense that the company’s workforce be diversified to realise business benefits. For example, if a company opened a retail store in a Hispanic neighbuorhood it would be to their advantage to hire Hispanics from that community, but without the pigeonhole mentality. A major advantage is that the residents would be more receptive to buying store merchandise when they see someone they can relate to working there.

Likewise, Chapman suggests that another benefit of having a diverse workforce that resembles the community in which it operates is the issue of harmony as it relates to social responsibility. How can this be one might ask? It is often said that an unhappy worker is an unproductive worker. Many workers are affected by what is happening at home, be it childcare or elderly care for parents.

Most companies, when putting policies

in place, rarely think about how it will affect the different cultures that make up their workforce and community. Given the diversity of the workforce that reflects the community, Chapman suggests that it forces firms to rethink their personnel policies from recruitment, to flexible work practices, to medical coverage that reflects differing family structure (Chapman 2002).

Also, by employing a diverse group of employees allows an organisation to identify talent from different backgrounds and widen the spectrum of knowledge available to the organisation.

An article; A Strong Prejudice in the Economist Magazine (2002) suggests that diversity can boost creativity. For example in a research that included an ethnic and homogeneous group of people given the same problem. What they found was that the diverse group’s output was greater because they were able to draw from their different experiences (Economist 1995).

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Sustaining workforce diversity

Sustaining workforce diversity in my opinion comprises four crucial components that companies should adhere to: commitment, monitoring, accountability, and celebrating milestones. Probably the most essential element in sustaining diversity in the workforce is commitment. Commitment to diversity must start with the CEO and trickle down to senior and the middle management. Management must be seen by the workforce to be an active participant in this process. Diversity must be one of the core values of the organisation. The senior management team must model the acceptable behavioural norm that says: ‘Our competitiveness and success is defined by our differences’. But the key is to let go of anyone however important who is accused of discrimination.

For example, many organisations sponsor cultural events for minority employees, but very seldom do CEO or anyone else from senior management attend. Management at all levels must attend these functions to sustain diversity within their company. Furthermore,

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Success in sport or business is all about managing and enhancing human relationships within a corporate culture that encourages constructive disagreement.

diversity. For instance, awards should be given to employees or members of the management team recognising their accomplishments. Such as, a yearly awards program recognising a manager that have exemplified leadership in ensuring that diversity is demonstrated not only in his department but throughout the company. Also, through celebrating each success on an individual basis could prove to be a motivating factor for others.

Conclusion

management must promote involvement and commitment from everyone else within the organisation through training and conducting various activities that focus on diversity.

In addition, monitoring is another vital component in sustaining workforce diversity through conducting periodic analysis to recognise areas for improvement. Another vital component of sustaining workforce diversity is holding management and employees accountable. Executives, managers and supervisors must be held accountable for achieving results. This I believe can be achieved by determining a manager’s bonus on how they promote diversity through mentoring and developing minorities within their department.

Also, senior management bonuses and incentives should be based on the success of the development programs implemented and their participation in diversity events within the company.

Finally, celebrating milestones or success of diversity programs is important in sustaining workforce AUTHOR BIO

A final benefit of having a diversified workforce is that it allows you to enter untapped markets, those markets that have been closed due to language or cultural barriers. For example, Avon realized that the influx of Asian immigrants created an untapped market.

Avon started a campaign to recruit Asian American representatives that understood the culture and could Communicate effectively with the target market (Economist 1995). The issue here is that the world is a global community requiring both a diverse product portfolio and workforce.

Furthermore, as companies strive to expand their products globally, having a diverse workforce of different cultures affords the company insight specific cultures, economics and language, ultimately, saving the company time and money.

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The commitment to ensuring diversity throughout the organisation must start with the CEO and senior management. However, the Human Resources Department must be an active participant in this process.

Celebrating the milestones or successes of diversity programmes is the key to sustaining workforce diversity. In order to identify high potential employees and replace key executive talent, HR management must first identify the companies’ future goals and challenges.

Once this is established then HR can specify the skills, knowledge and characteristics needed in the potential candidates. Corporations retain high potential and fast track employees through profitability forecasts. These are decisions made by managers regarding the advancement potential of their subordinates. These high caliber employees are highly motivated and often elect to participate in mentoring programs, employee networking groups and organisational task groups. All of these programs are important to Corporations because they emphasise the importance of its most valuable resource: their employees.

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

THE SURGEONS HOUSE

The complete surgical destination SHL Surgeons House Private Ltd. (The Surgeons House) is a platform to integrate surgeons with an aim to develop best group surgical practices. The objective is to develop a one-stop solution for patients to address their medical and surgical needs in an affordable manner, coupled with quality. With Surgeons House, we intend to establish multi-speciality clinics by bringing super-specialised surgeons under one roof. This would help the patients save time by allowing a speedier consultation process and multiple added benefits at the same time. As a startup, we intend to collaborate with hospitals in order to meet the surgical needs of our patients.

Group practice amongst specialised doctors to provide affordable and quality services to the patients is at the heart of Surgeons House.

Goals 1. We believe in implementation of evidence based scientific practise for better surgical outcomes. A collaborative approach is the key to achieve this goal.

2. Evidence based approach would help us develop standardised surgical practice which we intend to implement in all our branches, within and outside India.

3. To create long term database for demographics, disease and outcomes of patients by implementing a central data collection centre which will contribute to science and research significantly.

Our approach 1. To encourage surgeons promote and work to speciality based group practise. We intend to develop various allied surgical specialities in group practice format not pertaining to single speciality but combined with all surgical specialities.

2. To encourage surgeons to participate in advancements of surgical sciences and implement newer surgical techniques and procedures.

3. To provide flexibility to surgeons to help them reach their true earning potential, which is not common in a salary-based model.

4. To build surgical leaders amongst ourselves who

would manage potentially our branches across the country.

5. We intend to provide services to geographies which lack surgical facilities or specialised surgeons by collaborating with local governments in long term.

6. To implement a feedback system to improvise our results.

Solution A collaborative approach is the key to achieve the vision of Surgeons House. Our values and culture is aimed towards group practice amongst specialised surgeons that would help us implement evidence based practice and ensure standardised outcomes We intend to partner with hospital groups to ensure our goals move in right direction. Secondly, we intend to partner with technology companies to create a strong data centre to achieve our goal of standardised evidence based practice. We believe this this initiative will further ensure better solutions to the Indian healthcare system.

The other major area as we grow up is to act and develop corporate social responsibility in various health related issues which will be very helpful to society in turn to SHL surgeons and healthcare organisations. This is a considerable moral responsibility of being health professionals to impart knowledge and give better meaning to our initiative.

Endnote

As we step forward to create and establish our platform, we would encourage surgeons, healthcare professionals, entrepreneurs and investors to help us establish our vision of “one stop shop for all your surgical problems�.

Dr Saurabh Bansal is a very passionate General, laparoscopic and Minimal access surgeon practising in National capital region of Delhi, India. He is strongly behind the concept, design and implementation of The surgeons House and justifying his role as Founder and Managing Director of SHL Surgeons House private Limited.

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ExpertTalk

HEALTHCARE MANAGEMENT

TRENDS IN HEALTHCARE DELIVERY In emerging ASEAN, where there is a wide spread of rural and metropolitan areas, connectivity can help expand the reach of specialists, who are typically based in larger hospitals in the city. This will help alleviate the patient load typically seen in the cities and improve the level of healthcare access for patients in provincial or rural areas are able to receive.

What are some of the trends driving healthcare delivery in Singapore and emerging ASEAN? We are seeing more emphasis placed on value-driven care across emerging ASEAN and particularly, in Singapore.

Clinicians are increasingly focused on delivering better value, in addition to positive healthcare outcomes. What this means for healthcare equipment providers is the need to demonstrate our clinical value through efficiencies

How have these opportunities changed since COVID-19?

COVID-19 has left a profound impact on the healthcare industry. We have seen a shift in demand for strategic essential medical products such as ventilators, patient monitors and mobile x-rays as governments stock up supply of these equipment in their countries.

COVID-19 has also accelerated the healthcare industry’s reliance on technology and digital infrastructure to maintain and improve service to patients. This was gaining interest

What are some examples of new technology such as AI, data analytics in healthcare delivery ? Where is the uptake on that in Singapore and emerging ASEAN? We are seeing more partnerships emerge across the ecosystem between

large MNCs like GE Healthcare with hospitals, start-ups, developers and more to drive digital adoption in healthcare.

In November 2018, GE Healthcare launched Edison, a platform that helps accelerate the development and adoption of AI and empower providers to deliver faster, more precise care.

Clinical partners will use Edison to develop algorithms, and technology partners will work with GE Healthcare to bring the latest advancements in data processing to Edison applications and smart devices.

Some examples of Edison applications and Edison-powered devices include an AI-based, automated workflow tool for MRI brain scanning designed to increase consistency

and productivity. Most recently on 18 June 2020, GE Healthcare launched a collection of eight AI algorithms in collaboration with a Korean medical AI software company. The solution helps alleviate clinical strain in crisis situations such as COVID-19 by quickly analysing chest x-ray findings and flagging abnormalities to radiologists for review. The solution is also able to highlight lung findings of leading health challenges in emerging ASEAN, including tuberculosis, lung nodules, and other pulmonary and cardiovascular illnesses. In Southeast Asia, we believe that these digital adoption models will pick up and we are partnering hospitals in the region to understand their needs and support them on this journey.

Jeong Jae Youn, Country Manager, Singapore & Emerging ASEAN, GE Healthcare

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that improve the patient’s experience, reduces waste in the clinician’s workflow and lowers the cost of care.

This has resulted in the integration of digital technology solutions such as Artificial Intelligence (AI), data analytics and remote connectivity into hospital equipment and solutions.

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slowly before COVID-19 but has since increased rapidly ever since. Going forward, we expect technology and digital solutions to continue to be essential as healthcare demand in the region rises with economic growth.

What are the resulting benefits of these innovations?

Clinical value driven by automation, predictability and connectivity.

AI and data analytics can help drive automation and predictability, generating quicker results and streamline workloads. For example, AI-enabled software aggregates the data using the cloud, allowing medical professionals to view a patient’s status remotely. Clinicians can monitor multiple patients simultaneously as well as cross-reference a patient’s past electronic medical records to highlight any contradictions. This reduces workflow inefficiencies, enabling clinicians to attend to more patients and more effectively prioritise the highest risk cases, while also reducing the risks of infection.

Data gathered by analytical technology can be used to minimise down

improve the level of healthcare access for patients in provincial or rural areas.

The pandemic has proven that data, analytics, AI, and connectivity will only become more central to delivering care.

time within the hospital’s operations.

Engineers can get a virtual understanding of the equipment’s conditions, with the hospital’s unique environmental factors taken into consideration.

The data can be used to ensure the availability of parts and engineers to ensure the customer does not face any unplanned downtime.

In emerging ASEAN, where there is a wide spread of rural and metropolitan areas, connectivity can help expand the reach of specialists, who are typically based in larger hospitals in the city. This will help alleviate the patient load typically seen in the cities and

What is the role of technology in healthcare delivery in Singapore and emerging ASEAN post-COVID? The pandemic has proven that data, analytics, AI, and connectivity will only become more central to delivering care. For GE Healthcare, that means continuing to advance intelligent health and providing innovative technologies. This journey will require new and reinforced partnerships across the healthcare ecosystem – hospital administrators, medical professionals, medical device manufacturers, technology solutions

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providers and more – to work together towards transforming how healthcare is delivered in the New Normal and beyond.

AUTHOR BIO

In your opinion, how do you foresee patient experience changing over time with the use of these new age technologies such as AI, data analytics, and digital connectivity?

The clinical value brought about by AI, data analytics and connectivity will certainly have positive benefits on patients. They can expect to have a smoother and faster experience and have peace of mind to undergo care that is backed up by more data points from their medical history.

When undergoing diagnostic procedures, for example, deep learning algorithms built into the CT or MRI technologist’s workflow can automatically identify anatomical structures to prescribe the slice locations, and the angle of those slices, for neurological exams, delivering consistent and quantifiable results. This will allow the clinician to make a more accurate and informed diagnosis for the patient.

Data analytics can provide a predictive and proactive solution that automatically selects the best settings for each patient over the precise area of interest based. It drives consistency and eliminates variation, ensuring a smoother patient experience without the need to do re-scans.

Digital connectivity can encourage the secure sharing of patient data,

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allowing care teams across various departments and locations to more efficiently collaborate on patient cases.

This helps reduce handling costs for foreign studies, the time spent preparing for multi-disciplinary meetings, increases patient referrals and allows easy sharing of images and records directly with patients.

How do you think the industry landscape is going to change in the next five years, and what are the growth opportunity areas in the sector?

Digital integration into healthcare delivery will continue to be a key theme in healthcare. As we move into a period of living with COVID-19, healthcare providers will be considering how they can leverage technology to drive healthcare transformation and pandemic preparedness.

This will create opportunities for new and reinforced partnerships across the healthcare ecosystem from hospital administrators, medical professionals, medical device manufacturers, technology solutions providers and more.

As mentioned, this means that medical device manufacturers like GE Healthcare will need to show the value of its solutions and offerings.

To that end, we expect more partnership approaches as we offer not only technology and digital tools that suit local healthcare needs, but also build a long-term solution that sets the hospital up sustainably for healthcare transformation.

Jae Youn (JY) is the Country Manager for GE Healthcare’s Imaging, Ultrasound, Life Care Solutions and Services business segments in Singapore, Myanmar, Cambodia and Laos. He has more than 16 years of sales and marketing experience in the Healthcare sector in Korea and Asia Pacific. JY took on his current role in March 2020 and is responsible for GE Healthcare’s go-to-market strategy for Singapore as well as for accelerating the business’ growth in developing markets. JY holds a degree in Applied Statistics from Konkuk University, Seoul, Korea.

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FOOD SAFETY AND REGULATIONS

Emerging role of technology While drug regulation would be a topic of frequent updates and discussions on this platform, food safety and regulations has come to the fore because of COVID19. The new normal will be introducing a lot of changes in the way people eat out and the food vendors prepare food. All practicing physicians and specialists who are running their own facilities should be updated about these regulations. More so because their customers and patients may not be well versed and may require that information from a credible source.

This topic is now getting attention from regulators in various countries. It's noteworthy that while every country will have its own outlook and standards towards food safety and is at a different stage in terms of health-technology, the pandemic situation might bring them all at the same level.

Kent L Bradley, Chief Health and Nutrition Officer, Herbalife Nutrition

F

ood and food-related safety has come to the fore because of the current pandemic. Healthcare institutions and hospitals dealing with children and the elderly who are at a much higher risk need to provide more vigilance and scrutiny in the services they deliver. Food hygiene in hospitals1 pose peculiar problems, particularly given the presence of patients who could be more vulnerable to microbiological and nutritional risks. Consumers are curious, confused and worried about food handling and the supply chain. There are a whooping 362K online searches on

1 https://www.researchgate.net/publication/6413532_ Food_safety_in_hospital_Knowledge_attitudes_and_ practices_of_nursing_staff_of_two_hospitals_in_Sicily_Italy

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‘food safety’ since Jan 2020 with per day mentions rising up to 60K which is 70 per cent higher than the previous year R1.

This has made governments rethink strategies that involve not just domestic production of food but also exports and imports. For example, in Asia Pacific, countries are focused on modernising their food safety systems2 to ensure the availability of safe and nutritious food for the projected five billion inhabitants in 2050. These procedures vary based on the regulatory framework followed by country. The current pandemic, however, has made it important for having a global standard of food safety; something that needs to be followed by all nations alike.

Use of technology

Despite updates from the US Centers for Disease Control (CDC) and the World Health Organization (WHO) on safety of food during the current pandemic, the topics of food, eateries, packaged food, food production, and delivery supply chain have come under much scrutiny.

The reasons are obvious. Myths around spread of diseases through food are many and, in the case of a pandemic, being extra cautious is the obvious reaction by the individuals.

A lot of this paranoia is also leading consumers and food business owners to invest more time to ensure food safety and hygiene measures are well in place.

Part of the issue is that contamination of the food supply can occur at various points of the supply chain from the farm to the table3. Each step of the way may introduce risk and thus should be assessed for proper preparation, storage, and handling. Technology can help play a huge role and introduce uniformity of standards, in this process Multiple technologies already exist in this realm and there are a few which are bringing unprecedented levels of transparency and insight,

What entails Food Safety?

The internet is the host to a wide variety of opinions without the need for substantiation which can be confusing to the consumer. For experts, physicians and science academicians its critical to understand the different aspects of food safety because in times like these, doctors and physicians are the most credible sources of food, nutrition and health safety information.

Food safety is not limited to just the storage and preparation of food. It starts right from the raw material used and ends with the different aspects of the supply chain which is responsible for delivering the food in the hands of consumers. This gamut of procedures involves:

• Safety in handling food contents (like nuts, soy and mushrooms) to which few consumers could be allergic to • The cooking or preparation of the food • Preservation techniques • Packaging (with proper labelling) • Delivery • Storage pre-consumption Maintaining food safety and adhering to the regulations is a tedious and intricate process. The regulations surrounding food safety are different in each company and provider but, maintaining the movement of food along the food chain is an essential function to which all stakeholders need to comply and contribute. This is also imperative to maintaining trust and consumer confidence in the safety of food that they are consuming.

2 http://www.fao.org/3/MV819en/mv819en.pdf 3 https://www.cdc.gov/foodsafety/production-chain.html

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4 https://techcrunch.com/2018/09/24/walmart-is-bettingon-the-blockchain-to-improve-food-safety/

The current pandemic, however, has made it important for having a global standard of food safety; something that needs to be followed by all nations alike.

safety testing programmes that provide an unprecedented insight into supply chains at a rate and scale that has never been experienced before.

Role of doctors and physicians

Although there is no evidence of food, food containers, or food packaging being associated with the current pandemic, it is a virus that can survive5 on surfaces or objects.

To address this concern, the latest guidelines released by WHO includes a recommendation for the food industry to reinforce personal hygiene measures and provide refresher training on food hygiene principles to eliminate or reduce the risk of food surfaces and food packaging materials becoming contaminated6 with the virus from food workers.

While technological advances, digitalisation, novel foods and processing methods provide a wealth of opportunities to simultaneously enhance food safety, and improve nutrition, livelihoods and trade, there are additional challenges on the horizon — myths surrounding food safety 5 https://www.who.int/publications/i/item/covid-19-andfood-safety-guidance-for-food-businesses 6 https://www.who.int/publications/i/item/covid-19-andfood-safety-guidance-for-food-businesses

AUTHOR BIO

paving the way for a safer food future.

They include blockchain, industrial internet of things (IIoT) and next generation sequencing (NGS). The use of blockchain technology gives organisations the ability to record and secure the validity of a wide variety of data. In the supply chain, this is already being realised as the blockchain is being used to amplify the traceability of products. For instance, Walmart has been working with IBM for over a year on using the blockchain4 to digitise a wide variety of products. Blockchain has been used to document the journey of everything from wine to salmon from source to table.

Another area of promise is the rise of the industrial application of IoT through the widespread adoption of sensor technologies that accurately and consistently capture and communicate data. Advances in networking, storage, and processing have created a mass market for sensors delivering real-time data from across the food supply chain.

The net-new data gathered by innovative sensors will be leveraged to build safer food manufacturing plants that will operate more efficiently, monitor for unintended contamination, and protect against food fraud. Each one of these potentialities would strengthen food safety programmes and help brands identify problems more accurately and earlier.

The third technology is NGS-based food tests and software analytics that have the potential to significantly improve the scalability and accessibility of food safety and quality measures. NGS-based tests have very low limits of detection; the increased sensitivity of NGS produces more accurate results along with much higher levels of specificity and resolution in a single unified test. This results in more actionable information, faster and at lower costs. The result of NGS adoption will be bulletproof food

in times of a pandemic. One of the most effective means we have today to assuage food safety concerns is simply to educate consumers by providing them with information and help alleviate their concerns.

Healthcare providers (HCPs) can play a significant role in imparting awareness around the following aspects: • Busting myths through sharing credible information and encouraging them to use reliable information sources like CDC and WHO • Educating their patients and consumers about basic hygiene measures and precautions to take in these times • Reinforcing their faith in the regulations and processes by way of mentions about technology implementations in this field.

Food systems are becoming even more complex and interlinked, blurring the lines of regulatory responsibility.

Solutions to these potential problems require inter-sectoral and concerted international action. Hence, greater international cooperation is needed to prevent unsafe food from causing ill health and hampering progress towards sustainable development. It also calls for a sustained investment and coordinated, multi-sectoral approaches for regulatory legislation, good manufacturing practices, accredited laboratory capacities, and adequate disease surveillance and food monitoring programs, all of which need to be supported by information technologies, shared information, training and education.

References: R 1. Source Meltwater: Search results for “Food Safety” and “Covid19”

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

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A Global Leader in Digital Health As the first company to build cellular connectivity into each CPAP device, ResMed is now a global leader in daily remote patient monitoring1, with more than 11 million cloud-connectable devices in our network. And that number is growing every day.

Over 936 million people worldwide are afflicted by Sleep Apnea2.

90+

million

2.5+

accounts in out-of-hospital care network

million

patients are on myAirTM

ResMed has more than

11 million

1+

cloud-connectable devices

~100

API calls per second from integrators

million diagnostic tests

processes in the cloud

13

million

patients on AirViewTM

The Thought Leadership Continues Online Join our webinar series where experts discuss the latest developments in sleep and respiratory care, and the best practices in providing connected care for patients.

To register your interest, go to resmed.com/webinar or scan the QR code.

Visit resmed.com today to find out more about the future of sleep therapy.

1. Berg Insight AB. mHealth and Home Monitoring – 8th Edition. Gothenburg, Sweden. M2M Research Series; 2017.

2. Benjafield AV, Ayas NT, Eastwood PR, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir Med 2019.

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How Daily Remote Patient Monitoring is Changing Sleep and Respiratory Care Management in Asia An Interview with Mervyn Lim, Vice President of Asia Growth Markets at ResMed For healthcare professionals, the COVID-19 pandemic has revealed many areas in which we must take technology further to serve our patients. For somnologists, or specialists treating patients with sleep-related comorbidities, care that is constant and connected has always been important – but even more so in today’s socially distanced world.

Today, Mervyn Lim, vice president of Asia Growth Markets at ResMed speaks about the significant impact that remote patient monitoring will have on sleep and respiratory care in Asia Pacific.

Why is elevating awareness around sleep disorders and innovation important for Asia Pacific?

As mentioned, researchers recognize that sleeping disorders are prevalent across age groups and nationalities, and is often unrecognized, underreported, and undiagnosed. The impact of sleep disorders on patient quality of life, workforce productivity, and longerterm health economics is significant. Because of its broad-ranging effects, many clinicians believe such disorders represent a major public health concern in our region.

number of sleep labs and long wait times for medical care for patients that critically need this service to learn whether they have sleep disorders. Our work in this space will have long-term impacts even after the reopening of many markets to ensure more digitally-connected delivery of care.

How are digital health technologies and cloud-connected medical devices continuing to transform care and outcomes in the sleep space?

Certainly, interoperability is not a new concept. Most of us understand that it is inevitable for healthcare systems to interconnect to other systems. But the application of this concept to the sleep disorder space is exciting.

“ Remote and selfmonitoring combine to help raise sleep apnea patients’ adherence on CPAP therapy up to 87 percent (compared to roughly 50 percent on a non-connected device) 1.“

How has the pandemic impacted the ability for healthcare professionals to monitor and provide care for those with sleep apnea, chronic obstructive pulmonary disease (COPD), and other chronic diseases?

I believe that cloud-connected medical devices and IT software and innovative solutions that treat sleep disorders related to COPD, sleep apnoea, or other chronic diseases will continue to play a big role in keeping people out of hospital and empowering them to live healthier, higher-quality lives.

During the COVID-19 pandemic, the need for clinicians to closely monitor patients with sleep and breathing disorders has created an equally critical need for advances in digital health to support.

One great example is digitally-enabled home sleep testing.

Home sleep tests are overcoming the obstacles of the limited

Remote and selfmonitoring combine to help raise sleep apnea patients’ adherence on CPAP therapy up to 87 percent (compared to roughly 50 percent on a non-connected device)1.

Digital applications like myNightTM allow patient to perform self-screening in their home. The cloudbased application, AirView communicates with ResMed devices, enabling healthcare providers and hospitals to not only monitor and treat their patients remotely but also use apps such as myAirTM for daily self-monitoring.

What are the challenges you see for Asia’s sleep clinics as countries reopen?

For a period of time, on-site visits with a healthcare professional was not possible, as most sleep labs were closed due to government-enforced quarantines. During that time, our teams have explored many viable models to enable patients to manage their conditions, with the help of their HCPs, remotely.

Still, it will take a bigger integrated effort – among our people, patients, customers, government, partners, and healthcare leaders – with an awareness of the need for developing new pathways to treatment. To do so, ResMed is engaging HCPs to share best practices and reopen sleep labs while also working actively to integrate tele-monitoring solutions.

1. Malhotra A, Crocker ME, Willes L, Kelly C, Lynch S, Benjafield AV. Patient Engagement Using New Technology to Improve Adherence to Positive Airway Pressure Therapy: A Retrospective Analysis. Chest. 2018;153(4):843-850.

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CASH MANAGEMENT IN EMERGING ASIA-PACIFIC HOSPITALS The king is back!

Hospitals in Emerging Asia are expected to see a challenge with cash flows in the next 2-4 years. As seen post-SARS, outpatient and ambulatory services could only be back to usual levels in 3-4 years. Given evolutionary phase, Telemedicine will not fully compensate. Adding pressure to cash cycles are slow payments by universal coverage, mounted by reduction in elective surgeries. Hospitals will have to deploy a multitude of options to address cash flow challenges.

Aditya Agarwal, Principal, Roland Berger

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A

s markets in Asia-Pacific gradually reopen and a sense of normalcy returns, various analysts expect private hospitals to have a strong performance from second half of 2020 relying on pent up demand of patients for elective and chronic treatments. However, drawing from lessons of SARS 2003, and per conversations with hospital leaders, the path to recovery is likely to be uneven and might be painful financially. Hospitals need to navigate this difficult time with deft cash flow and resource management.

Low to no elective visits, COVID-19 volumes provided some buffer in Q1 2020, but profits and cash flows show signs of strain

During the pandemic's first wave at its peak: hospitals have been overburdened, ICU's crowded, while hospital rooms quiet.

Excessive demand for critical care, need for enough medical supply and PPE, staff shortage, put severe cost / Opex pressures.

At the same time, elective procedures reduced drastically driven by government directives and reprioritisation of cases plus, modalities of outpatient services were either strongly modified (e.g. moved to online consultant) or completely shut down.

Initially as the pandemic unfolded, patient

volumes were buffered by COVID-19 inpatients, and reimbursements offered in some markets. However, markets like Thailand, Vietnam and lately, Malaysia and Singapore that have managed to control the pandemic better saw fewer patients with COVID-19, exposing private hospitals to the challenge of improving occupancy rates. (Figure 01) The drivers of lower profits and cash flow range from a reduction in most profitable treatments to a complete decline in medical tourism usually forming 10-15 per cent of the revenues but about 20-25 per cent of the profit Not a V sharped recovery, but an uneven path forward: as COVID-19 recedes, elective and ambulatory services would come back to full potential only gradually

While various surveys had predicted a full recovery of elective procedures in markets like Thailand and China by end of May-June, the overall number of elective procedures is not rising as fast as expected: per recent analyst reports of healthcare groups and suppliers with major operations in China, elective surgeries are back to ~50 per cent volume. For example, Aoxin Q&M, a

Reduction in elective surgeries and occupancy rates in ASEAN and India Reduction in elective surgeries in ASEAN example Urology (%) 58.20 Complete shutdown Reduced >50% Reduced by 25 to 50%

Impact of COVID on occupancy rates (normal ward) Q1 2020 for leading private hospitals in ASEAN Pre-COVID

60-70%

18.60

25.50

14.10 Elective procedures (Q1 2020)

Ayushman Bharat claims pre-lockdown vs. post lockdown, India.

Claims per week......Change (%) Medical services.......-46

Reduction for those treating COVID patients

5-10%

Surgical services......-57 Oncology care...........-64

Reduction for those not treating COVID or COVID cases have reduced

30-50%

Haemodialysis..........-6 Normal deliveries......-28

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Profits and cash flow impact

Outpatient visits over 3 years at a Taiwan hospital post SARS 2003

Leading private hospitals profit in Thailand and Malaysia Q1 2020 Revenue, net income and cash flow from ops.

(Y-o-Y)

Revenue.......................- 6% Net income..................-58% Cash flow from ops.....-38% leading dental chain, has already advised of a weak recovery in sight for this year's operations.

Hospitals in Thailand too are not back to full potential: a case in point, Bumrungrad Hospital reported weak Q1 2020 earnings but might have a worse Q2 2020 per DBS group estimates.

In order to boost demand, hospitals in Thailand have started offering promotional packages: buy one physical check-up and get one free. Some of the mid-tier hospitals are expected to report a revenue decline by 7 to 10 per cent.

In Malaysia, one of the leading private

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hospital groups, KPJ, too has warned of a weak Q2, 2020.

These trends, while underwhelming, are not different from how patient visits evolved during SARS. Studies which tracked hospital performance post-SARS in the two most affected cities, Taipei and Toronto, suggest that outpatient visits were only back to full capacity in year 3 of the outbreak and elective procedures

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also took about 15-32 months to come back to usual levels.

The challenge in the case of COVID-19 is further exacerbated by the possibility of second wave of cases after economies re-open which shall only further slowdown recovery for hospitals.

Telemedicine's adoption is a boost for the healthcare sector, however guidelines, business models and reimbursement

HEALTHCARE MANAGEMENT

models are evolving. Telemedicine helps hospitals provide a viable engagement model, but two key uncertainties remain: whether the relatively relaxed guidelines shall persist, and if the adoption would sustain. Most likely, while the overall levels of telemedicine usage would be substantially higher than pre COVID19 levels, the sustainability would vary from market to market. Singapore, China, and Malaysia are expected to lead while Indonesia, Japan, and Thailand shall remain close followers. Given the dependence on a physical set-up for a procedure and the varying adoption levels across markets and demographics, telemed volumes and payments are less likely to fill the gap with lower outpatient visits.

The challenge with most coverage schemes in the region though has been budget shortages and, as a result, slow payment cycles, which have already put pressures on hospitals’ working capital.

A Case mix increasingly reliant on universal coverage, exposing to longer receivable cycles

Beyond financial stimulus: how can hospitals release cash manage the liquidity challenge?

In the past 4-5 years, universal coverage in Asia-Pacific has been a mega trend: from BPJS in Indonesia to Ayushman Bharat in India and coverage levels increasing in Vietnam and the Philippines. Private hospitals which were so far being selective in case mix and participation of universal coverage are likely to see a larger portion of revenues in the interim through the reimbursed programs.

Three reasons driving this shift are: i) The reduction in cash patients as patients continue to be reluctant on elective visits, plus lower medical tourism, both from within and outside the country; ii) increased reimbursements: lately, SSS in Thailand had 7+ per cent increase in reimbursements, BPJS premiums are rising at least for the formal group and reimbursement rates are expected to rise at least for a few services. Case in point, COVID-19 outpatient reimbursements are better than the usual INA-CBG class A rates in Indonesia; similarly Ayushman Bharat included cancer coverage in late 2019; iii) The expected second wave of COVID-19 cases.

Hospital groups recognise the need for cash management to be prioritised and it can be seen in the strong advocacy for financial stimulus. However, beyond relying on an already pressured healthcare and stimulus budget, and to brace for a longer road to recovery, hospitals can deploy a range of options.

At the outset, we expect that most CFOs have already set up a 13-week cash flow assessment cycle; it’s a hygiene practice in the current scenario. Below are some initiatives that can be deployed and monitored in the immediate term: Demand reassessment tailored to therapy area: Another learning from SARS is that, not all departments would see a steady uniform recovery.

Hence it would be key to rebalance purchase orders for drugs, equipment based on the patterns emerging of the different therapy areas seeing increase in occupancy. Instead of using the traditional demand models, deploy simpler assessment tools like drawing recent insights from analogue markets which are weeks / months ahead in reopening. Frequent collaborations on sharing knowledge with peers and

national health authorities might yield lasting benefits.

Inventory pooling: Chain hospitals and multi-speciality hospitals could try to pool inventories to use the buffer stock available. This is drawn from the concept of warehouse pooling which retailers have successfully deployed in consumer goods and electronics. Sports medicine, wound care, essential drugs, consumables are possible areas where an inventory pooling might work Capex shifts: Depending on the purpose, certain Capex decisions could be shifted to next year. For example hospitals with a 256 slice CT scanner can potentially delay in executing plans to upgrade to a 1152 slice CT scanner or revisit the payment models where a decision for an outright purchase is changed to a lease or a deferred payment schedule. Similarly, for new hospital wings coming up, the activation of new departments should be delayed as per the demand pattern being observed • Cash pooling: Cash pools reduce interest costs and increase efficiency of resources. While the concept is not new, traditionally only large-scale hospitals have opted for this solution.

With increasing focus on serving SMEs in the banking sector, small to mid-tier hospitals too have options to partner with banks on integrated cash management offerings which include interest overlays and virtual accounts Cost brakes: The biggest challenge in executing cost reduction at hospitals

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Beyond financial stimulus, hospitals have a range of initiatives to deployed in the immediate term

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cycles might not be influenced with increased collection focus. However, for cash, employer sponsored programmes, collections from tax authorities such as VAT, and private insurance, a renewed collections approach which includes account segmentation (per cash requirements and strategic focus), reducing process bottlenecks, deploying a dedicated approach for reconciliation of outstanding payments and offering early payment discounts.

Innovative payment models: Hospitals have sporadically tapped into innovative payment solutions but with the adoption and embedment of telemed, they can start looking at developing new packages and solutions for cash and private insured patients, these could include pre-paid AUTHOR BIO

is usually around internal change readiness especially for clinicians.

COVID-19 provides an opportunity to leverage the wave of embrace of new ideas and new ways of working: telemedicine, use of AI based triage, bots for disinfection are some examples.

Cost containment quick wins could include use of locums based on adoption of telemedicine, consolidation for generics and consumable brands for purchases Terms renegotiation with suppliers: With regards to Capex shifts and cost brakes, for ongoing fixed costs example use of reagents, assays, and other consumables, non-medical services, payment terms could be renegotiated leveraging scale, existing relationships, potential short term extension of contract for well performing vendors; the cash strain could be challenging for vendors, hence a quarterly review to monitor the situation, taping into mutually helpful options like supply chain financing could be considered.

Revised collections approach: Universal healthcare groups' payment

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packages such as chronic conditions, subscription-based services (on-demand home-based care).

Uncertainty looms over the relative control we can gain over the pandemic.

Hospitals face a conundrum of treating all patients, ensuring their safety, but also sustaining the business.

Proactive cash management should provide some relief in the interim before strategic options like changing case mix, influenced resumption of elective procedures, and effective use of telemedicine and virtual care start becoming mainstream. Hospitals that rely less on financial stimulus and more on in-house cash release approaches will likely emerge stronger in financial maturity once the new normal arrives.

Aditya is a Principal with Roland Berger in Singapore. He is a core member of the Healthcare and Life Sciences practice, serving clients on a range of strategic and performance improvement issues. You may reach him at aditya.agarwal@rolandberger.com

HEALTHCARE MANAGEMENT

SUPPORT BEYOND MEDICATION Doctor-patient relationship in the times of a pandemic HCPs are most trusted sources of nutrition information and therefore, have a more critical role to play for their patients, especially in times of this pandemic. Beyond medication, HCPs can play a significant role in educating their patient’s about right nutrition and ways to leading a healthy lifestyle.

Kent L Bradley, Chief Health and Nutrition Officer, Herbalife Nutrition

W

e have often heard of the adage, “A good physician treats the disease, the great physician treats the patient who has the disease.”The relationship patients have with their doctor involves a great amount of trust and vulnerability; and like any relationship, this too deepens with time. The encounters entailed in this relationship may not always be perfect and desirable, but it is one of the most moving and meaningful experiences shared by human beings.

Trust is a function of multiple aspects put together. According to the American National Institute of Health, trust, knowledge, regard, and loyalty are the four elements that form the doctor-patient relationship1, and the nature of this relationship has an impact on patient outcomes too. The quality of care, knowledge and time a physician invests in the patient is 1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC473230 8/#:~:text=The%2520doctor%252Dpatient%2520relatio nship%2520has,fiduciary%2520relationship%2520in%2 520which%252C%2520by

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an important aspect. But what really drives the trust meter is a personal connection with the patient.

The pandemic has changed the world around us. Lives and functions of doctors and physicians are the most impacted. We are also entering the phase of AI and telemedicine that is enabling better access to consultation for patients who cannot transit in

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current situations. Conversational Artificial Intelligence2 (AI) for instance, is changing the way mental health care is delivered.

The current conditions require a new approach and opportunity for doctors. According to a surveyR1 conducted by Herbalife Nutrition 2 https://pubmed.ncbi.nlm.nih.gov/31681047/

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in Asia-Pacific, it was revealed that the number one reason healthcare practitioners (HCPs) are unable to have an expansive consultation about general health and nutrition with their subjects is the lack of time. To achieve success beyond prescription, sufficient time for coaching and counsel is required. It often relates back to providing support in a patient’s

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well-being through counsel on diet, nutrition, exercise and lifestyle. One of the key insights derived from this study was that consumers (74 per cent) in Asia-Pacific were looking to HCPs as the most credible source of nutritional advice.

The physicians do have a new and more significant role to play in the new normal. As a continuum of trust and credibility healthcare providers are often playing the role of the healer archetypes, wearing the hat of health coaches. HCPs acting as a counsel, must adopt the “whole person” approach where, the patients are treated holistically3 – catering for their physical, mental and social needs. Attempting to better understand not only the patients’ sickness, but also their social, cultural and economic profiles and, above all, their expectations can greatly help the doctors in this new role.

Nutrition counsel

Balanced and right nutrition is one of the key areas where healthcare practitioners can support their patients. The global rise of diet-related non-communicable diseases plus the double burden of obesity and malnutrition means that it is imperative more than ever that all HCPs are able to provide at least basic evidence-based nutrition advice.

3 https://apps.who.int/iris/bitstream/handle/10665/205942/B5022.pdf?sequence=1&isAllowed=y

A study4 on clinical level students from the University for Development Studies, School of Medicine and Health Sciences (UDS-SMHS), who had covered over 50 per cent of the curriculum noted that participating students believed that doctors should be the first ones to provide basic nutrition care and refer the patient to a nutritionist/dietician for specialised care if needed.

Improving an individual's diet requires more than just information, it requires consistent and long-term support to change and maintain new behaviours. While doctors acknowledge that nutrition plays a crucial role in health and agree that providing nutrition advice is part of their role, it is not a part of their regular practice5 sessions.

Time is one of the factors that is a critical enabler for imparting any form of advisory; in this case about nutrition.

The current pandemic has resulted in more work hours and pressure for many doctors in the frontline and limited their ability to be available for such counsel.

The surveyR1 conducted by Herbalife Nutrition in Asia-Pacific, witnessed a participation from HCPs 4 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5809975/ 5 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5809975/

and consumers alike. It was aimed at understanding the level of nutrition knowledge and information needs among these respondents. The outcomes of the survey indicated that 7 out of 10 consumers considered it extremely important to have accurate nutrition information and social media was the most frequently used channel in their search for answers. However, there are a cacophony of voices and opinions being paraded as nutrition facts and scientific findings, and consumers often encounter information that are contradictory. The situation is exacerbated when there are unqualified individuals masquerading as experts.

Suffice to say, cutting through the clutter to sieve out accurate and reliable nutrition facts is a challenge for many consumers who lack the basic tenets of nutrition knowledge.

Considering the high trust consumers and patients lay in HCPs, they have an opportunity to help patients shift to right sources for information, healthier food choices and share strategies to handle their food intake habits. Information about healthier fats, carbs, cutting sugars and overall better food and supplementation intake, active lifestyle, exercise and positive psychology should be incorporated in regular counseling sessions by the HCPs.

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Include a nutrition checklist:

To know that your healthcare provider is there to support you in your journey, beyond prescription itself, creates a feeling of community and belonging for patients. As strengthening on this relationship becomes critical, so is the responsibility of HCPs to take on the role of providing adequate nutritional and well-being advice to their patients.

Here are a few steps that can be taken to include nutrition advice in actual practice:

• Create a checklist that can be a part of your consultation papers and can be filled up by the patient while in the waiting • Apps and online tools too can be used to capture the nutritional awareness and needs of the patients Create a community: • Communities are a great way to stay connected with like-minded people and those who share a passion or a common goal. Communities can

Start talking about nutrition: • Your patients may not know that you are available for giving nutrition advice. So, speak about nutrition in general when engaging with patients and encourage them to ask questions • Capture the questions in a form or ask your patients to share their questions in an email. These questions can be answered at the doctor’s availability and convenience • Have nutritional information available at your clinic and on your website. Provide links to evidencebased sites for information.

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AUTHOR BIO

How to tread this change?

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

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be on the digital platform too like WhatsApp, Facebook and blogs. With social media being the most frequently used channel for consumers seeking nutrition information, HCPs can use this wisely to share more accurate sources of information.

In parallel, health care practitioners should also take time to focus on their own wellbeing. We need them to be fully charged in this new normal. Taking care of their own physical, social, and mental wellbeing is critically important. There is a sense of fatigue that can occur and when we do not attend to our own need for nourishing our body and mind, we may burnout. As a healthcare provider, I want to encourage each practitioner to intentionally focus on nourishment for themselves as an essential worker that is needed by so many. Ironically, the patient-provider relationship can be a source of energy when it becomes an enriching experiencing focused on connection and support. Technology is an enabler that can be thoughtfully applied to maintain the human connection that both the patient and provider need. This level of support, beyond medication, may be a way forward that re-energises the HCP and provides hope for the patient.

References: R 1. Herbalife Nutrition Myth Survey with 5,500 consumers and 250 healthcare providers in Asia-Pacific (2020)

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FIGHTING THE COVID-19 PANDEMIC Siemens Healthineers responds The growing number of COVID-19 infections worldwide are confronting healthcare institutions around the world with unprecedented clinical and operational challenges pushing many of them to their limits and putting the issue of health into sharp focus for all of us. Many of the already existing challenges such as access to care or shortage of qualified staff, have been further intensified by the pandemic. In this interview, Elisabeth Staudinger explains the role of digital solutions in care delivery and how the current pandemic is accelerating the efforts of digitalising healthcare.

Elisabeth Staudinger, President Asia-Pacific, Siemens Healthineers

E

ven before the pandemic, digital solutions had started to penetrate our daily lives. Online shopping made our lives more convenient.

Navigation systems made our car ride more efficient by avoiding areas of increased traffic. Our watches told us how we were keeping up with our fitness goals. Today, connecting care teams and patients has become easier than ever before and making decisions based

on data is easing the workload of care providers and enabling more accurate diagnoses. In fact, even before the pandemic, 9 out of 10 physicians saw the benefits of virtual care technologies1. The pandemic has accelerated the adaptation of digital means. For healthcare, that’s good news. Digital solutions will enable 1. Deloitte. (2018). What can health systems do to encourage physicians to embrace virtual care? New York.

healthcare providers to deliver higher value care and tackle the challenge of providing access to care in this region.

Access to care in Asia Pacific

Improving access to care is one of the most pressing challenges in many countries in Asia. While countries such as Australia and Japan are ranked 4th and 8th respectively in the Global Access to Healthcare Index, others such

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as the Philippines, Indonesia, Vietnam and India still have much room for improvement with their ranks ranging from 35th to 45th position2. Those living on distant islands, remote mountains or rural regions face even harder challenges than those living in the cities. Ironically, the fewest healthcare professionals are usually found where the health needs are greatest, the so-called “inverse care law” in healthcare. In addition, in 2014 countries in South Asia spent on average just US$67 per capita on health – significantly lower than the OECD average of US$4,7353. At the same time, the Asia-Pacific region has the highest 2. The Economist Intelligence Unit. (2017). Global Access to Healthcare: Building sutainable health systems.

London.

3. The World Bank. (2019). Current health expenditure per capita (current US$). Retrieved May 21, 2020, from World Bank website: https://www.google.com/ search?client=safari&rls=en&q=Current+health+expendit ure+per+capita+(current+US$)&ie=UTF-8&oe=UTF-8

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level of dependence on out-of-pocket expenditure of any region according to the World Health Organization (WHO) and the highest number of households driven into poverty in order to pay for healthcare4.

Improving access to care means making care more affordable, available and accepted by the population.

Affordability means that patients can ‘consume' or use health services such as state-of-the-art diagnostics and treatment without causing financial hardship.

Availability means that healthcare services are there when and where they are needed, in particular, close to the patients. Finally, accepted means helping populations to understand the value of care and utilise their care options.

4. World Health Organisation (WHO). (2008). Health in Asia and the Pacific. New Delhi.

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Access to care during the pandemic

During the pandemic, even countries with the best healthcare systems struggled. Availability became a challenge as most resources were shifted to care for COVID-19 patients.

Even patients who usually would have had access to care were suddenly left with none or very little. Outpatient services, elective procedures and non-emergency cases were put on hold. Access became more difficult with limited transportation or higher cost of travel due to social distancing.

As financial struggles grew among the poor, healthcare became even more unaffordable. Yet, others may have actively chosen not to utilise care options either to stay away from the potential risk of infection or because they could not justify a visit during the crisis. The result is an increased disease burden. In fact, delaying treatments can

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have lasting consequences. For example, in breast cancer patients, delaying treatment from two weeks to more than six weeks can lower the five-year survival rate by as much as 10 per cent5.

The vision for healthcare is to keep people as healthy as possible and that requires people to be able to access care.

More than ever, the efforts of MedTech players like Siemens Healthineers need

5. Caplan, L. (2014). Delay in breast cancer: implications

for stage at diagnosis and survival. Front Public Health, 2(87).

to be geared towards improving access to healthcare in many parts of the world, and especially in Asia.

Connecting care teams and patients

During the pandemic, people started seeking ways to obtain care from

Connecting care teams – staff shortages The lack of skilled healthcare professionals became painfully obvious during the pandemic. Despite all efforts to attract, train and retain healthcare professionals, the WHO projects a global deficit of about 12.9 million skilled health professionals globally by 2035. In South-East Asia, the absolute deficit is projected to be 5 million and thus highest in the world – representing 39 per cent of the global total1.

Highly qualified personnel are scarce, and also a relevant cost factor, for hospitals that are already trying to cut costs while keeping quality high. At the same time, most of these health professionals live centrally, making access difficult for the large populations living in distant, remote or rural areas. We must find ways to do more with less and to ease the burden of the overworked healthcare professionals while also extending their reach to farther 1. World Health Organisation (WHO). (2014). A universal truth: No Health Without A Workforce. Geneva

away locations. There is no healthcare without people to deliver it.

Remote scanning assistance can help in realising this. It helps to make expert knowledge accessible across sites in real time. Technologists can always call on an expert for live support. During the pandemic, such technologies also helped reduce staff exposure to infectious patients.

In India, at the Sree Chitra Tirunal Institute for Medical Sciences and Technology, remote scanning assistance has been of immense use during the pandemic. While there are normally three personnel in the console room during an MR exam, only one technologist managed the exam on site, while the other two worked remotely.

This not only helped to keep the staff safe but also required less personal protective equipment which is a scarce resource in current scenario.

Such technologies also help to extend reach. Prachachen Imaging Center (PCC), a leading imaging centre based in

Centralizing all expert technologists in one room and providing remote assistance.

Bangkok, Thailand has 17 centres across the country. Normally, their expert radiology team in Bangkok would often travel to these centres, especially for clinical consultation.

When an emergency case came in during the lockdown from a centre 500KM away from Bangkok, the experts could make a timely and accurate diagnosis of the patient thanks to remote assistance.

In cancer care, HealthCare Global Enterprises Ltd (HCG) is relying on the hub and spoke model of delivery. Dr. B.S. Ajaikumar, Chairman and CEO of HealthCare Global (HCG), is using this model to take cancer centres to the furthest away places. He has 100 oncologists at the central hub supporting the spokes through telemedicine, tele-radiology, multidisciplinary tumor boards and remote consultation.

In addition, during the pandemic, more than 200 oncologists located across the country were providing virtual consultations, too. The clear goal was to ensure consistent, ongoing patient care.

Knowledge sharing is also crucial to keep the quality of care high. Technologies that allow you to share image studies to discuss cases with your peers, even beyond the borders of your own institution are meaningful. It fosters knowledge exchange and research and helps to get the opinion of a more experienced radiologist.

By making scarce resources available to more people, we can improve access and quality of care.

To find out more, please click here or scan the QR code:

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home for the reasons mentioned above. First, digitalisation made inroads in the self-assessment of COVID-19 symptoms.

Second, we have seen providers ramping up their telemedicine capabilities and recruiting more doctors faster than ever. These services connect healthcare providers and patients though virtual platforms. Third, various digital solutions are being developed in the area of home monitoring to support the patient, monitor vitals and provide alerts. Bendigo Health became one of the first hospitals in Australia to roll-out telemonitoring in the fight against COVID-19. Our digital care application supplies doctors and nurses with a dashboard of daily updated symptoms and health vitals to remotely stay on top of their patients’ health.

Governments play a vital role in accelerating the adoption of such technologies. In Indonesia, for example, the Ministry of Health partnered with ride-hailing technology firm Gojek and telemedicine provider Halodoc to offer quick online consultations for those experiencing COVID19 symptoms. South Korea eased restrictions on telemedicine to treat COVID-19 patients remotely, while Japan launched a free governmentsupported remote health consultation.

Australia extended Medicare coverage for telemedicine consultations.

In essence, digital solutions can provide better access and triage patients, starting as ‘digital front door’ and – depending on the condition – continuing with the provision of health services, such as telehealth. In doing so, we can keep non-urgent patients away from the hospitals that are overloaded, and patients can get care in the comfort of their home, avoiding travel, cost, waiting times and the potential risk of infections.

In short, by creating ways to connect care teams and patients we can make healthcare delivery more efficient.

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Future perspective on access and digitalisation

Every hour, about 240,000 patients are either diagnosed or treated on systems we have built, supporting our customers in the delivery of healthcare.

Asia is at the forefront of digitalisation.

In fact, eight Asian nations are in the top 10 when it comes to leading the customer shift to mobile payments, out of which six are in Southeast Asia6.China is leapfrogging the world and has already reinvented ways of accessing primary care and enabling patient self-management as well as expanding telehealth. Access to primary healthcare is a challenge in China, and there is great variability in the quality of care delivered. To cope with this, 6. PwC. (2020). Mobile payments in Vietnam fastest growing globally, Thailand emerges second in Southeast Asia. Retrieved May 25, 2020, from PwC website: https:// www.pwc.com/th/en/press-room/press-release/2019/pressrelease-30-04-19-en.html

Empower data-driven decisions Given our lack of skilled professionals, we need to make sure they can allocate most of their scarce time to focus on patients. That means we need to enable them to spend less time on administrative tasks, ease their workload and aid their decision making. Artificial Intelligence (AI) can help remove or minimise time spent on routine, administrative tasks, which can take up to 70 per cent of a healthcare practitioner’s time1. With AI, for example, if you have robust, validated data from one patient, you could compare that to an enormous quantity of data from other comparable patients. We call this clinical decision support. For example, AI applied to CT images can be a useful tool for the detection of COVID-19 symptoms and to help with follow-up and treatment planning. AI-powered analysis of chest scans has the potential to alleviate the workload of radiologists, who must review and prioritise a rising number of patient chest scans.

We will also see decision support for patients or consumers, working in a similar way. Algorithms can assess patients’ needs and prompt them to make lifestyle changes or talk to a care provider in order to better manage—or even prevent—chronic conditions. Healthcare that starts from home is much more efficient than care that starts at a hospital. The later we intervene, the higher the disease burden, requiring more cost and resources.

1, eit Health, McKinsey & Company. (2020). Transforming healthcare with AI.

To find out more, please click here or scan the QR code:

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7. Ping An Good Doctor. (2020). Ping An Good Doctor’s Revenue for 2019 Amounted to RMB5.065 Billion, with its Losses Continuously Narrowed and Online Medical Services Revenue Doubling by 109% over the Same Period.

Retrieved May 21, 2020, from Cision PR Newswire website: https://www.prnewswire.com/news-releases/ ping-an-good-doctors-revenue-for-2019-amounted-tormb5-065-billion-with-its-losses-continuously-narrowedand-online-medical-services-revenue-doubling-by109-over-the-same-period-301002912.html 8. Ping An Good Doctor LinkedIn Page. (2020). Retrieved May 21, 2020, from LinkedIn website: https://www. linkedin.com/company/ping-an-good-doctor/

healthcare system will become a central issue on the long-term agenda for each country’s growth, along with ensuring ecological sustainability and expanding the digital infrastructure.

Our role in fighting the pandemic

Every hour, around 240,000 patients are either diagnosed or treated on systems we have built, supporting our customers in the delivery of healthcare.

We play a crucial role in fighting the disease. This includes the development and CE certification of a molecular test kit to detect a SARS-CoV-2 infection in record time, the fivefold increase in production capacity of blood gas analysers in just a few weeks, and the development of an antibody test with an outstanding sensitivity of 100 percent (14 days post PCR) and specificity of >99.8 percent9.

We have put CT scanners in containers to help increase the supply in emergency hospitals and have developed AI 9. Siemens Healthineers. (2020). Siemens Healthineers to expand SARS-CoV-2 testing to include a total antibody test to aid in the COVID-19 pandemic. Retrieved May 21, 2020, from Siemens Healthineers website: https://www. siemens-healthineers.com/press-room/press-releases/serologytest-covid-19.html

algorithms to diagnose the disease.

Beyond this, our role is to further enable the exchange and collaboration across nations. During the pandemic, we have provided a platform to share the lessons learned and actionable insights on how to tackle the COVID-19 challenge.

As a global company operating in 70 different countries, we can help by connecting key stakeholders.

For our company, this means we will become even more important and relevant in the future. More than ever before, our customers and, beyond that, society and politics expect us to provide technical solutions to meet the enormous challenges we face. For example, these include solutions to digitalize healthcare systems, to improve the quality and efficiency of care, or to improve access to modern healthcare.

As a company providing solutions for in-vivo and in-vitro diagnostics as well as in image-guided interventions and digital solutions, our goal is to enable healthcare providers across the world.

I am glad to be in an industry where we can make a significant difference to people’s lives. It is up to us to play a decisive role in shaping the future of healthcare.

Elisabeth Staudinger is currently President of the Asia-Pacific region within Siemens Healthineers.

With a successful track record in international management roles, she is a remarkable senior leader in the healthcare industry. Leading a team of over 7,500 people who are passionate about shaping the future of healthcare, is her source of inspiration.

She and her team share a common goal: to enable healthcare providers, particularly in Asia-Pacific, to deliver high-value care.

AUTHOR BIO

the Chinese government is investing in Artificial Intelligence (AI). Digital means are already being used to access primary care, to schedule appointments and to triage patients based on AI. Ping An Good Doctor (PAGD) is a good example with its online one-stop healthcare ecosystem in China with over 315 million registered users7. In fact, during the pandemic, their platform recorded 1.1 billion visits with a 10 fold increase in newly registered users and a 9 fold increase in daily consultations8.

And they are not the only one – big players like Alibaba and Tencent are also changing the way primary healthcare is delivered.

If we look at India, the government has launched ‘Ayushman Bharat’ – and demonstrated its strong commitment to providing healthcare for all. Several other initiatives such as ‘Digital India’, ‘Start-up India’, ‘Make in India’, are part of the county’s development plan paving the way for improved access to care. With increasing focus on healthcare sector through these initiatives, I am bullish on India’s growth story. For both these growth markets, we will continue to optimise our offerings for local demands to meet the country’s specific needs.

Overall, I believe that the pandemic has accelerated the speed of digitalisation.

The COVID-19 pandemic reminds us that healthcare is part of a country's critical infrastructure. Expenditure for healthcare will come to be viewed as an investment in a country’s prosperity and competitiveness, and no longer as an annoying and unproductive cost factor.

Consequently, development of the

Elisabeth studied sinology and economics in Vienna, Nanjing, and Beijing and holds a master’s degree in both subjects. She has worked in Asia-Pacific since 2013 and is currently based in Shanghai.

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Improving Patient Experience By engaging your employees Susan Haufe, Healthcare Chief Industry Advisor, Qualtrics

Healthcare organisations (HCOs) have long been focused on improving patient experience. They have set up elaborate systems to listen to their patients and families, redesigned their incentive programs to align with this commitment and organized teams to improve the experience they are providing.

As the leader accountable for patient experience, I watched as leaders around me struggled to understand how to respond to the voice of their patients.

Teams desperately wanted to do the right thing, but were burdened by the complexity of the system and by competing priorities that overwhelmed their days.

They wanted to understand their patient experience

data and respond in a way that would change the experience their teams were providing. However, they felt trapped by the inadequate information provided by traditional surveys and frustrated that nothing they seemed to do had any impact.

When they would call me to their offices to review their data and make recommendations of what they could do (remember, they all desperately wanted to do the right thing!), they were often surprised by my response. Instead of pressuring them to study that data and continue to search for answers within the feedback directly from patients, I would often encourage them to stop looking at their patient experience data and instead focus on their employees.

Now, don’t get me wrong. I was not telling them that the voice of their patients and families did not matter. In fact, my intention was quite the opposite.

My hope was that if leaders could feel a little relief from the burden of work and turn their attention to the wellbeing and engagement of their people, they would ultimately see the dual benefit of improved employee experience leading to improved patient experience.

Does improved employee engagement lead to improved patient experience?

Well, the short answer is a resounding yes.

Research clearly shows a correlation between the two. Study after study report that engaged employees lead to higher patient satisfaction, not to mention higher quality care and stronger financial margins.

A recent study from nearly 150 VA medical centers over a three-year period shows that higher employee engagement correlated with higher patient satisfaction, lower nurse turnover and better all center performance.

The infamous article from HBR in 1994, titled Putting the Service Profit Chain to Work, has tremen-

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However, patient experience and employee experience are often separate initiatives today.

For as long as I have been leading experience work and for as hard as I tried to link these strategies, measuring the experience of our patients and the experience of our people has been siloed.

We haven’t looked at the data in a comprehensive manner, much less gained insight in a way that drove improvement. The fact is, disconnected efforts often result in disconnected results.

There is tremendous opportunity to create an authentic connection between your patients and your employees. It takes cultural transformation and a commitment to activate your employees, and the result is a better experience all around.

Qualtrics healthcare experts and XM Scientists have designed a 4-part webinar series to help healthcare providers and systems deliver the services and experiences the entire sector needs during this period of unprecedented demand. In this series, you will hear how leaders are putting strategies into practice.

AUTHOR BIO

dous value in HCOs today. It’s quite simple actually: when you invest in taking care of your people, they are more productive and committed, resulting in a superior experience for your customers (ahem, patients) - and ultimately leads to strong financial performance. We don’t need more research to tell us these things are inextricably linked.

Susan Haufe, Healthcare Chief Industry Advisor, Qualtrics, With 20 years of experience combining the tools, discipline, expertise, and passion to design and drive a customer-centric culture, Susan Haufe is known for organisational transformation built on brand promise, purpose, and values. She currently serves as the Chief Experience Officer, Healthcare Practice at Qualtrics. Prior to joining Qualtrics, Susan served as the inaugural Chief Experience Officer for Yale New Haven Health.

To watch Qualtrics Healthcare Experience Management webinar series, please scan the QR code or visit: https://tinyurl.com/q-healthcare

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I

woke up burning with fever. There was no one home to drive me to a doctor. I could not have risked asking my elderly parents or my young child to take me to the clinic or hospital during this time. They are at vulnerable ages for this new virus. I looked up the doctor chat option of my health insurance. They gave me a number to connect to a hospital remotely. I dialled in and booked my appointment. I could have used my phone however I chose my computer to log in with the doctor for a call. I did have a basic kit – thermometer, BP monitor, oximeter at home. These helped. I quickly measured these, downloaded the hospital app and uploaded these details so my doctor could record these. She came online, the video chat was very helpful. I told her about the symptoms. She could look at my eyes and throat as well. Checked a rash as well. Hopefully this is a regular flu. She sent me the e-prescription via the app and the email as well. On my app popped up a message from the pharmacy. I quickly requested a delivery for the prescribed medications as well as some OTC items. I got the medication in two hours. Am feeling better as the meds kick in. In case they don’t, my doctor has requested for some blood tests which I will schedule through the app. And if I need more care, I can opt

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The new normal will also impact how we chose to consume healthcare services. The new realities around this pandemic and the threat of more such, should also make us sit up and reflect on wellness and good health along side a good curative system.

Gurrit K Sethi, Hospital Chief Operating Officer, Care Hospitals Strategic Advisor for Global Health Services, Global Strategic Analysis

for a home care package where I will be assigned a nurse who will connect with me daily and get my doctor to look me up when needed. Gosh, am I thankful for this service!

The pandemic has exposed the virtuality of our lives and yet it is the virtual that has come to our rescue at this time, especially for supporting our health and well being. The virtual healthcare systems we already find ourselves leaning on have indeed a lot more to offer.

These systems have at this critical time offered multiple solutions to common global challenges for providers and service users: healthcare access at home, overcoming scarcity of skill and talent across distance, saving time and administrative hassle at physical locations, information at finger tips, doctor on your phone, and remote monitoring and care. During the ongoing pandemic, and given the

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nature of the disease and its spread, virtual health has offered a safety bubble for those suffering from chronic diseases requiring ongoing care as well as those getting new infections and being able to do with remote care thus reducing the load on the already overloaded and COVID-19-ensnared healthcare systems.

The two key global issues that every healthcare system faces today are – availability of health services and the quality of care. Virtual systems can support both these requirements along with the support system of pharmacy and diagnostics at the doorstep.

In India, as also in many parts of Asia and Africa, the adoption of virtual healthcare through digital solutions has picked up rapidly in the last quarter.

The pending policy decisions were speeded up to take the immediate advantages offered. Of course, there is a lot more to be done on this front to

INFORMATION TECHNOLOGY

provided and used. This could better the experience as well as reduce costs on huge infrastructures and maybe also make it more efficient. In addition, it will provide employment opportunities in the deeper etches of the state, thus de-congesting the overpacked urban areas. In yesteryears in India, the healthcare experience was of the doctor and/or the ’vaid’ coming home to see the patient in the comfort of his / her home and his / her room, surrounded by family members and loved ones. The doctor would interact with everyone and the respect for him in everyone’s eyes was supreme. Maybe this heralds a way back to the basics, albeit with more technology and support for the treatment now available to the healers through virtual tools.

Walking through the time zone here I share my future experience.

I am born in the comfort of my home, sealing an inexplicable mark of presence in the room that I was born. The special photographers invited for the occasion clicked me with my very new Mom & Dad, my doctor and my nurse and the souvenir hangs on the wall of my room alongside the clay imprints of my tiny hands and feet. My mother had chosen a water birth in a makeshift

collapsible pool in my then to be room.

The makeshift baby care area stood by as part of the sterile zone created for the birthing. Of course, the advanced life support ambulance had stood by in case she or me had to be run to the hospital for specialised care.

As I grew, I vaguely remember (imprinted memory from photographs) monthly visits from my nurse and paediatrician. In they came with their cute trolley with a volley of all the things they would require. These things would roll into my room and I would get only get more excited, at the prospect of exploring anything new that entered my room.

Through my slightly older years I remember fondly sitting on my grandparents lap as they perched in front of their computers for their monthly doctor consults. From time to time an ambulance rolled in front of the house where they went for their exams and diagnostics. And the medicines were delivered by kind sweet people who also sometimes brought me a lollypop.

Once I remember my grandma became really ill and she had to be taken to the hospital. This was a small emergency room like area; then she

HOSPITAL SUPPORT FUNCTIONS

MEDICAL & CLINICAL SUPPORT

NON MEDICAL & ADMIN SUPPORT

PATIENT SUPPORT FUNCTIONS

SUPPLY CHAIN VIRTUAL HEALTH TOOLS

push towards building a homogeneous system—during the pandemic as well as well after.

Going forward, there are many opportunities lying dormant, both in terms of supporting a safe means of outreach to the patients, as well as overcoming resource snitches in semiurban, remote and rural areas. There is another advantage too. A good amount of cost savings can also be done by adopting the various offerings of virtual healthcare through digital solutions.

And much more if we add the big data and AI possibilities.

In fact, apart from offering new features to add to the already existing service lines, virtual healthcare comes with a multitude of prospects. Each of these lines is already at work in their own niches and areas. The task ahead to make this successful is to integrate them. Those of us who have worked with various IT systems trying to digitise our work flows, know very well the nuances and the wide disparities which come to the fore while trying to integrate multiple systems for data flow.

Today, ‘smooth’ is the much needed dictum whether in implementation or post-implementation working of these softwares. Apart from the code challenges, there is one more challenge that needs to be overcome: the available internet quality and bandwidth.

This will eventually become a critical deciding factor for these systems as the usage expands to semi-urban, rural and remote areas. These virtual systems will need to rest on the underlying basic IT and telecom infrastructure to prove successful in the long-term.

And if virtual healthcare becomes a thriving reality, the future hospital experience could be a lot different as well. The non-critical medical services will move out of the hospital to a virtual and remote mode supported by mobile clinic services and small specialised setups. Home care services will also grow. All this will change the paradigm of how healthcare services will be

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INFORMATION TECHNOLOGY

CREDIT MANAGEMENT TOOLS

HIS SYSTEMS

(Digital support systems for insurance and other credit approvals, bill processing, approvals)

(EHR, EMR)

PATIENT MANAGEMENT SYSTEMS (Appointment reminders, Pharmacy refills)

HIT

PATIENT COMMUNICATION SYSTEMS

PACS AND RADIOLOGY INFORMATION SYSTEMS VIRTUAL HEALTH TOOL

DIGITAL LABORATORIES HEALTHCARE ADMIN TOOLS

CLINICAL DECISION SUPPORT SYSTEMS

was shifted to the ICU. After 2 days she was back home with a nurse by her side for another two days to help her recuperate. A physiotherapist came by daily and gave her interesting exercises to do. These were fun exercises where you played games through AI. I won many times and these brought me brownie points with my parents as they earned loyalty points at the hospital.

Every year I see my parents fill up some forms on their phones. They sometimes ask me questions like ‌ They also take my height and weight etc. They measure theirs too. They are filling the Health Risk Analysis. If any of the scores not ok here, I expect the health van to roll across to take some tests. My parents hate that because that means their mandatory insurance will take away some bonus points.

Health means wellness and so wealth! All of us are incentivised to keep well in many different ways by our insurance companies as well by way of tax relaxations

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AUTHOR BIO

(Rostering, Training, HRM, Call Centre)

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

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INFORMATION TECHNOLOGY

TELEHEALTH IN THE BEFORE COVID-19 AND AFTER COVID-19 ERA A story from India

Every sixth human on Terra firmalives in India. Providing quality accessible, affordable healthcare to anyone, anytime, anywhere is more than a daunting task. For the last two decades the author and others have repeatedly stressed that Telemedicine is the only answer to address the ever-increasing urban rural health divide in India. From a third worldcountry, India became an emerging economy and has even been described as a potential super power.

The growth of remote Health Care has been steady but only incremental. With the outbreak of the COVID -19 pandemic Telehealth has become a buzz word in India. The exponential radical transformation ushering in ‘Contactless Healthcare’has been to say the least, incredible. This review discusses what Indian Health careappears to be posed for.

K Ganapathy Krishnan, Director, Apollo Telemedicine Networking Foundation; Director, Apollo Tele Health Services

E

very sixth human on Terra firma lives in India. Providing quality accessible, affordable healthcare to anyone, anytime, anywhere is more than a daunting task. For the last two decades the author and others have repeatedly stressed that Telemedicine is the only answer to address the everincreasing urban rural health divide

in India. From a third world country, India became an emerging economy and had even been described as a potential super power. The growth of remote healthcare has been steady but only incremental. With the outbreak of the COVID -19 pandemic, it has become a buzz word in India. The exponential radical transformation

ushering in ‘contact less healthcare’ has been to say the least, incredible. This review discusses the likely future of telehealth in India.

Telehealth in the pre-covid era

On March 24 2000,President Bill Clinton formally commissioned the world’s first VSAT enabled village hospital at Aragonda in the state of Andhra Pradesh in India ,s ee 1. This day marked the birth of formal clinical telemedicine in India. In 2001 Apollo Telemedicine Networking Foundation (ATNF) was formally established as a not-for-profit, Section 25 company.

Taking modern healthcare to remote areas using technology was the mission of ATNF. Over the past two decades the Apollo Telemedicine Division alone has touched 10 million lives.

The oldest and largest multispeciality telehealth network in South Asia, ATNF has been followed by many other organisations. Arvind Eye System, and Shankara Nethralaya are globally renowned ophthalmic institutes running the world’s largest tele ophthalmology systems. There are at least 20 other institutions running full fledged active

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telehealth units besides hundreds of individual doctors and small clinics.

However, for a population of 1300 million, telehealth was never really accepted by the community, including healthcare providers;and then came COVID 19.

When I first embarked on Telemedicine 24 years ago, the very word was unfamiliar to most. It took a decade of intensive persistent evangelisation to create the semblance of an awareness.

The second decade was spent in trying to achievea behavioural modification and technology acceptance among all stakeholders in the eco system.

During the last four years thanks primarily to Public Private Partnerships revenue generating business models have started to become available. The single most important challenge facing Telemedicineis addressing the question What is in it For Me(WiiiFM). WiiiFM is different for each stakeholder.

Public Private Partnerships

The first Telehealth public private partnerships (PPP) project in India commenced 5 years ago. Over 18,500 teleconsultations have since been given at a height of 14,500 ft. The world’s first 24/7 tele emergency service has seen about 1300 patients. Over 1 million teleconsultations have been

provided under the Mukhyamantri Arogya Kendram (e-UPHC) project covering 182 Centres from October 2016. Another major PPP is one in tele-ophthalmology being carried out in 115 existing community health centres / vision centres run by the Department of Health and Family Welfare, Government of Andhra Pradesh in 13 districts.

Through this Mukhyamantri e-Eye Kendram or MeEK project 1.5 million patients have been screened in 2 years.

355,000 fundus examinations were done remotely by 30 Opthalmologists from Chennai. We are also executing many other PPP projects in several other states.

PPPshave brought remote healthcare into the mainstream.

Perhaps the challenges facing telemedicine today are far less as they are also addressable. The world has turned upside down because of the pandemic. I foresee that the challenge will no longer be to convince the healthcare provider and the beneficiary that telemedicine has advantages over in-person visits. Today the challenge is to quickly customise and make available a cost-effective, needbased, user-friendly, technologically efficient, and secure telehealth system which is compliant with newly formed regulations. The telemedicine system must be future-ready and culture sensitive.

Figure 1: Inauguration of world’s first VSAT enabled village hospital for Telemedicine March 24th 2000 @ Aragonda, Andhra Pradesh marking the beginning of formal Clinical Telemedicine in India

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Insurance companies in India have already started recognising telemedicine for reimbursement. Revenue generation is critical for ensuring self-sustenance.

But necessity is the mother of invention, and there is an opportunity in every crisis.

The challenges facing us in introducing telemedicine are not insurmountable as there is a pressing need for these services.

This universal demand for telehealth alone makes all challenges to promote telehealth adoption,pale into oblivion.

Telemedicine, like medicine itself, is not a black and white concept. It has still various shades of grey. Look back to March 10th 1876 when Alexander Graham Bell made the world’s first telephone call – a request for medical help: “Watson come here I want you” after having spilt battery acid on himself.

COVID-19 is providing us with tens of thousands of virtual non-COVID patients! One cannot ask for a more opportune time to start telemedicine.

Following notification of COVID19 as a pandemic, the Ministry of Health,Government of India, notified the Telemedicine Practice Guidelines for the country on March 25, 2020.

The proposal had been pending with the government for some time. Many doctors were not deploying telemedicine due to uncertainty of its legality.

Following this, several thousand doctors

INFORMATION TECHNOLOGY

Fig 2 Consultation in the pandemic era

private sector offering teleconsultations pro bono during the pandemic this would be considered the gold standard, even in the post-pandemic era. The first Nobel Prize in Economics was for the concept that “there is no free lunch”.

There is a cost to everything. Someone will have to pick up the bill.

Epilogue

deploying virtual healthcare— we are always there 24/7 on a small or large screen.

Conclusion

Looking back, the growth of telehealth during the past 20 years has been rather slow. Many of us were in a hurry, impatient, wanting to get things done yesterday. The first decade was spent in evangelising the idea, developing the product, and creating general awareness.

For a product to excite the masses it must elicit customer delight and cater to consumer needs. Every member of the telehealth ecosystem needs to get a return on investment (RoI) not necessarily monetarily alone. Revenue generation is a must for sustenance. Philanthropy and corporate social responsibility can initiate an activity, not maintain it.

Potential new users of telehealth are concerned that with the public and

Not in my wildest imagination would I have ever expected the slow incremental annual growth of telehealth adoption in India over the Last two decades to radically transform into an explosion.

A strand of RNA has become the Global Chief Transforming Officer for Telehealth. Contact less healthcare will be the new normal. Distance will become meaningless. Geography will become History. Recognition of telemedicine

by Insurance companies in India augurs well. Formal recognition of importance of telemedicine by the Govt. of India and state governments is making all the difference. No less a person than the Prime Minister of India has repeatedly stressed the importance of deploying telehealth. I am sure that from the outskirts where telehealth was lingering all along it will soon become centre stage. One day doctors and patients will probably ask “should it not have been like this always?”

K Ganapathy Krishnan is on the Board of Directors of the Apollo Telemedicine Networking Foundation & Apollo Telehealth Services, India. He is Past President of the Telemedicine Society of India & the Neurological Society of India, Emeritus Professor @ the Tamilnadu Dr MGR Medical University India, a Visiting Professor Taipei Medical University & Member of WHO Roster of Experts on Digital Health. URL www.kganapathy.com

AUTHOR BIO

have attended orientation programmes conducted by the Telemedicine Society of India and other organisations. I have personally given 22 webinars in the last 3 months on role of Telehealth in the present situation. Over 30,000 doctors have attended. One webinar was attended by 11,775 doctors. Another webinar was for 8 countries and 808 attended . The interest has been unbelievable. Simultaneously hundreds of hospitals in the public and private sector are offering free teleconsultations for screening of COVID-19 patients.

It appears that the work from home (WFH) culture will include doctors as well!

Telehealth is here to stay and will take centre stage after having been in the periphery for the last 24 years. There is no doubt whatsoever that COVID-19 in four months has achieved what we could not in 24 years.

Theoretically every single individual, healthy or sick, rich or poor, urban or rural, educated or not, can benefit in different ways through “contactless” medicine. Physical distancing is here to stay. This should not be mistaken for social or clincal distancing. Distancing is a term that should not exist for those

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Digital Healthcare Transformation and Innovation Optimising knowledge flow

COVID-19 has accelerated the pace of healthcare innovation and potentially extended how medical care is delivered.

While these solutions hold incredible promises, we are adding more variables to variation in care. The future of healthcare should be driven by knowledge to deliver optimal care with patient safety and quality considerations.

Ian Chuang, Chief Medical Officer, Elsevier

I

nnovation in digital health has become a by-product of our collective healthcare experience through the COVID-19 pandemic.

Since the onset of the pandemic, we have seen an explosion in innovation in the digital health space. Many countries in Asia, including China, Singapore, and Australia, were the first to experiment and roll out contact tracing mobile applications to step up preventive measures . In some regions, including South Korea, the government has also temporarily relaxed restrictions on telemedicine consultations to allow physicians to conduct remote diagnosis and monitoring . More recently, experts are racing to deploy other digital solutions to flatten the curve and recalibrate societies back to normal.

What is more likely to be true is the realignment towards a new reality.

While these new solutions and technologies hold incredible promise, there are potential quality and safety considerations that need to be thoroughly

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examined. It is equally important to consider the impact and optimisation of the user experience, for both clinicians and patients.

Fragmentation of different innovation solutions

Patients, clinicians, and health system funders realised that the old model of healthcare did not hold up well to the

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challenges and continuing evolving needs introduced by COVID-19.

Technologists and entrepreneurs do what they do best; their creative and enterprising minds think of ways in which technology can address the myriad of challenges and barriers that have been identified. Find and identify the problem; solve it is the mantra.

Telemedicine will solve the access

INFORMATION TECHNOLOGY

Knowledge-driven care process to healthcare digitalisation and innovation

The future of healthcare will be a more Knowledge-driven Care Process.

What does this mean in tangible terms applied to healthcare digitalisation and innovation?

Basically, healthcare delivery and what patients should expect is a level of care and consistency that aligns with the latest body of evidence-based knowledge and best practice standards, delivered via an optimised consumer-centred experience that is efficient, and cost-effective. A digital system to enable this vision is the basis of this proposed knowledge-driven care framework. Whatever technology we bring forth and however we transform healthcare delivery, it must align towards a knowledgedriven care process.

Dissecting the Knowledge-driven Care Process Framework

D FL ATA OW

In order to enable knowledge-driven care, there are three intersecting dimensions (Clinical Workflow, Decision Flow and Data Flow) to consider, which are required to optimally deliver knowledge flow across a care process.

Time, Space, IT System

KNOWLEDGE FLOW

Clinical Decision Making, Cognitive Task

ON SI CI W DE FLO

constraint; apps can solve x, y, z; big data, artificial intelligence and machine learning will produce all this new knowledge and insights for clinicians. And the new normal is going to achieve a new state of equilibrium.

The risk of this kind of innovation approach is that we may think we have arrived at a solution, but really the solution addresses only one piece of the care puzzle. We may be introducing other problems or unintentionally pushing the pain point for clinicians, the consumer/patients or both somewhere else. The common analogy is what happens when you just squeeze one part of a balloon; the other sections naturally expand and will experience additional strain. Any introduction of new technology should streamline the entire process, and produce a positive and impactful experience for all stakeholders.

Patient Care

CLINICAL WORKFLOW

Clinical Workflow Clinical care is a series of complex, multi-disciplinary process that often cross clinicians and organisations, geography and time through the care continuum.

Each step in the workflow has different contextual needs for data to support work and decision making. Whether it is electronic medical record (EMR) functionality or apps, making sure the technology clearly supports and if possible, improves the clinician’s workflow which is so important. There are too many experiences in which the technology is adding stress for clinicians and creating a barrier between the important human connection of the clinicians with the patients.

Decision Flow Along the workflow for a care process, many clinical decisions are made by clinicians. These decisions take place in the context of the clinical work and activities. Technology that aids the clinicians with this cognitive work such as clinical decision support (CDS) should smartly know what information is needed to make the best decisions; what decisions regarding care and treatment are important. Care should be coordinated across the care continuum and across clinicians; ideally all the decisions should be aligned to a common basis of knowledge, evidence and best practice targeting a common set of outcomes.

Data Flow Key to knowledge is the availability of quality, machine interpretable data for easy access by clinicians and patients, and leveraged for decision support. Often, we assume the data is there. This passive mindset assumes that the important data to support clinical workflow and decision-making are accessible, reliable and computable. It takes planning and data architecture to ensure this. If there is a reliance on the use of specific data, then effort must be taken to ensure that i) the technology respect and handles the required data focused on validity, veracity, and ii) the clinical process sources the data in ways that will lead to usability of the data for clinical decision support.

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thinking, knowledge can be made accessible where and when healthcare professionals need it in a logical and utilitarian way. Clinical decisions and actions are made easier and more transparent through tools such as Clinical Decision Support (CDS) that design and manage machine computable data and factors in the clinician workflow in the design and system integration.

Conclusion

What does it take to truly enable a knowledge driven care process? Because care takes place across time, involving different places and people, the key to the knowledge driven care process is the ability to support Knowledge Flow in the digital healthcare ecosystem.

Knowledge flow as the name implies, is how the right knowledge can be accessible throughout the care continuum, by the right individuals to make optimal treatment and care decisions to achieve the desired outcomes. With the new, foreseeable digital innovation and design of the new normal for healthcare delivery, considerations to each dimension of the knowledge flow is necessary to be successful and effective in achieving true knowledge-driven care. Basically, as an integrated framework, the flow of knowledge is achieved when the digital system supports the optimised clinical care activities (i.e. clinical workflow) based on sound and coordinated clinical decision making across the entire care process (i.e. the flow of decisions), and taps the right data necessary to support care and clinical decision making (i.e. data flow).

Fundamentally, we must appreciate and optimise how care is delivered, the important clinical decisions that must be made to guide clinical care,

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and the relevant information when or where it is necessary to support the clinical work and decisions. All three dimensions intersect to optimise how the most current and relevant evidencebased knowledge can flow and achieve the goals we desire, at the point of clinical action. Without simultaneous consideration and optimisation of all three dimensions, in the aggregate, there will be a lack of a cohesive process, and the physician-patient experience will not be ideal.

Fortunately, if we approach technology and the digitalisation of healthcare with human-centred design

Ian Chuang is the global Chief Medical Officer (CMO) for Elsevier's EMEALAAP Health business. Dr. Chuang’s focus at Elsevier is collaborating with healthcare leaders to improve Healthcare Information Technology (HCIT) adoption, especially as it relates to clinical decision support and improving health system decisions and processes of care to improve outcomes.

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AUTHOR BIO

Optimising Knowledge Flow throughout the care continuum

The road is littered with the casualties of experiences where technology was just thrown in as the answer to a problem.

In providing a specific capability or solving a targeted problem area, the unintended consequences can include negative user experience, confusing data and information, or not achieving the desired outcome and possibly risk of safety and quality issues. As we continue riding the incoming waves of the pandemic with a new pace of innovation adoption, we must not overlook the need to ensure the flow of knowledge actually aids the clinician in a positive way and to ensure that patients continue to receive a level of care and consistency that puts patient safety and quality at the forefront.

INFORMATION TECHNOLOGY

MENTAL HEALTH IN COVID-19

An e-health service to provide tele-mental health support in pandemic To fight against COVID-19, most of the governments are allocating a significant portion of their health budget for health safety equipment, COVID-19 testing machines, and kits, etc. while mental health issues due to COVID-19 are mostly ignored in almost every country. To control the pandemic, governments have imposed several restrictions on travel, public gathering, which makes social distancing almost mandatory. These restrictions worsen the situation in developing countries of Asia and Africa, where mental health professionals and services are scarce. This article will discuss an innovative e-health service ‘Mind Tale’ for providing mental health services while addressing the resource scarcity and social distancing issue in the pandemic. It will also describe the unique service delivery model of Mind Tale, which make its potentials role model for other developing countries to provide mental health support despite the existing digital divide.

Nazia Akter, General Manager & Head of Business Solution, Synesis IT Ltd. Rupayan Chowdhury, Group CEO, Synesis IT Ltd. Tanjir Soron, Head of Mental Health, Synesis IT Ltd.

T

ill date, COVID-19 has affected the lives of millions, and with time the death toll is increasing, so as the economic downturn. Though it seems like this pandemic is distressing the physical health of human beings, what we cannot neglect is rising of mental health issues due to COVID19. During epidemics, distressing experiences stimulate behavioural responses which can propel psychosocial distress, psychiatric disorders, stigma and social issues.

According to a recent KFF poll, nearly half (45 per cent) of the adults in the United States stated that their mental health had been impacted due to worry and stress over the virus.

Experience of the past pandemic situations of SARS and Ebola indicated that this pandemic is also going to have long-term implications on mental health.

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1 Psychiatrist for 8,00,000 people

92.3% adults don't seek help thinking of

confidentiality

60% adults don't seek help due to

social Stigma

Figure 1: Mental health context of Bangladesh

But, in most of the developing countries, the availability of mental healthcare professionals is inadequate and so as the allocated budget for mental healthcare. On top of that, in response to the COVID-19, the World Health Organisation (WHO) has strongly recommended ways to minimise physical contact between patients and healthcare providers to maintain social distancing whereas mental health services require hours of psychotherapy and counselling sessions. Now, these countries have to fight simultaneously with mental health and other health issues while maintaining social distance measures to keep the people safe.

Providentially, there exist e-health and telehealth services which can play a significant role in the pandemic, especially for developing countries.

Telehealth, which is a subset of e-health,

can provide health-related services and information via electronic and telecommunication technologies for distance patients and can provide easier access to health facilities for mass people.

This article discusses the competences of telehealth in COVID-19, and presents ‘Mind Tale’ as a prominent solution to provide distant mental health service during COVID-19. Mind Tale is a 24/7 accessible telehealth solution operating in Bangladesh with a unique service delivery model which is ensuring quality health services despite the existing digital divide and has enormous potentials to be a role model for the developing countries.

Telehealth approach for Mental Health

Bangladesh, a developing country in the South Asia region, emerged as a

Counselling Psychologist

Educational Psychologist & Others

Clinical Psychologist

Psychiatrist

Figure 2: Service delivery flow

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rapidly developing economic power with a population with 18 crore people. According to the WHO & Ministry of Health & Family Welfare of Bangladesh, nearly 17 per cent of adults in Bangladesh are suffering from mental health issues. Among them, 92.3 per cent do not seek medical attention due to stigma (Figure 1). Every year more than 10,000 people commit suicide, and among them the majority are young women. But unfortunately, there is only one psychiatrist or mental health expert perone million people who are mainly concentrated in two megacities.

Considering all the limitation and facts, the e-health solution ‘Mind Tale’ was designed and implemented. ‘Mind Tale’ is a psychologists and psychiatrists based mental health helpline and information dissemination platform with multi-domain service delivery model. The effectiveness of the service is promising for improving the bottom line in COVID-19 by providing remote care for patients while saving time and cost.

With the help of this telehealth service, health professionals are able to serve people from rural areas inconsiderate of their local presence. This section depicts the service delivery model and other important aspects of Mind Tale.

Multi-domain service delivery model

Mind Tale’s multi-disciplinary approach over the phone with different kinds of professionals can instantly facilitate required mental care for a person.

The workforce of Mind Tale has clinical psychologists in the 1st level, psychiatrists, along with counselling and education psychologists in the 2nd level (Figure 2). Furthermore, a medical board is formed with experts to take care of the most critical cases. Roundthe-clock availability of the service with two-way communication technology makes it more potential for people with mental health issues which gets worst in the night when no one available for sharing their mental troubles. The standard operating process and service

INFORMATION TECHNOLOGY

with proper encryption. Additionally, advanced network and system security architecture is incorporated to prevent all internal and external security threats.

Call Logs

Database

Database

Diagnosis History Patient Records

Call Centre Solution

CRM

SMS Platform

Health CMS

Voice Delivery Platform

Subscription Platform

Reports Engine

2G / 3G / 4G network

User with smarts / basic phone / landlines

Access to rural and vulnerable population

The system design of Mind Tale consists of simple user access protocol to ensure availability of the service especially for women, adolescents, disabled people, low-income groups, illiterate or uneducated people, also for people living in rural areas. The service is designed to reach to rural people where every household has at least one mobile phone.

Professional service of Mind Tale can be avail through any basic phone over 2G/3G network, and it does not have any dependency on the mobile handset, network, operating system or location.

Male Female Ratio

Figure 3: Mind Tale Service Architecture

32%

Female

delivery guideline are designed as per the mental health guideline DSM 5 (The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition by the American Psychiatric Association’s) to provide quality mental healthcare.

Integrated service delivery platform

Mind Tale has an inclusive service design and delivery platform which consists of an Integrated Patient Record System with Voice, SMS and Video Calling Systems along with Health CRM, Content Management System. e-Prescription, Referral System, call transferring options provides this service more robustness. This integrated solution enables the health care providers to deliver quality health care service and experience to the end-users.

A simple architecture of this complex system is depicted in Figure 3.

Information security and data privacy

One of the biggest obstacles for mental health service is gaining the trust of the patients and ensuring their privacy, especially for the rural population where stigma prevents to seek help from the professionals. The appealing feature of Mind Tale service is that here people can talk over the phone and their identity remains confidential, which is very crucial, especially for vulnerable groups like children and women. When a patient is calling, the call automatically triggers the patient’s previous health records if available.

At this stage, the service provider can view the patient’s record, but all personal data and caller identification and phone numbers are kept hidden.

Moreover, all confidential personal information is kept in a secure database

68% Male

Urban & Rural Ratio

38% 62%

Urban

Rural

Figure 4: Male-Female and UrbanRural service users Ratio

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Just dialling a 3 or 5-digit short-code by any phone people can access this service and take counselling from experts. As a result, the service has an extraordinary acceptance rate among rural people and females. Mind Tale has urban and rural service users’ ratio as 64 per cent and 38 per cent respectively, and male and female service users’ ratio as 68 per cent and 32 per cent respectively (Figure 4).

Response of telehealth in the pandemic Major Mental Health concerns in COVID-19

With the rising number of COVID19 affected people, COVID-19 related mental health issues such as stigma,

The use of emerging IT and telecommunication technologies in telehealth expands the reach of mental health professionals to a widely spread patient population, especially in rural areas.

Figure 6: Rising trend of new users in COVID-19

depression, anxiety disorders, etc. are also increasing. The before and after call pattern analysis shows us how COVID19 is affecting people’s mental health issues in Bangladesh (Figure5). The pattern shows the percentage of mental disorders related call has decreased dramatically, whereas the rate of all other services has increased during the pandemic. Concern related to education and career has risen by 1 per cent, which resembles the current economic downturn and lockdown situation. The graph also shows 7 per cent of people took service for COVID-19 related

stress and calls due to sickness or death of closed ones increased from 7 per cent to 14 per cent in this epidemic. There is a significant rise in calls related to relationship issues and psycho-sexual problems.

Shifting towards telehealth in COVID-19

When COVID-19 started spreading in Bangladesh at the end of March, the new user of the service has been increased extensively so as the number of services taken from Mind Tale (Figure 6). The pandemic hit Bangladesh officially on 8th March of 2020; right after that new caller started taking the service, which changed the previous trend of new users’ engagement to this service. This trend indicates that due to the epidemic when people are required to stay at home for maintaining social distance, they prefer telehealth over regular mental healthcare.

Reasons for choosing telehealth COVID-19

A random survey was conducted on randomly chosen 413 new users, who used the Mind Tale service during COVID-19 for the first time, to understand why people were choosing telehealth in this pandemic.The survey results revealed, people who are stuck at home due to COVID-19 had availed

Figure 5: Pre- and During COVID-19 mental health issues

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Response of the Survey Anytime access from home Stress from COVI1 -19 Afraid to seek help physically Currently in isolation or quarantine Unavailability of Experts Due to Privacy Issue 0%

5%

10% 15% 20% 25% 30%

Figure 7: Reasons to choose telehealth in this pandemic

Conclusions

this service most, and easier access to the service from anywhere and anytime intrigued them to take this service (Figure 7). Other prominent reasons were privacy issue and unavailability of mental health experts nearby. Mind Tale provided the opportunity to get help though telephone, which is very much required during the pandemic as people needed the help of an expert while maintaining social distance.

Moreover, 24-hours of professional’s availability make this service more appropriate for persons who hesitate to seek for help physically.

Nazia Akter is an expert of e-health services in Bangladesh. She is a Certified Project Management Certifies Professional (PMP). Akter has more than 12 years' professional experiences, specialised in ICT Consultancy, Telecommunication, and e-health experience and has solely spent last five years in general and mental health-related projects in both public and private sectors and brought several innovations in health digitalisation and e-health.

AUTHOR BIO

According to the WHO & Ministry of Health & Family Welfare of Bangladesh, nearly 17 per cent of adults in Bangladesh are suffering from mental health issues. Among them, 92.3 per cent do not seek medical attention due to stigma.

In COVID-19, mental trauma, anxiety, distress, anger, depression etc. are evident. Also, mental disorders might get worsen if treatments are not time on time. However, due to social distance measures, face-to-face therapy and diagnosis are not possible at this moment. In this context, telehealth provides the opportunity to serve unmet health needs for professional resources in developing countries, aided by advancing capabilities of an everevolving and universal technology and

the promise to improve the bottom line of the mental healthcare in several ways. Engaging different professionals from different domains improves the chances of more effective diagnosis and treatment. Furthermore, the use of emerging IT and telecommunication technologies in telehealth expands the reach of mental health professionals to a widely spread patient population, especially in rural areas. Using previous records of patients and knowledgebase available in telehealth, professionals can provide individual case basis personalised quality healthcare.

The telehealth solution Mind Tale containing all the features as mentioned above has already proven to be a great alternative to provide mental health support during the breakout of this epidemic Bangladesh.

Though limitation exists for people with cognitive disabilities, still e-health or telehealth services such as Mind Tale can be an example for other developing countries with similar socio-economical and health infrastructure context.

Data sources: Data of Mind Tale service for the article was collected from Synesis IT Ltd., thus gratefully acknowledged.

Rupayan Chowdhury is a Certified Information Systems Auditor (CISA); also, is MCSP (Microsoft Certified Professional). He has more than 15 years’ professional experiences, specialised in ICT Consultancy and in charge of Business Planning and Project management activities for Synesis IT’s countrywide operations.

He has a remarkable contribution towards the ICT industry and e-governance innovations and is recognised as one of the prominent leaders in the ICT sector of Bangladesh.

Tanjir Soron He is a Certified Psychiatrist and the first telepsychiatrist in Bangladesh with the experience of planning and developing technology-based mental health services in resourcepoor settings. He is known as Digital Health Expert by World Health Organization (WHO) for General Programme of Work (GPW13), and Sustainable Development Goal 3: Ensure healthy lives and promote well-being for all at all ages.

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INFORMATION TECHNOLOGY

ARTIFICIAL INTELLIGENCE ENABLED PATIENT EXPERIENCE Implementation of AI in solving problematic healthcare challenges at various touch points of patient experience is an upgrading and effective tool in healthcare management. Improving patient experience clinically and personally has always been a key goal for the healthcare team. Today, AI is widely used clinically in terms of diagnosis and in management of the treatment.

In future, with AI enabled services, every decision maker in the Healthcare chain will be better-informed, reducing the loopholes and leading to better patient outcomes.

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

L

ot has been written on how to work for improvement in patient experience, how to engage patients, how to improve patient satisfaction, or how to apply lean management in emergency situation.

Today’s COVID-19 pandemic situation has made us think and take all possible actions that would help us to save as much as lives we can. It was beyond our imagination to break the ceiling and think of various solutions available around the world and apply the best fit to save people. It is available with the help of Artificial intelligence technology.

The COVID-19 outbreak has disrupted the entire healthcare industry.

It has lead to a stressful, unprecedented healthcare crisis that no one thought

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of. As healthcare redefines itself, patient experience is what will guide the industry towards right direction in future.Imagining today’s situation without digitisation would be kind of black and white movie. Digitisation is no more optional, it is the requirement of a bright future.

Artificial intelligence (AI) at patient’s service

With increase in health awareness, the competitive business in healthcare sector has boomed. Experienced health providers and executives are aware of the fact that retaining the existing patients and attracting new patients via referrals, advertising or other ways of marketing is a challenging process.

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Over-advertising also leads to reducing brand value, so an optimum way has to be carved out to have a good going. And one of the ways to carve out a positive way ahead is by providing valuable service leading to positive patient experience.

Managing the processes at hospital is challenging; to have a better control, we should focus on optimising patient experience touch points.Touch points are the interaction or contact spots between a healthcare provider and patient.

So it starts with a basic step of marketing whereby your patient gets to know about your service, with intermittent steps of treatment till the follow-ups of the patient recovery process. So it’s a short or long process depending on the illness, with many loopholes in management.

These loopholes are sometimes invisible to a healthcare provider, but can be easily traced by a patient. Thus, optimising the patient experience parameters by means of touch points eases out the process.

Four ways of enabling patient experience with AI

Let’s look at few AI-enabled services that are applied by some of the hospitals.

1. Real-time health monitoring: This is an innovative and highly alert system like the ones used by air traffic systems.

This technology is used by some

INFORMATION TECHNOLOGY

hospitals and is commonly observed in aerospace and aviation industry. It works as a centralised clinical command which is continuously monitored digitally.

Real-time monitoring helps patients and physicians to save their time by cutting down follow up checkups. All their vital health parameters such as heart rate, blood pressure, respiration rate, blood glucose, oxygen level, body temperature etc., can be digitally monitored through home sensors or smart watch sensors. This helps in getting real-time support whenever needed and thus helps in positive patient feedback.

Consider a wearable or microfluid sensor.They can be placed near the patients or at locations whereby risks of accidents are higher like near washrooms or staircase or in elevators. These sensors act as a real-time support tool to monitor the vital health parameters before any adverse consequences or it alerts healthcare service provider beforehand in case of emergencies.

For example, in 2014, the Cleveland Clinic launched an e-programme by enabling a clinical command centrenamed Bunker on the hospital’s main campus.

2. Support through health tips and knowledge: With Google Assistant or Amazon Alexa, people are used to gettinginformation when and where

they want. But in case of health, the data is so varied that coming to a conclusion is tedious. Nowadays, 80per cent of healthcare information is browsed on search engine. So getting health queries solved quickly using virtual assistant is a need.

Nextwe are going to look for a realtime access tool for medical knowledge.

It will be an AI-powered, virtual care assistant that can answer or direct your queries directly to the most eligible person at the hospital. The questions related to diagnosis, treatment, recovery experiences, and medication schedules, can be answered by your virtual assistant tool. This helps in lowering the stress and frustration level thereby leading to better patient feedback.

This device can also act as a data repository, which stores patients’ medical history, lab results, consultation times;patients with similar case history can alsoshare their experience. This will not only help patients but also their families to manage their time.

For example,the Ohio State University’s (OSU) Wexner Medical Center, in collaboration with Epic Systems, created Epic’s MyChart and OSUMyChart, which are online applications for outpatients and inpatients, respectively. Figure 1 3. Managing documentation and patient flow: The most chaotic table at a hospital is a reception desk. It

is observed that patients mainly get stressed out during documentation process because of various clinical questions. And thus most of the times, patients stumble during admission and discharge process leading to dissatisfaction.

Using machine learning, patient history and illness data can be configured withAI tools to create an online registration process. After registration, based on physician’s advice, thepatient will receive an AI-based customised welcome kit, that would help in directing patient experience.

This data can help in providing choices to patients on decisions such as type of hospital room, diagnostic choices, having non-medical support, stocking of medications or follow up plans after discharge, etc., based on socio-demographic profile of patient or family. One has to ensure that this is to simplify the choices and help in decision making.

For example, Ireland’s New Children’s Hospital (NCH), opening in 2021, is a hospital full of digital technologies.

4. On time delivery of medical needs: With COVID-19 we have ARTIFICIAL INTELLIGENCE ENABLED HEALTHCARE SERVICES

1

REAL TIME HEALTH MONITORING

3

2

MANAGING DOCUMENTATION & PATIENT FLOW

SUPPORT THROUGH HEALTH TIPS & KNOWLEDGE

4

ON TIME DELIVERY OF MEDICAL NEEDS

Figure 1

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realised that the supply of essential medicines around the globe is not that easy. Interoperability, data security, inefficient processes and delays in manual handling challenge the efficiency. This in turn also increases the cost, quality and data integrity issues.

AI-enabled blockchain technology is a revolutionary way to ease out operational management.

The blockchain technology can be

integrated in hospitals’ inventory management, whereby planning, purchasing, and tracking of inventory across supply chain can be taken care of. This way we can arrest counterfeit practices as well. This technology helps in tracking, tracing, monitoring the supply of inventory thereby reducing the operations of hospital inventory management and also ensuring on-time delivery of medical devices and medicines.

AUTHOR BIO

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.

Summary:

Post-pandemic, the healthcare services will redefine themselves and orient towards patient-centricity. Mapping patient experience manually would be a challenging and skilful job.

But using integrated AItools to map patient experience will come in handy with other real-time access tools.

Incorporating artificial intelligence tools would be valued by hospital staff and patients as well. In future, we can look forward for healthcare services enabled with artificial intelligence to foresee available treatments to cure, length of hospital stays, manage patient flow and improve care delivery, and customise the posttreatment follow-up calls.This type of healthcare service is efficient and more convenient for hospital management, doctors as well as patients and directly helps in improving patient experience across their patient journey.

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IF YOU KNOW WELCH ALLYN, YOU KNOW HILLROM Hillrom is a global medical technology leader focused on one mission: Every day, around the world, we enhance outcomes for patients and their caregivers.

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References: 1. Children’s Eye Foundation. https://www.childrenseyefoundation.org. Accessed January 2, 2019.

2. Children’s Eye Foundation. https://www.childrenseyefoundation.org/see. Accessed January 2, 2019. © 2020 Welch Allyn Singapore PTE Ltd. ALL RIGHTS RESERVED. APR98501-r1_23-06-2020_ENG-APAC 1 Yishun Avenue 7 Singapore 768923 Tel.: +65 6499 7350 Fax: +65 6499 7351

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