Asian Hospital & Healthcare Management - Issue 54

I S S U E 54

2021

w w w.asianhhm.com

Chris Lee President Asia Pacific

Medtronic’s Strategic Objective Accelerating healthcare technology innovation

Telehealth The next frontier of virtual care Associate Partner

2030 vision Looking toward the future of interoperability www.asianhhm.com

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Foreword Telehealth

Driving the future of digital health Technological advancements and the advent of modern care delivery models have in a way narrowed down the gap between physical and virtual healthcare environments. Since the COVID-19, public health emergency has increased the utilisation of technology to safely access and deliver healthcare. Virtual health companies are coming forward to grow at record levels to innovate and find winning models. There has been a significant change in the attitude towards embracing virtual health, both from patients and service providers’ perspective. On the other hand, investments in telehealth and digital health have shot up exponentially along with favourable regulatory changes.

According to a survey conducted by Applause in July 2021, 46 per cent of respondents used telehealth services at least once and 84 per cent opted virtual platforms to avoid in-person activities during the Covid-19 pandemic.

Over the last year, Telehealth has certainly redefined patient care bringing forth the importance of virtual care giving with the help of digital technologies. We have witnessed the emergence of virtual care and digital health business models to improve patient experience, accessibility, affordability, and outcomes.

While telehealth services have seen a tremendous uptick in the Covid environment, the rate at which it grew has normalised. Now, there is a need for additional reforms that focus on making telehealth an integral part of value-based care. The Covid-19 pandemic has indicated it’s time to make Telehealth a fundamental step and a priority for caregiving, thus creating avenues to modernise care delivery. A recent McKinsey study suggests that the telehealth market has a tremendous growth potential from US$3 billion to US$250 billion by 2025.

Decisive action is required for healthcare systems to develop capabilities at scale to provide high-quality patient care. From building capabilities to supporting the

workforce requirements, health systems have to focus on accelerating the growth of telehealth usage across regions.

From healthcare organisations and technology providers standpoint, it is essential to evaluate the impact of virtual care in various scenarios, identify the need to build assets and capabilities required to execute an effective telehealth implementation plan. This way, the stakeholders in the industry will be better prepared to adopt a virtual health roadmap. Today, Telehealth appears to be the way forward, but it requires a holistic shift rather than a unidimensional approach. Beginning with the development of infrastructure, it is essential to obtain necessary regulatory clearances/ approvals in time. Most importantly, train and prepare the caregivers to leverage technology for highly-effective care delivery.

This issue features an article by Angela Lee, Principal and Regional Managing Director for Asia Pacific at HKS and Gordon Gn, Design Director at HKS Singapore. In this article, Angela and Gordon take us through how Telehealth can be the next frontier of virtual care beginning with impact on physical design of facilities while delving into how a physical-digital hybrid approach. The issue also covers an interesting writeup on leveraging space technology for improving healthcare outcomes by K Ganapathy, Director, Apollo Telemedicine Networking Foundation, and other insightful articles. Hope you find the issue very interesting.

Prasanthi Sadhu Editor

www.asianhhm.com

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HEALTHCARE MANAGEMENT 06 Pandemic Pivots Mind 'n' Matter

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Gurrit K Sethi, Strategic Advisor, Global Health Services, Global Strategic Analysis

12 Patient-centricity The foundation of building a sustainable healthcare access ecosystem in Southeast Asia

COVER STORY

CONTENTS Joseph Saba, Co-founder and Chief Executive Officer, Axios International

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

22 Single Specialty Hospitals A game changing healthcare delivery model in Asia Anwar Anis, Director, ALTY Orthopaedic Hospital

MEDICAL SCIENCES 34 Benefits of Natural Immunity from COVID Must be Credited Beverly A Jensen, President/CEO, Women's Medicine Bowl, LLC

40 Cardiac Transplantation in the Adult Congenital Heart Disease Population Juan M Ortega-Legaspi, Cardiologist, Penn Medicine

TECHNOLOGY, EQUIPMENT & DEVICES

Medtronic’s Strategic Objective Accelerating healthcare technology innovation Chris Lee President, Asia Pacific

43 Emerging Technologies and Techniques Unveiling new possibilities in the treatment of atrial fibrillation

FACILITIES & OPERATIONS MANAGEMENT

Choi Eue Keun, Professor, Internal Medicine (Division of Cardiology) Seoul National University’s College of Medicine

48 Ultraviolet Light Disinfection Systems For operating room treatments Franklin Dexter, Division of Management Consulting, Department of Anesthesia University of Iowa

INFORMATION TECHNOLOGY 54 Healthcare from Space, Down to Earth!

K Ganapathy, Director, Apollo Telemedicine Networking Foundation

58 Telehealth The next frontier of virtual care Angela Lee, Principal and Regional Managing Director, Asia Pacific, HKS Gordon Gn, Design Director, HKS

62 2030 Vision Looking toward the future of interoperability Leigh Burchell, Vice President, Policy and Government Affairs, Allscripts

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Advisory Board

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

EDITOR Prasanthi Sadhu EDITORIAL TEAM Grace Jones Rohith Nuguri Swetha M

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

ART DIRECTOR M Abdul Hannan PRODUCT MANAGER Jeff Kenney

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

SENIOR PRODUCT ASSOCIATES Ben Johnson David Nelson Peter Thomas Susanne Vincent

Nicola Pastorello Data Analytics Manager Daisee

PRODUCT ASSOCIATE John Milton Veronica Wilson CIRCULATION TEAM Sam Smith SUBSCRIPTIONS IN-CHARGE Vijay Kumar Gaddam

Gurrit K Sethi Strategic Advisor, Global Health Services Global Strategic Analysis

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

HEAD-OPERATIONS S V Nageswara Rao

Associate Partner

In Association with

A member of Confederation of Indian Industry

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

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

Peter Gross Chair, Board of Managers HackensackAlliance ACO

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

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

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HEALTHCARE MANAGEMENT

PANDEMIC PIVOTS MIND 'n' MATTER Given that the mind defines our behaviours, and the matters that drive it, our environment becomes one of the most important factors of our well-being.

The Pandemic has affected our environment in unprecedented ways, and although it is not the first or the last time such an event shook the world, it has definitely been one of the most impactful and definitive, because of the global nature of the impact. The mental being of humanity as a whole has become one of the most critical pivots of the current pandemic.

Gurrit K Sethi, Strategic Advisor, Global Health Services, Global Strategic Analysis

T

he pandemic has affected our lives in multifarious ways that we are still trying to ascertain, still trying to bounce back from, and ways that have left us wondering how we can transform our society for the better. Given the changed behaviours

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

in response to a changed environment during the pandemic, various facets of life have also evolved including how we interact, how we work, how we move around, how we conduct our business, and, most of all, of how we view our health. Our health has suddenly become a key focus including our own and others perceptions of individual health.

Try sneezing in a public place today and the heads that turn with ‘the look’ tell you just that! Alongside physical health, mental health and well-being has also now taken on a new dimension.

In a world where mental health always played second fiddle to priorities like work, physical health, aesthetics, etc., the COVID-19 pandemic served as a wake-up call to many. The pandemic pulled the speed brakes on many aspects of social life along with personal and professional life. It provided a

IS S UE - 54, 2021

forced break, albeit unwanted and unexpected, from overly-packed days with hours of commuting, working, and socialising in multiple physical spaces, and restricted us all to our personal confines. In these bounded personal spaces, our relationships with our own selves became ever more important and people began to be confronted by their mental health, or their continued negligence of it.

Physical spaces have up till now been silos for different activities social spots for friends, houses for families, offices for work. In this set-up, mental health could easily be dissociated from our being and personal needs could easily be made second to those two extra hours in the office on a Friday, or the drink with a friend at the newest bar etc. However, being continually cooped up in the same space made it harder for

HEALTHCARE MANAGEMENT

providers. All behaviours are driven by the Mind which finally minds all these matters!!

So, from a business perspective, we need to take stock of this new emerging ‘Mental Being’ with the changed the product and service user patterns, and given the stages of the pandemic, with those which are continuing to change.

How do we establish a connect without a connect, engage without a physicality, touch lives without touching them? Or, how do we cater to those who choose these new behaviours and those who prefer the old ones? This is another critical pivot the pandemic has created.

In a way this Mental Being is also creating a more efficient way of living..

This evolution has impacted healthcare as much as all other businesses in general as well – in the way consumers now approach these as well as the ways the providers had to find to conduct these, given the new constraints.

Another critical pivot of the pandemic is going to be the further evolution of healthcare. In the medium we choose to consume the services – physical, digital / remote; as well as the different aspects of it – preventive as well as curative, mental as well as physical. The digitisation which was earlier being looked at as an efficiency tool, is today a need. The mental well-being today is beginning to be recognised as almost a precursor to the physical one as doctors and people in general are waking up to the effects as well as the convenience of this.

Gurrit K Sethi, 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 different healthcare businesses in different domains and verticals. 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 20 years in healthcare under her belt, 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.

In a way this is emerging as another big business opportunity for healthcare players in the product as well as the services sector. Healthcare is at the cusp of change towards connected health with connected devices alongside telemedicine solutions. Connected devices offer monitoring for wellness and preventive / pre-emptive data for healthy life style solutions through specific devices or even through mobile phones. Some connected devices also offer remote disease specific monitoring so timely medical interventions can be done reducing emergency / critical hospitalisation episodes. Diagnostics is evolving to home self-screening options and point of care checks.

Tele-medicine is showing how these dots can be connected for wellness, preventive or curative episodes. Thus healthcare is slowly changing for the providers as well as the consumers as the global communities wake up to the challenges of more such possible pandemics while dealing with the one ongoing.

The question is, how do we unmask – be it at a personal level as the protective layer we believe to be our saviour, or, at a conceptual level to wake up to a new reality – the need to upgrade our health as well as our economic status?

And the only answer is by adapting and innovating!

AUTHOR BIO

people to continue to ignore or repress their mental health. With the continued impact of the pandemic, people began or atleast attempted - to refocus their lives towards a greater balance for mental well-being. This moment provides an important pandemic pivot as well as a key moment in the 21st century lifestyle, and highlights the importance of mental health. This moment also led to a significant shift in people’s internal and external lives, interactions, and even consumer patterns.

Since this is so similar across the global communities, I choose to call this The ‘Mental Being’ of the whole humanity. And this has affected our environment, or, perhaps, vice versa!

The fear of getting infected, the stigma that arises (yes even today) out of it, the fear of dying as has been exemplified by the sheer statistics of the spread of the disease by volume across the globe, has created different types of fears, frustrations, limitations, needs, lifestyles etc.

And it is this Mind that matters.

This matters because it defines how we deal with everything around us as well as the environment, and in this particular context, the business environment, which needs to change to respond to the now differing consumer behaviours.

One of the most major pivots arising out of the pandemic is in the way we need to do business now, how we evolve and adapt to the new ways of consumer behaviour. It is an equal challenge for the consumers as well as the service

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medavis RIS

Implementation of single data entry with efficient workflow and patient safety Angella Alfa Chrispa Aulia, Head, Department of Product and Application Specialists, PT Noah Arkindo

Saint Borromeus Hospital, founded on September 18th in 1921, is one of the oldest hospitals in Bandung, Indonesia. The hospital was started by six nuns from the Sisters of Charity of St. Charles Borromeo Congregation. Until now, St. Borromeus Hospital has succeeded in becoming the leading hospital in West Java. The trust given by the community has made St. Borromeus Hospital known as a referral hospital for the city, province and even a strategic partner of several well-known hospitals at the Asian regional level. In the work of health services, St. Borromeus Hospital has become a government partner for the National Health Insurance System Implementation Program.

Vision of Saint Borromeus Hospital: To be a world-class, trusted and professional service hospital based on the spirit of love St. Borromeus Hospital’s vision is to be a worldclass, trusted and professional service hospital based on the spirit of love. To realize this vision and maintain public trust, the management of St. Borromeus Hospital always provides the best health services for patients, especially in radiology services. Currently, St. Borromeus Hospital provides up to 5,000 radiological examinations every month and the number continues to increase according to Robby Hermawan, Sp.Rad.M.Kes as Head of the Radiology Department. With 15 doctors and 57 staff, the radiology medical support unit belonging to St. Borromeus Hospital is of course very busy.

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Robby Hermawan

Head, Radiology Department Saint Borromeus Hospital

Robby Hermawan, with the support of St. Borromeus hospital management, has implemented the radiology information system medavis RIS in 2018. Today, the radiology workflow at St. Borromeus Hospital is running digitally because medavis RIS has been connected with PACS, HIS and modalities in the hospital.

Improving Patient Safety

According to Th. Widjajanti S, MM as the Head of the IT Teams at St. Borromeus Hospital, medavis RIS has met the hospital management’s expectations.

Workflow digitalization with medavis RIS has been proven to improve work efficiency and accuracy of radiology service data. Currently, patient data and patient radiological examinations can automatically be seen in the modality with high accuracy. Based on this, for St. Borromeus Hospital, the use of medavis RIS has also proven to increase the efficiency of service time per patient. This can be seen with the increase in requests for radiology examinations.

Especially requests for sudden examinations (cito)

can better be served by radiology staff and hospital radiologists today. Another positive improvement from the radiological digitization is the fast availability of the patient’s diagnostic results in the form of digital images and reports. Apart from making images and reports quickly available online to referring doctors through the HIS, the ease of viewing radiology results digitally also enables a significant reduction in costs for the use of consumables such as films.

Doctor Widjajanti also stated that patient safety in providing health services for the community is the main concern of the St. Borromeus Hospital Manage-

Petrus Mayar Santoso Senior Radiographer Saint Borromeus Hospital

ment. This includes the process of transferring accurate patient data from medavis RIS to the modality, as well as supporting radiologists in producing accurate and timely radiological examination reports for each patient.

Mr. Petrus Mayar Santoso, SST as the Senior Radiographer of St. Borromeus Hospital said that “medavis RIS makes it easier for radiology staff, especially in inputting patient data only once (Single Data Entry), thus shortening the service time per patient.”

Today, radiological examinations, especially for patients from within the hospital, can be started and completed more quickly and precisely. Clinic and ward physicians can now refer patients to the radiology unit for examinations, including specific instructions from the HIS workstation. In the RIS, incoming radiology examination orders are shown automatically and the radiology staff can schedule patients instantly with a few clicks.

The radiographer can see the patient with a queue number on the worklist at the workstation. When the

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patient’s turn arrives and the radiological examination is ready to begin, there is no longer the process of entering patient data and examinations into the modality. Now, the radiographer only needs to select the patient in the medavis RIS worklist and press the START button, then the patient data and the examination will appear automatically in the modality. “We save a lot of time and reduce human error,” says Mr. Santoso.

After the examination is complete, the Radiographer only needs to press the END button on the RIS workstation. The patient images are automatically stored in PACS, and at the same time, the radiologist can see the information on the worklist that there is a patient examination ready for reporting. Radiographers no longer need to print patient images on film and send the film to the radiologist. When the radiology report has been released by the radiologist, medavis RIS will automatically send the information to the HIS for the referring doctor.

from installing and preparing the medavis RIS application, the medavis-Noah team has also provided individual training per user group. During the last 2 weeks prior to Handover, our users were provided with assistance in the field so that they could become more proficient in using medavis RIS in their daily work. Mr. Yaten concludes: “The medavisNoah team has provided the best solution during the implementation process of the medavis RIS. Based on my assessment, I gave a score of 9, on a scale of 1 to 10, for that team.”

Fast System Implementation

Nico Santono

Incharge, Radiology IT Saint Borromeus Hospital

Mr. Santono continues: “If we ever report a problem, PT Noah Arkindo as the local partner of medavis GmbH always provides the right solution and the problem is resolved immediately.”

“During the process of implementing medavis RIS at St. Borromeus Hospital, medavis GmbH and PT Noah Arkindo have provided tremendous support,” said Mr. Yaten Purwono, ST as the Deputy Head of the IT Teams. The medavis RIS Implementation Project, starting from the Kick-Off Meeting to the Handover, was carried out in just 6 weeks. Apart

AUTHOR BIO

medavis RIS gives comfort and convenience in terms of usability and maintenance, according to Mr. Nico Santono, ST who is in charge of Radiology IT at St. Borromeus Hospital. The radiology staff became proficient in performing day-to-day operations without problems in less than one month. medavis RIS operates 24x7 non-stop, is very stable and has more than 99% availability.

Angella Alfa Chrispa Aulia joined PT Noah Arkindo in 2015 as Department Head of Product and Application Specialists.

Alfa holds a degree in Pharmacy from Sanata Dharma University in Yogyakarta, Indonesia. She has more than 10 years of project experience with the implementation of hospital and radiology information systems in large hospitals throughout the Indonesian archipelago.

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

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Learn more about how you can benefit from optimized Radiology Workflows by medavis and join our webinars.

Upcoming webinars in your region presented by our local partners: India Malaysia Philippines Indonesia (in local language)

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About medavis medavis GmbH is a German specialist for process optimization in radiology and offers customized software solutions that ensure stability, reliability, and performance. With workflow solutions from medavis, radiologists ensure a fast, secure, and digital flow of information and sustainably increase the efficiency of patient care.

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HEALTHCARE MANAGEMENT

Patient-centricity

The foundation of building a sustainable healthcare access ecosystem in Southeast Asia Southeast Asia’s healthcare access ecosystem is now at a critical juncture.

To improve access for the long term, Joseph shares why healthcare stakeholders in the public and private sectors must enhance sustainability around the key aspects of finance, treatment and health systems.

Joseph Saba, Co-founder and Chief Executive Officer, Axios International

S

outheast Asia’s healthcare landscape has irrevocably changed.

Due to the demographic shifts the region has been experiencing – such as ageing populations1 and the rise in non-communicable diseases (NCDs)2 – governments and healthcare

stakeholders must now reassess3 healthcare expenditure and reforms to not only improve health ecosystems in terms of equitable access, but also sustainability.

However, a major challenge to these is that the healthcare ecosystem has not evolved in tandem with broader socio-

1 https://www.who.int/southeastasia/health-topics/ageing 2 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7371561/

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3 https://www.adb.org/sites/default/files/publication/684701/adbi-wp1220.pdf

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economic development4, especially in Southeast Asia’s emerging markets. This challenge was exacerbated further due to COVID-19, which spotlighted the gaps5 within the region’s healthcare access ecosystem.

4 https://iigh.unu.edu/publications/articles/health-andhealthcare-systems-in-southeast-asia.html 5 https://www.brookings.edu/blog/order-from-chaos/2021/01/14/covid-19-in-southeast-asia-regional-pandemic-preparedness-matters/

HEALTHCARE MANAGEMENT

Southeast Asia’s healthcare access ecosystem is now at a critical juncture.

To improve access for the long term, healthcare stakeholders – both in the public and private sectors – must focus on enhancing sustainability around the key aspects of finance, treatment and health systems. Achieving this requires placing patient-centricity at the core, namely by striving to achieve better health outcomes for them.

Supporting patient involvement at every step

Generating better outcomes for patients requires supporting them throughout their treatment journey – even at the very beginning. This can be done by ensuring that access needs to be a core component of every pharmaceutical company’s overall strategy. It is a crucial step before implementing any access solution; it must be considered during the planning process and not just as an afterthought.

Providers need to deploy more patient-centric approaches that involve patients throughout their healthcare journey. This can be done by ensuring those solutions are specifically tailored to them and consider them as individuals, as access is being redefined from a short-term, one-off strategy to a long-term solution.

To do so, patient-based solutions must focus on the entire patient journey, starting with access to diagnosis. Before being able to access6 treatment, many patients face a long process to get referred to the right specialist, get misdiagnosed or cannot afford the diagnostic tests – especially for rare diseases. Improving diagnosis access thus requires disease awareness and physician capacity building, in addition to giving patients more financial support to access diagnostic testing.

6 https://www.who.int/southeastasia/news/detail/0409-2018-countries-in-who-south-east-asia-regionresolve-to-make-essential-medical-products-accessibleaffordable-to-all

Additionally, solutions must also consider treatment affordability. Many people in Southeast Asia are particularly vulnerable in terms of healthcare financing7 and governments have been working on health financing reforms8 to reduce dependence on out-of-pocket payments. As much as these efforts are important and significant, they are not sufficient to cater for all health care needs.

The private sector can play a supportive role here via cost-sharing programmes9 and tools that measure patients’ financial capabilities10 to help determine how much monetary assistance patients need to follow through on their treatment in the long term.

Healthcare ecosystem stakeholders can also offer services to support patients throughout their treatment journey to ensure patients receive the full course of treatment and maximise treatment benefits. This is as non-adherence rates are rising across the region, even in more mature markets like Singapore11 and Malaysia12. If left unchecked, the long-term effectiveness of treatments would be compromised and may critically affect a population’s overall quality of life. Better health outcomes for patients can be achieved by making adherence interventions more effective, as studies13 note that doing so can potentially generate more impact on a patient’s health – more so than making improvements in specific treatments. This is as medical advances would inevitably face obstacles in fulfilling their potential 7 https://www.who.int/southeastasia/health-topics/healthfinancing 8 https://www.researchgate.net/publication/49787717_ Health-financing_Reforms_in_Southeast_Asia_Challenges_in_Achieving_Universal_Coverage 9 https://axiosint.com/accessinthailand 10 https://www.liebertpub.com/doi/abs/10.1089/ pop.2012.0049?journalCode=pop&

to reduce illness burdens, especially for chronic cases, if a system that addresses adherence determinants does not exist. Essentially, treating diseases successfully requires doing more than just improving access to medications.

This is why interventions are essential.

A multi-sectoral approach will help improve medical outcomes by making it easy for patients to track and manage their treatment via Patient Support Programs (PSPs).

Another focal point is ensuring robust compliance with access initiatives. Unsafe medical care contributes to poor patient outcomes, a challenge that is especially pertinent in emerging markets14 within Southeast Asia. Patient access programmes must go beyond being just well-designed.

Program management must fully comply with the region’s best practices in standard operating procedures (SOPs), data security conformity with General Data Protection Regulation (GDPR) and local data privacy policies in each country, patient consent, and pharmacovigilance15.

Going digital to support access initiatives of burdened healthcare institutions

Existing healthcare infrastructures, particularly hospitals, are now being stretched to their limits.

Simultaneously, populations are growing and healthcare demands are rising – pressure points growing even before COVID-19, which has further exacerbated this dire situation16.

Hence, the proliferation of digital tools and solutions outside of hospitals (namely, those that can complement existing services) must be raised.

Today, digital healthcare solutions are being promoted in advanced

11 https://journals.sagepub.com/doi/ full/10.1177/2010105820933305

14 https://academic.oup.com/intqhc/article/27/4/240/2357347

12 https://www.researchgate.net/publication/332804991_ Interventions_on_Improving_Medication_Adherence_in_ Malaysia_A_Mini_Review

15 https://www.who.int/teams/regulation-prequalification/ regulation-and-safety/pharmacovigilance

13 https://pubmed.ncbi.nlm.nih.gov/12076376/

16 https://www.internationalaffairs.org.au/australianoutlook/southeast-asias-responses-to-the-covid-19-pandemic/

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markets like Singapore17 and even in more emerging economies, such as Thailand18, which uses more advanced technologies such as 5G to improve telehealth services. More can be done to stimulate similar advancements but promoting the use of digital tools that can enable effective out-of-hospital services must also be taken on by private sector healthcare ecosystem actors to help reduce patient reliance on in-hospital services. This is a crucial step in building a digital ecosystem that connects different stakeholders in the patient’s journey in the programmes they are in – including the patient themselves, the physician, the pharmacist, the pharmaceutical companies, civil society groups such as charities, as well as labs and distributors.

When designing digital solutions, patients must remain at the core; patient centricity must be maintained amid 17 https://www.edb.gov.sg/en/business-insights/insights/thehealthtech-boom-in-southeast-asia-big-strides-and-newopportunities-for-healthcare.html 18 https://techwireasia.com/2020/12/thailand-aims-to-bethe-new-apac-medical-hub-leveraging-smart-health/

the move to making processes faster, simpler and easily accessible for them and to improve engagement between healthcare system stakeholders. This can ultimately lead to an increase in adherence in health programmes.

Diagnosis, access and adherence programmes that are digitally delivered and personalised can also facilitate and expedite the patient journey. While ensuring the human interaction still plays an important part, the greater proliferation of data can help improve decision making and programmes improvements. Real-world insights gleaned from access programmes can help deliver breakthrough insights on disease evolution, treatment, patients’ perceptions, outcomes and cost.

The three core pillars of healthcare access sustainability

The creation of an access ecosystem can generate greater financial, treatment and health system sustainability. Here, multi-sectoral collaboration is crucial in supporting governments that have long been stretched in improving access by themselves.

Financial Sustainability

PATIENT CENTRICITY Treatment Sustainability

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Health System Sustainability

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When access initiatives are designed with the patient in mind over the long term, we can attain the following three pillars of healthcare sustainability: Financial sustainability By designing initiatives that are personalised to the patient, the financial support provided is no longer limited to budget constraints of the government, pharmaceutical company or the patient. The multistakeholder collaboration allows the initiatives to be financially sustainable and can be scalable over time to reach as many patients as possible, while the patients don’t eventually need to pay out-ofpocket amounts that are beyond their means.

Treatment sustainability By addressing both affordability and adherence challenges, more patients can stay on their prescribed treatment for as long as medically necessary, ensuring they are getting the maximum benefit from their treatment. At the same time, physicians would have a greater capacity to treat more patients.

Health system sustainability By complementing the healthcare system with patient management mechanisms implemented outside of health institutions (i.e., hospitals), burdens can be lifted from the healthcare system, enabling it to cope with the increasing older population, improves the cost-effectiveness of healthcare interventions, ensuring better health outcomes, and allows the healthcare system to expand, keeping the expenditures in proportion to the GDP sustainable.

When we address access holistically, we achieve this trifecta of sustainable access. We have seen this first-hand in Axios-managed Patient Support Programs. For instance, we collaborated with a multinational pharmaceutical company to develop their 'access to medicine strategy', ensuring that access was not an afterthought. Together we designed a shared payment access programme. The programme

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is focused on improving access to treatment for selected haematological and gastroenterological conditions.

It was important to go beyond just reimbursement and identify a more tailored approach that segments the patient population.

This programme uses Axios’ Patient Financial Eligibility Tool (PFET) that considers both formal and informal income sources – enabling patients to complete their prescribed treatment even if they can’t afford to pay for it in full. By understanding the individual patient's circumstances, we can define a quantity of payment comfortably within their means and ensure that only those who need the support benefit from it. The company was able to reach its average discount goal without reducing the price. At the same time patients only paid what they could afford – and so it became financially sustainable.

The cost-sharing has significantly reduced the financial burden, resulting in larger patient enrolment in the programme with more patients able to stay on treatment, which significantly improved the duration of treatment, reaching optimal medical outcomes.

In fact, in 75 per cent of cases, a higher-than-expected duration of treatment was reached. Concurrently, this led to broader healthcare provider satisfaction and so enrolment accelerated.

Here, treatment sustainability was reached.

The programme was then able to scale globally – now supporting patients in Asia, Africa, Europe, Middle East and Latin America. For some countries, our suite of digital tools has connected patients to their healthcare providers outside of the hospital care setting while integrating stakeholder coordination into one seamless ecosystem, which became essential during the pandemic. With many more patients able to access and stay on treatment longer, while having an out-of-hospital support

system to complete the HCP efforts, the burden on the healthcare system is lighter, especially as patients adhering to treatment means less complications and less hospitalisations. By doing so, we keep the healthcare system sustainable and ready to extend care to more patients.

Access success requires building a sustainable ecosystem

Southeast Asia's healthcare access ecosystem is being strained to the point that it cannot quickly adapt to patients' ever-evolving needs. The region's population is growing at a rate of knots, and the increasing population density means the healthcare system cannot rely solely on hospital care anymore; Because hospitals are not equipped to care alone for patients living with lifelong conditions or chronic diseases requiring long-term treatment forever. The patient must return home at some point, so there is a considerable gap in care because HCPs cannot be everywhere. If patients are on treatment that requires technical expertise like a self-administered injection, they need to be supported, or adherence rates will drop, patients will not get the full medical benefits from the treatment, and their condition

could worsen. We must build and extend healthcare capabilities beyond the hospital while keeping patients connected to facilitate the patient journey. By conservative estimates, the pandemic has accelerated the digital transformation of healthcare by at least five years, and technology is essential to integrating all components of a multi-faceted ecosystem that reaches patients wherever they are. Patient support programmes include medication management and counselling, significantly improve care and overall patient experience in chronic disease states, especially with complex therapies. The goal is to generate more, improved health outcomes for the region's patients in the long term, supported by a robust network that plays to the strengths of every collaborating stakeholder.

True healthcare access sustainability can be achieved through such outcomes, but a multi-sectoral, multidimensional response must support the process. This call has to be taken actioned by access specialists in both the public and private sectors and by placing patients at the centre of their healthcare access strategies.

AUTHOR BIO

Joseph Saba is Co-Founder and Chief Executive Officer of Axios International, a global healthcare access company with 20 years of specialized experience developing practical and sustainable solutions to patient access challenges in emerging markets. Under his leadership, the company has launched a number of successful drug access programs and developed innovative access strategies and new models for healthcare systems strengthening.

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The Medical City

Communicating in times of crisis Martin P Samson, Chief Operating Officer, The Medical City

Winston Churchill once said never let a good crisis go to waste. The wisdom behind that statement is perhaps never truer or more applicable today than it did 76 years ago as he uttered that now famous statement at the end of WW II. As the world helplessly grapples with the pandemic, it is increasingly clear that every country, international body, and corporation worldwide were blindsided by it and are now requiring an overhaul of the textbook business contingency and recovery plan it put together. No organisation, to this day, can claim that their business continuity program considered the crippling effects of the pandemic on its operations.

In fact, I suspect that no corporation, no matter how sophisticated, can say that their business continuity plan effectively helped them weather the pandemic's bleakest impact. As for the Philippines, a study on the adverse effect of the pandemic conducted by the Asian Development Bank (ADB) on four countries showed that the pandemic's worst effect was felt here among the Micro, Small and Medium Enterprises (MSMEs) and their employees. On a global scale, determining the total number of businesses worldwide that permanently shut down because of COVID-19 is unimaginable. In the US alone, in 2020 that number is nearly 100,000. With the surge of infection continuing to rise unabated in most parts of the world, the figures for 2021 will surely be greater.

Even first world countries with well funded government agencies solely dedicated to forecasting the coming of the next catastrophic infectious diseases have been caught flat-footed by the virus. With infection figures at more than 220 million worldwide with casualties of approximately 4.55 million and multiple mutations that seem to defy and penetrate vaccine protection, experts to this day are still trying to understand how best to outrun this disease. While the number of waves or surges that can be expected is still the subject of debates. One thing is clear, COVID-19 and its deadly impact will not be behind us anytime soon. Suffice it to 16

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say, this is a pretty darn serious situation. The kind of "good crisis" in some grotesque sense, that Churchill may have been alluding to.

A crisis in communication

Nothing creates profound fear in people's hearts more than the unknown. Especially when all that is publicly available so far is either life threatening or life ending.

Such is the dire condition that practically accompanied eventual lockdowns and border closures all over the world as covid ravaged relentlessly every corner of the globe. For the Philippines, the imposition of the world's longest and possibly strictest lockdown, as its government's sole strategic monumental response, started on March 15, 2020. Such action coupled with the newness of the virus and the scarcity of accurate information from reliable sources on how to effectively deal and manage COVID-19 infection, especially in the healthcare setting, cast the darkest shadow of paranoia one can imagine, on the population.

Amidst the unlikely scenario of this horrific public health crisis, we at The Medical City (TMC) found an opportunity to flourish where others only embraced despair. Having become acutely aware that the lack of valuable communication allowed confusion and panic to proliferate in the community or worse, that the information vacuum was fast filling up with misinformation.

The Medical City set about furiously developing relevant content in what may well be the greatest number of creative communication materials it ever produced on a single public health subject matter within a short period of time, in its more than 50-year history. In a mere 18 months, TMC generated and shared 536 materials in various formats through all its social media platforms to reach the widest audience possible.

These communications have influenced some of the country's big private healthcare institutions as well as government action, to some degree. But more importantly, TMC's communication campaign from the

beginning to this day helped to fill a gaping void for a community thirsty for valuable information to ease their worst fears about this virus.

At the height of the first surge, private hospitals acted independently of other institutions in dealing with the overwhelming number of patients with COVID-19, arriving at their emergency rooms. This isolated approach did not give people a full capture of how badly the situation was deteriorating. To paint the big picture, TMC was the first private healthcare institution to publicly announce that its COVID-19 emergency room was filled to capacity and could no longer accommodate patients. This move was later followed by other big private hospitals. And for the first time, the public was collectively made aware how serious and untenable the situation was fast becoming at healthcare institutions, public or private. It underscored the demand for appropriate government agencies to participate and conduct a more coordinated approach instead of abandoning private healthcare institutions to work it out on their own. This eventually catalysed the national government to create a unified system for managing among others, emergency room demand for patients with COVID-19. TMC was also first to publish the census of its COVID-19 cases and other relevant statistics to highlight the urgent need for people to do social distancing and practice all other proper safety protocols.

While others lament that social media made a significant impact on spreading fear and panic related to the COVID-19 outbreak, The Medical City used its official Facebook page (https://www.facebook.com/TheMedicalCity) to keep people safe and informed during the crisis. Full-length versions of all the materials posted on Facebook were even uploaded to our YouTube channel (for the videos) and the TMC website (for the articles).

The Major Themes

The communication campaign focused on the following major segments; (1) AskTMC (2) Safe Zone for All (3) DOCumentaries (4) Get Vaccinated (5) I Am Vaccinated.

AskTMC and parts of DOCumentaries featured TMC's own infectious disease expert, Dr. Karl Henson, answering frequently asked questions from an information-starved public. For the first time, people were able to listen and see an actual expert talk about their worst fears on the coronavirus and provide answers based on expert medical opinion. The goal was to create the country's own version of a Dr. Anthony Fauci, an expert in infectious diseases, who provided reliable information to correct public confusion.

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COVID-19 is not the only pandemic

AUTHOR BIO

As the first surge waned, the Safe Zone for all messaging was created to sound the alarm on the growing number of the unhealthy but non-COVID population who continued to stay away from hospitals out of fear, neglecting much needed medical follow ups and

I am a lawyer by education and profession.

In 2012, I was hired by The Medical City to be its Chief Legal Officer and by 2018, I was offered the opportunity to be its Chief Operating Officer. A position that helped me discover my true passion.

treatments. A recipe for a second pandemic, this time from stroke, heart attack, end-stage cancer, and other illnesses that are otherwise manageable if treated early.

TMC supported its call to return to hospitals by creating the 2 systems within 1 hospital complex.

This allowed non-COVID patients to come for medical treatment without fear of exposure. Other institutions followed shortly. This initiative, recognised by PR Asia for Best PR Campaign for Healthcare and Pharmaceuticals and Best COVID-19 Related Response, bested 400 other entries from across Southeast Asia, South Asia, and the ANZ regions.

When vaccination became a reality, TMC was at the forefront in encouraging the public to get vaccinated.

Its "Get Vaccinated" and "I am Vaccinated" campaigns were produced with individuals speaking in several dialects to ensure the widest reach possible in a nation of 7,000 islands and multiple dialects. The material was so innovative, the Department of Health (DOH) borrowed it for their own purposes.

Then until now, knowing what we didn't know was just as important and we made sure never to be reckless with the information we shared. TMC pushed the envelope towards helping people live with the reality of COVID-19 but it was always careful to always be facts based.

Did we make a difference? At the end of 2020, a share of voice analysis revealed that five out of every 10 individuals who read any information or watched news about COVID-19 will say they saw a The Medical City content on the subject. Among all pieces of content published about the leading hospitals’ response to the pandemic, The Medical City garnered the biggest share of voice. Bigger than four of the country's other big hospitals combined. Our online engagement metrics have also seen all time high numbers, with 1.8 million minutes of COVID content viewed, 40 million reaches of which 507,000 are new, and 66,900 new unique conversations generated.

As we try to predict how this COVID narrative ends, The Medical City's story will not be nearly complete without including the individuals who tirelessly work because they care, our medical and non-medical frontliners. From the beginning of the pandemic, TMC has proudly proclaimed that in its hospital are the bravest and the kindest people you will ever meet - that message conveys the unspoken truth about healthcare frontliners, and the burden now forced upon them to bear.

This crisis continues and the end is not nearly in sight. But when you hold people's feet to the fire, in this case, organisations, some will burn but others turn golden.

Advertorial

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HEALTHCARE MANAGEMENT

BEHAVIOURAL HEALTHCARE The COVID-19 pandemic has brought some muchneeded attention to mental health services in India.

Various aspects of behavioural health including depression, anxiety, substance abuse, etc. require considerable attention in today’s scenario. To efficiently meet people’s behavioural healthcare needs, hospitals and government have to be more vigilant in terms of mental healthcare services.

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

I

n a country like India, where there is no scarcity of human resources, material supplies, and even though infrastructure is getting developed and impacted positively, healthcare still remains a matter of concern. Majority of the Indian population describes good health as a ‘disease-free condition’; mental health is not often prioritised by them. Mostly in rural areas, where there is a minimum access to even primary healthcare services, people prefer Babas and God-men for mental illnesses.

Behavioural health, which is not only about mental health, but also consists of several disorders such as inattention, hyperactivity, impulsivity, defiant behaviour, drug abuse, criminal activity (more are shown in the Figure 1), etc. It is still a very new and upcoming concept in India.

Looking at the Indian hospital services for behavioural health, there is a strong need for innovative healthcare programmes to improve the behavioural health services. Moreover, government initiatives toward behavioural healthcare along with some policies facilitating hospitals to offer advanced services is a need of the hour.

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Following can be some innovative steps on which Indian hospitals and government can work to build stronger behavioural healthcare facilities in the country.

much better by the time of actual treatment.

Integrating behavioural health services can be an essential step to initiate overall health impact on patients.

1. Integrated behavioural health

2. Technological transformation

Possible impact- Prevention, early detection, timely treatment and management of behavioural health problems can be achieved through Behavioural health integration.

Integrated behavioural healthcare, also known as 'behavioural health integration', is a blended care provided to treat medical conditions and behavioural health issues associated with it. It's a new way of 'caring for the whole person' and emerging as a high-quality healthcare service. This patient-centric approach focuses on overall health of individuals and can be introduced in Indian hospital facilities for better treatment outcomes.

Along with improved health and patient experience, this service can also reduce unnecessary healthcare expenditure and delays in treatments.

Other benefits associated with integrated behavioural healthcare are• Patients with chronic health conditions are often susceptible to behavioural health issues; integrated behavioural healthcare actively addresses this concern and provides services with overall health benefits.

• Rather than going to a behavioural healthcare setting, they prefer the facilities which work like 'one-stop shopping’, such as hospitals. Hence, for hospitals, integrated behavioural healthcare can be a good move to make.

• Having a behavioural health clinician in the facility can help medical providers to cope with the patient's behaviour-related problems more precisely.

• In terms of cost, integrated behavioural healthcare can even bring down the expenditure involved in actual behavioural healthcare services as the patient's health condition becomes

Possible impact- Digital care provides ease of behavioural health counselling even from home where patient is surrounded by his loved ones which can lead to better outcomes. Moreover, digital apps can be highly helpful in updating caregivers about patient’s health status with real-time communication.

Managing behavioural health can become easier and more impactful with digital transformations.

A range of disruptive technologies that can transform behavioural health ecosystems are emerging. Virtual assistants are one of those technologies.

These are AI chatbots and emotion-based algorithms which offer psychological support and information by using natural interaction. Such chatbots can be implemented by behavioural healthcare providers which can not only bridge the gap between care but also can offer 24/7 service and support to the patient.

TESS is an emerging example of such chatbots which delivers strategies to attain emotional well-being.

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During the pandemic, willingness amongst consumers to share health related data has increased to the noticeable extent.

In future, there is a high possibility that consumers may share their behaviour health data as well.

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NeuroFlow is a digital consumer experience technology which can monitor and exchange health information remotely between the patient and caregiver. Along with this, it also manages patient relationships and connects them with some experienceenhancing auxiliary tools. This technology is of great help in integrated behavioural healthcare.

Moreover, the technologies involved in diagnostic support, neurological interventions, etc are also shaping entire healthcare differently. Physical, augmented and virtual reality providing hyper-realistic virtual environments offering individualised psychological interventions are also well accepted by patients recently.

3. Innovative programmes

Possible impact- Such programmes are essential in early detection and prevention of behavioural health problems amongst community.

Moreover, patient can become selfefficient in terms of managing his behavioural health with little medical interventions.

Ranging from school children to adults and elderlies, psychological difficulties can be faced by anyone due to any reason. The hospitals and

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4. Data sharing

Possible impact- Real time data sharing is an essential step while treating the patient with behavioural health issues. It can prevent the unnecessary delays in the diagnosis and treatment of mentally ill patient and cause better communication amongst health providers.

During the pandemic, willingness amongst consumers to share health related data has increased to the noticeable extent. In future, there is a high possibility that consumers may share their behaviour health data as well. This data can be passively collected via sensing technologies which will lead to increased access to behavioural health treatment. Sharing data will not only inform the current health status of a person but also will allow early identification of the health issues before they arise.

This step requires advanced governance standards and a secure centralised database as ensuring consumers' privacy will remain a crucial factor.

Data sharing is becoming a reality in the US state of California with essential steps being implemented at the regulatory level. The legal guidelines

published by the government of California are promoting efficient sharing of behavioural health and substance use disorder information which is strongly backed by database security technologies like block chain.

This will be a revolutionary step for the behavioural healthcare of California.

Towards overall health

Addressing behavioural health issues of the population is an immensely important step toward improving the overall health. Huge number of adults and even a considerable count of adolescents are struggling with mental illness, however, not everyone is able to receive the required treatment.

Policymakers and healthcare providers

have to look into allocating more resources to behavioural health and redesigning the care models to target overall health of the patient.

The world has encountered enormous challenges in 2020, however, some disruptions in healthcare are evolving as future prospects. Governance and healthcare providers should strategically think in terms of using different technologies, scientific insights, data, business models etc. to transform behavioural healthcare services in India.

To improve health and wellness and to create strong societies, such steps must be prioritised.

References are available at www.asianhhm.com

R B Smarta, Founder and Managing Director of Interlink Marketing Consultancy Pvt. Ltd. Being a thought leader in Pharmaceutical, Nutraceutical and wellness industry, he has been contributing globally through Interlink Consultancy and building business performance of his clients for 33 years. Having a Master's degree (M.Sc.) in Organic Chemistry in Drugs, MMS in Marketing, PhD in Management, and FRSA (Fellow of Royal Society of Arts) London, he is-perusing his passion of converting science to Business.

Besides being a consultant, he has been teaching at IIM, prestigious management institutes, Pharmacy College, Pharmacists Associations, guiding PhD students and written as many as seven books on Management, Pharma, Nutra, Foods domain, and many articles in prestigious journals/magazines.

AUTHOR B IO

government have to be vigilant about ensuring the well-being of the people through an active collaboration between people and health practitioners.

An Indian hospital, Fortis, is an excellent example to mention over here.

The hospital not only offers high-quality patient care but also promotes several programmes to boost the psychological health of the society. Few can be named as School Mental Health Programme, Sport Psychology, Organizational Psychology Initiative, etc. In these programmes, they conduct interactive talks, workshops where various aspects of behavioural health are touched effectively.

Government and hospitals should promote such programmes while supporting the infrastructure.

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Single Specialty Hospitals A game changing healthcare delivery model in Asia

M

odernisation since the start of the 20th century has catalysed specialisation in line with the predominant economic thought of the era. As was first espoused by eminent British economist David Ricardo, the virtues of comparative advantage gave birth to focused industries and lean production leading many sectors of the economy to be more specialised.

Within the global healthcare sector, demand for such focused healthcare operations is fast catching on. This new wave of decentralised, customer-centric treatment options is evident from the mushrooming of multi and single

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Arriving at an era of focused healthcare operations, single specialty hospitals allow for a healthcare delivery structure that is nimble and efficient thus enabling hospital networks to optimise their performance.

They help to ensure continuity of patient care and that urgent medical care is available for all those in need. In Asia, where the pandemic has led to disruptions in the healthcare industry, single specialty outfits can reduce the overburdening of healthcare infrastructures and ensure continuity in patient care.

Anwar Anis, Director, ALTY Orthopaedic Hospital

specialty hospitals, specialised units within general hospitals as well as freestanding ambulatory surgical centres.

While the COVID-19 pandemic led to disruptions in the global healthcare industry, it also acted as a catalyst to revisit conventional operational strategies to ensure industry sustainability. Once again, several Asian markets including Malaysia rose in response by integrating technology and healthcare to provide digital healthcare services to ensure continuity in patient care.

The pandemic has also opened discussions around better patient management and addressing urgent patient needs in times when most hospitals are already overburdened. This has shifted the conversation around patient management to focus on single specialty hospitals as effective delivery models to address patient needs.

Arriving at an era of focused healthcare operations, single specialty hospitals allow for a healthcare delivery structure that is nimble and efficient, thus enabling hospital networks to optimise their performance. They help to ensure continuity of patient care and that urgent medical care is available for all those in need, without overburdening the existing healthcare infrastructure.

Addressing the gaps in Asia’s current healthcare delivery

Most countries within Asia operate renowned healthcare systems, with both government and private healthcare facilities offering quality treatment to patients. However, the pandemic has led to several challenges within this ecosystem. This includes paranoia among patients to visit multispecialty and government facilities, overburdening of hospital resources, the need for timely action to respond to patient needs, and fatigue among healthcare workers.

In the post-pandemic era, single specialty hospitals can provide focused and superior services in healthcare.

Single specialty hospitals are designed to cater to specific patient types and are fitted with the right resources and operational strategies to address urgent patient needs, without the hassle of long waiting periods and competing for resources with other specialties. This is especially crucial in the current healthcare scenario where medical care needs to be accessible, convenient, and efficient. For patients suffering from non-infectious diseases, single specialty set-ups therefore provide a fast and safe option for treatments, without having to further delay medical care.

Between general and specialised healthcare

Multi-specialty hospitals cover a vast spectrum of medical specialties, from childcare to geriatric care, orthopaedics, cardiovascular diseases, dermatology, women’s health, and reproductive services, just to name a few. It is not entirely a new phenomenon, but single specialty hospitals have in recent decades increased in popularity and are commonplace in major cities around the world. This has stirred a heated debate between specialised and general healthcare.

Proponents argue that single specialty hospitals are more efficient and can deliver operational advantages relevant to the specialisation compared to general hospitals. Multi-specialty hospitals on the other hand, can sometimes deliver far too broad a range of healthcare services leading to conflicting goals at an operational level.

This can ultimately result in mediocre performance in health outcomes and costs.

Through the increased focus and specialisation of services, single specialty hospitals not only deliver healthcare services with greater efficiency but also promote innovation. This is motivated in part by such hospitals behaving like “focused factories.” Because of the focused approach of specialty hospitals, it permits a standard of care which can be embedded and controlled along the entirety of the healthcare sequence – from patient admission, to care and finally discharge.

This allows facilities to deliver predictable, high-quality outcomes across the clinical hierarchy to junior doctors and even nurses, thus lowering costs without compromising quality.

It also enables a steeper learning curve for staff creating a dynamic learning environment for them which is congenial for innovation and sustained improvement. Similar developments have taken place in other industries which have successfully

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undergone a transition towards more specialised production units, such as in manufacturing, transportation, education and even banking. Studies comparing different types of healthcare delivery units have also shown significant advantages for specialised facilities.

Services offered in single specialty hospitals can often be easily detached, independent, planned, repetitive, predictable and with a low degree of patient comorbidity. Patients at these hospitals have access to extraordinary expertise, resources and therapy programs that aren't often available anywhere else. Single specialty hospitals often have physicians or surgeons with decades long experience of treating individuals within their specific field of specialisation. These hospitals then have the necessary dedicated facilities for patient and family support to help them overcome and navigate through their medical trauma.

In contrast, the multi-specialty or general hospital model can be highly capital intensive, given the need to cater to multiple specialities. As such, they accrue high fixed costs which can inflate the costs for treatment across the board.

This also leads to added bureaucracies that are more doctor-centric rather than patient-centric. On top of that, co-locating different specialties within a fixed space and limited staffing options makes it a challenge in ensuring smooth hospital operations. The complexities that ensue result in the fundamental inability for these hospitals to tightly link input costs to output value.

Consequently, patients are potentially left to deal with higher hospital bills.

A potential game-changer

As single specialty hospitals continue making waves throughout the region, more emphasis is now put on the healthcare consumer per se. The striking difference of how patients are treated today compared to a generation ago is in the quality of care and attention

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The popularity of specialty hospitals over the past few years has increasingly raised significant opportunities for emerging healthcare businesses across a gamut of subspecialties, especially in the Asian region.

provided. The pandemic has also ushered in a major shift in people’s perception towards doctors and hospitals with many now realising that getting the best care for their ailments necessitates a focused environment which a single specialty hospital engenders.

Just imagine a patient in need of an orthopaedic surgery having to compete for medical attention from doctors who themselves must deal with patients of varying medical conditions. Under a single specialty hospital environment, that patient would get everything under one roof – multiple doctors who are specialised in orthopaedic function as well as an end-to-end suite of services including post-operative care. They are seen to deliver better amenities for its patients and achieve a higher percentage of patient satisfaction.

This patient-centric approach is already gaining currency in places where people are opting for increased comfort alongside expert treatment and care.

For some healthcare procedures, it is often more comforting for patients to enter a single specialty centre which is less intimidating than a multi-specialty

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facility. The patient can rest easy knowing that the resources available in a single specialty hospital will be catered to his or her condition and this in effect improves the chances of positive medical output.

These hospitals also put greater management responsibilities on the doctors that help to improve quality as well as productivity. This is exemplified in the physician ownership structure which most speciality hospitals operate on.

The value of physician leadership and collaboration in hospital design, management, and operations to improve quality and efficiency must be recognised.

An article by the Harvard Business Review (HBR) concluded that the best hospitals are indeed ones which are managed by doctors themselves1. They make the best leaders simply because they have a deeper understanding of their fellow physician’s motivations which then better inform their leadership and managerial decisions.

If a manager understands via their own experience the requirements to complete a job to the highest standard, they are able to inculcate a high-quality work environment, set appropriate goals and accurately evaluate colleagues.

Having an exemplary physician at the helm of a hospital also sends the right message to external stakeholders including patients, new hires and investors on the hospital’s organisational priorities and methods of operation.

Optimising healthcare delivery with a focused approach

Moving beyond the narrative of the COVID-19 pandemic, single specialty hospitals are acquiring a unique position of accountability, affordability and agility in operations thereby garnering greater interest from healthcare professionals and patients alike.

Without the operating costs of a larger multi-specialty hospital and 1 https://hbr.org/2016/12/why-the-best-hospitals-aremanaged-by-doctors

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other administrative expenses, single specialty hospitals can drive down costs and improve outcomes (Value Driven Outcomes), thus increasing accessibility to affordable and quality care for patients.

In a single specialty hospital, seamless patient care also becomes a reality as the healthcare professionals working within this set up are trained and equipped to cater to the needs of patients. Preliminary checks, followups, post-surgical assistance, and other similar patient requirements can easily be managed through a central system, making personalised attention and care possible, giving patients more control on their overall health outcomes.

On the operative front, lower costs allow hospitals of this nature to invest more in technology and equipment, and be more efficient in the Operating Rooms, and more agile in the decisionmaking process. In the long run, this allows for better optimisation of overall processes and improved patient outcomes.

With a focused approach on specific conditions, single specialty hospitals also allow specialists and healthcare professionals to fully develop their

AUTHOR BIO

professional knowledge and expertise.

They also act as a platform for doctors to work on their niche specialties and dedicate time to research which improves the overall delivery of treatments.

For example, at ALTY Orthopaedic Hospital, our dedicated healthcare professionals from consultants to nurses are trained to cater to patients suffering from orthopaedic conditions throughout their treatment journey, from patient registration to postsurgical care. Providing dedicated care for joint and spine health, we are also able to invest in world class imaging and diagnostic techniques, partner top doctors and specialists and create an overall infrastructure that ensures each patient we work with experiences the best in-class patient care. As a group practice, the patients also have access to top specialists in the country where complex cases are discussed weekly within the group to make the best management plan for the patient.

While single specialty hospitals are not novel to healthcare systems, their growth in Asia is inevitable. This also resonates with the changing preferences of consumers and the way healthcare

Anwar Anis started his career in healthcare when he joined Gleneagles Kuala Lumpur in 2003, setting up its International Business Development Department and subsequently heading the entire Marketing and Corporate Communications Division.

Currently he is one of the Directors in TE Asia Healthcare (TE), an outfit which co-invests and develops single specialty centres around Southeast Asia. He is specifically involved in TE’s Malaysia projects, providing oversight, having successfully commissioned CVSKL, and now focused on the rollout of its orthopaedic hospital and a second cardiac hospital. Additionally, he sits on the Board of APHM (Association of Private Hospitals Malaysia) and is co-lead of a workforce in MPC’s (Malaysian Productivity Corporation) Productivity Nexus, having previously served as a Board Member in MSQH, the Malaysia Society for Quality in Healthcare.

services are consumed. In Asia, with a growing ageing population and the rise of affluent income households, there is a continued demand for healthcare services that are fast, convenient, affordable and accessible. The rising popularity of Asia as a healthcare travel destination also contributes to this growth, attracting more capital to the single specialty model of healthcare delivery.

The single specialty model of healthcare delivery will ultimately continue to grow, even post pandemic, and offer a long term alternative to relief the overburdening of healthcare systems and improve medical outcomes for both patients and healthcare professionals.

Single-specialty hospitals — the choice moving forward

The popularity of specialty hospitals over the past few years has increasingly raised significant opportunities for emerging healthcare businesses across a gamut of subspecialties. This is especially the case in the Asian region which is now facing the ancillary effects of a global pandemic and a spike in elder population.

From the viewpoint of an insured consumer where elective care is feasible, the advantages of single specialty centres are aplenty – from observable amenities such as rooms with specialty specific design elements and more convenient locations to the quality of care demonstrated by a higher nurseto-patient ratio. This results in higher overall patient satisfaction.

Such organisations have continuously set a fresh benchmark for healthcare service providers by leveraging associated economies of scale and scope, by concentrating expertise with increased specialisation in augmenting patient choices. The result, lower healthcare costs and further enhanced quality of care. Therefore, it is no surprise that single speciality hospitals are fast becoming the primary choice for many.

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Medtronic’s Strategic Objective Accelerating healthcare technology innovation What has been the effect of the COVID-19 pandemic on your operations and work power, and how did Medtronic respond?

When COVID-19 emerged in early 2020, it immediately impacted our business, industry, and daily lives.

Demand for our products and services began to dry up. Our APAC business, which grew at a consistent rate over the past several years, quickly declined.

Hospitals cancelled all elective surgeries, delayed essential procedures, and banned non-employees – including our sales teams, who were used to spending their time in hospitals, supporting doctors in surgery, ensuring our devices run smoothly, and selling directly to staff.

We were worried about our business, but we made the collective decision to protect our employees above all else. We secured all necessary PPE for our teams, prevented them from traveling, and enlisted our medically licensed employees to assist anyone showing COVID-19 symptoms. We immediately introduced an employee engagement program, ‘We are Stronger Together’ to help our people, and their families, through this time of uncertainty. Focused on three pillars – Mind, Body, and Spirit – the program included trainings to upskill our employees and broaden their understanding of our business; equipment to work from home; weekly food delivery credits to offset the stress of working and cooking; and a Family Reunion Program that offers our expat employees paid flights home and extra days of leave to reunite with their loved ones after it is safe to travel.

Beyond that, we revisited our business strategy to see how we could pivot to better support our customers and patients under the new normal. Our Go Digital strategy, which we launched before the pandemic to drive digital transformation across APAC, became even more relevant. It allows us to use data and analyt-

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ics to develop business intelligence and tools for salesforce effectiveness, to enable virtual training, and to drive customer engagement through digital and social media. We increasingly prioritised these areas and strengthened our digital capabilities even more with the launch of the Medtronic Open Innovation Platform (OIP).

We often see that in times of uncertainty, the reaction is to pull back: play it safe, save money, and do the minimum. Our teams did the opposite. And we showed our partners – and each other – just how far Medtronic is willing to go to support our people and ultimately, our patients. This resulted in a +14-point increase in Employee Engagement and our revenue is back to growth.

Medtronic has been named as one of the world's best working environments for innovators. Would you be able to share a little insight into the market drivers and the necessities that Medtronic is responding to?

At Medtronic, there is the fundamental belief that good ideas can come from anyone, anywhere. We may be the world's largest medical technology company today, but we started humbly: a 25-year-old electrical engineer, his brother-in-law, and a garage-based medical equipment repair shop.

This October, we officially launched the Medtronic Open Innovation Platform (OIP) through an MOU with the Singapore Economic Development Board.

OIP aims to build capabilities and innovations in Artificial Intelligence, Robotics, Machine Learning, Internet of Things, and Digital Health, in addition to the Medtronic Portfolio.

At its heart is MDT Spark, and internal program that we introduced three years ago. Any employee can submit their idea to accelerate revenue growth,

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drive simplification, or improve employee engagement across APAC. We then provide the funding, senior counsel, and resources to implement the most promising ideas. Of the 531 ideas submitted to date, we have invested in 24. And those have delivered millions of dollars in additional revenue or savings for our business.

The other two OIP pillars are the Medtronic APAC Innovation Challenge (MAIC) and the Digital Medtronic Innovation Center (dMIC). Our dMIC, which will open in early 2022, will prove an immersive space for us to explore new technologies with our partners; MAIC, which we just launched will allow us to identify – and invest in – startups offering innovative solutions to attack the most complex and challenging health problems in the region.

Ultimately, this is our goal in everything we do: to innovate, develop new medical technologies, and improve the lives of our patients.

huge milestone – not just for our India team, but for our teams across the region. Technological developments like HugoTM make minimally invasive surgery more accessible to doctors and hospitals; our training centres and curriculum, like our newly inaugurated Surgical Robotics Experience Center (SREC) in Gurugram, India, ensure that medical professionals know how to use them. Together, they will play a critical role in addressing the region’s future healthcare needs.

According to you, what are the most critical emerging technologies in APAC? We are advancing many technologies here in APAC, but one of the most significant is Robotic-Assisted Surgery (RAS). Surgical robotics will be increasingly important to how we deliver for our patients. Patients who undergo minimally invasive – as opposed to open – surgery, can experience fewer complications, shorter hospital stays, faster return to normal activities, and smaller scars.

Recently the first procedure using the HugoTM Robotic-Assisted Surgery (RAS) system in APAC was successfully completed in India. It was a

Chris Lee President Asia Pacific

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But these are just the start. It is not possible for one company to deliver every new technology – but we can bring key players together, to collaborate and open-source innovation. And we created the Medtronic APAC Innovation Challenge (MAIC) to do just that. Through MAIC, we will seek out ideas that can lead to life-changing technologies, better outcomes for growing markets across the region, simplified healthcare, or more personalised healthcare solutions.

COVID-19 has brought challenges for all stakeholders in the healthcare space, from travel restrictions to border closures, supply chain stresses, remote working, and drops in medical tourism and non-essential hospital visits. What have been the key items on your clients’ agenda over the past few months?

From a product perspective, medical professionals across the region (and worldwide) have asked for our ventilators. To meet this demand, we made several unprecedented decisions for our business: we openly shared the design files for our Puritan BennettTM 560 ventilator system so manufacturers – in our industry and beyond – could increase production of our lifesaving ventilators; we partnered with SpaceX and others to temporarily produce a critical valve for our most complex ventilators; and we reached out to collaborators and competitors alike to form the global Ventilator Training Alliance.

More broadly, we have heavily invested in digital solutions to meet medical professionals’ needs.

For example, Augmented Reality Vuzix Smart Glasses are one of the tools we are now using to make virtual trainings for HCPs more engaging. The Smart Glasses capture the trainer’s viewpoint and augments it with virtual elements so that trainees viewing remotely can get a more immersive experience despite the distance.

Our Digital Medtronic Innovation Center, opening in Singapore in early 2022, will advance our focus in this area by accelerating our efforts in digital technologies, Artificial Intelligence, and robotics. The ultimate goal is to benefit our customers and patients using technologies to overcome access barriers.

Is Medtronic’s APAC on the lookout for M&A opportunities or other forms of collaborations with start-ups in the region?

Yes. We just launched the Medtronic APAC Innovation Challenge, or MAIC, which gives startups the chance to shape the future of digital healthcare in

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APAC. Our goal with this initiative is to partner with startups in the region, provide them access to our network, partners, and existing MedTech solutions to ultimately lead to new life-changing technologies and accessible healthcare solutions.

While the MAIC is new, our commitment to advancing the startup ecosystem is not. We held our first Innovation Forum in Korea in 2018, to achieve similar goals. At that time, we received more than 70 applications, of which, two went on to develop commercial pilots with Medtronic. We are excited to build on this momentum across the rest of APAC, as I know it will lead to promising change for the region.

Medtronic has a robust product pipeline in the fields of heart and vascular field, restorative therapies and diabetes. How critical are these products for driving your development in APAC? There are several trends driving the APAC healthcare market: our ageing population, rising healthcare costs, increasing adoption of digital technology, and shifting consumer expectations. The last one is particularly important; consumers are more informed about their conditions than ever, more engaged than ever, and they expect better healthcare experiences.

You mentioned diabetes, and I think that is a great example of how we are developing products to address these needs. Later this year we are bringing

Chris Lee is also a member of the Medtronic Executive Committee.

He leads the APAC team, which includes more than 10,000 employees across 20 countries, in Medtronic’s Mission to alleviate pain, restore health, and extend life for millions of patients. Before Medtronic, Chris was Regional Head and Senior Vice President, Asia Pacific at Bayer HealthCare.

He has a strong record of global leadership in the healthcare sector. He has worked in executive positions across pharmaceuticals and medical technology, instilling his inclusive leadership style, commitment to meritocracy, and proven business results.

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our most advanced insulin pump system to several APAC markets. It mimics some functions of a healthy pancreas for balanced levels through auto correction dosing; allows people living with diabetes to instantly know their real-time sugar levels; and notifies them, their care partner, and doctor, if their levels are too high or low.

We are also bringing Micra™ AV to many countries in our region. It is the world’s smallest pacemaker – 93 per cent smaller than conventional pacemakers and with 63 per cent fewer complications. That means patients have no visible or physical reminder that they have a pacemaker, and don’t have the usual pocket-related and/or lead-related complications.

These kinds of technologies, in which we make it easier for people to address their health concerns, are what will continue to drive our development in APAC. What technologies have you adopted for planning and forecasting for future pandemic conditions?

As the world’s biggest medical technology company, we are constantly evaluating and adopting new technologies to improve all aspects of our work – and all aspects of our patients’ lives.

But I personally believe that technology is only as good as the people behind it, which is why we are partnering with INSEAD to host the FY22 APAC INSEAD + Medtronic Leadership Camp. It is a customised 8-month training program that will upskill 30 of our top employees in the region to succeed in the future.

COVID-19 showed us that our future APAC leaders will need to be equipped to address the evolving APAC healthcare landscape, readily adopt and integrate new technologies and solutions, and manage through quick and dramatic change. Our hope is that this program will help give them the tools and critical thinking to do just that.

What do you see as the biggest challenges and opportunities facing the company and the life sciences sector going forward?

For Medtronic, I think our biggest challenges are also our biggest opportunities. The first is talent.

We want the best people in APAC working with us to improve the lives of patients here in our region.

The second is healthcare access. It is varied across our region, especially when you compare developing and developed markets.

We are investing heavily to address both. As an employee, I can confidently say that Medtronic APAC is a great place to work. Our people know that they – and their wellbeing – are our priority, but we want top talent outside our company to know that too. So we have been very focused on boosting our employer branding over the past year, winning awards and being named one of the top 30 Best Workplaces in Asia™ and #1 in the healthcare industry. This has translated into better talent coming into our organisation, and I expect that to continue.

Second, as we saw in the pandemic, healthcare access is unequal across the region and we have taken several major steps to address this. We recently restructured our organisation to increase the autonomy of our local teams in addressing – and quickly responding to – the unique needs of their markets. We invested in new technologies to bring robots into more surgical suites around the region.

And we are continuously innovating new technologies, rethinking traditional business models, and improving healthcare delivery to reduce barriers to affordable care.

What are the strategic objectives you envision Medtronic to achieve, over the next couple of years?

Coming out of the pandemic, we have an ambitious new goal: for Medtronic to be the undisputed leader in healthcare technology. This will allow us to attract the best talent, develop industry-leading products, and better serve more patients.

We have several strategic objectives to achieve this: (1) accelerate innovation-driven growth: our product pipeline is the strongest it’s ever been, and we are focused on making it more sustainable – particularly through less invasive therapies; (2) bring our technologies to emerging markets; (3) create better experiences for our patients, customers, and employees; and (4) turn data, Artificial Intelligence, and automation into action.

On a more personal note, you have been with Medtronic since 2012, working in different various roles. What do you most like with regards to working for Medtronic?

At Medtronic we have industry-leading products and breakthrough technologies – but with purpose and meaning behind them. This combination of innovative tech and our Mission, to alleviate pain, restore health, and extend life for our patients, is what makes me excited to come to work each day.

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KEEP CALM AND TELECONNECT The pandemic mantra for keeping healthy!

Pandemics over centuries, such as the Bubonic plague (1346), Cholera (1817), the Spanish flu (1918), and now COVID-19 have been collectively responsible for millions of fatalities across the globe. Yet, unlike its historical counterparts, healthcare management of the COVID-19 pandemic can draw on new technologies for prevention, symptoms triage, self-isolation, quarantine and, medical management. Due to the new MCI telemedicine practice guidelines of March 2020, and immense acceptance across gender and age, healing at a distance (telemedicine) has successfully leapfrogged Indian healthcare. Triage, direct patient care are situations where it has been most used in India, which is but the tip of the iceberg. The scope is massive with homebased monitoring and quarantine, tele-ICUs, and community paramedicine or mobile integrated health care programs, which will allow patients to be treated in their homes, with higher-level medical support being provided virtually.

The institutional best practices of Indian hospitals must be shared and policy-makers must take advantage of the telemedicine experiences reported during this outbreak to further define the practices of e-healthcare under laws of privacy and data protection Naresh Trehan, Chairman and Managing Director, Medanta the Medicity (Global Health Private Limited)

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he Covid pandemic has on one hand, increased patient hesitancy towards physically visiting a health care facility, and on the other increased the need for healthcare support. The field of telemedicine, in which clinicians use remote evaluation and monitoring to diagnose and treat patients, has leapfrogged in the last two years. The World Health Organization (WHO) defines Telemedicine as, “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and

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communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.” The role of telemedicine in disaster management and pandemic control was understood by the health care systems and anticipating the increased need of telemedicine by health-care providers, the Medical Council of India released practice guidelines

in March 2020.These guidelines changed the face of Indian health care and the pandemic handling. They defined the diverse roles of telemedicine in acute care medicine settings, including virtual intensive care unit (ICU) care, after-¬hours medical admissions, and, most aptly, disaster management.

At Medanta hospitals, enabling delivery of remote, safe healthcare, the use of telemedicine rapidly

scaled up during COVID. Telemedicine made quality healthcare more accessible and transparent, and ensured inclusivity and equality of access. Increased use of electronic diagnostic devices like electronic stethoscope, BP, and SPO2 monitors enabled doctors to engage in virtual consultation and remote monitoring of patient health. Telemedicine facilitated staffing of facilities that found themselves overwhelmed with pandemic-related patient overload. This helped in easing the pressure the increased covid admissions put on an already stretched healthcare system.

Telemedicine changed the way chronic care is delivered at a time when people are hesitant of stepping out of their homes to seek medical care. Telemedicine can be used for ongoing management of chronic diseases such as bronchial asthma, hypertension, and diabetes mellitus, patients who need regular dose adjustments, no more need to travel to the hospital physically to consult their doctor. They can easily do so from the safe confines of their home through a simple mobile device. This has helped maintain the continuity of care amidst the pandemic.

As patients and doctors get increasingly comfortable with virtual consultations, this may well become a norm in the near future. www.asianhhm.com

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support. Patients were comfortable with the punctuality of doctors and the time spent in the consult along with the explanation of treatment process. The comfort and privacy of this consultation was most appreciated by the patients. The initial experience of doctors included some concerns around inappropriate dressing by patients and attendants but this changed over time, when instructions were shared with patients. The overall patient rapport and communication was appreciated by the doctors.

It was interesting to note that the gender and age distribution was well represented, this surely emphasizes the fact that it was easy to use and therefore the acceptance of this technology was high in the population independent of age or gender. The use of the technologies did not vary over tier 1, 2 or 3 cities, with access of the internet reaching the hinterland, patients all over the country were comfortable using telehealth technologies.

In addition, healthcare systems leveraging telemedicine for patient care will gain several advantages, including workforce sustainability, reduction of provider burnout, limitation of provider exposure, and reduction of personal protective equipment (PPE) waste. We utilised commercial telemedicine carts on-site at hospitals and laptops at home. Doctor workstations were enabled by adding web cameras to the existing workstations and purchasing additional laptops for new telemedicine providers. This made telemedicine a comfortable choice for both the user and the provider.

A feedback survey regarding the use of teleconsultations at Medanta revealed that both doctors and patients were satisfied with the experience. The Information Technology team was able to ensure ease of appointments and good quality of audio and visual

The greatest hope for use of telemedicine technology is that it can bring the expertise to remote medical practice and provide an opportunity for standardization and equity in provision of healthcare.

Uses of telemedicine

Diagnosis and treatment: Telemedicine increases efficiency and the quality of care, reduces unnecessary patient transport, decreases exposure in the time of the pandemic and increases physicians’ and patients’ satisfaction Monitoring: Telemedicine can be used for ongoing management of chronic diseases such as respiratory, cardiac, liver and kidney diseases; particularly during a time when social distancing is encouraged. It can play an important role in also providing psychological support to patients and their family members without getting exposed to the infection. Telemedicine also expanded support by helping train care providers of the elderly, young children and other dependents

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Community paramedicine: Community paramedicine is a new and evolving healthcare model. It allows paramedics and emergency medical technicians (EMTs) to operate in expanded roles by assisting with public health and primary healthcare and preventive services to underserved populations in the community. This is being tested along with telemedicine models in providing remote vaccination, and continued care for Tuberculosis and other chronic diseases in the remote community. Telemedicine has also helped in shouldering the challenge of health care during massive public gatherings, for example during Maha Kumbhamelas through Mobile Telemedicine system vans equipped with videoconferencing systems for visual communication enabling doctors in remote places connect to any of the telemedicine-enabled medical hospital and super speciality hospital for expert opinions.

Graph A: Trend of the number of Covid positive people – India

Source: https://www.worldometers.info/coronavirus/country/india/ (accessed on 20-07-2021)

Graph B: Trend in Teleconsultations at Medanta Gurugram Trends of increased teleconsultation use overlapped with the covid wave patterns over the two major waves seen in India. This brings to focus that despite comfort with telemedicine, patients may revert to in-person visits when the pandemic subsides. A change in practice towards use of telemedicine even during a nonpandemic condition will need Information-Education – Communication (IEC) modules that will help hospitals in connecting with new patients and providing continued care to the old one.

Although telemedicine holds promise for pandemic response, this technology has limitations. It requires robust IT infrastructure, training of both nurses and physicians, and modifications to integrate within hospital workflows. Major barriers encountered included cost, and equipment functionality. However, close coordination with executive leadership, and robust IT

support, we were able to move past these obstacles in expanding our telemedicine infrastructure for support during this crucial time.

The institutional best practices of Indian hospitals must be shared and policy-makers must take advantage of the telemedicine experiences reported during this outbreak to further define the practices of e-healthcare under laws of privacy and data protection.

The greatest hope for use of telemedicine technology is that it can bring the expertise to remote medical practice and provide an opportunity for standardisation and equity in provision of healthcare, both within individual countries and across regions and continents. Combined with geotracking it can play a pivotal role in anticipating epidemics and real-time monitoring of diseases. With preventive and promotive health becoming even more critical in these times telemedicine can be an important tool for health communication and disease prevention, relaying relevant information, enabling informed decision-making, improving health care communication process, create support systems and promote self-care and domiciliary care practices.

AUTHOR BIO Naresh Trehan is a worldrenowned cardiovascular and cardiothoracic surgeon and has been awarded the highly prestigious Padma Bhushan and the Padma Shri by the Government of India for his service to the nation. Trehan has over 90,000 successful openheart surgeries to his credit and is the driving force behind the one-of-its-kind hospital.

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BENEFITS OF NATURAL IMMUNITY FROM COVID MUST BE CREDITED Discussions concerning mandatory vaccination cards are ignoring the millions who have had the COVID virus. Over 98 per cent of those survived and have natural immunity. Now monoclonal antibodies are being reproduced in the lab for infusions. At the end of the day, our immune system is the best defense.

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

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n all the discussions regarding vaccination—to have one or two or none--there’s a critical component missing: our innate human capacity to heal ourselves, our natural immunity.

Never has the healthcare systems in the US, UK, and Canada, at a minimum, so failed to instruct the populace on how to take care of themselves by, basically, strengthening their immune system.

The only messages on how to ‘stay safe’ have been ‘wash your hands’ and ‘keep 6’ apart’. The dialogue that immediately rose from the health agencies, government, and the mass media became a single message— vaccination was the only solution.

And this message has become the only one permitted. Individuals who have promoted and educated readers/ website visitors/patients for decades in natural solutions for health challenges have been vilified. Censorship of leaders

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and of ordinary, interested individuals, has become a serious attack on democratic freedoms of speech and the press. And, ultimately, health freedom, the right to choose what we will do to care for our body/our life, is threatened.

This mono-message of vaccines as the only solution adds to the social divisions that Americans are already suffering. Deciding to strengthen one’s immune system and not inject vaccines that haven’t been tested according to FDA standards isn’t a political decision.

It’s a health choice. And it’s a choice every human being should have.

It’s quite understandable that the American Medical Association (AMA) wouldn’t endorse a programme of healthy living as a solution. Self-care programmes of detoxification, eating mainly live foods (unprocessed—no Boxes, Bags, or Cans), exercises for de-stressing and strengthening, and

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herbs to bolster the immune system aren’t part of their education or regime.

America’s physicians have one course in nutrition in medical school.

Their schools and programmes are built and supported by the pharmaceutical industry and use of pharmaceuticals is the modus operandi.

When I researched the content of WomensMedicineBowl.com in 2002, about 95 per cent of continuing education of US physicians was sponsored by the pharmaceutical industry. They’re not teaching herbal treatments and sitz baths.

So with the onset of a pandemic, the only solution obvious to the dominant medical paradigm was vaccines. But with the virus continuing to mutate, how many vaccine boosters will be endured? With what consequences?

Why is open communication of people’s experiences with the vaccines

MEDICAL SCIENCES

not being permitted? Why are the numbers of death and adverse events from the vaccines not openly discussed but, instead, censored?

Physicians in America and abroad who have developed protocols that are documented to have saved hundreds of thousands of Covid patients, are muted.

A UK physician was questioned on why she hadn’t recommended immune strengthening to the woman’s mother, who had died from Covid. The doctor replied that her license to practice would be suspended if she didn’t push the vaccines.

In the US the AMA issued a document to its members on how to talk to the media in doublespeak and ‘hospitalisations’ became ‘deaths’.

Millions of us have had some version of the corona virus, and over 98 per cent have survived. As a result of having had the disease we developed antibodies

Of the five proteins in a virus, the mRNA vaccines protect from only one, the spiked protein. Several studies have found that the vaccine disarms the T cells that are the sentries of the immune system and would protect the body from viruses and cancer cells.

to the virus and now have natural immunity—nature’s inoculation, of sorts.

A week before the lockdown in March 2020, my daughter and I both contracted the virus. We had been measuring EMF levels in the streets of Washington, DC, and stopped in a crowded restaurant for lunch.

Some 48 hours later, I began to have unusual fatigue. Another two days passed, I was awakened with severe body aches, my usual symptom of influenza.

I had been travelling internationally for several weeks, and, having lung challenges, I had been taking an herbal formula for bronchial support regularly during those weeks. That night I took a French homeopathy remedy for influenza, which is always in my suitcase.

In early March 2020, there were no testing sites. Usually, all flu symptoms disappear in 24-36 hours with the homeopathic treatment. When the fatigue lingered for another five days, we figured it was Covid. My daughter’s symptoms began two days after mine.

With the lung herbals, homeopathic for flu, and 2grams of vitamin C plus quercetin twice/daily, we were both recovered in a week.

So how does natural inoculation occur? Did it? In November, she was tested, and the Covid antibodies were present in her blood. I didn’t have the specific test for Covid antibodies,

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1 (www.sharylattkisson.com/2021/08/covid-19-naturalimmunity-compared-to-vaccine-induced-immunity-thedefinitive-summary/)

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Health England report showed that as a hospital patient, you are six times more likely to die of the COVID Delta variant if you are fully vaccinated, than if you are not vaccinated at all. (Public Health Briefing 15, June 3, 2021) October 4, 2021, Project Veritas released a video in which Pfizer scientist Nick Karl states, “When somebody is naturally immune … they probably have more antibodies against the virus,” correctly explaining that, “When you actually get the virus, you’re going to start producing antibodies against multiple pieces of the virus … So, your antibodies are probably better at that point than the [COVID] vaccination.”

(October 4, 2021) Cure-Hub data has found natural immunity confers much wider protection as your body recognises all five proteins of the virus and not just one. With the COVID shot, your body only recognises one of these proteins, the spike protein. (June 11, 2021) The reason natural immunity is stronger than vaccine-induced immunity is because viruses contain five different proteins. The Covid shot induces antibodies against just one of those proteins, the spike protein, and no T cell immunity (in fact, T cells been decommissioned from protecting).

When you’re infected with whole virus, antibodies develop against all parts of the virus, plus memory T cells.

A study that Harvard Medical School professor Martin Kulldorff wrote about on Twitter on August 25th, found that fully jabbed folks had a 13-fold increased risk of infection with Delta variant compared to unvaccinated people who were previously infected with COVID-19.

AUTHOR BIO

but I had a biofeedback programme done in December that found traces of the virus.

For how long does the body retain the antibodies? It surely varies with each unique individual, but that biofeedback programme found traces of a serious virus I had contracted at age 15, more than 50 years ago. So I have a natural (earned) immunity with viruses. And surely everyone does.

While talk of vaccine passports has forgotten the natural immunity of covid survivors, nearly everyone somehow sees the value of antibodies. Monoclonal Covid antibodies (from natural sources) are now being reproduced in labs, and those who refused the untested vaccines are lining up in the US to pay US$2,000 for infusions of nature’s antibodies. There is serious irony here.

In fact, pharmaceutical companies are finding it increasingly difficult to discount natural immunity.

There are dozens of studies showing natural immunity from a previous infection is robust and long-lasting, something that cannot be said for the COVID shots. Natural immunity is typically lifelong, and studies have shown natural immunity against SARSCoV-2 is, at bare minimum, longer lasting than vaccine-induced immunity.

One Israeli study of 2.5 million people that found the vaccinated group was actually seven times more likely to get infected with COVID than those with natural immunity from a previous infection.(IsraeliNationalNews.com 7/13/21) Another Israeli study that included 700,000 people, posted August 25, 2021, on the preprint server medRxiv, found those with prior SARS-CoV-2 infections were 27 times less likely to develop symptomatic infection for a second time, compared to those who were vaccinated1. A June 2021, Public

A major implication, says Kulldorff, is that only allowing jabbed people to participate in society is “scientific nonsense… discriminatory and unethical.” After all: if injected people can get and are getting infected – and may even be more likely to get infected than people who recovered from a prior SARS-CoV-2 infection – then why are officials and employers only requiring unvaxed people to get routinely tested or stay out of public spaces?

Political Agenda

Failing to acknowledge the reality and strength of natural immunity appears to be entirely a geopolitical decision. There’s no medically valid reason to promote vaccines as the only solution. The fallout on the credibility of the medical profession in the US with this monomessage of vaccines was discussed in The Washington Post on Sept. 15, 2021.

Nations beyond the West are employing indigenous anti-viral herbal treatments and supplements.

In Thailand, health officials used bullhorns on autos driving through neighborhoods to tell residents of a local herbal treatment. In Bali, Andrographis Paniculata is prescribed for both prevention and treatment. China has used intravenous Vitamin C treatment, and herbal treatments are the norm.

Now with the censorship of online discussion of COVID policies and consequences, there’s a small likelihood that this information will be published or broadcast in the US. Next week I’ll see whether I’m allowed to enter the grocery shop without a Vax card.

Beverly A Jensen works globally to promote individuals’ education and participation in their health. She is an international speaker, corporate wellness consultant, health coach, and author of 21st Century Wellness Rx (2020). Her website to promote natural health. www.WomensMedicineBowl.com, opened in 2003.

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Renewed Vision Driven by Intelligent Solutions Canon MRI is evolving

With our vision to advance healthcare by delivering unlimited MRI everywhere, Canon is developing intelligent solutions to simplify and expand MRI capability Akira Adachi, General Manager, MRI Systems Division, CT-MR Division, Canon Medical Systems Corporation

Two years ago, rather surprisingly to us, the most common question that our employees received when promoting Canon’s technology globally to customers was: “Does Canon make MRI?”. Following the sale of Toshiba’s medical division to Canon in 2016, the company name was changed to ‘Canon Medical Systems’ in 2018. The challenge ahead for us then was in addressing the issue that the name ‘Canon MRI’ did not immediately spring to mind for many people in the MRI community. Now in our fourth year as Canon Medical, we feel that the people who knew Toshiba as an important contributor to MR imaging, now realise that Canon has ‘taken the ball’ and is running quickly into the future with it.

Making our mark in the MRI community with AI Firstly, we would like to express our deepest appreciation to healthcare professionals and all those who continue to work on the frontline during the ongoing COVID-19 pandemic. The COVID-19 situation has altered the focus of MR requirements to contributing efficiently to hospital income while providing a safe and sterile system with integrated and streamlined workflow. In relation to these changes to the healthcare landscape, we are convinced that AI’s impact in improving image quality and workflow can contribute to meeting these requirements Over the past 3 37

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years, Canon has established an industry-leading position in Artificial Intelligence (AI), and not only boast the world's first deep learning technology for MRI, but also utilisation of AI across our entire medical imaging portfolio. And we know that the benefits of AI in diagnostic imaging are only just beginning to manifest. We are now utilising the knowledge we have gained from our clinical partners to continually improve existing applications and develop new ones that can help our customers image more intelligently and efficiently.

Intelligent MRI The world of magnetic resonance imaging (MRI) is one of the most challenging in terms of technicality and determining appropriate investment in the right technologies. Over many years of our participation in the medical imaging field, Canon Medical Systems has steadily increased its focus on both, with a recognition that MRI is a modality with tremendous potential to impact medical diagnosis. Recently, we have sharpened our view on to what we call the three C’s; representing ‘confidence’ in our systems and the clinical results that they produce, ‘comfort’ that helps us focus on patients and the feeling we want them to have when being scanned by a Canon MRI system, and ‘cost-effectiveness’, meaning the

economic value that our systems bring to facilities from installation through to operation.

So how are we achieving this? The simple answer is, with what we call ‘intelligent MRI’, which not only encompasses the exciting new frontiers of AI, but also our relentless pursuit of smarter ways to optimise every aspect of the MRI experience. We believe that intelligent MRI can deliver three concrete outputs for the MRI suite. The first of these is productivity, because we recognise that healthcare needs to deliver bottom-line performance – increasingly so in meeting the current challenges imposed on healthcare teams by the COVID-19 pandemic. Without economic benefits for healthcare facilities, we do not have the chance to deliver a second output: safe, comfortable and reliable imaging for the patients.

Patients deserve the most secure environment possible, as well as confidence that the results delivered are accurate, clear and definitive, and help them

So how are we achieving our renewed vision for MRI? The simple answer is with what we call ‘intelligent MRI’, which not only encompasses the exciting new frontiers of AI, but also our relentless pursuit of smarter ways to optimise every aspect of the MRI experience.

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understand their condition and possible treatment options. And finally, our third output is enhanced assurance for the operator in meeting increasing challenges of budget and time-pressures that are imposed upon them by administrative changes. It is Canon’s strong belief that Intelligent MR solutions can deliver on all of these promises without compromise.

Changing the game with Advanced intelligent Clear-IQ Engine (AiCE) In 2019, Canon introduced Advanced intelligent Clear-IQ Engine (AiCE) to the market on the Vantage Orian, making it the world’s first Deep Learning Reconstruction (DLR) MRI system approved by regulatory bodies globally. Shortly after the release on Vantage Orian, AiCE became commercially available on Canon's Vantage Galan 3T, Vantage Centurian and Vantage Elan.

AiCE utilises a deep learning reconstruction technique to remove noise from images and restore SNR. The power of deep learning has now been translated into clinical practice to provide exceptional image quality across a wide variety of clinical applications, including in combination with our range of rapid scan acceleration technologies.

New tools for enhanced productivity With the enormous upheaval that has affected upon society and healthcare over the past 2 years, there is a renewed need for quick, sterile and safe MRI procedures. In response to these requirements, Canon will deliver new solutions that feature AI and focus on optimising the entire MRI procedural chain. These productivity and workflow solutions will be launched at the RSNA congress at the end of November 2021 and will be become available in each region once regulatory approval is gained.

AUTHOR BIO

The vision we hold within Canon MRI to improve the life of patients in partnership with our clinical partners has never been clearer. MRI plays a critical role in diagnostic decision-making yet is still unavailable in many parts of the world, due to the size and cost, let alone the clinical and technical education required

to operate an MRI machine. And yet, we know that the capability to image without radiation is vital to both patients and radiologists, and we have a burning passion to widely expand MRI to support Canon’s ‘Made for Life’ philosophy.

At this time of enormous social change brought about by the events of the past 12-18 months, we firmly believe that the contribution that Canon MRI is making, and will continue to make, is more important than ever to the vital work that our clinical partners perform every day.

We are very proud to introduce some key developments that we have been working on and welcome you to take another look at Canon MRI. We hope you will be surprised by what you find and realise the value that Canon MRI can offer. We look forward to continuing on a journey with you, as we deepen our footprint in this important imaging modality, driven by what we refer to as ‘Intelligent MR’ performance.

Akira Adachi is currently General Manager of the MRI Division of Canon Medical Systems, a global healthcare company based in Japan. He successfully lead the project for the 1.5T Vantage Elan which is now sold globally. Under his leadership, the company was the first to release AI-equipped MRI in 2019, and will continue to develop new solutions for the medical industry to support global healthcare, with a particular focus on AI.

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MEDICAL SCIENCES

The adult congenital heart disease population continues to grow thanks to the success of their management in the paediatric age. This manuscript will briefly review the special characteristic of this patient population when they progress into end stage disease and require treatment in the form of heart transplantation.

Juan M Ortega-Legaspi, Cardiologist, Penn Medicine

Cardiac Transplantation in the Adult Congenital Heart Disease Population H

eart transplantation has become an effective therapy for patients with end stage heart failure. The success rate has now been translated to a median survival of close to eleven years. Considering patients with end stage heart failure have a mortality that is close to 100 per cent at one year, this is a fabulous achievement from science and medicine. It must also be noted that heart transplantation has had reasonable stable volumes for many years with less procedures than needed. It has only had a steady slight increase from 1993 to 2004 reaching an all-time high in 2015 with just over five thousand operations done worldwide. Not only does the heart failure population continue to grow overall, making heart transplant an even more precious resource, but there is also a patient population that has increased at an even higher proportion. This population is that of the patients with adult congenital

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heart disease who currently only represent approximately 3 per cent of the heart transplant operations done.

Nevertheless, while that 3 per cent seems small, it represents a 40 per cent increase compared to the previous decade. This population is therefore likely to need wider representation in the near future.

Congenital heart disease is the most common cause of birth defects.

The fact that this patient population is increasing is testament to the success of the surgical and medical management of the paediatric population. In the not too distant past, the more complex patients within this group of disorders used to end their lives in childhood. Thanks to breakthrough science, technology and medical improvements, the expected survival of these patients has improved dramatically. This has led to formal adult congenital heart disease programs that now care for these patients as they grow older.

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As these patients grow older, they continue to require intense care. While it is true that the simpler and more common lesions such as an atrial septal defect rarely progress to end stage heart failure, the more complex cases such as those with tetralogy of Fallot, systemic right ventricle or the myriad of conditions that end up in single ventricle physiology do tend to continue to decline. Very notably, the main causes of death of the complex congenital heart disease population are by far due to cardiac reasons. Furthermore, within those potential cardiac causes of death which can include sudden cardiac death, ischemic heart disease or peri-procedural complications, the main cause is not the aforementioned but, indeed, end stage heart failure. If one keeps in mind that continued decline and refractory class IV symptoms are an indication for advanced therapies, such as cardiac transplantation, one can only expect that the number

MEDICAL SCIENCES

of patients with adult congenital heart disease that need a transplant will continue to increase. It must also be pointed out that this patient population is often ineligible to receive other forms of advanced therapies such as durable ventricular assist devices also known as mechanical circulatory support due to their specific anatomy and physiology.

The latter comment means that, often heart transplantation is the only option despite the fact that some progress has been made with mechanical support and experience is being accumulated but so far the published data shows that there have been less than 200 durable mechanical devices in patients with congenital heart disease.

One of the most important reasons that the population in question merits its own chapter within the advanced heart failure subspecialty is that these patients carry more and very specific challenges.

Some of these challenges are due to the

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MEDICAL SCIENCES

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The adult congenital heart disease transplant comes with higher complexity and up front risk but with better long term outcomes.

disease; but there is also an even higher incidence of arrhythmias, pulmonary hypertension, coagulopathy, congestion and allosensitisation. In addition, these patients have a tendency to develop collateral blood flow that is understood as a mechanism to compensate for the lack of a ‘right sided pump’. The problem with these collateral vessels is that they can represent a higher, and sometimes prohibitively risk of bleeding for thoracic surgery. Another point that is important to underline is that the chronic congestion can lead to liver failure requiring also a liver transplant in order to survive. Evidently, this further increases complexity. It has nevertheless been demonstrated that with adequate patient selection and management by a multidisciplinary team in a high volume centre, it is possible to have a successful dual heart and liver transplant

AUTHOR BIO

fact that these patients have a higher incidence of entities such as chronic cyanosis (low oxygen levels in blood), multiple previous operations which means the tissue is harder to access and there is higher risk of bleeding; higher likelihood of kidney or liver impairment, higher incidence of pulmonary hypertension and the possibility of being sensitised immunologically. All these factors, alone or in combination mean that this kind of transplants are, in essence, higher risk transplants.

Consequently, the mortality at thirty days and one year is significantly higher.

Very notably, possibly due to the fact that this patient population tends to be younger than the overall cohort of adult heart transplants and that many of the challenges can slowly be overcome in the long-term after transplant, the mortality trend tends to be very similar at five years and, in fact, a higher proportion of patients with a history of congenital heart disease are alive compared to the rest of heart transplants. In other words, there is a higher up front risk but the long-term outcomes are better.

One subset of patients that warrants special attention is that of some of the most complex ones. These are the patients with single ventricle physiology or also commonly known as those who have had a Fontan procedure. What this means is that there is passive flow from the venous return into the pulmonary circulation without a ‘pump’ or right/ subpulmonic ventricle. Blood passively flows through the pulmonary bed and returns to the single ventricle in order to be actively circulated systemically. While this is a life saving procedure, without which these patients would almost certainly die early in childhood, it has a large number of potential long-term complications, some of which add to the challenges seen at the time of requiring a heart transplant as the only choice to prolong life. Not only are there exclusive entities associated to the Fontan procedure which are protein losing enteropathy and Fontan-associated liver

programme for the failing Fontan patient.

It is not all bad news and challenging scenarios for the adult congenital heart disease population. In addition to the better long-term outcomes detailed above, some of the most complex patients that require a liver transplant can count with an immunologic advantage from the donated liver. In other words, in those patients whose immune system is sensitised against potential foreign tissue, the liver provides protection. These patients have lower incidence of rejection and when done carefully, can even afford some degree of incompatibility between the recipient and the donor. This effect is so prominent that the use of liver tissue has even been suggested as a strategy to successfully transplant sensitised patients.

In conclusion, heart transplantation is a formidable therapy for the adequate patient with all different sorts of end stage heart disease. One of this sort of diseases is that of the adult with congenital heart disease which is a patient population that continues to grow thanks to the paediatric successes. This is a special group of patients due to particular challenges that make their transplants higher risk. This risk is translated as higher short term mortality but overall better long-term outcomes. Further scientific and medical advancement is needed to further serve this growing population.

References are available at www.asianhhm.com

Juan M Ortega-Legaspi completed his MD and PhD at the National Autonomous University of Mexico. He then continued training in internal medicine at Emory University followed by cardiovascular diseases fellowship and postdoctoral stay at the University of Washington. He finalized his training in advanced heart failure and cardiac transplantation at the University of Pennsylvania where he is now part of the faculty.

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TECHNOLOGY, EQUIPMENT & DEVICES

EMERGING TECHNOLOGIES AND TECHNIQUES Unveiling new possibilities in the treatment of atrial fibrillation

Emerging technologies and techniques are unveiling new possibilities in the treatment of atrial fibrillation (AF), such as improvements to procedural times and outcomes through the use of Visitag Surpoint® (previously known as Ablation Index) guided high-power ablation, as shown in a recent study led by Choi EueKeun. Against a backdrop of heart-related complications emerging among patients infected with COVID-19, there is now a greater urgency for healthcare professionals to advance the efficacy of AF treatment.

Choi Eue Keun, Professor, Internal Medicine (Division of Cardiology) Seoul National University’s College of Medicine

How is the growing incidence of atrial fibrillation impacting population health across Asia-Pacific?

Atrial fibrillation (AF) is a growing epidemic that affects over 16 million people in the Asia Pacific alone1. This number is 1 Global Burden of Disease Collaborative Network (2017) Global Burden of Disease Study 2017 (GBD 2017) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2017. Accessed 2019-07-16. Available from http://ghdx.healthdata.org/ gbd-results-tool

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TECHNOLOGY, EQUIPMENT & DEVICES

only expected to increase, reaching as high as 72 million by 20502,3, due to ageing populations and increased incidence of lifestyle-related risk factors, such as obesity, physical inactivity, and hypertension.

AF has detrimental consequences and can negatively impact one’s quality of life as well as increase the likelihood of other debilitating conditions such as stroke, heart failure, and cardiovascular mortality. It also places a substantial burden on healthcare systems. Direct costs have increased exponentially over the past two decades. With Asia-Pacific expected to see more than twice as many AF patients than Europe and North America combined, the burden of the disease is expected to be far greater than in any other region4.

Now more than ever, there’s a need for all healthcare professionals to explore how we can optimise the treatment of AF to improve patient outcomes and ultimately reduce the financial burden.

What challenges do physicians face in treating atrial fibrillation?

AF is often associated with morbidity and mortality, and timely diagnosis and treatment challenges largely drive this. If left untreated, patients face an increased risk of disease progression and further complications. For 20 per cent of patients, the condition typically progresses from intermittent to persistent AF within a year of diagnosis5,6, and potentially leads to 2 Wong CX, Brown A, Tse HF, et al. Epidemiology of Atrial Fibrillation: The Australian and Asia-Pacific Perspective. Heart Lung Circ. 2017;26(9):870-879.

3 Chiang CE, Wang KL, Lip GY. Stroke prevention in atrial fibrillation: an Asian perspective. Thromb Haemost.

2014;111(5):789-797.

4 Chiang CE, Okumura K, Zhang S, et al. 2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation. J Arrhythm.

2017;33(4):345-367.

5 Nieuwlaat R, Prins MH, Le Heuzey JY, Vardas PE, Aliot E et al. (2008) Prognosis, disease progression, and treatment of atrial fibrillation patients during 1 year: follow-up of the Euro Heart Survey on atrial fibrillation.

Eur Heart J 29 (9): 1181-1189 6 Schnabel R, Pecen L, Engler D, Lucerna M, Sellal JM et al. (2018) Atrial fibrillation patterns are associated

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the structural remodelling of the heart, therefore making it harder to treat.

Early intervention of AF is crucial in preventing the worsening of symptoms, reducing the likelihood of arrhythmia recurrence, and improving quality of life in the long run. However, some patients present no symptoms, leading to difficulties in diagnosis and increased prevalence of untreated risks for morbidity and mortality. Furthermore, despite close to half of the patients in Asia-Pacific struggling to manage their condition through anti-arrhythmic drugs (ADD)7, awareness towards related procedures remains low. This in turn hampers timely intervention. with arrhythmia progression and clinical outcomes. Heart.

Oct;104(19):1608-1614 7 Wang KL, Wu CH, Huang CC, Wu TC, Naditch-Brule L et al. (2014) Complexity of atrial fibrillation patients and management in Chinese ethnicity in routine daily practice: Insights from the RealiseAF Taiwanese cohort. J Cardiol 64(3):211-217.

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In addition, many primary physicians have regarded AF as a non-treatable disease, thus choosing to not pursue rhythm management. This approach eventually leads to permanent AF. Education on this condition is therefore needed for primary physicians to perform appropriate therapy in patients with newly diagnosed AF. Has the onset of COVID-19 impacted patients with atrial fibrillation or treatment in any way?

A growing number of studies reveal direct correlations between COVID19 and cardiovascular complications, including arrhythmias, heart failure, and blood clots, all of which are accompanied by an increased risk of adverse outcomes8. Similarly, patients 8 Samidurai, A., & Das, A. (2020). Cardiovascular Complications Associated with COVID-19 and Potential Therapeutic Strategies. International journal of molecular sciences, 21(18), 6790. https://doi.org/10.3390/

TECHNOLOGY, EQUIPMENT & DEVICES

who suffer from existing cardiovascular conditions are at greater risk of morbidity and mortality when infected

by COVID-19 due to the presence of infection in the heart and lungs.8 Therefore, treatment of AF should not be delayed, even amidst the global pandemic, as it places patients at greater risk and can potentially reduce the success of outcomes. In addition, more attention should be given to cardiovascular protection during the treatment of COVID-19.

What are some of the common procedural techniques used for rhythm management?

AF is characterised by an irregular and often fast heartbeat that results in uncoordinated contractions of the atria. Catheter ablation is one of the common procedural techniques adopted to treat this condition by blocking abnormal electrical signals that cause arrhythmia.9,10, It is highly effective in reducing arrhythmia recurrence as well as the long-term risks of AF-related complications, including stroke and heart failure. Patients are also ijms21186790 9 Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D et al. (2016) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 37(38):2893-2962.

AUTHOR BIO

10 Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB et al. (2017) 2017 HRS/EHRA/ECAS/APHRS/ SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 14(10):e275-e444.

10 times less likely to develop persistent AF than those who opt for ADD, as demonstrated by the Atrial Fibrillation Progression Trial (ATTEST)11, and in the long run, rely less on medication.

Pulmonary vein isolation (PVI) is also a widely accepted treatment strategy for catheter ablation, and over the years, it has undergone significant evolution to optimise clinical success and minimise the risk of complications.

We are now seeing an influx of new technologies and techniques in the healthcare space. What are some of the latest solutions used in the treatment of atrial fibrillation?

Recent technological advancements in catheter ablation have allowed healthcare professionals to achieve a more effective and safer PVI. The use of an automated tagging module, such as the VISITAG SURPOINT®, annotates the ablation site objectively whenever predefined criteria such as catheter stability, time or contact force are fulfilled12,13. Since its introduction, 11 Kuck KH, Lebedev, D., Mikaylov, E., Romanov, A., Geller, L., Kalejs, O., Neumann, T., Davtyan, K., On, Y.K., Popov, S., Ouyang, F. (2019) Catheter ablation delays progression of atrial fibrillation from paroxysmal to persistent atrial fibrillation. ESC Late-breaking Science 2019. Paris, France. August 31, 2019.

12 Cho, M.S., Kim, J., Do, U. et al. Clinical outcomes after pulmonary vein isolation using an automated tagging module in patients with paroxysmal atrial fibrillation.

Int J Arrhythm 21, 13 (2020). https://doi.org/10.1186/ s42444-020-00021-9 13 El Haddad M, Taghji P, Phlips T, Wolf M, Demolder A, Choudhury R, et al. Determinants of acute and late

Choi Eue-Keun is a Professor for Internal Medicine (Division of Cardiology) at Seoul National University’s College of Medicine.

He is an author of over 240 peer-reviewed journal publications and book chapters and has been presented the ‘Best Paper Award’ by the Asian Pacific and Korean Heart Rhythm Society in 2010 and 2015 respectively. Dr Choi is an active member of several national medical societies, including the Korean Society of Internal Medicine and Cardiac Arrhythmia.

several studies have highlighted the efficacy and safety of these solutions. 14, On the back of new findings around ablation procedures, I led a study titled Acute and long-term efficacy of ablation index-guided higher power shorter duration ablation in patients with atrial fibrillation: A prospective registry, to explore the efficacy of PVI using high power catheters guided by the solution.

Through the research, we were able to ascertain that the use of increased power during AF ablation reduced the procedural time by 30 per cent and can be performed safely using an automated lesion tagging module. The technique also resulted in comparable acute pulmonary vein reconnection rate and long-term survival without significant complications within a four-week and one-year time frame, compared to conventional-powered PVI. How do such techniques and/ or innovations help to optimise treatment outcomes?

Advancements in techniques, as seen from our recent study, coupled with innovations from industry players such as Biosense Webster have unveiled new possibilities in the treatment of AF. With prevalence on the rise, continued advancement of treatment options will help healthcare professionals to achieve long-term outcomes that ensure their patients are able to live their best lives possible. In the context of AF treatment, this refers to freedom from symptomatic arrhythmia recurrence and improved quality of life. Deploying the right treatment approach also allows physicians to optimise the use of resources and reduce the burden on healthcare systems. pulmonary vein reconnection in contact force-guided pulmonary vein isolation: identifying the weakest link in the ablation chain. Circ Arrhythm Electrophysiol. 2017; 10(4):e004867.

14 Taghji P, El Haddad M, Phlips T, Wolf M, Knecht S, Vandekerckhove Y, et al. Evaluation of a strategy aiming to enclose the pulmonary veins with contiguous and optimized radiofrequency lesions in paroxysmal atrial fibrillation: a pilot study. JACC Clin Electrophysiol. 2018; 4(1): 99– 108.

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VACUETTE EVOPROTECT ®

The safety blood collection set EVOPROTECT is the next stage in blood collection. The semi-automatic click mechanism protects the user from the risk of needlestick injuries and makes the daily task of blood collection easier.

VACUETTE® EVOPROTECT provides for gentle collection and safety from injury because we believe that every needlestick is one too many. The safety blood collection set meets current safety recommendations and requirements and provides substantial support for safe blood collection and infusion with the same set.

tial needlestick injuries are minimised by the activation of the safety mechanism while the needle is still in the vein.

The VACUETTE® EVOPROTECT is suitable for a blood collection and a following infusion with the same set.

User-friendly with an optimised design

The VACUETTE® EVOPROTECT Safety Blood Collection Set has a semi-automatic safety mechanism.

The triggers are located on the side of the product, facilitating one-handed activation. The needle is

The VACUETTE EVOPROTECT is ergonomically designed and intuitive to use. It has a winged needle, specially developed for one-handed use. The poten®

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Maximum safety

then automatically retracted and, at the same time safely and irreversibly enclosed in the safety shield.

A clearly audible click confirms that the safety mechanism is successfully activated.

Designed with patient comfort in mind

The ultra-sharp, triple bevel needle tip ensures optimal patient comfort. A view window between the needle and the tubing gives an immediate visual indication that vein entry was successful. The tubing is designed to ensure that the needle stays as still as possible in the vein. The location of the safety mechanism triggers, on the side of the device, minimises the risk of the needle moving in the patient’s vein during activation.

The gentle touch in four steps Winged needle The material and surface design of the wings provide a simple, safe grip and op-timal hold during puncture.

Safety mechanism The safety mechanism is activated while still in the patient’s vein, offering the user an even higher level of safety. The design of the safety mechanism pro-motes a straight removal of the needle from the vein therefore offering more pa-tient comfort.

Tubing The tubing is particularly flexible with minimal memory effect.

Needle The extra-thin walls of the 21G and 23G needles have a positive effect on flow rate and thus the duration of blood collection/ infusion.

Step 1 Perform venipuncture (with patient´s arm in downward position). Flashback will con-firm successful vein entry, depending on the patient´s venous pressure.

Step 2 Collect blood according to your facility´s procedure.

After completion, place gauze over collection site without applying pressure.

Step 3

The product is intended for in-vein activation. With one hand, activate the safety mechanism by pressing the blue coloured release buttons. Take care not to hinder the automatic retraction.

One click can make the difference. Protect yourself from needlestick injuries.

Step 4 The safety mechanism will automatically slide backwards until an audible click is heard. The click is a sign that the safety mechanism has been correctly activated. Dispose of device in a sharp’s container per facility procedure.

More information on our website www.gbo.com or www.power4safety.com.

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FACILITIES & OPERATIONS MANAGEMENT

Ultraviolet Light Disinfection Systems For operating room treatments Germicidal ultraviolet light (UV-C) disinfection reduces healthcare-associated infections. The time it takes to disinfect an operating room is not constant (e.g., not ‘20 minutes per room’). Recent industrial engineering studies show how to make operating room management decisions for the robotic systems, whether for one case or terminal cleaning.

Franklin Dexter, Division of Management Consulting, Department of Anesthesia, University of Iowa

G

ermicidal ultraviolet light disinfection contributes to reducing bacterial transmission and surgical site infections. Treatment may reduce Coronavirus disease 2019.

However, using ultraviolet light robotic disinfection systems in practice in surgical suites depends in part on the time they take for disinfection. Three recent industrial engineering studies help understand the best possible operating room management for ultraviolet disinfection. From the references, these papers were published in the American Journal of Infection Control, Cureus, and the Journal of Clinical Anesthesia, respectively.

When ultraviolet disinfection is being used, operating room management is not straightforward because the treatment times differ among rooms and treatments of the same room. The figure shows the ultraviolet disinfection times for the 133,831 treatments described in the Cureus paper. Surfacide sent the data for the research studies. The mean time was 18 minutes and the 90th percentile was 26 minutes. The ratio of the 90th percentile to the mean (i.e., the proportional variability) was comparable to that for surgery. Just like surgical

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FACILITIES & OPERATIONS MANAGEMENT

cases of the same procedure routinely take more time or less time than expected days ahead, the same applies to ultraviolet disinfection. A good analogy to the times for ultraviolet disinfection (Figure) are times for cataract surgery.

That procedure has brief mean times but substantial variability in time.

Average time for one ultraviolet disinfection treatment

Imagine the operating room scheduling office has arranged two surgeons in an operating room. The first surgeon has a list of cases, followed by the second surgeon.

The first surgeon has a patient with an infection. Ultraviolet disinfection will be used after environmental cleaning.

Because of surgeon availability, the case for ultraviolet disinfection will be last among the first surgeon’s cases, but not the last case of the day.

In the American Journal of Infection Control study, we considered how much time to schedule for the ultraviolet disinfection. We calculated the mean of the durations for each of the 700 rooms that each had at least 100 treatments. The mean times differed a lot among rooms.

The standard deviation among rooms of each room’s mean was 20 per cent

of the overall mean. That considerable variability implies that when scheduling ultraviolet disinfection treatments in advance (e.g., using an operating room information system), estimated times for disinfection should not be listed as UV-C or equivalent. Instead, what should be scheduled is ultraviolet disinfection of a specific room (e.g., UV-C main surgical suite room 12). For scheduling multiple disinfection treatments, and doing so multiple days before surgery, use the mean value for the room.

This need to consider the room of the treatment is quite unlike surgery. Usually, for surgery, it matters little whether a surgeon performs her cesarean section in one operating room or the adjacent room. There may be some advantages for convenience, but not the surgical time. For ultraviolet disinfection, which is untrue, because it is the room that influences the time for treatment (e.g., because some rooms are larger or smaller than other rooms).

Longest expected time for each ultraviolet disinfection treatment

When that last case is nearly finished, the second surgeon calls inquiring about the expected start time. You, the operating

room manager want to be realistic, but conservative to set reasonable expectations. A good choice would be to provide the 90th percentile of duration.

For mathematical reasons, if there are fewer than 19 prior disinfection times, use the most recent nine observations and use the largest value. That is because the 90th percentile of nine numbers is the largest of the nine (i.e., 0.9 × (9 + 1) = 9). If there are more than nine times but fewer than 29, use the second-longest of the most recent 19, and so forth. I explain more about the arithmetic in the scientific paper. What is important to understand is that the 90th percentile can be considerably longer than the average. Referring to the figure, for many operating rooms, the 90th percentile will be even 50 per cent longer than the average disinfection time. That is why understanding that ultraviolet disinfection times are quite variable in duration based on what surgical items are in the operating rooms is valuable knowledge.

Importantly, once the ultraviolet disinfection towers are in the operating room, the controlling tablet will give your technician the calculated time.

Then, when started and running, that time remaining is nearly exact. For example, if the time shown as remaining is 22 minutes, then literally that will be 22 minutes. Consequently, have the housekeeper (or whoever else is using the equipment) update the estimated time (e.g., call the front desk and then they text the surgeon).

There are several details to use these methods in practice. So, rely on the full article in American Journal of Infection Control.

Room coordination

Another situation that arises sometimes is that the operating room manager has two(or three) rooms of cases for which ultraviolet disinfection will be used after each case. Often these patients will recover in the operating rooms initially and then promptly bypass the phase-I

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Buying, leasing, or planning technicians’ time for disinfection

If your surgical suite does not currently have an ultraviolet disinfection robotic system, then a decision to make will be how many to buy or lease (for example, one system or two). Another related decision will be whether to schedule a technician for 8-hours or 10-hours to use the system in the rooms planned for disinfection, and whether the technician would have time left over for other activities. There would not be value to buying the system but not planning

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staff to run the equipment. Then, the robotic system may sit around being unused, especially if used one room at a time by the same personnel doing the terminal cleaning.

Because each operating room will take different amounts of time, it is not that a company can answer that question for the hospital. Instead, each hospital will need to do a trial.

The question of importance is how to structure the trial to obtain the answer reliably (As mentioned in the Cureus paper).

A nine-night trial means in practice having a system for a fortnight, from a Monday, through that week, and then picked up the following Friday. With that two-week trial, a hospital can empirically arrive at the correct answer, one or two rooms less than the correct answer, or one room greater than the correct answer with ≥99 per cent probability. What does that mean in practice? Suppose that a hospital has 21 rooms. For each of the nine nights, the number of rooms with ultraviolet disinfection is recorded.

While each room is being disinfected, the technician is moving items back in place for the preceding room and making way for the robot easily to enter the next room. Among the nine nights, the minimum number of rooms disinfected in 10 hours was 18 rooms. (Among the other eight nights, there were 19 or 20 rooms disinfected). Then, long-term, the hospital can expect to reliably (defined as 90 per cent) disinfect at least 17 rooms.

Likely the 90th percentile long-term will be 18 rooms, but it could be as high as 19 rooms.

AUTHOR BIO

post-anaesthesia care unit. We would not want to schedule these cases with one surgeon operating in a room, then a second surgeon, then back to the first surgeon, and maybe a third surgeon followed by the second. Mixing up the surgeons would reduce their productivity. However, the manager could inquire of the surgeons about their availability to revise their arrival times to try to best use your teams in the face of the time for ultraviolet disinfection.

The turnover times are going to take substantial time versus typical. In the Journal of Clinical Anesthesia paper, we considered when potentially resequencing the surgeons would be useful. We treated the workday as 12 hours because of the longer turnover and recovery times. The study showed that the operating room manager should look among the operating rooms for any that are estimated to have at most 8 hours of cases and turnovers in the 12-hour workday. When so, do take the time to evaluate if changing the start times of the surgeons could compact the schedule and let another case be done. The surgeons would need to be contacted, and sometimes the change would be possible. There is expected to be moderate (2.9 per cent ) increases in productivity if done the day before surgery before cases start. There can be large (5.6 per cent) increases if done also on the day of surgery when actual case durations are realised.

With a 19-night trial (i.e., four work weeks), the second-largest observed numbers of rooms disinfected is the 90th percentile. There was a ≥99 per cent probability that over the long-term the true 90th percentile of rooms will be the same, one less, or one more. For example, suppose that after four weeks (i.e., 19-night trials except for the last Friday), the second-fewest numbers of rooms disinfected in 8 hours were 16 rooms. Then, over the long-term, the 90th percentile of rooms disinfected nightly will likely be 15, 16, or 17 rooms. That is how many the hospital can plan when buying or leasing a single ultraviolet robotic disinfection system of the studied type (e.g., that shown in the Figure). The information also can be used when planning the technicians’ (housekeepers’) staff scheduling. Just like for the other decisions, details are in the published scientific papers.

Disclosure

The University of Iowa Department of Anesthesia received an unrestricted research grant from Surfacide that was used in part to fund the research (Waukesha, WI). The company also supplied the data used in the published studies. I receive no funds personally other than my salary and allowable expense reimbursements from the University of Iowa and have tenure with no incentive program. My family and I have no financial holdings in any company related to my work, other than indirectly through mutual funds for retirement.

References are available at www.asianhhm.com

Franklin Dexter got his MD and PhD in Biomedical Engineering from Case Western Reserve University. He did his Anesthesiology residency at the University of Iowa. He teaches his four-day intensive course in operating room management several times annually. He has performed >790 consultations for >225 corporations. He has published >610 papers.

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Guerbet’s Digital Imaging Solutions A holistic approach The 2nd decade of the 21st century is where Guerbet has evolved from being a radiology pharma and device provider to a solution company which includes digital solution provider in diagnostic imaging. The right diagnostics at the right time are increasingly important in enabling clinicians to make data-driven decisions.

Given the challenges faced with accreditation and re-accreditation from national and international organisations such as the Joint Commission, mandatory radiation dose monitoring is required, especially when displaying large volumes of data and demonstrating evidence of continuous improvement in your department.

In recent years, Guerbet has invested into the digital ecosystem and currently offering 2 solutions to aid Radiology department’s workflow efficiency, safety, auditing and standardisation without compromising on image quality – Contrast&Care and Dose&Care.

What is Contrast&Care and why?

Contrast&Care is an integrated IT solution that enables imaging centers to collect, archive, review and

optimise patient injection data. Examination involves an injection (contrast agent, injection protocol, patient data, etc.) and interfaces with the information systems used in radiology, including the RIS (Radiology Information System), the PACS (Picture Archiving and Communication System) and EMR (Electronic Medical Records). It helps improves traceability and efficiency while simplifying the decision-making process at imaging centers.

One of the key features of Contrast&Care is that it can automatically collect data from both HIS (patient data, worklists) and injectors (volume, flowrate) following each examination. Users can view a patient’s data history, the examinations that required an injection and the doses of contrast media administered. Upon continuous examinations, it’s possible to send the protocol which was validated by both radiographer and radiologist from Contrast&Care directly to the injector. Contrast&Care also allows users to review protocols, create protocol libraries and see statistics and trends on injection activity and use of contrast media.

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What is Dose&Care and why?

Accumulation exposure of X-ray doses in computed tomography and interventional examination procedures has long-term health risks such as cancer and is an increasing source of concern even with advances in technology according to the EPA (United States, Environmental Protection Agency, https://www.epa.gov/radiation/radiation-health-effects).

Dose&Care is a ‘Patient X-ray Dose Management Solution’ which can be connected with all types of radiation emitting machines – a solution that seamlessly integrates into all modality vendors.

Dose&Care is capable in building comprehensive and consistent histories based on patient exposure, detailed dosimetry results, cumulative dose, patient characteristics and modality settings – tailored dose to each patient. At the same time detect at-risk patients and review their upcoming exam according to their specific condition and dose history, determine the optimal balance between X-ray exposure and image

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quality according to the patient profile, implement and monitor according to the best practice policy = ALARA principle.

Radiation dose monitoring is employed to ensure radiation dose delivered to the patient is not over the pre-set threshold when trying to achieve optimal image quality. Radiation dose creep has been a concern to radiology departments since the beginning of x-rays, were radiation levels increase over time without knowing that can potentially harm the patient. This creep can potentially harm the patient.

An increasing source of concern in computed tomography with radiation dose is that we are giving greater levels of lifetime attributable risks of cancer to patients through imaging. More importantly, the number of CT scans has significantly risen 10-fold over the last decade and radiation dose still remains at high levels compared to new advances in technology. Therefore, careful auditing and

consistent monitoring allows radiation dose levels to be monitored whilst maintaining optimal image quality set by the institution, resulting in significantly reduced lifetime attributable risk to cancer because of unnecessary radiation dose.

The Future

Future of imaging is centralised in digital solution to increase efficiency, reduce waste, cost whilst maintaining a safe radiology service without compromising on image quality and patient safety.

Guerbet offers a turnkey solution that provides a holistic approach to medicine.

Driven by its commitment to advance radiology today and tomorrow, Guerbet has designed a portfolio of interconnected diagnostic imaging solutions to enhance decision-making at each point of the patient journey from diagnosis to treatment and follow-up, in order to efficiently improve patient outcomes. This is UNIK.

UNIK concentrates on 4 pillars: high quality contrast media for MRI and for Xray, a large range of injectors and associated consumables covered by expert 360° technical support, and innovative digital solutions to ensure automatic traceability, improve efficiency, and heighten patient safety in the areas of contrast administration and radiation dose management.

Enhancing the imaging workflow in the hospital is our answer to this challenge. We are uniquely positioned as the only player with a strong foundation in contrast, injection systems, advanced informatics and AI algorithms.

A major global player in the diagnostic imaging market thanks to the established reputation of its contrast media products, Guerbet is much more than a mere supplier of contrast agents.

For more information on Contrast&Care and Dose&Care, explore these videos:

Contrast&Care

AUTHOR BIO

https://bit.ly/3DEGAsz

Charbel Saade joined Guerbet from a very solid academic and clinical background. He was the Professor and Chair of Radiology at the American University of Beirut and still holds many Adjunct Professor roles worldwide. He has published more than 100 scientific papers and 80 conference abstracts in international congresses. He served as the APAC Clinical Applications and Education Manager and now taking charge of the APAC Digital Solutions and Technical Service. He is passionate about lifting the clinical and technical practice of Diagnostic Imaging for better patient outcomes.

Dose&Care

https://bit.ly/3BzCMqO Advertorial www.asianhhm.com

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HEALTHCARE FROM SPACE, DOWN TO EARTH! The Sky is the limit. This 20th century cliché is no longer true! With scores of millions on earth malnourished and having major health problems it may appear outlandish to invest in space science and encourage space tourism for the super, super rich. Be that as it may there are many, many bye products which are a direct offshoot of technology customised initially for space exploration, resulting in better healthcare to earthlings on Terra Firma. This article gives a glimpse as to how trillions spent in space exploration may eventually be justified after all – a peep into the fascinating world of space technology enabled healthcare on earth.

K Ganapathy, Director, Apollo Telemedicine Networking Foundation

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ASA to send humans to the moon once again – but this time we will stay. This media release says it all. This will be a forerunner to the manned mission to Mars. With 600 individuals already having gone into space in the last 55 years and space tourism having started, extra-terrestrial healthcare is now a reality. Sceptics question mega funding for space projects. It is seldom realised, that phenomenal technological advances in healthcare during the last two decades, is a direct spinoff of technology, primarily developed for space exploration. Cynics argue that proving technology transfer is exceptionally complex. Nevertheless these snapshots illustrate some of the 2000 products identified by NASA as a by-product of space exploration.

Bringing space, down to Earth is not a pun. Representing almost one per cent of global economic activity, the multiplier effect and stimulus to health and economic growth is real. There is considerable similarity between probing the emptiness of space on distant galaxies and getting into millimetre

sized capillaries in the heart and brain of the unborn – to paraphrase Star Trek, to go “where no man has ever gone before”.

Innovation often originates from technology transfer or spinoffs where the original technology was developed with extremely high standards, with failure not an option. Healthcare designed for extreme environments of space, has improved care on earth.

Quarantine during lockdowns is a crude

Global navigation satellite systems developed for space exploration have proved a panacea for disaster responses, telemedicine, tele-education and for safe and efficient transportation.

naïve simplistic illustration. Astronauts on the International Space Station (ISS) live and work in an isolated and confined environment under stressful conditions and in a hostile environment. High-level performance is expected throughout.

Space provides a unique environment conducive to studying effectiveness of drugs and to test new drug therapies.

There is a potential to decrease drug development and medicinal costs.

Economic models suggest that a 10 per cent improvement in failure prediction rates prior to enacting clinical trials could save US$100 million in development costs per drug. An ISS National Lab project from 490 Biotech, Inc., is studying a bioluminescent assay tool kit to reduce failure rate of current drug discovery efforts. If confirmed the tool kit could have a high impact on the estimated US$12 billion market for this technology Deploying wearable sensors and software in the ISS represents the ultimate remote patient monitoring scenario. A wearable tech, called Astroskin, collects scientific data on activity levels, sleep quality and

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vital signs, including blood oxygen levels, blood pressure, heart rate and electrical activity, and breathing rate.

These products, designed to track the health of astronauts, will eventually make healthcare system on earth more accessible.

As many as 235 astronauts from 18 countries have participated in various healthcare projects in the last 23 years at the ISS located 400 km above the earth. Every one of the remaining 365 who have left earth has also been part of healthcare studies. Following outbreak of Covid-19, in 37 days NASA and the Jet Propulsion Laboratory in Houston developed the VITAL ventilator. 31 licenses were awarded to 100 applicants making it the most licensed NASA technology. When the Perseverance rover made a successful landing on Mars it used ultraviolet laser to look for invisible organic materials. Preliminary work for this resulted in similar devices being used by the pharmaceutical industry and waste water treatment plants offering considerable cost savings.

Invisible dental braces, tracking sensors, nutraceuticals, battery-powered surgical instruments, Emergency blankets (survival/anti-shock) and appliances to develop fine motor skills are illustrations of deployment of space technology.

3D printing of living tissue could address shortage of cadaveric organs for transplant. Bio-print facilities to produce functional complex human tissues in a microgravity milieu during Low Earth Orbit flights are in the offing. Techshot has already signed an agreement with a space station company Axiom space to install the first commercial bio-printer on the International space Station (ISS). space station Research platforms paves way for manufacturing in zero gravity. Cultivating clinical-grade stem cells for therapeutic applications in humans—the aim of an ISS National Lab investigation by the Mayo Clinic—may improve understanding of cancer resistance to chemotherapy.

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Protein crystallisation studies on earth are being extended to the ISS National Lab. Larger and more uniform crystals grown in microgravity help better interpretation of their molecular structures. This may result in new drugs to control cancer growth, improving drug discovery and delivery methods and reducing side effects.

A programme through the National Cancer Institute’s Chemical Biology Consortium will conduct multiple protein crystallisation experiments.

Cancer-related projects have improved 3D cell culturing methods for higheraccuracy drug testing. The ISS National Lab is a unique research platform available to US researchers from small companies, Fortune 500 companies, research institutions and government agencies, all interested in leveraging microgravity Merck & Co. utilised the ISS National Lab to grow millions of highly ordered, uniform crystalline particles of the therapeutic monoclonal antibody Keytruda® with the potential to improve drug delivery for patients.

The research team’s preliminary results were successful, with crystals grown in microgravity clearly showing more uniform size and distribution. A protein crystal growth project from the Frederick National Laboratory for Cancer Research aims to reveal the structure of RAS proteins produced by three of the most common oncogenes in human cancer. Mutations in RAS proteins are implicated in one fourth of all cancer cases and are involved in early

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onset and progression of 90 per cent of the deadliest cancers, including lung, colon, and pancreatic cancers. A project from Hauptman Woodward Medical Research Institute, Inc., looks to grow crystals of four proteins associated with human disease. Larger, better-organised crystals of these specific proteins could have a significant impact on drug development for Parkinson’s disease, bovine spongiform encephalopathy, ethyl malonic aciduria, and cutaneous squamous cell carcinoma.

Global navigation satellite systems developed for space exploration have proved a panacea for disaster responses, telemedicine, tele-education and for safe and efficient transportation. Space products include portable broadband telecommunication systems using satellite video phones. These are particularly useful for providing remote healthcare in disaster management.

Charge-coupled devices (CCDs) used on the Hubble Space Telescope to convert a distant star’s light directly into digital images was modified for better imaging of breast tissue. This resulted in new digital mammography biopsy techniques. Reducing light scatter in cameras on spaceships resulted in tiny cameras stationed in malleable fibre optic tubes, negotiating through mm sized blood vessels Miniature cameras for study of the GI tract can be swallowed. Capsules swallowed can be converted into balloons in the stomach reducing gastric capacity. This assisted weight reduction method will compete with invasive bariatric surgery.

INFORMATION TECHNOLOGY

Ventricular Assist Device, a life-saving heart pump for patients awaiting heart transplants was designed by combining supercomputer simulation of fluid flow through rocket engines. Programmable

AUTHOR BIO

K Ganapathy is a Former Secretary and Past President Neurological Society of India, Telemedicine Society of India & Indian Society for Stereotactic & Functional Neurosurgery Hon Distinguished Professor The Tamil Nadu Dr. MGR Medical University. Member Roster of experts Digital Health WHO. Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services, India.

Website : www.drkganapathy.com E Mail : drganapathy@apollohospitals.com

pacemakers, micro-transmitters used in foetal monitoring, laser angioplasty and light-emitting diodes (LEDs) used in neurosurgery are all modifications from space technology. Advances in

treatment of osteoporosis and muscle wasting diseases are secondary to study of mechanical loading and tissue remodelling in microgravity environments, a problem encountered in space. Detailed studies in microgravity of cells and microbes have resulted in better understanding of diseases on earth.

POCD (Point of Care Diagnostics) where a drop of blood analyses 50 blood parameters and handheld ultrasound smartphone applications are other by-products. Smart watches measuring heart rate, blood pressure, temperature, oxygen saturation are entirely fallout of technology used for space exploration.

Wearables include smart vests which will record and transmit temperature and blood sugar.

Admonitions not to float in Cloud Nine but to come down to earth and have one’s feet firmly on the ground may not be really relevant in the years to come. The sky will no longer be the limit for terrestrial problems.

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TELEHEALTH The next frontier of virtual care

Today, smartphones and tablet computers have become, in many cases, the first access points for healthcare. Coupled with the rapid adoption of telehealth during COVID-19, and predictions for how sustained this change may be - we investigate how telehealth will impact the physical design of clinic facilities, and the fundamental duality that will drive healthcare design as a digital/physical hybrid.

Angela Lee, Principal and Regional Managing Director, Asia Pacific, HKS Gordon Gn, Design Director, HKS

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n a few short months during the initial periods of COVID19, telehealth went from almost nonexistent, to boom, and has begun to decline towards a yet undetermined state of normalcy. At its height, telehealth was projected to transform what was an estimated US$3 billion in total annual revenue to a projected US$250 billion in US healthcare spending post COVID19. Yet, the pandemic has highlighted the need for fully integrated telehealth to provide access to care and ensure business continuity now and in the future. Healthcare organisations have a

INFORMATION TECHNOLOGY

tremendous opportunity to build upon the lessons learned during COVID19 to transform care delivery moving forward. By determining which services will stay in the footprint, which services are best suited for virtual care, and which services can be agile, moving between in-person and virtual visits, healthcare organisations and independent provider practices can more effectively and efficiently respond to shifting market demands and meet evolving patient and provider preferences and needs.

As technologies advance and care delivery models morph, the boundaries between the physical and digital environments will continue to blur. It is essential to ensure that our clinic facilities can seamlessly and effectively support the integration of virtual care into their physical spaces. Agility between digital (cloudprint) and physical (footprint) assets, equity in terms of digital access and in-person and virtual interactions, and enhanced human experience will all

be key components to ensure success of Internet of Medical Things (IoMT), as we continue the quest for better health outcomes. Here, we outline a few design strategies for cloudprint and footprint to address the future of healthcare services: 1. Determine which clinical services are best suited to be delivered virtually

When considering which types of services were best suited to being conducted as a telehealth visit, 88 per cent of primary care physicians polled

by HKS in 2020 considered telehealth to be a viable option for conducting primary care visits. For mental and behavioral health visits, 78 per cent of mental and behavioral physicians considered telehealth a suitable form of conducting visits, while 57 per cent of urgent care physicians and 46 per cent of women’s health physicians felt telehealth visits were suitable. Speciality services such as neurology, cardiology,

oncology, orthopedic and radiology that are technology dependent were rated by physicians who conduct those services as the lowest in terms of applicability for telehealth use. Ultimately, physicians believe telehealth will increase patient volumes, requiring clinics to maintain their existing footprint while expanding their cloudprint.

Some health interactions are better suited to telehealth, some are better suited to an in-person visit, and some are agnostic- and can be either in-person or virtual. Understanding the nuances of each interaction is important to assess whether telehealth, in-person visit, or a hybrid approach are best suited for primary care and family medicine. It is essential to program not just space, or technology, but rather the interactions that create a seamless experience across both. By establishing clear guidelines as to what types of services need to be delivered in-person, this will enable providers to determine which services

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can effectively move to a virtual platform in the mid-term and long-term.

Within HKS’ Batist Health Hamburg Outpatient clinic design, spaces for virtual care delivery are embedded in multiple areas and at multiple scales, to support increased flexibility for accommodating present and future spatial needs – as well as the provision of a flexible layout for spaces that support telehealth to ensure they can be easily modified to support changing practice needs over time.

2. Digital literacy and accessibility are key in the transition to the cloudprint

In HKS’ same 2020 poll, physicians also noted access and convenience as the greatest opportunities for telehealth moving forward. Telehealth possesses great potential to increase access to highquality services for patients in remote or rural areas that lack speciality services and those with physical challenges or transportation issues, but all this is dependent on digital literacy and accessibility.

Educational sessions, both virtual and in-person provide the foundation in supporting patients in expanding their digital literacy, and

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providers should utilise telehealth platforms that are intuitive and easy for patients and providers to use to support ease of adoption. Telehealth can save both patients and providers valuable time and effort due to reduced travel time to the office, the potential for extended hours, increased opportunities for follow-up for non-exam related issues, and the opportunity to engage quickly and more frequently with patients. By leveraging virtual visits to increase service options and convenience for patients, it is also imperative to consider creative opportunities to provide necessary resources for those with limited access to technology or internet services in their home.

Within the footprint, telehealth capabilities can be seamlessly integrated in exam rooms to access virtual visits with external providers, and sufficient spaces within the clinic program will support conducting a virtual visit with multiple care team members in the same location. Beyond handheld devices and tablets, E-kiosks can also create an alternative for patients to electronically access their health information, so it is vital to ensure patient privacy and security of this health information.

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All these factors are crucial in establishing increased profitability, efficiency and safety as key opportunities for telehealth moving forward, as well as improved care and increased patient satisfaction.

3.Ensure connectivity and flexibility to the digital incorporation of data and activities into the overall process

In ensuring a reliable cloudprint for both synchronous (telemedicine) and asynchronous (store and forward) telehealth, the provision of high-speed internet capabilities must be adequately met to ensure seamless connectivity throughout the virtual visit. Whilst leveraging remote monitoring devices to support care continuity across the continuum, telehealth also calls for virtual technology support services, which play a key role in the assistance of device set-up and maintenance for both patients and providers.

Within the physical footprint, enhanced video and audio capabilities will support high-quality synchronous communication between patient and providers, addressing challenges and increase the ease of connectivity during the virtual visit. In-person technology

INFORMATION TECHNOLOGY

4.Leverage usability and simplicity for a tele-integrated platform

Despite the relatively high patient satisfaction and its perceived benefits, virtual care is still seen as a ‘proxy’ to the in-person visit. If telehealth is to reach its full potential, digital interactions during a virtual visit must be made a worthy substitute of the in-person visit, creating more experiential and more personal interactions that enhance the relationship between patients and physicians – thus, it is essential to ensure equity in terms of digital access and virtual interactions. These mean that applications to access platforms, as well as interfaces should be intuitive and easy to use, whilst ensuring simplicity of the digital format. The user interface is an opportunity to enhance the patient and provider experience, hence, applications should reduce redundancy such that information is only requested once, as well as consider single port of entry into telehealth platform that allows for text, video, email, etc.

In today’s world, systems are needed where our physical interactions can be mirrored in digital space, and viceversa so the experience (and resulting outcome) is enhanced, creating beneficial redundancies for care delivery.

This can also provide clinics with longterm resilience- be it in response to unforeseen events like the pandemics, or rapid advancements in technology, to ensure business continuity. The clinic footprint at HKS’ recently completed Parkland Moody Outpatient centre integrates adjustable lighting to reduce glare, sufficient illumination, enhanced video capabilities, professional and distraction-free backgrounds that have a light colour and glare reducing finishes to enhance communication, as a few interior conditions that were considered in design to optimise the virtual visit.

In terms of equipment, providers should consider ergonomic furniture with adequate horizontal worksurface to support staff comfort and ensure camera placement allows for the provider to establish visual connection with the patient while dual monitor capabilities support synchronous viewing of EMR information and patient during the virtual visit.

Are we there yet? Seeking the patient and system perspective

Telehealth will very likely be an additive component to primary care, especially for family medicine and internal medicine, allowing health providers to have more business continuity, extended access, and higher convenience. At the same time, how telehealth can improve provider-patient interaction, and overall health outcomes, still warrant investigation. As healthcare organisations and independent physician practices consider how to leverage telehealth to provide the greatest benefit to patients and providers, it will be essential to think

AUTHOR BIO

support services, such as a tech bar within the clinic, allow telehealth platforms to support ease of device set-up and maintenance for patients.

beyond current care delivery models and explore how an integrated physical/ digital hybrid model will impact the future of clinic design.

Furthermore, while these strategies provide a snapshot in time to telehealth’s current limitations and future aspirations, it also serves as an impetus for further exploration and innovation to address growing questions on the topic. Can telehealth be leveraged to address the imminent healthcare worker shortages across the world? How can advances and improvements in technologies such as AI, the Internet of Things, and remote patient monitoring be leveraged to solve some of the emerging challenges with equity, engagement, and experience across the continuum of care? As more care shifts to the virtual environment in the coming future, it is imperative we begin to consider the future of home health, mobile health, retail health and healthcare’s distribution from other third places. While telehealth is the start in carving out a new frontier in virtual care deliver, it will certainly not be the end.

Angela Lee is a Principal and Regional Managing Director for Asia Pacific at HKS. As founding director of HKS Singapore, Angela helped design award-winning medical projects of all sizes. A recognised thought leader, she is often asked to serve as a juror in design competitions and speak at health, technology, and design events.

Gordon Gn is a Design Director in the HKS Singapore office. He has worked extensively within the Asia-Pacific, Middle East/North Africa regions and the US, handling clients and project teams from conceptualisation to completion. Gordon has superb insight and experience, and his healthcare designs have won numerous awards.

We would also like to thank all our esteemed colleagues at HKS and CADRE for their valuable research, analytics, publications, and reports.

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2030 VISION

Looking toward the future of interoperability Interoperability in healthcare has rapidly revolutionised over the last two decades, corresponding to the increased expectation that the industry should have the capability to ‘do better’ with data and leverage it to advance patient care. With the heightened demand for smart applications in healthcare, there is a need to take a deep dive into the next phase of interoperability and the wide-ranging possibilities that can be realised from unencumbered data exchange.

Leigh Burchell, Vice President, Policy and Government Affairs, Allscripts

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hat will the average hospital or healthcare practice look like ten years from now?

How does one envision the future healthcare model, and how does it fit into the interconnected global economy?

What will it take to get there, and will the industry achieve it?

These enduring thoughts are pondered by decision-makers in the healthcare world, where organisations and providers strive every day to work towards a solution to these nuanced and complex questions. Globally, countries are exploring how the effective integration and use of health IT will further transform the future of care, especially in an environment made up of complex healthcare systems and differing delivery models spread across diverse demographics. Accordingly, there is a heightened demand for smart applications in healthcare as a part of larger detailed plans and carefullycalculated longer-term strategies, with each building on overarching

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interoperability efforts. Collaboration between industry stakeholders is also well underway as experts forecast what advanced interoperability will facilitate before the next decade begins.

As the healthcare industry as a whole shifts from digitising within the four walls of individual care environments to coordination with other organisations also seeing those patients, there is a need to take a deep dive into what the next phase of interoperability will look like by 2030, as well as the wide- ranging possibilities that can be realised from unencumbered data exchange.

Healthcare with IT interoperability: Seamless, efficient, and effortless data access and exchange

Interoperability in the healthcare industry has been rapidly revolutionised over the last two decades, corresponding to the increased expectation that the industry should have the capability to ‘do better’ with data and leverage it to advance patient care. There is a spotlight

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on the effective use of healthcare information that is housed across disparate EHRs and enabling crossexchange and cooperation with each other. Looking ahead, it is clear that more standardisation and alignment in the industry around data transmission and consumption is expected, continuing the growth of interoperability adoption in the years leading up to 2030.

Different EHR systems have typically offered varying enhanced interoperability capabilities, which has resulted in isolated islands of patient data, housed and confined within the four walls of different healthcare organisations. Conversely, advanced interoperability functionality can smoothly enable connections between health information networks, ensuring care providers are able to access a patient’s data from wherever he or she receives care, with no compatibility barriers. Further, as patient data flows more freely between different EHR systems, subsequent transparency

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around data provenance can follow, building higher levels of clinician trust in the information presented to them and allowing them to deliver increasingly informed care to their patients.

This improved access to real-time, harmonised information from across the care continuum demonstrates clinically meaningful interoperability at its best.

Building open, connected communities of health, accessible to everyone

Interoperability is expected to deliver a new scale of efficiency to healthcare professionals as the world enters the next decade - a level they have long desired.

The act of transferring information from one EHR to another EHR will now be a simple one, no longer a frustrating, timeintensive process.

With the introduction of artificial intelligence and machine learning technologies, data will be mapped and made usable automatically, saving valuable time and resources that are vital in the healthcare world. For example, comprehensive data mapping technologies will remove strain associated with patient- matching and identification during the exchange between and retrieval of information from disparate systems, presenting a win for patient safety. This paves the way for people to better deploy their time to focus on more valuable and high-impact tasks rather than mundane, administrative aspects.

An example of this is the South Western Sydney Primary Health Network’s (SWSPHN) innovative Integrated Real-time Active Data’s (iRAD) interoperability project in Australia. There was an identified need in the country’s healthcare sector for an application that was capable of accurately sharing agreed- upon, critical patient datasets between hospitals, general practices and other connected healthcare professionals on-boarded within disparate systems. As part of iRAD, SWSPHN implemented Allscripts’ dbMotion platform during its pilot phase over a 12-month period, enabling healthcare organisations to share patient-consented health records across the continuum of care securely and judiciously. The healthcare network was then able to focus its efforts on care delivery, emphasising informed decisionmaking and high-quality patient outcomes rather than time-consuming records retrieval or other administrative tasks. The project also provided the healthcare network with the foundation to scale up at speed across its region, achieving an Australian-first integrated health system that is fit for purpose.

In addition to improved efficiency, the increased adoption of application programming interface (API) standards is already enabling EHRs to interoperate with smart apps, platforms and connected devices, all of which elevate the quality of care for the patient and convenience of the process for all involved. Care delivery will be able to further transition from being primarily hospital-based to taking place in the patient’s home, which is usually less costly, while still supporting the necessary real-time alerts delivered to the dedicated care team whenever needed. Bringing acute-level care to patients with the assistance of technology can also provide them with the choice and comfort to recover from procedures at home in a familiar environment, as well as age in place as they get older, all with the option of engaging care teams as needed. And as patients choose to receive

care outside of the hospital, virtual and augmented reality technologies will dramatically expand their options as we currently know them, elevating telehealth capabilities beyond simply voice and video to even incorporate holo-tech in the near future. The pandemic has already re-adjusted the broader market’s perception of in-home care, with surveys showing that patients and healthcare providers alike are now more receptive to it and accepting of such an option.

Adding enhanced interoperability to that can facilitate advancement of a wellsupported healthcare ecosystem that enhances care delivery.

Improved interoperability capabilities will not only support the use of technology within the care setting, it will also accelerate the pace of clinical research through the extraction of realworld data from EHRs, moving toward the goal of achieving safer clinical outcomes. Interoperable data will equip research teams with a well-rounded, inclusive and more comprehensive view of patient populations, contributing to a more equitable care experience for all. As therapeutics and devices go-tomarket, fast healthcare interoperability resources (FHIR)-based clinical decision support hooks will point clinicians in the EHR to relevant information and newly-determined best practices at the point of care, where much of it will also be based on real-world data derived from EHRs. The COVID-19 pandemic and ensuing lessons learned about vaccines has shown us just how critical time is and can be with respect to research and development.

As interoperability progresses within each individual country, this also a multiplier effect when barriers to data exchange between different countries also come down over time.

As standards are harmonised, adopted and implemented across international borders following agreement between standards development organisations, this will increase data liquidity and allow for greater transfer and transport

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of public health data. This also translates to broader benefits for the good of patients around the world. The pandemic has demonstrated and shown how healthcare, while local, also plays a global role in advancing public health. In a nutshell, good healthcare anywhere is good for healthcare everywhere.

representatives, provider organisations, technology partners and policymakers to achieve this vision. The required technology, tools and know-how already exist, waiting to be integrated,

AUTHOR BIO

Forging ahead: The path of interoperability and the ‘end goal’ with it for healthcare

The future of interoperability – in the form of an open and secure health IT ecosystem that the international community envisions and strives towards – is both aspirational and attainable. The end goal for all healthcare stakeholders remains to collaborate across patient advocacy groups, public health

Leigh Burchell advocates not only for the interests of the software development community but also the company’s almost physician clients and hospitals.

Burchell is also active in many industry associations, including the Electronic Health Record Association (EHRA), where she was a past Chair and currently leads the Public Policy Workgroup; the eHealth Initiative, where she sits on the Leadership Council and the Policy Steering Committee; and HIMSS, where she is an active participant in the Public Policy Committee. She speaks frequently on topics ranging from information exchange to the digital intersections with social determinants of health, information blocking to how health IT can assist with opioid crisis.

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implemented and put to work. The pace at which the industry is moving presents great opportunity for tremendous progress by the year 2030, all for the good of patients everywhere.

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