Asian Hospital & Healthcare Management - Issue 25

Healthcare Management SURGICAL SPECIALITY Medical sciences TECHNOLOGY, EQUIPMENT & DEVICES FACILITIES & OPERATIONS MANAGEMENT i t

I s s u e 25

2012

w w w.asianhhm.com

Medical Errors and Litigations Are they preventable?

Healthcare, the Cloud, & Information Security Telemedicine One Small Step for IT A giant leap for healthcare

Breast Cancer The past, present and future In Association with

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Foreword

BREAST CANCER The changing face

History traces detection of Breast cancer (malignant breast neoplasm) in Egypt to as early as 1600 B.C. Over the centuries, a wide variety of explanations were proposed, with no conclusion given till date. At one point in time, breast cancer was treated as divine punishment by patients. In the modern era, advances in medical sciences and technology, improved detection and treatment regimes have made significant progress in treating breast cancer. These changes have helped several breast cancer patients overcome initial hesitation and come forward for treatment.

Breast cancer—a cancer that affects the breasts or mammary gland—is the second most common cancer after lung cancer and is the fifth most common cause of cancer death world wide. The risk of developing breast cancer in women is 100 times more frequent when compared to men.

According to American cancer society, in 2012, approximately 226,870 new cases of breast cancer in women are expected to be detected while the number of deaths is expected to be 39,510.

Breast cancer incidence and death rates increase with age. In the US, women aged between 20-24 years had the lowest incidence rate, 75-79 year old women had the highest incidence rate and according to 2011 Breast Cancer Fact Sheet, 50 per cent of women who developed breast cancer were 61 years of age or younger at the time of diagnosis.

The relative survival rates for women diagnosed with breast cancer are found to be 89 per cent at 5 years after diagnosis, 82 per cent after 10 years and 77 per cent after 15 years. In India, however, the overall 5 year survival rate for breast cancer patients does not appear to

be even 60 per cent presently because over 50 per cent breast cancer patients in India present (get diagnosed) in stages 3 and 4, according to PBCR’s report.

New discoveries are helping to create new metabolic strategies for cancer prevention and therapy. The cover story in this issue of Asian Hospital & Healthcare Management, Mohammed Jaloudi and Jihad Kanbar from Tawam Hospital, Al-Ain, Abu Dhabi, UAE, give their focus on the complexities of breast cancer and how public perceptions about the disease have changed over the past few decades. The authors also detail how recent advances in molecular and genetic sciences are creating novel therapeutic strategies showing way for the future hope. The future of breast cancer treatment should be faced with optimism.

In other articles, Gloria N Eldridge, Initiative Director, Strategic Innovations for Health Care Reform, USA talks about Strategic Innovations in Care Transitions for HighCost Populations; Dennis M. Seymour, Chief Security Architect, Ellumen, Inc., USA talks about Risks Associated with Medical Devices and Mobile Medical Devices; Dennis Kaiser, Principal, Perkins+Will, USA talks about how Integrating technology with a healing environment greatly improves the patient experience; Feisal Nanji, Executive Director, Techumen LLC, US talks about Cloud computing and many other interesting topics covered by other industry experts.

Prasanthi Potluri Editor

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Advisory Board

Editor Prasanthi Potluri Copy Editors V Rashmi Divakar Rao Jenny Jones Art Director M A Hannan Project Managers Khaja Ameeruddin Jeff Kenney Prabha Nandikanti Breiti Roger John E Adler Professor Neurosurgery and Director Radiosurgery and Stereotactic Suregery Stanford University School of Medicine, USA

Sandy Lutz Director PricewaterhouseCoopers Health Reseach Institute, USA

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

Peter Gross Senior Vice President and Chief Medical Officer Hackensack University Medical Center, USA

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Compliance Team P Bhavani Prasad P Shashikanth Sam Smith Steven Banks CRM Yahiya Sultan Naveen M Subscriptions incharge Vijay Kumar Gaddam IT Team Ifthakhar Mohammed Azeemuddin Mohammed T Krishna Deepak Yadav D Upender Head - Operations S V Nageswara Rao

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Contents

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Breast Cancer

Past, present and future Mohammed Jaloudi & Jihad Kanbar Department of Oncology, Tawam Hospital, Al-Ain, Abu Dhabi, UAE

Healthcare Management 06 The Spine of Healthcare Delivery Dirk Dumortier, VP, Cross Industry Solutions, Alcatel-Lucent Enterprise Group, Asia Pacific

FACILITIES & OPERATIONS MANAGEMENT 36 Considering the Human Factor Integrating technology with a healing environment greatly improves the patient experience

10 Medical Errors and Litigations Are they preventable?

Hossam Ghoneim, Executive Director, Medical & Clinical Affairs, Doctor Soliman Fakeeh Hospital, Jeddah, KSA

Dennis Kaiser, Principal, Perkins+Will, USA

16 Strategic Innovations in Care Transitions for High-Cost Populations A guide for healthcare systems, providers and payers

information technology

Gloria N Eldridge, Initiative Director, Strategic Innovations for Health Care Reform, USA

SURGICAL SPECIALITY 26 Treating Diabetes as a Surgical Disease

Eldar S Brethauer SA Philip R Schauer, Professor of Surgery, Lerner College of Medicine Director, Advanced Laparoscopic & Bariatric Surgery Helen Heneghan, Advanced Laparoscopic & Bariatric Surgery Research Fellow

40 Telemedicine - One Small Step for IT A giant leap for healthcare Rashi Agarwal, Director, Praxis Healthcare Pvt. Ltd., Jaipan Industries Ltd., India

46 Enabling Transformation of Healthcare Delivery with IT Jim Warren, Chair in Health Informatics, The University of Auckland, New Zealand

52 Healthcare, the Cloud and Information Security Feisal Nanji, Executive Director, Techumen LLC, USA

Bariatric and Metabolic Institute, Cleveland Clinic, Ohio, USA

TECHNOLOGY, EQUIPMENT & DEVICEs 32 Risks Associated with Medical Devices and Mobile Medical Devices Dennis M Seymour, Chief Security Architect, Ellumen, Inc., USA

56 Successfully Implementing Healthcare IT A health informatician’s perspective Thanga Prabhu, Clinical Director, GE Healthcare IT, India

special features 30 Events 45 Books

36 40 4

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Healthcare Management

The Spine of Healthcare Delivery While the SPINE of the healthcare delivery—EMR-EHR— comes into a maturity stage, it is time to unlock its full potential by increasing the adaptation rate for caregivers via the implementation of communication technologies.

Communication technologies linked to EMR-EHR can make it easier for caregivers to access EMR-EHR from any where, any-device. Collaborate between stakeholders, make workload automatically dispatched, while working towards one direction… The Patients outcome.

Dirk Dumortier, VP, Cross Industry Solutions, Alcatel-Lucent Enterprise Group, Asia Pacific

A

s the ‘spine’ of the healthcare delivery – the EMR - comes into a maturity stage, it is time to unlock its full potential by increasing the adaptation rate for caregivers via the implementation of communication technologies. The same communication technologies can be used to further increase the potential of the EMR by enabling the collaboration between stakeholders and by dispatching 'work tasks’ automatically to eliminate waiting times and increase efficiency. This will drive an improved patient outcome.

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While an outcome-based payment system is still far away, the implementation of an EMR system has already created a proven track of record. The EMR is now the ‘spine’. However, before it can function correctly it needs arms and legs and only then the knowledge (brain) can be developed and used to improve the outcome. We are all trained and passionate about helping patients, but the 'quality’ time per patient is decreasing fast, it is time to look into technologies that would help in delivering a patient outcome that is more

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predictable, less costly and has a better patient touch.

The implementation of an EMR system is a time and money consuming process and already a huge challenge for the IT teams by itself. Linking all the clinical systems together and creating that single view per patient is easily said, but behind the scene each doctor, nurse will have their own requirements to make that single view work for her or him. A look at all the implementations around us, and we look a bit beyond the EMR implementation challenges, we see four new elements that are not directly linked to EMR but impacting the EMR adaptation rate, the healthcare efficiency, the collaboration between caregivers and how we close the loop by integrating the patient into this. Let’s look a bit closer to each of them: Imagine that the IT team in an organisation comes out with the perfect EMR solution, including ‘that’ single view that each specialist, doctor or nurse has been dreaming about. But now put it into reality and as an example, we are following a doctor and head nurse doing their morning round in the ward. To be clear 'paperless’. In normal cases we will use the COW (computer on wheels). Let’s walk with them for one patient.

• Doctor logs into the EMR and looks into his single view and discusses the progress with the patient. He asks the nurse to follow up his temperature on a more regular basis • Doctor need to logoff and nurse needs to login to add this into the patientnurse work schedule • Doctor decides to add some medicine and this requires again the nurse to logoff and the doctor to login.

Healthcare Management

Workload: Efficiency

Communication Technologies

Goal: Patient

Teamwork: Collaboration

While EMR-EHR goes into a maturity stage, it is time to unlock the potential of the Caregivers with one goal: The Patients outcome

Clearly, nobody will use the system the way it is designed for and the nurse and/or doctor will write it down and starts adding things into the EMR when behind her / his desk with all the risks involved. So to make it practical, each caregiver must have access to ‘their’ EMR almost on a permanent basis. This opens the discussion to have medical tablets, like iPads, for each caregiver. Furthermore, doctors can use patient barcode scanning or even location tracking to make it easier to map patients with the correct EMR info.

So to me the first element to make EMR implementation a success and to increase drastically the adaptation rate is to implement a pervasive mobility concept that allows caregivers to connect all the time to their EMR views. What needs to be looked at to implement this?

• Wireless LAN coverage covering the entire building including corridors, elevators, waiting rooms etc., and it need to be able to expand beyond the walls of the hospital as Specialists can work in multiple locations or even having a private practice in parallel.

Technologies as 3G-LTE and Home office need to be seamlessly added into it • Besides coverage, security will be the

Spine: EMR - EHR

Infra: WLAN

next big thing. How to make sure that each care giver is authorised and has access to the right information with the right quality of service. Security needs to be addressed as well because of the sensibility of the information, so nothing can be stored inside the device and the IT team needs to have access to configure and disable it in case of theft or loss • As we work in a consumer-based environment, care givers will insist to use their own preferred devices for this and we enter the debate of BYOD (Bring your own device) • Without jumping into the other elements such as efficiency and collaboration, care givers jumping on to this medical tablet concept will add these points from the very first discussion • It must to be mentioned, but also goes unnoticed, that the system has to be very intuitive for the care givers to use.

They are not IT folks.

The second element that needs to be looked at when using EMR is how it can help caregivers in reducing costs by optimising workflows. To make it clear, EMR is not per definition a workflow, or related to that, a workload management platform. What is known through EMR is all the major tasks that need to happen with each patient. Admission,

tests (lab-radiology), medication and discharge.

Behind each major task you have a lot of small tasks that need to be executed in sequence by different teams.

Let us take an example of a simple x-ray requirement • Specialist initiates a x-ray request into the EMR system • The radiology department need to schedule a slot • Radiology need to inform patient transport to transport the patient on time • After the x-ray is taken, the patient needs to be sent back but also the x-ray need to be sent to a radiologist to write the rapport. So a radiologist needs to be found • After the rapport is ready, a message need to go back to the originating specialist for urgent follow-up if needed.

The above looks simple but try to add some real world complexity: what if there is a working shift change? Also, what is in most of the cases the reality?

The specialist will ask the nurse to inform him when the results are available, more so when there is more than one task to be done like a lab test and an x-ray. So the nurse ends up checking the EMR for the results. There is a lot of room for workload optimisation.

Today there are a lot of point solutions available in the market to help a particular team in executing their tasks.

A simple nurse call system is one of them.

However, the more point solutions you add the more complicated it becomes.

It is crucial to look into this with a very holistic view. None of the teams you have can work on an island; healthcare delivery is a multi-discipline, multi-team teamwork. So a workload management system should be as well and it should give you all the tools (intelligence) to make optimised decisions. Where are the bottlenecks? What is the expected gain if I modify this or add a person there? It is all about bringing the whole workload into a clear picture.

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Healthcare Management

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The EMR is now the ‘spine’ and it needs arms and legs to function correctly and only then the knowledge (brain) can be developed and used to improve the outcome.

There is no need to go into more details, but as long we do not make it easy for a doctor to collaborate in an ad-hoc basis with colleagues it will not improve the situation. We are in a world where everybody is connected all the time with everybody. We have technologies like presence (knowing if somebody is available before you even dial his number), instant messaging, desktop sharing tools, video etc., yet these technologies are not linked into the EMR system, thus, not making it easy for doctors to collaborate. My last point is linked towards the patient centricity. Governments around the globe are all in consensus that we need to put the patient at the centre of the healthcare delivery as opposed to letting the patient come to the healthcare. In a world that is fast ageing and where people are able to spend more on their personal and family health, patient centricity is not just an option, it is the only way to go.

If all the above points of the EMR adaptation rate improvement via a pervasive mobile network are combined for improving the efficiency of the healthcare delivery and enhancing the collaboration between the caregivers, it

Author BIO

Next comes collaboration. EMR provides individuals (doctors) with snapshots of a patient. That is already a huge improvement over each doctor having some handwritten notes.

However, we all need to recognise the fact that diseases become more complex and more and more patients will see multiple specialists simultaneously.

How do specialists collaborate with each other? Are they not being trained as individuals in their specialty? Leaving that aside for a while, this is how the future will look like: • Governments are seeking for remotehealth / tele-health to reduce hospitaliation costs • Governments are developing stepdown care to offload hospitals and bring people that are recovering into nursing home style of facilities • Governments try to reach out to the entire population hence pushing telehealth • Private hospitals are using tele-health to optimise revenues.

EMR is the only way to make sure that each care giver has a total picture of the patient, but it becomes even more critical that caregivers are able to discuss a patient’s situation on an ad-hoc basis.

It is not that care givers would not talk to each other, as the goal of being a doctor is to help patient, but how can this be facilitated? In other words, how easy is it for a doctor to rope-in another doctor to discuss in two minutes the best course to help a patient. Let’s create a quick scenario: • Doctor X is in front of a patient and sees in the EMR system that Doctor Y (from another discipline) prescribes medicine ABC. Now Doctor X wants to discuss this with Doctor Y • Doctor X can navigate through the HIS to try to find the telephone number of Doctor Y (in some cases Doctor X will ask a nurse to find Doctor Y) • Then he makes a call and there is no answer.

• Later he finds out that Doctor Y is not on duty .

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would automatically contribute towards patient centricity. At the least, it would create a better dialogue by creating more quality time between the patient and the care givers. Healing people is more than a prescription of a medicine; in most cases it requires a change in habits or lifestyle and that requires much more talk time.

There is, however, one more simple point on patient centricity. In the EMR system it would be good if you could find all the scheduled appointments for a particular patient and even better if it would be possible to call-out or at least reach-out to the patient one day in advance of the scheduled appointment to double confirm that the patient will come. This exchange would allow the specialists not to overbook their appointments, and by doing so reduce the frustration of the patient.

If we leapfrog into the near future, say 3-5 years, patient centricity will be much more linked towards tele-health than today. If we are not able to solve the current issues or at least use the EMR system as the spine, we will never be able to move forward.

I hope that with these examples I was able to make some points clear. My only hope is that some of you out there are able to make the link between healthcare delivery and communications. What is described in this article is not a dream, it is full reality. However, it will take the hospital IT teams, the EMR providers and the communication providers some more time to make it a fully preintegrated part. As healthcare is about teamwork, we all should put our hands together to make this happen.

Dirk has more than 20 years' experience in Europe and 9 years in APAC. His extensive expertise covers each domain of the business, from engineering to management, from infra to consultancy and he covers multiple industries like Government, Healthcare, Banking, Hospitality and Education. As a forerunner he launched successful Managed Services businesses, deployed service breaking City Networks and spearheaded the move towards industry specific solutions. He is a well know and appreciated guest speaker for various universities lectures and delivered key notes in major telecom events in Europe and APAC. Dirk is a graduate of Telecommunication and Microprocessors at the University of Antwerp.

Healthcare Management

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Healthcare Management

Medical Errors and Litigations Are they preventable?

The number of medical litigations is increasing worldwide.

That does not necessarily reflect the quality of healthcare givers as much as it reflects the public expectations and awareness. Implementing healthcare quality standards is a key factor in maintaining public trust and significantly reducing the medical errors, ultimately reducing medical litigations.

A comprehensive Enterprise Risk Management Program, focusing on patient and staff safety, is what is recommended for all healthcare organisations to harbour and implement.

Hossam Ghoneim, Executive Director for Medical & Clinical Affairs, Doctor Soliman Fakeeh Hospital, Jeddah, KSA

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edical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, infection or other ailment.

Medical errors happen when something that was planned as a part of medical care doesn't work out, or when the wrong plan was used in the first place.

Medical errors can occur anywhere in the healthcare system hospitals,

Healthcare Management

in clinics, outpatient surgery centres, doctors' offices, nursing homes, pharmacies or even in patients' homes.

Napoleon Bonaparte claimed that “physicians kill as many as we do Generals”. Frank Lloyd Wright wrote “The physician can bury his mistakes, but the architect can only advise his client to plant vines.” (New York times, 1953).

A landmark in the history of medical errors and patient safety is the report of the Institute of Medicine in 1999, ‘To err is Human’. The report estimated a yearly death rate in the United States between 44,000 and 98,000 due to preventable medical errors. These figures are higher than the death rate for Motor vehicle accidents (43,458) and Cancer breast patients (42,297).

The total US National cost was estimated between US$ 17 bn and 29 bn (lost income, lost household production, disability and healthcare cost). Hospitals are thought to spend 10-15 per cent of their budget on medical errors.

How big is the problem?

According to the 2005 commonwealth fund International Health Policy Survey, it is estimated that 22 per cent of admitted patients in UK hospitals experience a form of medical error.

This is estimated to be around 23 per cent in Germany, 25 per cent in New Zealand, 27 per cent in Australia, 30 per cent in Canada and 34 per cent in the United States of America.

Comparable figures are not available for the developing countries. In Egypt, there are around 1200 medical claims against physicians per year.

In Kuwait the number is around 250, while in Saudi Arabia the number of studied claims in the year 2009 was 1356, 50 per cent of which were dismissed.

Under or non-reporting is the main reason for the unavailability of accurate medical errors data in the developing countries. This is mainly due to the unavailability of a robust reporting

Why do we have medical errors?

Traditionally medicine is practiced by certified physicians that carry the ultimate responsibility for patient’s safety. In reality and in practical terms, patient care is a multi-speciality practice in extremely complex hospital settings. Decisions are made, polices and procedures are designed at the top management level.

The practice of medicine is influenced by the work environment, staffing levels, the team involved, the equipment available and the very well-known patient predisposing factors. This is the atmosphere that can lead to errors, violations and unsafe acts if the system designed defenses are penetrated. If we exclude personal staff training and skills, complicated equipment with ongoing emerging technology, powerful medications and long working hours are the most common contributing factors for medical errors.

The complexity of the operating room is the perfect example contributing to the commonest medical error, surgical care. Inside the operating room there are several equipment that needs to be tested and maintained on regular basis before use to ensure its safe operation. Staff needs to be trained on equipment and activities have to be coordinated. Outside the operating room there is the receiving end for patients, instruments, medications, blood and specimens with two-way communication with the inside environment.

Medication errors are the second most prevalent and expensive cause for medical errors. Prescribing errors remain at the top cause for medication errors (39 per cent) followed by errors in administration of the medicine itself (38 per cent), transcribing ranks 3rd (12 per cent) and lastly dispensing (11 per cent).

system with clear case definitions and accountability for reporting. The fear of litigation and the absence of a legal safeguard are added factors.

Can we prevent medical errors and hence litigations?

It is of extreme importance to define the common causes of failures in the healthcare environment in order to prevent errors from happening. Root cause analysis is the preferred method to highlight the real causation. Individual staff negligence, on the average, constitutes less than 10 per cent of the root causes for medical errors. Therefore 90 per cent are correctable system issues that need the utmost attention of healthcare organisations. Communication failure is the leading root cause followed by lack of proper orientation and on the job training, proper patient assessment with missing vital information, staff credentialing, privileging and competency assessment, compliance with policies and procedures,

safety of the environment, leadership, lack of care continuum and care planning and finally the organisations own culture. Physicians and nurses usually fail to communicate due to a historical hierarchical issue, past and vast experience of nurses and their level of empowerment and finally due to the different personal communication styles.

A comprehensive enterprise risk management programme, focusing on patient and staff safety, is what is recommended for all healthcare organisations to harbour and implement.

Enterprise risk management and patient safety In general, risk management is the process of identification, assessment, and prioritisation of risks followed by coordinated and economical application of resources in order to minimise, monitor, and control the probability and / or impact of unfortunate events or to maximise the realisation of opportunities.

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Healthcare Management

In enterprise risk management, a risk is defined as a possible event or circumstance that can have negative influences on the enterprise in question. Its impact can be on the very existence, the resources (human and capital), the products and services, or the customers of the enterprise, as well as external impacts on society, markets, or the environment.

There are 2 main approaches to risk management The proactive approach: Works on forecasting and identifying risks and designs or implements well known and tested solutions to prevent it from happening.

This approach has shown by time to be the most effective, but requires a lot of skills and experience.

The reactive approach: Where all errors are collected and analysed, focusing on finding common system issues that could be corrected in order not to repeat the same error. It is much simpler than the pro-active approach but still requires skills, dedication and expertise.

Proactive risk management Improve communication Most organisations find the I-SBAR communication acronym to be a very useful pro-active tool to be utilised in all patient care related communications. It definitely eliminates the nurse / physician sensitive issue as well. The acronym stands for “I”: Introduce yourself and the reason for calling “S”: Situation for the patient (age, gender, general condition) “B”: Background of relevant details, including medical history “A”: Assessment and the related findings “R”: Recommendation/request Failure of hands off written communication between shifts This is a well-recognised cause for medical errors. Hands off communication occur between the same category of healthcare givers (for example physician to a physician) at the end of a shift or

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A comprehensive enterprise risk management programme, focusing on patient and staff safety, is what is recommended for all healthcare organisations to harbour and implement.

the beginning of a new shift. The Agency for healthcare research and quality advocates the use of the ‘Five Ps’ for hands off communication which stands for: patient, plan, purpose, problems and precautions.

Multi-disciplinary patient care meetings At times the most responsible physician is unable to reach a diagnosis or formulate a definite plan of care for his/ her patient. This is the time to call for a multi-disciplinary meeting involving all healthcare givers looking after the patient and also to invite suggested specialities that may help in solving the problem at hand. It is best to involve the patient/ family in the outcomes of the meeting with full explanation so all agree on what is required to be done. The meeting is to be carefully documented in the patient's file, including the patient / family understanding and agreement.

Standardised verbal and telephone orders This is a common cause for errors related to receiving test results or orders. Verbal orders should be limited to emergency situations when there is no time to appropriately write the order required.

The staff receiving the order should acknowledge hearing the correct order by verbally repeating it to the ordering staff. The ordering staff should immediately write the order as soon as the emergency is over. Telephone orders should be repeated in a read back fashion, whereby the receiving staff immediately writes the

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order in the file and reads it back to the ordering staff.

Credentialing and privileging The credentials of each and every healthcare giver should be carefully studied by a group of experts to ensure that the staff has the right qualification and experience necessary to carry on the job description of the desired post. It is of utmost important to check on the authenticity of the evidence of qualifications and experience by contacting the source where the certificate originated from. Physicians are assigned what their qualifications and experience allows them to perform in clinical practice (privileging). This could be further categorised to include what is allowed to be performed with and without supervision to enhance their training. All privileges has to be available to all ancillary staff in areas where procedures are performed, in order to ensure that the physician is performing what he/she is allowed to only. The process of credentialing and privileging should be periodic to cover the initial assignment period and any further contract renewals and it also has to be flexible to allow for revision of a physician's privilege or credentials when the need arises (recent morbidity, new certification in a procedure or a new qualification).

Development, use and monitoring of clinical practice guidelines and clinical protocols Evidence-based guidelines and protocols, targeting the management of high risk diagnoses, the high volume or the problem prone cases, have proven to improve clinical outcomes. It also serves as a legal back up in a court case.

Accountability of the attending physician It is important for attending physicians to review all consultative orders and plans requested by other physicians and healthcare givers to ensure uniformity of care and avoid conflicts in plans. Coordination of care, for example by case managers, does not

Healthcare Management

Professional development This is an integral part of any human resource plans. Organisations should always encourage the staff to seek higher degrees and training by providing them with time and opportunities for learning.

Standardised assessment and re-assessment forms To ensure that all information required for patient management is available at any time for all healthcare givers.

Electronic medical records In addition to its great value in standardising the process of documentation, it also provides a safer platform for medication management as it eliminates transcribing errors, alerts physicians of possible interactions, maintains a drug profile for each patient and helps in administering the right drug to the right patient in the right dose and format and at the right time and saves a confirmatory document.

General orientation and on the job orientation: New comers have to be given enough time to orient to the organisation and their area of assignment. Hospital general orientation program should be based on quality standards that affect patient and staff safety, in addition to the general employee relation issues that interests new staff. Departmental orientation is meant to focus on how the staff can perform their duties in the most effective and efficient way, including the different interactions with other departments.

Ongoing monitoring and evaluation of staff performance It is very important to have an objective assessment tool that highlights areas of weakness in the staff members for further improvement. This tool includes, but not limited to, personal interactions, reports on clinical outcomes (length of stay patterns, ordering of blood and blood products, operating times

and patients' returns to operating room, significant morbidity, preventable mortality, compliance with patient safety goals), self-professional development and quality of medical records documentation.

Active patient and family education and participation in the care process A well-informed patient and family can rarely complain about outcomes, especially with effective documentation.

Optimising staffing levels Overworked and exhausted staff are liable to make mistakes. Staffing levels should follow acuity of care rules as well as the nature of practice.

Reactive Risk Management Healthcare organisations must track all incidents, morbidities and mortalities. Risk management team should be involved in analysing all such events and putting together corrective system recommendations to prevent it from recurring. Hospital staff should receive a periodic feedback on the events and a summary of the recommended corrective actions. Examples of the possible tracking methods include: Compulsory reporting of accidents, variances, sharp injuries, medication errors, adverse drug reactions, blood transfusion reactions and patient falls Audits, targeting a specific procedure, diagnosis or staff member Open and closed medical records review Trigger tools Reporting of sentinel events and near misses Morbidity and mortality reviews.

Finally, it is obvious that all this requires a change in the culture of organisations and individuals to move from a physician oriented and controlled practice into a team work within the borders of an evidence based system of patient and staff safety. A system where transparency is the rule and information is shared in order to establish further improvements and actively prevent errors from happening.

Patient safety goals Implementation and monitoring of patient safety goals has proven to reduce errors related to patient identification, communication, the use of high alert medications, wrong site, wrong procedure, wrong patient surgery, patient falls and healthcare acquired infections.

Leadership rounds When constructed in an educational format helps leaders to identify staff weaknesses and assures staff of the continuous support to quality from leaders. Further educational programs can be designed according to common findings.

Structure and process design It is very important to realise that patient outcomes are very much linked to the way a procedure was designed to be executed or the design of the place where the procedure takes place. Therefore, any new procedure to be modified or introduced to the organisation or a modification to an existing area or constructing a new procedure area has to be studied carefully by a multidisciplinary group that have the skills and knowledge to reach a safe procedure or design.

Author BIO

substitute the accountability of the attending physician.

Hossam Ghoneim is the Executive Director for Medical, Clinical and Nursing Affairs for one of the largest private healthcare organisations in Saudi Arabia (Dr. Soliman Fakeeh Hospital). He is also an Intermittent Consultant for the Joint Commission International.

He has over 17 years of leadership and management experience in healthcare, experience in quality management and patient safety and 25 years of clinical experience in Obstetrics and Gynecology and Women's Health.

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MEDICAL FAIR ASIA The most definitive platform for innovative medical and healthcare technologies in Asia 9th International Exhibition on Hospital, Diagnostic, Pharmaceutical, Medical & Rehabilitation Equipment & Supplies

Presented by Messe Düsseldorf Asia, under the Messe Düsseldorf Group’s international series of medical trade shows, the biennial MEDICAL FAIR ASIA has a 15 year proven track record offering a dynamic business platform for procurers, healthcare givers, practitioners and professionals, and high calibre decision makers from across Asia to network, source for products and share expertise.

Riding on the success of the last eight editions, the ninth edition of MEDICAL FAIR ASIA will once again be the central exhibition for the region’s hospital, diagnostic, pharmaceutical, medical and rehabilitative sectors.

Set to take place on 12 to 14 September at Suntec Singapore, MEDICAL FAIR ASIA 2012 is the largest and most comprehensive edition to date, with an impressive 50% expansion in floor space from the last edition held in 2010. A clear indication of the appeal and relevance of the exhibition, the show expansion also reflects the rising demand for improved medical and health products and services in the region.

MEDICAL FAIR ASIA 2012 will showcase the industry’s latest products, solutions and services from some 500 leading international and regional manufacturers and suppliers from 35 countries.

The internationality of the exhibition is further enhanced by the strong participation of national groups and pavilions from Austria, China, France, Germany, Japan, Korea, Malaysia, Singapore and Taiwan. Growing from strength to strength, MEDICAL FAIR ASIA 2012 is also expected to attract 10,000 trade visitors, a 30% increase from 2010.

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Product Range Accident & Emergency Equipment Building Technology & Services Catering & Kitchen Equipment Communication & Information Technology Dental Equipment & Supplies Diagnostics Disinfection & Disposal Systems Electromedical Equipment/ Medical Technology Fabrics/Laundry Medical Furniture & Equipment Laboratory Equipment Medical Consumables Ophthalmic Supplies Rehabilitation Equipment/Orthopaedic Supplies Pharmaceutical Supplies Services & Publications Visitor Target Group Health Ministry Officials Hospital Managers and Employees Doctors (Surgeries and Hospital Nursing Officers Hospital Technicians Biologists, Biochemists, Technicians Dispensing Chemists, Pharmacists Physiotherapists Rehabilitation Organisations, Nursing Homes Organisations for the disabled Care Services & Self-help groups Visitors from Industry and Commerce

Date / Venue / Opening Hours 12 - 14 September 2012 Suntec Singapore Level 6, Hall 601, 602 & 603 10.00 am to 6.00 pm Admission Open to all involved in medical and healthcare. Admission is free by registration only.

Dress Code Office/work attire Exhibitor Registration Book your booth space online at www.medicalfair-asia.com Visitor Registration Pre-register online at www.medicalfair-asia.com

Connect on a global scale: The internationality of MEDICAL FAIR ASIA 2012 is enhanced by strong participation of national groups and pavilions from Austria, China, France, Germany, Japan, Korea, Malaysia, Singapore and Taiwan.

MEDICAL MANUFACTURING ASIA Inaugural exhibition on manufacturing processes for medical technology.

Raising the bar and providing a platform for the medical technology segment, this year, Messe Düsseldorf Asia will present a new trade exhibition – MEDICAL MANUFACTURING ASIA 2012 in partnership with the Singapore Precision Engineering & Tooling Association (SPETA).

Widen your market exposure. Achieve your sales targets. Forge new business partnerships. All at MEDICAL FAIR ASIA 2012. Book your booth space today at www.medicalfairasia.com.

Market facts By 2012, Asia Pacific’s healthcare market is expected to reach close to 27% of the global market and estimated to be valued at about US$ 349 bn.

With a double-digit growth rate for the past few years, India, Singapore and Thailand dominated the region’s medical tourism industry, with a combined market share of over 89% in 2010.

The medical tourism market in Asia is projected to hit US$ 5.4 bn by 2012.

Held concurrently with MEDICAL FAIR ASIA and OS+H Asia (Occupational Safety + Health Exhibition for Asia) 2012, this inaugural exhibition comes at a time when the Asia Pacific medical device market is expected to account for 25% of global market share and reach US$ 62.3 bn in revenue by 2012. In collaboration with IE Singapore and SPRING Singapore, the exhibition is supported by Messe Düsseldorf GmbH, organiser of COMPAMED, the world’s leading international trade fair for suppliers of the medical manufacturing industry.

With both MEDICAL FAIR ASIA 2012 and MEDICAL MANUFACTURING ASIA 2012 presenting the complete synergistic range of medical products, exhibitors and visitors alike can expect to see the whole process chain for medical devices, and interact simultaneously with manufacturers, suppliers and system partners.

For more information: MEDICAL FAIR ASIA 2012 E: medicalfair-asia@mda.com.sg T: (65) 6332 9620 W: www.medicalfair-asia.com MEDICAL MANUFACTURING ASIA 2012 E: mma@mda.com.sg T: (65) 6332 9620 W: www.medmanufacturing-asia.com

Advertorial

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Healthcare Management

Strategic Innovations in Care Transitions for High-Cost Populations A guide for healthcare systems, providers and payers

This care transitions guide for healthcare systems, providers, and payers elucidates strategies for addressing the high cost of multiple chronic conditions. Care transitions are organised into five dimensions and innovations are presented that maximise the value proposition in healthcare.

Innovations include service delivery, payment, information technology, and education models.

Gloria N Eldridge, Initiative Director, Strategic Innovations for Health Care Reform, USA

W

hether they are an advanced, emerging or developing economy, countries throughout the world struggle with the economic effects of chronic conditions and co-morbidity, also known as Multiple Chronic Conditions (MCC).

This review outlines the key USA strategic innovations in care transitions, some accelerated by the 2010 Affordable Care Act and others by entrepreneurs keen on leveraging health information technologies.

This review is intended as a guide for structuring care transitions towards minimising cost escalation and maintaining or improving quality (a combination known as the ‘value proposition’).

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Healthcare Management

Five dimensions of care transitions In healthcare systems, individuals with MCC often require care transitions between multiple providers, and the science of structuring care processes becomes paramount to care quality and cost. Metrics that indicate effective care transitions include: • Decreased costs of care for institutionalisation, such as for hospitalisations due to ambulatory-care-sensitive conditions, readmissions, and nursing home admissions; • Reductions in emergent care costs and utilisation; and • Reductions in total cost of care.

As part of this science, strategic innovations in care transitions can be organised in five dimensions: information flow, hospital discharge and readmission, medication reconciliation, targeting high-risk patients, and patient and family activation. If these five care transition dimensions are addressed, then value will be realised in the most costly population facing healthcare systems: those with MCC.

Information flow A number of adverse events for individuals with advanced illness result from failures of information transfer and sharing within the healthcare system. These failures include not informing patients of clinically significant test results; inadequacies in hospital discharge summaries to document pending tests or to follow up with providers; inaccuracies in prescription drug regimen plans; and the failure to communicate critical information between care settings, such as advance directive preferences. Patients experience reductions in health outcomes, increased hospital readmission rates, and often a sense of clinician abandonment, particularly when they transition to end-oflife care. Interventions to improve the flow of information include standardised forms; adoption of full and accurate electronic medical record systems; and provider-to-patient communication strategies that emphasise patient activation, meaning active involvement in the care and care transition processes. Two types of information flow problems, hospital discharge and medication reconciliation, are so prevalent that they are broken further.

Hospital discharge Hospital discharge is the process of preparing a patient for moving from one setting to another, requiring multiple individuals and care settings to work in concert to provide a safe transition. In the USA, one in five hospitalisations result in post-discharge complications often requiring readmission.

Four problems emerge:

(1) Lack of standardisation across care settings and providers results; (2) Shortcomings in delineation of responsibilities and accountability; (3) Deficiencies in availability and timeliness of patient information post-discharge; and (4) Discharge summaries’ frequent lack of important and pending test results, full documentation of treatment during hospitalisation, medication lists, and family and caregiver education or counseling.

Medication reconciliation Medication reconciliation is the process of examining prior, current, and planned medications and the patient’s capacity to managed medication use in order to optimise medication use.

Furthermore, medication reconciliation compares a patient’s medication orders to all medications that the patient has been taking in order to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. In the United States, medication reconciliation errors are as high as 67 per cent for hospital inpatients at the time of admission, and adverse drug events are as high as 20 per cent among patients discharged from a hospital.

Targeting high-risk patients Strategies to identify individuals at high risk for hospitalisation in the next year or readmission within 30 days of discharge may involve predictive modeling techniques. However, data shows that an assessment by a skilled discharge planner or care coordinator does as well as any predictive model currently available.

The ideal process would identify high-risk patients and then introduce interventions that reduce the risk of hospitalisation or readmission. Currently, no predictive modeling techniques assess risk and how particular interventions change risk.

Patient and family activation Increasingly complex health systems rely on patients and families to be well-informed about their diagnosis or condition, its specific treatments, and their individual care plan. Patients who are involved in their own care—that is, who take charge of their health and participate in self-management behaviors—are described as being ‘activated’ or ‘engaged.’ A recent Altarum Institute meta-analysis resulted in the following lessons: patient activation levels can be measured, patient activation levels can predict health outcomes, and patient activation levels can be used to identify and predict at-risk patients.

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Healthcare Management

A new focus on the prevalence and costs of chronic disease The population health and economic burden of non-communicable and chronic diseases such as chronic respiratory, diabetes, cancer, and chronic cardiovascular disease received the attention of the United Nations (UN) General Assembly in autumn 2011. In only the second health-focused meeting of the UN General Assembly in its history (the first targeted AIDS), global leaders grappled with the staggering toll of chronic disease.

In the USA, healthcare systems are also pressed to address the specific dilemmas raised by multiple chronic conditions on health and costs of care. More than one in four Americans, or approximately 60 million people, have two or more chronic conditions. This number is only growing as the population ages. By the year 2020, an estimated 80 million people will have multiple chronic conditions. In the US Medicare program that provides health insurance to those over the age of 65 and the disabled, the high prevalence of MCC has profound cost implications. Currently, the 23 per cent of Medicare beneficiaries with five or more chronic conditions account for 68 per cent of the program’s spending.

However, these issues are particularly prevalent among dual enrollees at a cost of US$ 320 bn a year – a population enrolled in Medicare and Medicaid, the US health financing program for those with low incomes.

Strategic innovations in care transitions In general, multiple strategic innovations can be leveraged, including integrated service delivery systems, payment methodology reforms, and health information and mobile health technologies.

Information technology is especially important in care transitions for those with advanced illness and can include health information exchange and interoperable electronic medical record systems, remote clinician visits, remote health monitoring, mobile health (such 18

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as mobile phone applications), virtual patient advocates, and artificial intelligence. Addressed here is a selection of these strategic innovations.

Accountable Care Organisations (ACO) and Patient-Centered Medical Homes (PCMH) ACOs are networks or sets of providers and institutions, such as primary care physicians, specialists, and hospitals, that have joint responsibility for the quality and cost of care for a population.

To encourage physicians and hospitals to establish these organisations, a bonus payment structure (in addition to a standard fee-for-service model) that rewards ACOs for reducing cost growth and meeting established quality of care targets is required. Cost savings from this model result primarily from reduced hospitalisations and readmissions.

PCMHs are delivery models provided by physician practices that seek to strengthen the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term provider relationship. Each patient has an ongoing relationship with a personal primary care provider who leads a team that takes collective responsibility for each patient’s care. This care team is responsible for providing all the patient’s healthcare needs and, as needed, arranges for appropriate care with other qualified providers. ACO and PCMH models can exist alone or in combination with each other. The primary goal is a more integrated care system across the continuum of care where savings accrue to benefit the organisation and not just the thirdparty payer.

Bundled payment systems Bundled payment provides a single payment for all services related to a specific treatment, condition, or individual, possibly spanning multiple providers in multiple settings. Bundled payment gets away from fee-for-service arrangements that reward providers for maximising the quantity of services provided ISSUe - 25 2012

(e.g. the number of hospital admissions or prescribed services). Bundled payment works in integrated provider networks or arrangements, such as ACOs or PCMH models, that can arrange for an entire episode of care to be delivered for a set fee. It places providers at financial risk for service utilization and costs, including complications. For example, all services for coronary artery bypass graft surgery and 30 days of follow-up make a bundle in Geisinger Health System’s ProvenCare coronary bypass programme. First year evaluation results showed a 10 per cent reduction in readmissions, shorter average length of stay, and reduced hospital charges.

Remote monitoring The collection of biometric information through a standalone device or personal data assistant (PDA) is developing as an innovative strategy for clinicians to regularly track personal health data remotely. Remote monitoring devices exist for multiple types of biometric data collection, including pulse oximeters to measure the oxygenation of hemoglobin (for chronic obstructive pulmonary disease); blood glucose level monitors (for diabetes); electrocardiography (for heart conditions or where diagnosis involves interpretation of electrical activity of the heart); and basic measures such as pulse rate, heart rate, weight, and temperature. Furthermore, PDAs are being used to measure cognitive measures and subjective reports of mental health status, such as depression measures, for diverse populations from war veterans to elders to caregivers. One highly awarded company is MedApps Mobile Health Monitoring, which features a series of remote monitoring products that send health data to a cloud-based electronic health record immediately upon measurement and is capable of tracking this biometric information over time. Evaluation research on remote monitoring is sparse, and private and public consideration of reimbursement strategies is in its infancy. Remote

Healthcare Management

Table 1: Strategic Innovation by Care Transition Dimension Care Transition Dimension

monitoring potentially fits very well with PCMH and ACO models of service delivery integration.

Self-management education Self-management education interventions are generally 4–7 weeks in duration and designed to activate patients to manage their chronic conditions.

Formal training protocols, where fidelity of the program is maintained

Patient Discharge

Medication Reconciliation

Targeting

Patient Activation

Strategic Innovation

ACO and PCMH Bundled Payment Remote Monitoring Artificial Intelligence SelfManagement Education

is paramount as documented in the randomised controlled trials that have evaluated these interventions. The trials have found that a subset of these interventions significantly reduced hospitalizations and costs over a period of 6–21 months. The National Coalition on Care Coordination describe these efforts as enabling “patients to self-manage symptoms/problems, engage in activities that maintain function and reduce health declines, participate in diagnostic and treatment choices, and collaborate with their providers. The necessary education is provided by a mix of medical and non-medical professionals.” An example of self-management education is Stanford’s Chronic Disease Self Management Program. Multiple other evidence-based interventions address additional wellness modules beyond general education and activation for self-care.

Brief discussion and conclusion This review has presented a breakdown of five dimensions of care transitions. It

Author BIO

Artificial intelligence Artificial intelligence innovations involve the use of the vast storage and analytic capacity of computers and iterative learning technologies to improve healthcare. A number of artificial intelligence applications are either being used or under development. First, alert and reminder technologies are being used for prescribing physicians, pharmacists, family members, and patients to improve adherence to medication regimens as well as the prevention of adverse drug events due to medication reconciliation errors. Second, remote sensing devices are being used to indicate when an individual has left a bed, room, or house in order to track behaviour patterns and make sure that the individual has not fallen or wandered into an unsafe situation, as in the case of someone with cognitive difficulties. Third, mobile robots with visual image recognition and interpretation capabilities are being developed so that institutions such as hospitals and nursing homes are alerted if someone has fallen (e.g. iRobot’s AVA platform).

Fourth, ‘intuitive’ surgical systems are being used for a broad range of surgeries where the assistance of a vast array of past data points guides clinicians (e.g. Intuitive Surgical’s DaVinci system). Fifth, avatars are being used to guide hospital discharge processes so that family members and patients are walked through the key steps of a wellarranged discharge that minimises the potential or readmission or medication reconciliation errors (e.g. Project RED [Re-engineered Discharge]).

Information Flow

has also introduced six varied strategic innovations that can be used to address the challenges presented by these care transitions dimensions. Table 1 outlines which care transition dimension is addressed by which strategic innovation discussed.

In conclusion, the goal is for the healthcare system to be more integrated so that consumers receive the best possible care and payers support high-quality care for the most reasonable price. First, the strategic innovations in care transitions presented here, whether service delivery, payment, information technology, or education based, are intended to be used in concert with one another.

Strategic innovations must be seen as complementary and adopted, reimbursed, and evaluated as such. Second, in order for the value proposition to be achieved for high utilisation patients with MCC, incentives must work in the same direction, not to disparate ends.

Consumers, payers, and providers all have a role to play in aligning incentives to achieve the value proposition.

Gloria N Eldridge has worked extensively in health policy and on the economics and politics of national health reform. She is Director of Altarum’s Strategic Innovations for Healthcare Reform Initiative and a collaborating member of Altarum’s Center for Elder Care and Advanced Illness. While her work has concentrated on advanced economies, she has also worked in emerging markets and the developing world. The World Health Organisation/Europe (Copenhagen, Denmark), part of the UN network, and The Lewin Group (Washington D.C., United States and London, United Kingdom), a leading thought leader in healthcare reform, are previous employers. Dr. Eldridge holds degrees from the University of Texas at Austin, the London School of Economics, and Yale University.

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Medical sciences

B

reast carcinoma is among the most frequent malignant diseases in the world and is the leading cause of death among younger women in developed countries. Currently, 1 in 7 woman in these countries will have the disease in their lifetime (Boyle and Ferlay). Since 1940, the incidence of breast carcinoma has gradually increased at a rate of approximately 1 per cent per year in Western countries (Harris et al.). On the other hand, mortality from breast cancer has declined in coun-

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tries with organised population-based mammography screening (Smith et al.

2004).

New efficient therapeutic regimes have led to prolonged survival of patients with improved quality of life (Hortobagyi). These interventions have considerably increased the number of breast cancer survivors, and a further increase of 31 per cent is expected from 2005 to 2015 (De Angelis et al.).

Screening, diagnosis, and treatment will place an ever growing burden on

ISSUe - 25 2012

the healthcare system, in addition to the psycho-social consequences for the women of coming generations. Obviously, a paradigm shift in understanding the natural history of breast carcinoma is needed to develop new and more efficient preventive, diagnostic, and therapeutic alternatives and break the negative trend.

Mortality rates have declined in all age groups since the late 1980s (Figure 1). Between 1989 and 2008, the breast cancer mortality rate fell by 44 per cent

Medical sciences

Breast Cancer Past, present and future

While a cure has not yet been found, public perception surrounding breast cancer has changed dramatically. Once a disease that women felt ashamed to discuss, breast cancer now has lost much of its stigma, providing the opportunity for politicians and healthcare officials to acknowledge that economic and political considerations bear on the success of breast cancer treatment as much as advances in medical science.

Mohammed Jaloudi & Jihad Kanbar Department of Oncology, Tawam Hospital, Al-Ain, Abu Dhabi, UAE

in women aged 40-49 years; by 44 per cent in women aged 50-64; by 37 per cent in women aged 65-69; by 39 per cent in women aged 15-39; and by 19 per cent in women over 70. Two major reasons have been attributed to this decline: increased use of screening mammography and greater use and improvements of adjuvant therapies such as hormonal and chemo-therapeutic agents. In UK, breast cancer is the most common cancer accounting for 31 per cent of all cases in women; the next most common cancer in women is lung cancer. So nearly a third of all new cancers in women are breast cancers. It has been estimated that the lifetime risk of developing breast cancer in 2008 is 1 in 1,014 for men and 1 in 8 for women in the UK. A recent retrospective analysis in UAE showed that breast cancer risk is related to age, with 35 per cent of cases occurring in women aged 40 years and over. Nearly 24 per cent of cases of breast cancer are diagnosed in the 50-69 age groups (Figure 2). According to the World Health Organisation, the occurrence of breast cancer ranks number 1 in most Arabic countries (Table 1).

An increase of more than 50 per cent of breast cancer cases has been seen in UAE over the past decade.

Surgery Mammary carcinoma has been documented as far back as 6000 BC, but the attempts at treatment can only be considered barbaric. Egyptians treated this cancer by literally burning it out.

They would cauterize the mammary glands so painfully that women nearly never came forward when they noticed a lump. Dying of a mammary carcinoma happened to be a much better fate than the treatment of the day as was the case even up until the 18th century.

Mastectomy for breast cancer was performed at least as early as 548 CE, when it was proposed by the court physician Aetios of Amida to Theodora. It was not until doctors achieved

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Medical sciences

Figure 2: Trends of breast cancer in United Arab Emirates 2008 – 2010

ate outcome and determine the appropriate surgical procedure.

1200 1000 800 600 400 200 0 15 to 30

31 to 40

41 to 50

51 to 60

greater understanding of the circulatory system in the 17th century that they could link breast cancer's spread to the lymph nodes in the armpit. The French surgeon Jean Louis Petit (1674– 1750) and later the Scottish surgeon Benjamin Bell (1749–1806) were the first to remove the lymph nodes, breast tissue, and underlying chest muscle.

Their successful work was carried on

by Halsted who started performing mastectomies in 1882. Halsted became known for his radical mastectomy, a surgical procedure that remained popular up to the 1970s and was performed on Betty Ford.

By the 19th century, the use of anaesthesia as well as sterilization was brought into the surgical industry which lessened pain and improved the patient's chances of survival and complete recovery. Once this had occurred, not only were mastectomies much more common, but breast reconstruction become possible without putting the patient's life in as much danger as previously.

Since the advent of the modern era radical mastectomy first performed in 1882, great strides have been accomplished over the last century leading to the modified radical mastectomy in the 1980s and to present day breast conserving surgery. The Halsted radical mastectomy, once considered the ideal cancer operation, no longer has a place in the routine management of patients

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61 to 70

71 to 80

80+

All Ages

with breast cancer. This represents a major departure from Halsted's principles of the total resection cancer surgery which was very disfiguring.

Prospective randomized clinical trials in the 1970’s demonstrated no difference in survival between patients treated with modified radical or radical mastectomy. The most influential of the studies refuting the Halsted's principles was the NSABP-BO4 trial. Published results of modern prospective randomized trials comparing conservative surgery with radiotherapy and mastectomy have all shown equivalent survival between the two treatment approaches.

Other studies are ongoing as well to establish the validity of the less-invasive sentinel node biopsy in determining axillary nodal status. Perhaps the most significant change in today's approach to breast cancer is the reliance on wellcontrolled prospective studies to evalu-

Systemic hormonal therapy Advances in hormonal therapy have also had a great insight on breast cancer survival. In the 1880s a few physicians reported significant regression of breast cancer tumours following removal of the ovaries. In 1896, George Beatson performed the first bilateral oophorectomy as a breast cancer treatment. In 1966, the receptors for estrogen were identified. With this finding, a target to stop growth of breast cancer cells fueled by estrogen was explored. A few years later, V. Craig Jordan showed that Tamoxifen could prevent breast cancer in rats by binding to the estrogen receptors. In 1977 Tamoxifen was approved

by FDA for hormone positive breast cancer.

The Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) overview analysis demonstrated a significant advantage with the addition of Tamoxifen for five years to the adjuvant therapy regimen of women with estrogen receptors positive breast cancer regardless of age.

In 1998 Bernard Fisher reported that Tamoxifen reduced the incidence of breast cancer by 45 per cent in highrisk women; this was the first successful chemoprevention trial in breast cancer.

Treatment with Tamoxifen reduced the risk of death by 14 per cent in women younger than 50 and by 27 per cent in those 50 years of age and older.

Table 1: most common cancer in the Arabic region shows clearly that Breast cancer cases are higher than others.

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Medical sciences

The late 1990s saw the introduction of a new class of drugs called aromatase inhibitors. These drugs are currently available for hormone positive breast cancer in post menopausal women.

Although overall survival has not been reported, time to disease recurrence and time to distant recurrence, and reduction in the incidence of contralateral breast cancer all favor the use of AI’s.

Targeted Therapy The 1980s saw the discovery of the Cerb2 or Her2/neu gene by Dennis Slamon and others. Approximately 20 per cent of breast cancer patients have her2/neu positive cancer. This is associated with reduced survival and time to relapse. Slamon’s discovery provided an important opportunity to evaluate the concept of targeted cancer therapy and in 1998, Trastuzumab , the first humanized antibody targeting a cancer related gene was approved by the FDA for her2/neu – positive MBC. Eight years later, it was approved in the adjuvant setting. Another drug,

Lapatinib; which inhibits the intracellular tyrosine kinase domains of EGFR and her2 receptor was added to the armamentarium of her2 positive breast cancer in the 2008.

Pertuzumab, an anti-HER2 humanized monoclonal antibody that inhibits receptor dimerization, and has a mechanism of action that is complementary to Trastuzumab, has shown encouraging results in recently published clinical trials Systemic Chemotherapy Breast cancer is a relatively chemosensitive disease and chemotherapy in both the adjuvant and metastatic setting is used widely. Another major contributor to the improvement in breast cancer survival has been the institution of systemic chemotherapy in the adjuvant as well as the metastatic setting since the 1970’s. Randomized trials have addressed many fundamental questions related to adjuvant chemotherapy. The two major trials which had an impact on the care

of women with breast cancer and the design of future strategies were the NASBP trial using Melphalan and the trial by Bonnadonna using CMF. CMF quickly became the standard of care for node positive breast cancer. In recent years, anthracycline and taxanes have become the backbones of treatment as many trials incorporating these agents have had a great impact on survival. The new century brought with it the use of antiangiogenic agents to control cancer. This concept dates back to 1971 with the discovery

by Judah Falkman that angiogenesis plays a major role in tumor growth and metastases. Bevacizumab, a humanized monoclonal antibody that targets the VEGF became the first antiangiogenic agent approved by the FDA in 2004 for colon cancer. Approved in early 2008 for metastatic breast cancer, its use in the current setting has been revoked by the FDA, though the European Medicines Agency (EMEA) still considers Bevacizumab as a treatment option in certain settings

New Hope for the Twenty-first Century Breast cancer is by far the most frequent cancer among women with an estimated 1.38 million new cancer cases diagnosed in 2008 (23 per cent of all cancers), and ranks second overall (10.9 per cent of all cancers). It is now the most common cancer both in developed and developing regions with around 690,000 new cases estimated in each region, Current World wide Breast Cancer Age-standardized mortality rates is 14.1 per 100,000 population in 2008; while in U.A.E. it is estimated at 10.9/ 100,000 new cases diagnosed per year and an estimated 75 deaths With the decline of the Halstead radical mastectomy and a revised theory of metastases, physicians hypothesized about the origins of breast cancer and, during the 1990s, everything ranging from diet, chemical pollution, race, delay in having children, and breastfeeding was up for debate. A recent research has also shown that obesity may increase the risk of developing breast cancer as well. Despite this uncertainty, there are still advances in the treatments for breast cancer; with breast cancer rates and deaths remaining high until 1995.

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The improvements in chemotherapy, radiation, hormonal treatments, mammography, and surgery helped move breast cancer from an urgent disease to a chronic condition. Today, advances in molecular and genetic sciences are creating novel therapeutic strategies that give women not only hope but also more choices about their bodies. There are some studies in their initial stage are currently ongoing using the concept towards creating an anti breast cancer vaccine.

Breast cancer is a complex, diverse, and so subtly connected to genetic and environmental variables making a cure can often seem impossible. While a cure still has to be found, public perception has changed in recent years.

Once a disease that women were concealing, breast cancer now has lost much of its stigma and women are open to discussing their disease and seek treatment, providing the healthcare officials with an opportunity to acknowledge that economic and political considerations bear on the success of breast cancer treatment as much as advances in medical science.

Medical sciences

SUB NOW SCRIB ! E

as BRCA1, was responsible for many breast and ovarian cancers—as many as 5-10 per cent of all cases of breast cancer may be hereditary. The identification of two tumor suppressors’ genes BRCA-1 and BCRA-2 has provided great insights into the understanding of breast cancer genetics.

Epidemiological studies have established a set of relatively convincing risk factors for breast cancer such as:

family history of breast cancer, possibly due to inherited genetic abnormalities; rapid growth early in life, greater height, higher socio-economic status, and older age. In addition, some probable risk factors are: diet low in fruit and vegetable intake, or high in meat/ fat intake, higher alcohol consumption, high post-menopausal body mass index (BMI), and lack of exercise and history of benign breast tumours.

Mohammed Jaloudi is currently Chairman of Medical Oncology at Tawam Hospital in Al Ain, UAE. Dr. Jaloudi was born in Jordan and left at a young age with his family to the United States. He grew up in New Jersey where he attended grammar and high school. He received a Bachelor of Science degree in Biochemistry from Fairleigh Dickenson University, NJ in 1986. After graduation from Ross University school of Medicine, he started a general surgery residency at The Jersey Shore Medical Center followed by a residency in internal medicine at The University of Medicine and Dentistry of New Jersey (UMDNJ) from 1991-1994. He also served as Chief Resident from 1994-1995. During his medicine training, he was awarded the intern of the year and the Squibbs Humanitarian Award in 1995.

Author BIO

Genetic factors The most well-publicised breast cancer gene, and the one associated with the highest risk of developing the disease, is BRCA1. Another gene--BRCA2--causes significantly increased risk, as well. All people have these genes; only when humans inherit certain mutated forms do their breast cancer risk increases.

According to the American Cancer Society (2009), Women who inherit the mutated version of BRCA1 or BRCA2 have a 57 or 49 percent chance, respectively, of developing breast cancer by age 70. Fortunately, less than 1 percent of the world population carries the harmful versions of these breast cancer genes.

It is in the 1990’s, when Mary Claire King localized the BRCA-1 gene for inherited susceptibility to breast cancer to a specific site on chromosome 17, the BRCA-1 gene was ultimately cloned in 1994. King demonstrated that a single gene on chromosome 17, later known

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Surgical Speciality

Eldar S Brethauer SA Philip R Schauer Professor of Surgery, Lerner College of Medicine Director, Advanced Laparoscopic & Bariatric Surgery Helen Heneghan Advanced Laparoscopic & Bariatric Surgery Research Fellow Bariatric and Metabolic Institute, Cleveland Clinic, Ohio

Treating Diabetes as a Surgical Disease In addition to the significant and durable weight loss achieved with bariatric surgery, these procedures have been observed to induce profound metabolic changes including improvement or even remission of type 2 diabetes mellitus (T2DM), hypertension and dyslipidemia. This article outlines the metabolic effects of the most commonly performed bariatric procedures, with a particular emphasis on how they affect glucose metabolism and T2DM.

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T

he rising prevalence of obesity, coupled with disappointing results of non-operative weight reduction programmes, has led to the prosperity of bariatric surgery.

The development of minimally invasive surgery techniques over the last two decades has further enhanced the safety profile and appeal of surgically-induced weight loss approaches. It was recently

Surgical Speciality

estimated that close to 350,000 bariatric operations were performed worldwide in 2008. While the primary indication for these procedures is to achieve significant and durable weight loss, their remarkable metabolic effects merit equal attention. Improvement or resolution of the metabolic syndrome components, diabetes, hypertension and dyslipidemia form only a partial list of the obesityrelated comorbidities positively affected by bariatric surgery. In fact, the term ‘metabolic surgery’ has been coined to reflect the whole spectrum of effects induced by bariatric procedures.

In particular, the dramatic and prompt remission of T2DM postoperatively has stimulated researchers to investigate the exact mechanisms responsible for this phenomenon. Disease remission or improvement usually occurs before any significant weight loss has occurred, implying that other mechanisms are responsible for the improvement in

glucose homeostasis seen particularly after the Roux-en Y gastric bypass procedure. Currently, NIH guidelines recommend bariatric surgery for patients with a Body Mass Index (BMI) greater than 40 kg/m2, or a BMI >35 kg/m2 with obesity related comorbidities. The FDA recently expanded these criteria, approving gastric banding for patients who have a BMI >30 kg/m2 with obesity related comorbidities. As the safety profile of bariatric procedures has greatly improved, a growing number of clinicians believe this threshold could be lowered even further to offer surgical intervention to slightly overweight or even non-obese individuals with poorly controlled diabetes despite maximal medical therapy.

Perioperative morbidity and mortality The majority of bariatric cases can now be performed laparoscopically. This has

greatly decreased the operative morbidity and mortality previously associated with bariatric surgery. Conversion rates are in the range of 0-5.7%, with the highest rates observed in revisional cases and for complex malabsorptive procedures. In general, the less complex and technically challenging the procedure, the lower the morbidity and mortality. With greater experience and advancement in laparoscopic techniques, morbidity and mortality rates have decreased over the last decade and are now comparable to other common surgical procedures. Complication rates following bariatric surgery are quite acceptable; the Longitudinal Assessment of Bariatric Surgery (LABS) study reported a 4.3% incidence of major adverse events in the early postoperative period. Buchwald et al. reported extremely low early and late mortality rates after bariatric procedures; 0.28% and 0.35% respectively.

Metabolic surgery procedures The roux-en Y gastric bypass (RYGB), gastric banding, sleeve gastrectomy and biliopancreatic diversion (BPD) are the most commonly performed bariatric procedures at present. While gastric banding and the sleeve gastrectomy are purely restrictive in their mechanism of action, the RYGB and BPD have a malabsorptive component in addition to restrictive properties. Each procedure’s mechanism of action results in unique outcomes and also contributes to a constellation of procedure-specific risks, merits and limitations. Although regional variations exist with regard to preferences for individual procedures, the gastric bypass remains the most popular weight loss surgery in the USA and is gaining popularity rapidly in Asia, Europe, and Australia.

Gastric Banding An adjustable silicone ring is wrapped around the proximal stomach, connected to a port placed subcutaneously. This band creates a small proximal pouch with a narrowed outflow lumen. The creation of a small pouch restricts food intake and leads to early satiety. By serially inflating the band through the connected port, higher degrees of restriction can be achieved for better weight loss. Deflation of the band may be indicated in cases of partial or complete gastric outlet obstruction, secondary to malpositioning or over-filling of the band.

While this procedure is considered the least challenging technically, with the lowest perioperative morbidity and mortality rates of all bariatric operations, its long term complications and high reoperation rates have led to a decrease in its popularity.

The average excess weight loss (EWL) attainable with a band is reported to be 46%.

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Surgical Speciality

Sleeve Gastrectomy This involves resection of the greater curvature of the stomach resulting in a tubular, sleeve-shaped remnant stomach. Similar to gastric banding, this is also a restrictive procedure but yields greater EWL than a band with an average EWL of >55%. This is partially attributed to the fact that the majority of the stomach is removed, which results in alterations of gut hormonal levels with consequent effects on glucose metabolism. Until recently, this procedure was usually performed as the first of a multi-stage procedure in a severely obese high risk patient in order to minimize their operative risk. It is now accepted as a stand alone procedure with promising results. Lack of Long term follow-up has limited its acceptance among some surgeons.

Gastric Bypass he RYGB is the most commonly performed bariatric procedure worldwide and achieves its effects through two mechanisms; restriction is created by the formation of a small (10-20cc) gastric pouch, and malabsorption occurs by rerouting the proximal bowel so that the distal stomach, duodenum and proximal small bowel are excluded. The combination of these two mechanisms results in greater EWL (>60% on average) compared to purely restrictive operations. Although the RYGB is considered the most technically challenging of the aforementioned operations and is usually performed by experienced laparoscopic surgeons, it has a favorable safety profile and few adverse long term consequences.

Biliopancreatic diversion (BPD) While the BPD has a restrictive component it is primarily a malabsorptive operation, due to exclusion of the duodenum and proximal small bowel. Although EWL is greatest with the BPD (70% on average), this must be considered alongside the higher complication rate associated with this procedure, specifically the risk of severe malabsorption and nutritional deficiencies.

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Surgical Speciality

Mechanisms of diabetes resolution Multiple factors are thought to contribute to the dramatic effect of bariatric surgery on glucose homeostasis including: decreased caloric intake secondary to restriction of the stomach, weight loss leading to increased sensitivity of peripheral insulin receptors to circulating insulin, and alterations in the release of gut hormone which stimulate pancreatic beta cells to produce insulin.

Decreased caloric intake All of the aforementioned bariatric procedures involve gastric restriction, either as the sole mechanism of action, or in combination with a malabsorptive component. The direct consequence of restriction is reduced caloric intake, particularly of carbohydrates which results in a rapid decrease in blood glucose levels. As this restriction comes into effect immediately after surgery, diabetic patients show improved glucose levels immediately following surgery.

Increased insulin sensitivity A reduction in the volume of adipose tissue, especially central adiposity, is proposed to play an important role in mediating the metabolic effects which follow weight loss surgery, particularly by decreasing insulin resistance. Adipose tissue is not only specialized in the storage and mobilization of lipids, but it is also functions as an active endocrine organ releasing numerous hormones and cytokines, including proinflammatory molecules such as interleukin-6 (IL-6) and TNF-alpha. The resultant proinflammatory environment contributes to a state of insulin resistance and altered glucose homeostasis, which is characteristic of viscerally obese patients. Weight loss is accompanied by a reduction in inflammatory cytokines and an increase in anti-inflammatory mediators such as adiponectin, alongside an increase in insulin sensitivity and partial or complete resolution of T2DM.

Gut hormone alterations The third and perhaps most intriguing mechanism by which glucose metabolism improves following bariatric surgery is the result of alterations in the release of gut hormones which stimulate pancreatic beta cells to produce insulin and decrease appetite. Two main mechanisms have been proposed to explain the rapid post-operative shift in hormone secretion and improvement in glucose tolerance following RYGB. The ‘distal bowel hypotheses’, attributes the improvement in glucose metabolism to enhanced delivery of nutrients to the distal bowel resulting in augmentation of GLP-1 by L-cells. Rubino et al. have extensively evaluated the ‘proximal bowel hypothesis’, which states that exclusion of the proximal small bowel from nutrient exposure is primarily responsible for the beneficial effect of gastrointestinal bypass surgery on T2DM. The mediators and precise mechanisms responsible for this effect have yet to be identified.

Short- and long-term metabolic outcomes after bariatric surgery Bariatric surgery has an almost immediate beneficial effect on glucose metabolism. It is not uncommon for a diabetic patient to leave hospital a couple of days following gastric bypass surgery, with greatly reduced or no requirement for insulin or oral hypoglycemic agents. This dramatic effect precedes weight loss and

is therefore attributed to other mechanisms including reduced carbohydrate intake and alterations in gut hormones.

Similar to variations in weight loss outcomes, the metabolic effect varies following different bariatric operations.

Malabsorptive procedures such as the RYGB and BPD induce more profound changes than purely restrictive operations.

The observed resolution rates of T2DM for gastric banding, sleeve gastrectomy, RYGB and BPD are 57%, 70%, 80% and 98% respectively (Table 1). Diabetics with shorter disease duration and those who have not yet required insulin for management of their disease show higher postoperative remission rates, implying that earlier surgical intervention yields the optimal outcome. Long term data on diabetes remission following bariatric surgery remains elusive. It is well documented that almost 20% of gastric bypass patients will either fail to lose weight or re-gain a significant proportion of the weight they lost. Additionally it has been observed that with weight regain comes recurrence of T2DM and other weight-related comorbidities. In a series of 42 T2DM patients who underwent RYGB, all showed remission or improvement in their disease within the first 12 months postoperatively; however at 5 year follow-up, nearly 25% of these patients had experienced a recurrence or progression of their diabetes in association with weight gain.

Weight loss and diabetes resolution outcomes after bariatric surgery

Total

Gastic Gastroplasty Banding

Gastric Bypassb

BPD/DS

% EBWL

55.9

46.2

55.5

59.7

63.6

% Resolved overall 78.1

56.7

79.7

80.3

95.1

% Resolved < 2 y

80.3

55.0

81.4

81.6

94.0

% Resolved > 2 y

74.6

58.3

77.5

70.9

95.9

Reproduced, with permission, from Buchwald H et al. Am J Med. 2009;122(3):248-256.

Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis.

Table 1

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Surgical Speciality

Other positive effects of metabolic surgery The positive metabolic effects of bariatric surgery extend far beyond diabetes resolution. Hypertension and dyslipidemia show resolution/improvement rates in the range of 60-70% over long term follow-up. Mediated by its effect on cardiovascular risk factors, bariatric surgery has been shown to decrease a patient’s 10-year risk of cardiovascular disease. A recent systematic review conducted in our institution demonstrated a 40% reduction in Framingham risk score following bariatric surgery, and 60-75% remission rates for cardiovascular risk factors including diabetes, hypertension and dyslipidemia. No pharmacological treatment has ever been shown to have such a dramatic impact on cardiovascular risk profile.

Bariatric surgery positively affects many other obesity-related diseases, including obstructive sleep apnea, gastroesophageal reflux disease, arthritis and back pain, urinary incontinence, gout, thyroid/parathyroid function, nonalcoholic steatohepatitis, cirrhosis, asthma and others.

Metabolic surgery for non-obese diabetics Having observed such dramatic benefits in glucose homeostasis following bariatric surgery among metabolically unhealthy obese individuals, through weight lossindependent mechanisms, has led to the belief that these procedures may also benefit less severely obese diabetic patients. Several case reports and small case series have emerged documenting diabetes remission or improvement postRYGB in diabetic patients with a BMI of <35 kg/m2. In this population, diabetic remission rates as high as 65-83% have been observed. Performing weight loss surgery on patients who are not severely obese initially raised concerns regarding the potential for exaggerated weight loss and malnutrition in these individuals.

Interestingly, reports to date have shown this to be a very rare occurrence.

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Economic aspects of bariatric surgery Obesity and its associated health problems place a significant economic burden on healthcare systems globally. In the United States, this cost is estimated to be approximately US$ 150 bn annually. Additional economical considerations include the fact that severely obese individuals have been shown to have higher rates of absenteeism from work and decreased productivity in the workplace. The cost of medication for the treatment of diabetes and its complications also places a significant burden on healthcare providers. By inducing T2DM remission or improvement in the majority of patients, bariatric surgery reduces these costs significantly. Ghiasi et al. recently reported a decrease of almost 90% in annual diabetic medication costs just one year after gastric bypass surgery in a patient with T2DM (from $532 to $65).

Conclusion The metabolic effects of bariatric surgery are remarkable. Diabetes remission rates of over 80%, a substantial decrease in cardiovascular disease risk, and high resolution/improvement rates of hypertension, dyslipidemia, and obstructive sleep apnea among others, have never been achieved using any combination of pharmacotherapy. Improved technology and acquired experience have increased the safety profile of these metabolic procedures, reducing morbidity and mortality significantly. Metabolic surgery is also cost-effective from the healthcare economics perspective. The cost of these operations can be offset within 3 years of surgery, if one considers the decrease in patients’ medication expenses, savings related to prevention of disease progression and complications, while increasing individuals’ productivity and contribution to society. Primary care physicians and endocrinologist should be aware of the surgical options for the treatment of metabolic diseases such as diabetes, and consider it earlier in the course of disease.

ISSUe - 25 2012

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TECHNOLOGY, EQUIPMENT & DEVICES

s k d s e i t R socia cal i s d A h Me nd t i w vices a dical e e M D bile Movices De This article will look at how proliferation in mobility is affecting healthcare, and the key considerations for organisations to consider to start securely scaling their mobile strategy. Mobile devices, employer- or employee-owned inside health organisations is inevitable.

The author gives health IT a better understanding of why itâ&#x20AC;&#x2122;s important to embrace these devices, and how they can start implementing a bulletproof plan to secure and ensure privacy of data on these connected devices.

Dennis M Seymour, Chief Security Architect, Ellumen, Inc., USA

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M

obility is having an impact on consumer and business markets at a much faster pace than the introduction of the World Wide Web. There is a surge in the proliferation of mobile devices and platforms and it is changing how people share and access information in todayâ&#x20AC;&#x2122;s always-on, connected world. In lockstep, mobility is intersecting with cloud computing services and cloud-based technologies, such as location, search, communications and social capabilities that make apps stickier and more interactive for end-users. Moreover, mobile devices present an opportunity for apps to harness rich, frontend native capabilities, as well as backend corporate and third party data for a new wave of next generation mobile apps that are much more intuitive and engaging. The mobile arena is a hot and rapidly changing market not just having an impact on the consumer lifestyle, but increased consumption of mobile technologies is starting to reshape the enterprise.

The number of new platforms and form factors infiltrating enterprises is staggering. By 2015, there will be one mobile phone for every person on earth, according to Google. Tablets and smartphones are the most prevalent, and nowhere is that becoming more

TECHNOLOGY, EQUIPMENT & DEVICES

noticeable than in the healthcare industry. Mobile devices have shown to lower costs and improve quality of patient care. In the USA in particular, new call for a Nationwide Health Information Network (NwHIN) and virtual lifetime electronic medical record (VLER) for all military members from active duty through retirement, including civilian family members. The Obama Administration is offering incentives upwards of US$ 20 bn in federal stimulus funds to boost adoption of new health technology programs. Both government and private healthcare organisations in the USA are being challenged by the wave of mobile devices being integrated into their workflow and ensuring that sensitive, personal medical data is kept private and secure.

At the same time, healthcare organisations are facing budget cuts and mobile technologies and devices, such as laptops, tablets and SaaS-based (software-as-aservice) apps, offer a more affordable and scalable alternative than upgrading legacy PC and desktop workstations.

Healthcare organisations are looking at how they can build a mobile strategy to keep up with the proliferation of devices and apps and also another phenomena: BYOD, or bring your own device.

Employees are increasingly hooking into corporate networks and other enterprise information resources from their own mobile devices, often in an unsecured manner and without IT knowing. Should health enterprises support BYOD as part of its overall mobile strategy? Accounting for employee-owned devices might

help health IT to go through this wave coming in, rather than try to stop it.

What are the steps and considerations to secure mobile devices whether employer- or employee-owned? Are there separate precautions for patient owned devices that connect to hospital networks or the apps, for example, downloaded over its network? In addition to securing mobile devices, the nature of healthcare environments bring on increased challenges around ensuring the privacy of the information stored on smartphones, tablets, ultrabooks, etc.

This article will address these questions, as well as other key considerations for health IT to securely scale an enterprise mobility strategy to improve patient care, while making it easier for employees to get work done.

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TECHNOLOGY, EQUIPMENT & DEVICES

How to get started securing mobile in your healthcare organisation For a healthcare organisation, it is important to take into account several baseline steps a when considering the use mobile devices on their networks. Accommodating employeeowned devices is becoming a fact of life. Information security professionals need to design measures to minimise the risks involved in enabling staff members to use personally owned tablets, smartphones, and other mobile devices for business purposes, such as: • Conduct a survey of employees to capture the types of consumer mobile devices employees may want to use -and for what types of work-related tasks • Develop a risk assessment process for these devices, and solicit and include user input • Apply the same policies and security controls to personal devices as you apply to corporate-owned devices • Develop a legal agreement with those who use personal devices for work-related purposes • Implement an employee education training and awareness program A key benefit for organisations to support mobile devices is that employees are able to work from anywhere at any time. But there are several risks with permitting employees to use personal mobile devices. For example, smartphones are easily misplaced and tablets stolen, which can make any data stored on them vulnerable. Asurion, a leading electronics insurance agency, reports that over 56 per cent of users report losing or misplacing their phones for short periods of time each month. Notably, over half of all devices are reported to contain some company information. There is a risk when an employee quits or is fired. What happens if there is any sensitive corporate information stored on that person’s mobile device?

A health organisation must require security controls such as data encryption, and in this particular scenario remote-wipe capability.

Inevitably mobile devices are becoming prevalent in healthcare settings. It is common for users to use their mobile devices for both personal and business purposes.

When a user stores personal information, photos, etc. on their mobile device, it creates a more profound sense for them to want to protect the device and the information contained on it. With proper training, an organisation can help their users fully understand the requirements and rules set forth with using mobile devices for any work related purposes. This could include training on incident reporting, reporting of lost devices, how to properly back up

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ISSUe - 25 2012

personal information (music, photos, etc.), actions related to conducting a remote wipe due to a lost device, and general training on application use, encryption, malware software and related topics. Organisations must hold employees accountable for their actions; therefore, it is good practice for the organisation to consider possible actions that will occur, and consequences and remediation (or mitigation) steps during the risk assessment process.

There are also important legal precautions associated with financial risks, as well as in the critical event of a security breach of patient and organisational data that need to be accounted for. The organisation should have a legal agreement in place that users are required to sign. The document can outline and provision that personal devices used for any work related purposes are used in compliance with the rules set forth by the organisation, and are eligible for the organisation to access and review data at any given request. A clause can be worked up to say that any organisational data can be wiped off the device at management’s discretion. The organisation must develop this document and require users to agree before granting access to data by the device. This will underscore transparency across the enterprise and that the rules apply to all levels of the organisation.

For any mobile device brought or used within the walls of the healthcare enterprise, specific security controls must be in place. For example, an organisation can require that employees implement unique and strong password controls, including required characteristics (i.e. number and types of characters) and passwords that expire and periodically are required to be reset. The organisation can also record password history to prevent reuse of prior passwords.

Other minimum security controls recommended are: • Screen settings that include contact information on the owner that is viewable before login; • Inactivity time out • Lock out (and potential wipe of the device) after set number of failed attempts to log on • Remote wipe capability if the device is compromised • Encryption, if devices are capable of employing it, and • Employee education and awareness.

TECHNOLOGY, EQUIPMENT & DEVICES

all mobile devices or have an additional form of access control in place. This can be a PIN, pattern, software application, or biometric setting. The intent of these measures is to ensure security of the device, not authentication per se, to the network or applications used by the organisation. An added measure would include the ability to lock the device after a set number of failed login attempts. If a device is lost and found, it could be configured to show the owner’s contact information without being required to login. This could help someone return a device to their rightful owners, while also preventing unnecessary remote wipes.

An alternative would be to integrate a service that enables remote wipe of the device, in the event a mobile device is lost or stolen, or an employee quits and does not return the device. Remote-wipe capabilities permit management to delete data from lost or stolen devices, adding an extra layer of risk mitigation. For remote wipe to work, however, a device must be registered through the manufacturer’s website or through third party security apps before it becomes lost or stolen. Once the device is lost or stolen, it is too late to register the device-and thus it could be too late to save the data.

An important limitation to consider is that the mobile device’s SIM card could be removed or replaced. Therefore, this is not necessarily a control that can always be relied upon. It may still be possible for unauthorised users to gain access to unencrypted data.

There are strategies to encrypt sensitive data on mobile devices, whether employee or organisationally owned.

Only after entering the right PIN, pattern or password will the person using the device be able to access data.

The encrypting of data locally should Author BIO

Managing mobile devices and data It is most important for organisations to develop a policy around the management strategy of these devices, including support for the multitude of mobile device types, management tools or services, procedures for obtaining mobile devices, downloading applications and using subscription services. A level of effort required by support staff, service desk staff, and administrators to support these devices and the applications necessary to provide access to the data should also be considered.

One major issue facing healthcare organisations is whether to permit storage of sensitive information on corporate or personal mobile devices. There are two options. One to consider is to allow “view only access” from mobile devices. This essentially means users are not allowed to store data at all on their mobile devices.

A strong reason to consider not having local storage is that recent reports say less than 20 per cent of organisations have any management control over employeeowned devices. Moreover, more than 25 per cent of organisations have no control at all over their use.

If storage is an option, then encryption must be seriously considered as an additional requirement. There are grave legal issues should a loss of the device occur and they have been well documented in the media. Precautions need to be taken to minimize a healthcare organisation’s risks where sensitive patient data is involved. If the decision to encrypt data has been made, the issue may arise that some devices cannot accommodate full disk-level encryption.

Many organisations are allowing only applications and devices that permit at least some level of encryption, as well as devices that permit the use of software applications that provide the ability for the organisation to conduct a remotewipe of any organisational (or all data) if there is loss of a device.

Password protection is another common security feature, but in addition, healthcare organisations should require

be mandatory to allow the organisation to meet regulatory requirements. This includes for example in the USA requirements such as HIPAA, Sarbanes-Oxley, and other legal requirements. Internationally such standards as IEC 80001, Guidance for the Communication of Medical Device Security Needs, Risks and Controls is another example.

Get employee buy-In with education and awareness Education and awareness training is key to ensuring users understand the organisation’s mobile device security policy.

This should not be specific to only organisation-approved devices, but also include employee-owned mobile devices -- also taking into account any overlap for how a device is used. Training should address legal requirements, requirements for the use of encryption (when applicable), allowable backup procedures, reporting of missing devices, clearing data from devices no longer in use, and how to use anti-malware software.

The concerns related to transitioning to an environment where mobile devices are ubiquitous are real and happening now. It is important for healthcare organisations to understand and mitigate these risks early on, and they can start by developing a list of minimum requirements associated with their corporate mobile strategy.

Mobility is the way of the future for business and healthcare is no exception. It is important for an organisation to remain agile as new mobile platforms and form factors continue to proliferate and penetrate corporate walls. It is important for health IT professionals to acknowledge and embrace these devices to maintain a competitive advantage for their overall workforce and patient communities.

Dennis M Seymour has more than 15 years experience in federal healthcare security. He is a member of the HIMSS Privacy & Security Steering Committee, HIMSS Mobile Device Security Work Group, the Medical Device Security Task Force and the Risk Assessment Work Group.

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35

FACILITIES & OPERATIONS MANAGEMENT

Considering the Human Factor

Integrating technology with a healing environment greatly improves the patient experience

The article talks about the ever evolving and expanding need for technology and clinical equipment within the healthcare experience for patients and families. The resulting visual chaos is a significant challenge to the appearance of a nurturing, ordered and pleasing impression of the healing environment.

The article focuses on common sense, low cost design thinking that should be shared between the healthcare architect and end users toward a more humane healing experience.

Dennis Kaiser, Principal, Perkins+Will, USA

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I

n response to the anxiety many patients experience in a closed MRI—in some cases, requiring sedation before a procedure—the healthcare field developed open MRI technology and redesigned MRI suites to reduce patients’ stress. Yet few healthcare organisations have recognised the potential for common forms of technology—from harsh lighting and blaring pagers in public spaces to the myriad of cables, tubes, outlets and monitors in private patient rooms—to contribute to patients’ and families’ stress.

It is both desirable and practical to integrate technology with a humanistic, healing environment. Top healthcare leaders have made this a priority, examining the problem from a patient-focused perspective. They have found that cost-effective design solutions involve making thoughtful technology choices, reducing negative sensory impacts, and creating a positive focal point in the space.

FACILITIES & OPERATIONS MANAGEMENT

Here is a look at challenges and cost-effective solutions in common public spaces, clinical exam / treatment rooms, and private patient rooms, with examples from healthcare organisations that have successfully implemented them.

First impressions are lasting Public spaces, including entrance lobbies and waiting areas, are the literal and figurative ‘front door’ to the facility.

All too often, these spaces are designed with pleasing finishes and furniture, only to have the environment marred by haphazard deployment of common technology: harsh artificial lighting, a noisy overhead paging system, televisions, vending machines, visible cables, a clutter of signage, clusters of parked wheelchairs and equipment, and so forth.

Patients, families and visitors form first impressions in these spaces, which are lasting impressions of the facility and the organisation. Negative impressions are often expressed on satisfaction surveys as low scores for ‘overall impression,’ ‘lack of personal control’ and ‘comfortable environment.’

Unlike clinical areas, public spaces typically do not have a designated ‘user group’ and so they tend not to be a focus

Considering the human factor improves the patient experience, with potentially far-reaching impacts on patient satisfaction and outcomes as well as operational efficiencies. of programming and project budget.

Instead, priorities are understandably on the clinical spaces themselves and integration of mission-critical clinical technology.

Location and staffing issues pose additional challenges. When these spaces are located in the building core or below grade, it is challenging to provide soothing natural lighting and create a positive focus of attention, such as a view of the outdoors. Yet there are practical alternatives, including simulated natural lighting, a bold design feature using natural materials, or artwork.

Selection of technology may be based solely on staffing efficiency; for example, in an effort to reduce the number of administrative staff in the reception / registration area of a clinical department, the institution may use a noisy overhead paging system to call patients for their appointment.

They may overlook simple, efficient

alternatives, such as loaning individual pagers to each patient or silent visual cues. ATM-style self-registration kiosks and bedside registration systems can also enhance staffing efficiency as well as the patient experience.

For example, leaders of St. Joseph’s Healthcare Hamilton, Ontario, Canada, overcame these challenges through effective design of a new diagnostic imaging department. Although it is located below grade, the design solution for the entry / waiting area creates an environment that appears to be illuminated by daylight through use of light boxes with indirect artificial lighting and natural materials. The use of glass and other reflective, translucent and transparent materials enhances illumination without resorting to direct overhead lighting.

An accent wall of natural stone creates a positive focal point and is coordinated easily with the overall budget due to its relative minimal area.

The overall design of the space intuitively directs patients’ attention to their destination. Moreover, the registration area is clear to patients without requiring signage. A system displaying a number silently calls the next patient, avoiding the need for a paging system or staff calling out. At the same time, consolidation of six waiting rooms into

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FACILITIES & OPERATIONS MANAGEMENT

one enabled cost-effective staffing with one reception person to greet patients as they arrive.

In this case, leaders adopted a number of best practices from the hospitality industry, which has elevated greeting, registering and directing guests to an art form--seamlessly incorporating lighting, communication and security technology into a humanistic environment.

Creating positive focal points in clinical spaces Clinical spaces, such as peri- and postprocedure areas, exam and treatment rooms, create special challenges as they often involve highly technological medical procedures, with associated equipment and finishes designed for effective infection control. Yet, here too, there are cost-effective design solutions to reduce the anxiety and stress associated with the sensory impact of technology, create a positive focal point, and provide for an aesthetic alternative to stainless steel, plastic and tile surfaces.

Effective lighting is critically important for peri- and post-procedure, exam and treatment areas, yet effective lighting need not mean that the high-intensity lighting is also the ambient lighting -at least, not all the time. Instead, an energy-efficient Code Carts

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lighting system can be designed with a range of lighting types and fixtures, including indirect ambient lighting and optional use of overhead fluorescent and / or task lighting.

Effective use of acoustic wall and ceiling treatments, as well as personal head phones at times reduces the auditory stress associated with procedures, including MRI. Designing an alcove or partition to screen emergency equipment, such as code carts, reduces the stress that can be associated with this visual cue, yet the equipment remains readily available to staff.

Aesthetically pleasing alternatives to stainless steel, plastic and tile, such as scrubbable simulated-wood floor coverings and casework, are compatible with infection control procedures.

Finally, creating positive focal points on the wall facing the bed and on the ceiling in the exam / treatment room give patients a positive feature to explore during stressful procedures.

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For example, leaders at St. Josephâ&#x20AC;&#x2122;s implemented these room designs, lighting and finishing solutions in the periand post-procedure room and exam/ treatment rooms of their diagnostic imaging department.

Notably, they supported design features that create positive focal points-a simulated window view of the outdoors on the wall facing the beds and simulated â&#x20AC;&#x2DC;sky domesâ&#x20AC;&#x2122; in the ceiling above each bed and above the treatment table. Working with vendors and contractors on the selection and detailing of materials effectively managed the associated costs.

Moreover, close construction supervision ensured that these solutions were properly implemented.

Although the diagnostic imaging department is built into a hill, one end is exposed to grade where the MRI procedure room features an exterior window.

This required shielding from passersby on the outside. So designers created a planted green space between the

FACILITIES & OPERATIONS MANAGEMENT

sidewalk and the MRI room’s window, which creates a buffer zone while allowing natural light and views from within the room.

only expensive, but also tends to draw the focus toward the headwall rather than away from it.

Instead, it is more effective to create a positive alternative focal point, for example, a large window with a sill that is low enough to afford a good view from the bed, or a large flat-screen TV or a well scaled piece of art on an otherwise uncluttered footwall.

A solution to further reducing the clutter of wall-mounted glove dispensers, sharps disposal containers, and so forth, is to build the headwall about a foot from the wall, placing dispensers on shelves behind it.

Careful attention must be given to integrating room lighting, patient monitoring and communication systems, furniture, cabinetry and finishes in this environment.

In one case, for the Critical Care rooms at Saints Memorial Medical Center in Lowell, Massachusetts, USA, the designers and healthcare planning team worked so hard to integrate technology into a healing inpatient environment, that when the public health inspector suggested putting a glove box on the footwall, a nurse objected: “No, that’s the art wall.”

Author BIO

Integrating technology in the patient room Technology and a healing inpatient environment typically make strange bedfellows. The first challenge is location of the patient’s bathroom -- inboard or outboard?

Often, nursing staff express the need to see the patient at all times, so they advocate for the unobstructed views provided by an outboard bathroom and, sometimes, a window on the corridor wall. But here is an example where technology can and does meet this clinical need: often, the information nursing staff are looking for is already on their monitors, without the need to see the patient at all times.

Locating the bathroom inboard is an evidence-based design solution that maximises the family zone of the room adjacent to the bed, facilitates family participation in patient care, and increases positive outcomes. Accommodating family members and this consideration of the “ergonomics of handholding” also has an operational value; for example, family members can serve food to the patient, help the patient go to the bathroom, and take on some of the ‘hunt and gather’ functions of the staff for requested items, freeing staff for skilled care.

Seamlessly integrating the technology that surrounds the patient is often a challenge as it must be readily accessible for staff. Take the headwall, for example, which contains a myriad of outlets, cables and tubes--altogether, creating a negative environmental character for patients and family members. Some of the common solutions to disguising the headwall are well-intentioned but ineffective. Solid panels that can be slid over fixtures to try to disguise or hide this technology are often moved out of the way by nursing staff on a permanent basis. Wood paneling or special framing and edging around the headwall is not

This brings up an important point: leaders and staff are becoming advocates for the seamless integration of technology with a humanistic environment.

Patient-centered care is top priority; innovation follows When healthcare leaders and staff have a vision for patient-centered care as their top priority—including the patients’ experience of the environment—the programming of the project can become the starting point of a partnership among the healthcare leadership team, senior- and staff-level representatives of user groups, and designers to fulfill the vision.

In the process, the partners can fully explore design, technology and operational alternatives, analyse costs, and determine their relative values to the vision.

Often, as in the examples of the healthcare organisations above, innovation follows.

Considering the human factor— integrating technology with a healing environment—improves the patient experience, with potentially far-reaching impacts on patient satisfaction and outcomes as well as operational efficiencies.

Dennis Kaiser offers over 30 years in the design of healthcare environments. He is a frequent author and speaker on topics of facility innovation, operations, design and project delivery for the Healthcare Industry. His solutions explore the edges of healthcare operations and building design based on his conviction that the industry, and therefore its facilities, makes drastic change.

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information technology

Telemedicine One Small Step for IT A giant leap for healthcare

T

he first reference to telemedicine is probably the famous â&#x20AC;&#x2DC;Radio Doctorâ&#x20AC;&#x2122; cover image of the 1924 Radio News Magazine. One of the first telemedicine applications reported in the scientific literature was probably the project for transmission of radiologic images by telephone between West Chester and Philadelphia, Pennsylvania, a distance of 24 miles.

In the 1970s the number of telemedicine projects started to grow and first real-time applications are mentioned.

The STARPAHC Project, for example, tried to introduce telemedicine in the rural Papago Indian Reservation in Arizona.

Throughout the 1980s telemedicine, specialty specific applications started to emerge, for example telepathology, which was first mentioned in 1986. The field of radiology saw the development of the first standard on digital medical

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imaging which culminated in the release of the DICOM specifications in 1992.

The number of telemedicine applications started to grow rapidly in the 1990s due to availability of Internet and affordable computers and digital imaging solution. The technical breakthrough of telemedicine was probably the first transatlantic robotic operation which was performed in 2001 by a surgeon in New York on a patient in Strasbourg.

Telemedicine is the use of Information and Communication Technologies (ICT) to exchange medical information

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for the purpose of healthcare and health education. It is a field in health science with effective fusion of ICT with Medical Science having enormous potential in meeting the challenges of healthcare delivery to rural and remote areas besides several other applications in education, training and management in health sector. In the context of developing countries, good healthcare facilities are concentrated in the urban cities, while they still lack in rural communities with lower economies. Telemedicine provides a best solution to solve this disparity of health sectors between urban and rural areas.

Telemedicine or telehealth (videoconferencing for healthcare) has opened a world of speciality health services to people who are otherwise unable to access appropriate care. It may be as simple as two health professionals discussing medical problems of a patient and

Telemedicine, despite being in practice for a very long time in forms such as health consultation over telephone, has recently seen lot of action and development. The development in various fields including telecommunications, Information Technology have further aided in providing healthcare to the poor and the needy, which in turn is creating new market opportunities for the players.

Rashi Agarwal, Director, Praxis Healthcare Pvt. Ltd., Jaipan Industries Ltd., India

seeking advice over a simple telephone to as complex as transmission of electronic medical records of clinical information, diagnostic tests such as ECG, radiological images etc. and carrying out real time interactive medical video conference with the help of IT-based hardware and software, video-conference using broadband telecommunication media provided by satellite and terrestrial network. In rural areas of developing countries, a reliable communication link for telemedicine is one of the key challenges.

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information technology

Types of processes Real Time or Synchronous Real time telemedicine could be as simple as a telephone call or as complex as telemedical video conference and tele-robotic surgery. It requires the presence of both parties at the same time and a telecommunication link between them that allows a real time interaction to take place.

Video-conferencing equipment is one of the most common forms of technology used in synchronous telemedicine.

Store-and-forward telemedicine or Asynchronous This involves acquiring medical data (like medical history, images, etc.) and then transmitting it to a doctor or medical specialist at a convenient time later for assessment offline. It does not require the presence of both parties at the same time. Examples are tele-pathology, teleradiology, tele-dermatolgy.

India with its vast population, of which 70 per cent are poor and often live in difficult to reach and inhospitable terrain, along with inadequate healthcare network faces a daunting challenge of providing quality healthcare to its citizens. Here, the average per capita spend on healthcare is one of the lowest in the world and various healthcare indicators are also lower than the global average.

In order to provide quality and affordable healthcare to all, Telemedicine, has provided an impetus to the government’s vision of quality health for all by helping in delivering quality healthcare and in controlling the spiralling medical costs.

With Telemedicine, more than 300,000 people have already benefited.

Telemedicine in India has a market of more than $500mn and has been implemented in places far and wide under the Public-Private Partnership (PPP) model.

As the reach of Telemedicine increases, the market for medical diagnostic, healthcare providers, drug manufactures, telecom equipment manufacturers, software vendors is bound to increase.

Telemedicine, however, is not a panacea for India’s healthcare problems. It is

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IT Equipment Used

Hardware

• PC, Intel P4 3.0 Ghz (dual core), HT/915G/512 MB DDR2, 160 GB SATA HDD/ DVD ROM/LAN/ Graphic Card With 256 MBVRAM,Two USB ports • Ethernet port17” TFT-LCD Monitor • Keyboard • Mouse • Multimedia Speaker • Headphone & Mic. • Web Camera • Laser Printer • UPS 1KVA

Software

• Windows Vista OS • MS Office (latest Prof. Edition) application software • Customized Telemedicine Software: • With EMR Interoperability as defined by DIT, Govt. of India besides integration of Medical Diagnostic Systems like telepathology, radiology,ECG etc. Should be able interface with all communicable media – PSTN,ISDN, IP etc.

Medical Diagnostics Equipment • • • •

X- Ray Digitizer / Scanner Tele-Patholgy System Tele-ECG System (8/12 Lead) Digital Stethoscope

instead a great facilitator in bridging the healthcare divide, representing an early opportunity in the sector which has 5.2 per cent share in the Indian GDP. The future for Telemedicine at the moment looks promising with governmental backing and private initiative. An early move by private enterprise in PPP is highly recommended in the sector.

The telemedicine units located in suburban and rural India and the telemedicine units functioning in tertiary care hospitals are only the beginning. The 625 million Indians living in rural areas have access to less than 20 per cent of the available doctors which itself is only

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Telecommunication Equipment VSAT • Router • Dish antenna • Modem • DAMA unit

Terrestrial • Media Converter • Router • STM • Power back up for one hour • 6 U RacK ISDN • ISDN Modem • Data/ fax/ Voice Modem • USB Hub • 10/100 Switch • ISDN Phone Video Conferencing Equipments • Full ITU-T H.323 Standards-compliant for interoperability • Multi Network connectivity (IP and ISDN) • H.261 and H.263 video compression standard • Data Collaboration with XGA Input and Output port • QCIF – 176 x 144, FCIF – 352 x 288 video resolutions • Video Frame Rate Up to15- 30 fps • Audio Compression Standard G.711: 3.4 kHz @ 64 kbps/G.722: 7.1 kHz @ 48 / 56 / 64 kbps/ G.728: 3.4 kHz @ 16 kbps • Audio Performance 100-7100 Hz frequency response with Full duplex • 64 kbps to 384/512 kbps Data Rates • Automatic Noise Suppression • Acoustical echo cancellation • 42” Display Panel with RCA and X-VGA port Optional

1:2000. India spends only 0.9 per cent of GDP on health, of which only 0.09 per cent reaches rural India. However there has been an unprecedented growth and development in Information Technology. Pilot studies with hospitals on wheels with telemedicine facilities are being carried out. ISDN lines, broadband high speed internet and VSAT’s are used for connectivity. The Government of India is embarking on a major e-governance project with 110,000 multipurpose internet kiosks in villages.

Plans are afoot to provide basic healthcare using these kiosks. Tele education for medical personnel has taken off in

information technology

a big way. The Ministry of Health now has a major all India programme wherein doctors can listen to lectures and interact with eminent doctors remotely. The Ministry of Information Technology has drawn up standards on telemedicine and these will eventually be implemented.

GSAT-4, also known as HEALTHSAT, was an experimental communication and navigation satellite launched in April 2010 but failed to reach its orbit.

Telemedicine is not new for India.

There are many telemedicine systems running, several of which are described in this section. In India, telemedicine programmes are supported by both governmental and private parties. In this system, doctors do not have to go to the telemedicine centres; rather, the doctors can use their laptops through the Internet to check up their patient at remote a telemedicine center assisted by a nurse from anywhere.

Indian Space Research Organisation (ISRO) is a government organisation dealing with space technologies in India.

ISRO started a telemedicine project in 2001 to introduce the facility to rural areas. ISRO mainly uses INSAT Satellites as a means of communication for telemedicine. Satellites provide two main advantages: (1) They are reliable and (2) easy to reach in remote places. Although this is a costly solution, government support has made it possible. Using satellite, ISRO’s Telemedicine Network has connected 306 rural hospitals and 16 mobile telemedicine units to 60 super specialty hospitals located in metropolitan cities.

Availability of technology at a reasonable cost It is myth that to establish a telemedicine platform is expensive. The basic system needs hardware, software and telecommunication link. Most of these costs are well within the reach of most of the hospitals, and can be recovered by nominal charge to the patients and students (in case of tele-education) which would be much less than physical travel.

Accessibility Although information technology has reached in all corner of the country but the accessibility of people living in remote and rural area to the nearest health center (PHCs, CHCs or district hospital) may not be easy due to poor infrastructure of road and transport. It may be possible that the available telemedicine system in the health centers may not function because of the interruption in power supply.

Reliability Some healthcare professionals have doubt about the quality of images transmitted for tele-consultation and tele-diagnois. In tele-radiology, telepathology, tele-dermatology the quality of image (colour, resolution, field of view, etc) should be international standards to avoid any wrong interpretation and mis-diagnosis. The delay in transmission of data may be of critical importance in tele-mentoring and robotic surgery and have to be reduced to the minimum.

Funding / reimbursement issues There should be a format to calculate the investment and recurring cost of the telemedicine system. The insurance companies have to decide whether the cost of tele-healthcare should be reimburse or not.

Telemedicine provides a best solution to solve the disparity of health sectors between urban and rural areas.

Lack of Trained Manpower There is lack of training facilities with regards to application of IT in the field of medicine. Most of the healthcare and IT professionals are not familiar with the terms commonly used in telemedicine such as HIS, EMR, PACS, etc. Telemedicine is also not the part of course curriculum of medical schools.

Legal and Ethical Concerns Telemedicine technology has been proved and established and its advantages and benefits are well known but still many healthcare professionals are reluctant to engage in such practices due to unresolved legal and ethical concerns.

In case of a cross-border tele-consultation which country’s litigation laws will be applied in case– those of the country in which the patient is living or those of the remote physician?

Privacy and Security Concerns There are many issues that should be considered regarding the security, privacy and confidentiality of patient data, in telemedicine consultations. How are patients’ rights of confidentiality of their personal data ensured and protected?

How to ensure security of the data and restrict its availability to only those for whom it is intended and who are authorised and entitled to view it? How to prevent misuse and even abuse of electronic records in the form of unauthorised interception and / or disclosure?

Applications of telemedicine Tele-healthcare It is the use of information and communication technology for prevention, promotion and to provide healthcare facilities across distance. It can be divided into activities like - Teleconsultation and Telefollow-up.

2.Tele-education Tele-education should be understood as the development of the process of distance education (regulated or

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3. Disaster Management Telemedicine can play an important role to provide healthcare facilities to the victims of natural disasters such as an earthquake, tsunami or atornado and man-made disaster such as war, riots, etc. During a disaster, most of the terrestrial communication links either do not work properly or get damaged so a mobile and portable telemedicine system with satellite connectivity and customised telemedicine software is ideal for disaster relief.

4. Tele-home healthcare Telemedicine technology can be applied to provide home healthcare for the elderly or underserved, homebound patients with chronic illness. It allows home healthcare professionals to monitor patients from a central station rather than traveling to remote areas chronically ill or recuperating patients for routine check-ups. Remote patient monitoring is less expensive, more time saving, and an efficient methodology.

Tele-home care virtual visits might lead to improved home healthcare quality at reduced costs, greater patient satisfaction, increased access to healthcare providers and fewer patients needing transfer to higher, more expensive levels of care. A Computer Telephone Integrated (CTI) system can monitor vital functions of patients twenty four hours a day and give immediate warnings.

Advantages of telemedicine The main objective of telemedicine is to cross geographical barriers and provide healthcare facilities to rural and remote areas so that it is beneficial for the population living in isolated communities. Besides this, other advantages telemedicine are:

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• Eliminate distance barriers and improve access to quality health services • In emergency and critical care situations where moving a patient may be undesirable and/or not feasible • Facilitate patients and rural practitioners’ access to specialist health services and support • Lessen the inconvenience and/or cost of patient transfers • Reduce unnecessary travel time for health professionals • Reduce isolation of rural practice by upgrading their knowledge through tele-education or tele-CME. Factors aiding telemedicine adoption • With increased disposable income, lifestyle changes are leading to more chronic ailments putting further pressure on healthcare infrastructure • Telemedicine provisioning is a competitive advantage for healthcare providers • Availability of affordable technology to aid penetration far and wide • Shortage of trained healthcare professionals forcing better management of healthcare resources • Ageing population that is unable to reach for consultation • It is not only cost-effective to the patient but to the society as well.

Challenges in telemedicine • Lack of trained manpower to support Telemedicine • Interoperability of various software and hardware systems • 100per cent uplink and bandwidth

Author BIO

unregulated), based on the use of information and telecommunication technologies, that make interactive, flexible and accessible learning possible for any potential recipient.

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availability in remote areas • Lack of proper medical education • Low doctor-patient ratio • Poor Data Communication Infrastructure • System Features should be scalable • Cost of the system should be scalable.

The practice of telemedicine – through transmission of digitised data, audio, video and images – is getting popular all over the world as it provides hitherto unavailable access to tertiary level specialist healthcare even in geographically remote areas without displacement of the patient, physician or the equipment.

Healthcare in India is in the midst of a major market transition and technology is making a tremendous impact on the way healthcare is delivered.

Telemedicine, despite being in practice from a very long time in forms such as health consultation over telephone, has recently seen lot of action and development. Government has long realised that given the constraints, it is difficult to reach everyone to provide quality healthcare. The PPP model in Telemedicine is helping in delivering quality healthcare to wider set of citizens who earlier could not be reached. The development in various fields including telecommunications, Information Technology have further aided in providing healthcare to the poor and the needy, which in turn is creating new market opportunities for the market players.

The urban population has always had the benefit of specialist healthcare; Telemedicine is fulfilling the promise for rural population as well.

Rashi Agarwal has been providing consulting services to hospitals in India, UAE, Africa in areas of hospital planning, operational management, quality, human resource, medical tourism etc. She is also a visiting faculty and examiner to several health administration programs in India and has helped plan out educational programs for health administration. She has recieved her Master in Healthcare Administration from Washington University, St. Louis, USA and is a keen academician above her consulting business of healthcare practices.

Books

Telemedicine Technologies: Information Technologies in Medicine and Telehealth Editor: Bernard Fong, A C M Fong, C K Li No of Pages: 282 Year of Publishing: 2010 Description: In this book, the authors focus on how medical information can be reliably transmitted through wireless communication networks. It explains how they can be optimized to carry medical information in various situations by utilizing readily available traditional wireless local area network (WLAN) and broadband wireless access (BWA) systems.

In addition, the authors discuss consumer healthcare technology, Finally, the book explores topics such as communication networks and services, patient monitoring, information processing, system deployment, data security and privacy, information technology in alternative medicine, multimedia and health informatics, and caring for the community.

Introduction to Telemedicine Editor: Richard Wootton, John Craig, Victor Patterson No of Pages: 206 Year of Publishing: 2011 Description: The second edition of this introductory guide to telemedicine and telecare services will be an invaluable guide to students and new practitioners in this growing and developing field of medicine. In rural and sparsely populated countries, telemedicine can be a vital and life-saving link in healthcare. In those countries where demands on hospitals is ever growing, telecare can provide a safe and comfortable alternative to hospital based therapy.

This updated book will help you to assess the need for a service and how it can be implemented.

Grid Technologies for E-Health: Applications for Telemedicine Services and Delivery Editor: Ekaterina Kldiashvili No of Pages: 350 Year of Publishing: 2010 Description: Grid computing has emerged as an important new field, distinguished from conventional distributed computing by its focus on large-scale resource sharing and innovative applications as well as an establishment for the creation of e-health networks.

Grid Technologies for E-Health: Applications for Telemedicine Services and Delivery examines innovations to further improve medical management using grid computing. A defining collection of field advancements, this publication discusses the significance of automation and IT resources in healthcare technology previously infeasible due to computing and data-integration constraints.

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CaseStudy

information technology

Enabling Transformation of Healthcare Delivery with IT

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information technology

I

t is no secret that ‘business as usual’ in healthcare delivery is an unacceptable option. Beyond the desire to improve equity and quality of care, inexorable rise in demand with an ageing population and increasing rates of chronic illness are set to outstrip society’s ability to supply current levels of service no matter how we might mix public and private funding. Information Technology (IT) is looked to as a source of solutions to break out of this situation.

Health IT is not a panacea for the health system’s woes. Indeed, the evidence base for improved health outcomes from health IT, although growing, is quite limited. As recently as 2006, a major systematic review evidence on the effect of health information technology on healthcare delivery found the compelling results to be confined to a few areas of preventive care and questioned whether typical healthcare organisations could emulate the results coming from academic institutions with internally developed system. The situation is, however, changing rapidly;

for instance, the International Medical Informatics Association (IMIA) has a new journal Applied Clinical Informatics entirely dedicated to publishing practical findings about clinical and administrative use of health IT. In New Zealand, health IT is being pursued systematically as an enabler of the transformations needed to achieve sustainable high-quality healthcare.

Health IT in New Zealand New Zealand (NZ) has several key elements already in place that are powerful enablers for further innovation; most notably: • NZ has had a National Health Identity (NHI) number for all health consumers since the 1980s. This has recently been complemented by a Health Practitioner Index (HPI) • NZ ranks highly in its sophistication of computer use for community based physicians; these General Practitioners (GPs) act as the coordinators of care and the gatekeepers of more specialised health services.

NZ also benefits from national leadership and organisation in health IT. The IT Health Board (ITHB) is a sub-committee of the National Health Board that provides leadership on the implementation and use of information systems across the health and disability sector. The ITHB’s national health IT plan lays out two phases of work building on the existing infrastructure: • Phase 1 is based on increasing healthcare organisations’ use of health IT solutions to a consistent level of capability, including transfer of health information between healthcare organisations (e.g. electronic referrals) • Phase 2 looks at delivering a shared care capability with core patient information available across provider settings, care planning and decision support.

The National Shared Care Planning Programme (NSCPP) began a proof-of-concept pilot in early 2011, indicating the start of field experience directed at Phase 2.

The National Institute for Health Innovation at the University of Auckland has been working closely with the New Zealand IT Health Board to support implementation of New Zealand’s national health IT plan. We report on the transformational potential of IT for referral management, shared care planning and long-term medication adherence.

Jim Warren is Professor of Health Informatics at the University of Auckland, New Zialand, holding a joint position in Computer Science and Population Health. He has over 20 years research experience in health IT, with a particular interest in systems to support both patients and providers in better management of long-term conditions.

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CaseStudy

information technology

National Institute for Health Innovation (NIHI) NIHI is a research unit of the University of Auckland based at the School of Population Health. NIHIâ&#x20AC;&#x2122;`s mission in health IT is to promote its innovative use for improved equity and outcomes in health delivery. NIHI has been working closely with the ITHB to support implementation of the national health IT plan. Below we present three cases of NIHI research and evaluation where health IT is enabling the kind of transformation needed to enable a sustainable future healthcare system. We conclude with thoughts about the importance of iteration and evaluation in health IT implementation and the opportunities for incremental as well as more radical transformation.

Electronic referrals (e-Referral) In 2010 and 2011 NIHI was commissioned by the ITHB to evaluate three existing regional NZ implementations of electronic referrals (eReferrals) and to liaise with a larger project, in pilot at the time of the study, that would introduce eReferrals for the Auckland metropolitan area. The earliest of these regional implementation, for the area surrounding Hutt Hospital (serving the Hutt Valley region just outside of the capital city of Wellington), began operation in 2007. For this, 16 servicespecific referral forms and one generic form were developed to encompass all Hutt Hospital services except the Emergency Department.

The Hutt Valley implementation allowed GPs to transmit referrals from their general practice software over the area health messaging network to the clinical workstation server of Hutt Hospital. The GP receives electronic notification of key events including receipt of the referral at the hospital, and when the referral is reviewed and prioritised for a specialist appointment. This greatly improved the visibility of referral status for the referrer.

Within the hospital, in lieu of a paper

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referral sitting on someoneâ&#x20AC;&#x2122;s desk, an electronically managed eReferral could be reviewed by any appropriate staff member (including Emergency Department staff should the patient be admitted while awaiting their appointment); and electronic workflow management makes for easy identification of eReferrals in need of action. The system saw steady uptake in the first year of operation, rising to over 1000 eReferrals per month in 2008, and thereafter seeing sustained use and moderate growth to 1200 eReferral per month in 2010. eReferrals, as opposed to conventional posted or faxed referrals, constituted around 56 per cent of referral traffic into Hutt Hospital in 2010 (over 70 per cent of referrals from sites using the electronic solution, with the remainder being referrals from outlying areas).

Introduction of the system was associated with a significant reduction in the time until a referral was prioritised,

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with eReferrals being processed more quickly on average than paper referrals, but with processing of all referrals (paper and electronic) speeding up.

A second implementation in the north of New Zealand (the Northland region) was more incremental, starting with a referral form for colorectal investigation and expanding to subsequently include breast screening and diabetes services. This implementation was more lightweight on the hospital side as compared to the Hutt Valley solution, using a web based solution and thereafter proceeding to the pre-existing manual solution for routing and review within the hospital. This solution also has seen sustained uptake by area GPs. In the Canterbury region (the area around Christchurch), eReferral was taken up as an outgrowth of a broader initiative around Health Pathways.

These pathways define care processes as Web based guidelines with clear steps

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and / or flowcharts. Over 300 pathways had been developed at the time of our review (May 2011). The pathways are developed through a systematic process of specialist and GP workshops and aim to empower community based services to deliver care without referral where possible. Dissemination of pathway knowledge is promoted by information evenings for GPs and by specific online feedback to GPs where referrals are declined for not meeting public service criteria. Moreover, training and funding has been provided to community based services to take on expanded roles. This has led to significant demand reduction (and thus reduced waiting list) in a number of previouslyoverstretched hospital-based services including gynaecologic ultrasounds and dermatology (for excision of minor skin lesions). The pathways are seeing high and sustained interest from community based users with 2,500 distinct Canterbury health professionals making over 10,000 webpage visits in May 2011.

The dynamic health pathway content management system allowed earthquake-specific pathways to be provided during the 2010 and 2011 events (e.g. for management of frail / at-risk individuals and of anxiety).

Shared care planning Shared care is defined as “an approach to care which uses the skills and knowledge of a range of health professionals who share joint responsibility in relation to an individual’s care.” Collaborative intervention using E.H. Wagner’s Chronic Care Model (CCM) can be seen as a type of shared care and places emphasis on the role of the ‘activated patient’ as well as the ‘prepared, proactive care team’. Shared care is sometimes associated with care planning.

The UK Department of Health has suggested that every long-term care patient should have an “integrated care plan” developed and reviewed with a lead healthcare professional from the care team. NSCPP aims to provide an

IT infrastructure that facilitates shared care and care planning for patients with high need.

NIHI evaluated the proof-of-concept and ‘limited deployment’ phases of NSCPP in 2011, and is now following the more extended rollout in 2012.

The proof-of-concept phase focused on coordination of cardiac patients; in limited deployment the scope expanded to also include a respiratory service and gout management. In each of these three cases, a hospital based service used the IT solution to share data with general practice staff (GPs and practice nurses) at a number of participating community practices. Various other healthcare providers, such as pharmacists, were also given access to the shared care record, and a few patients have been given access to their own record on a pilot basis. As of 31 October 2011, 73 patients had been recorded in shared care planning system, of which 48 had care plans created and eight had been provided with Patient Portal access.

The software was actively used by the general practice and hospital staff to coordinate care through shared notes, messages and assignment of tasks. This transformed a situation where a patient might be formally referred from community to a specialist into a more collaborative approach among the healthcare professionals. Both doctors and nurses from community and hospital participated in the shared care dialogue.

Indeed nurses were the most active users

A key measure of success can be tracked in terms of plotting transaction volume on the new system to document system uptake, and thus user acceptance.

by a wide margin. A more challenging shift is the uptake of care planning and patient engagement, although training on care planning was provided as part of the project. Who pays for the time to sit with the patient and develop a care plan? And whose job is it to respond to a message posted to the portal by the patient in a timely fashion? While the technology is an enabler, there is a need for transformation in procedures and funding models if healthcare workers are going to commit fully to the use of shared care planning.

Long-term medication adherence While not specifically set as a work area in the national health IT plan, implementation of the plan will enhance the already significant ability for clinicians to track their patients’ medication supply in NZ. Using the NHI, matching GP prescriptions to pharmacy dispensing records is straightforward and can provide insights on the management of long-term conditions in the community at both an individual and population level.

Large opportunities for improved long-term condition management exist around medication adherence (i.e. the degree to which patients take medications as directed by their physicians).

Medications can significantly reduce the impact of conditions such as hypertension, diabetes and high cholesterol, but only if patients take them regularly.

One measure of adherence is medication possession ratio (MPR) – the percentage of days in given time period that a patient has sufficient medication supply to match the dosing regimen set by their doctor. When MPR falls below around 80 per cent, it is assumed that long-term management has been significantly compromised.

NIHI researchers have been examining the effectiveness of monitoring long-term medication adherence using the electronic records in general practice systems and making comparison

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for validation against national pharmacy claims data. We looked at MPR over 15 months for six of the most common long-term medications and found that fully 50 per cent of patients failed to maintain MPRs of at least 80 per cent across those medications. We also found that patients with diabetes and hypertension who maintained a good medication possession pattern were three times as likely to meet their recommended target blood pressure as those with poor medication possession.

We have organised an intervention to improve medication adherence for Pacific Island patients. Working with a Pacific-led practice in West Auckland we identified some 200 patients with a history of low MPR for blood pressure medication. Practice staff used this list to direct follow-up with these patients to discuss issues that may be inhibiting their ability to take medication regularly, and to provide motivation and reminders. The result was a significant improvement in medication adherence as compared to a control practice with similar caseload.

Iteration and evaluation Evaluation should be integral in all projects involving innovative use of health IT. Plan to assimilate user feedback and continue to improve. Monitor uptake and impact to sustain the effort and build the case for extended roll-out.

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In all cases where a new health IT system (or new feature) is deployed, one source of evaluation data is the database of transactional electronic records resulting from the use of the system itself. A key measure of success can be tracked in terms of plotting transaction volume on the new system to document system uptake, and thus user acceptance. Further quality measures may be possible depending on the system, such as completeness of records. In an environment where the new system integrates with existing technology, comparison to historical performance is relatively easy. This was the case at Hutt Hospital where referrals received conventionally by post or fax had already been tracked electronically upon receipt for several years before implementation of eReferral from the community. This allowed us to compare the mean (and variance) of times from receipt to specialist prioritisation and document the speedup as eReferral use became substantial. Look for such process measures as early signals that things are on track – over the longer term the benefits may translate to measurable productivity gains, but they may not in every situation since there are so many steps in the healthcare value chain that the benefits of a single change may be swamped by noise.

The value of qualitative data should not be underestimated. A wide selection of users should be interviewed after

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they’ve had some experience of using the system in the field. Their insights on how the system is adding value (improving quality of care or efficiency) will help to target quantitative studies. Equally, enduser concerns about difficulty integrating the system with real-world workflow, or potential threats to quality of care, should be taken seriously, confirmed by interview with more users and set an agenda for iterative improvement of the solution. In the language of philosophy, we should view the impact of IT as a social phenomenon and not restrict our evaluation to a mechanistic positivist view as is appropriate, say, for trialling the effectiveness of a new medication.

Conclusions IT can be deployed in many ways to effect positive transformations in healthcare delivery. We have illustrated this in terms of electronic referral management, shared care planning and long-term medication adherence.

Many worthwhile transformations can be achieved incrementally; e.g. electronic referrals can be introduced for a few high-volume services, or referral management protocols can be made available as online guidance in advance of implementing eReferrals at all. Pick a level of innovation that fits your current level of IT infrastructure and addresses a large area of opportunity. With a good system of patient identifiers and strong uptake up computing by community based physicians, however, much more is achievable. When deploying health IT, pursue user feedback early and often and make evaluation integral to the project plan. Don’t view IT as a ‘big bang’ solution with a discrete start and end – view continuing IT-enabled improvement as an integral aspect of your business.

Disclaimer: The views expressed herein are those of the author and should not be taken to represent the ITHB.

The 2nd Annual Wireless Healthcare Asia Summit 2012 will be taking place in Singapore from 23 - 24 April 2012.

Join us at this premier networking and content driven event in Asia showcasing the vanguard of developments in the Wireless & Mobile Health space.

Some of the issues addressed at the Summit include: Transforming mHealth and Wireless Ecosystem Minimally Invasive Biosensors and Continuous Monitoring in the Management of Diabetes Personalizing the Experience to Drive Consumer Engagement (Integrated Healthcare Delivery Model) Developing Portals and Online Apps/Tools for the General Educated Public on Healthcare How Operators Can Leverage on its mHealth Services to Increase Customer Loyalty and Revenues Proliferation of Consumer Device and Platforms in the Medical Device World / Developing Lean Health Care The Future of Mobile App Regulations in Asia-Pacific The Key Benefits of Mobile Technologies and Integrated Wireless Devices for Pharmaceutical Companies During Clinical and Behavioral Trials Mobile Learning for Medical Education - Experience from Korea Japan Ministry's Project for Standardized HIT (Healthcare Information Technology) Infrastructure Facilitating Cloud-Based Medical Services in Hospitals Across the Region How MNOs Can Monitise mHealth Services?

Assessing the Rapid Growth and the Importance of Wireless Technology in Telehealth Space Wireless Technology in Remote Monitoring in the Field of Cardiology, Diabetes and Neuro Modulation Care (Parkinson's disease) Optimal Disease Management Strategies & Remote Health Monitoring Platforms The Future of Wireless and Mobile Health Market

Mobile Health and Information Service, Biomedical Information Technology Research Center Providing Patients with Access to their Personal Medical Records On-The-Go

To register or for more information, contact merilynn@magenta-global.com.sg or call +65 6391 2549.

Visit the event website at:

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http://www.magenta-global.com.sg/WirelessHealthcareAsia2012/

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Healthcare, the Cloud and Information Security In this interview, we explore why cloud computing has taken root and list some advantages for health providers willing to pursue this as major IT transformation. We also discuss cloud variants or types, point out cultural barriers for adoption, and concerns when securing health information in the cloud.

Feisal Nanji, Executive Director, Techumen LLC, USA

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1. What is Cloud computing and how does it benefit healthcare providers and consumers?

Three fundamental things have spawned the surge of interest in cloud computing • The ubiquity of fast networks for commercial use • A web enabled eco-system – standard protocols for sharing information. These include TCP/IP. HTML, HTTP and Web services • And finally the concept of the virtual machine.

Combined these three aspects provide a flexible pool of computing, network and storage resources, which loosely defined is the ‘cloud’. Diving deeper, or for a more precise explanation of the cloud and its subsequent benefits to healthcare providers and consumers, we find that the ‘Cloud’ offers: ‘

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Innovative imaging PAC systems where several hospitals could share a single expensive Pictorial Archiving and Communications (PACS) or Radiology imaging system. One hospital would manage the PACS and simply charge an administrative fee. Not only would it lower costs for all hospitals but teleradiology specialists all over the world can now easily share diagnostic images to examine difficult cases.

Innovative Electronic Medical Record (EMR) delivery and exchange.

Rather than upgrading software on a regular basis as one would with regular EMR systems, a cloud based EMR service and allows hospitals with a simple way to keep their systems updated. So one can get the benefit of advanced technology without having to invest in a large IT staff.

Data mining of healthcare case studies allows for better etiology, disease management and more effective therapies. But data mining is usually an expensive proposition for a single small hospital accomplish on its own.

By aggregating data mining into a ‘shared resource’ through the cloud many more hospitals can now afford the full benefits of data mining.

In short, the sky is the limit to the way the cloud can be used for the Cloud has the potential to makes healthcare IT much cheaper, faster, better.

On-demand self-service A consumer can unilaterally provision computing capabilities such as server time and network storage as needed automatically, without requiring human interaction with a service provider.

Resource pooling The provider’s computing resources are pooled to serve multiple consumers using a multi-tenant model. Different physical and virtual resources are dynamically assigned and reassigned according to consumer demand.

Rapid elasticity Capabilities can be rapidly and elastically provisioned

—. To a Healthcare provider the capabilities available for provisioning often appear to be unlimited and can be purchased in any quantity at any time.

Measured service Resource usage can be monitored, controlled, and reported — providing transparency for both the provider and consumer of the service.

Thus there are lots of possible uses of the cloud in can substantially improve healthcare delivery and make it cheaper to implement. Some clear examples include:

2. What are the major concerns of securing health information in the cloud?

Perhaps the question could be broadened to ask if the cloud is more secure.

The clear answer to this is that Cloud Computing isn’t necessarily more or less secure than your current environment. In some cases moving to the cloud provides an opportunity to re-architect older applications and infrastructure to meet or exceed modern security requirements. At other times the risk of moving sensitive data and applications to an emerging infrastructure might exceed your tolerance.

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However cloud security has the vast potential to surpass the levels of information security that are possible today but only if it is done right. This begs the question, how is Cloud security different from traditional IT security?

Let’s consider a traditional (or non cloud) data center’s security requirements and approach. Again, that is something that is not in cloud mode.

Several things occur to ensure security in a traditional data center: 1. Physical configuration management governs deployment and controls implementation. That is once you configure a physical system you rely on a specific set of controls. The cloud, on the other hand let’s you escape from this throttle so you can be fine grained about your controls.

2. Physical control - if you are facing a massive rapidly spreading virus attack you can literally pull the plug in a data center and shut down a system. With the cloud it’s not so easy to pull the plug for the cloud is by definition amorphous. Where do really pull the plug in the cloud? It’s not an easy answer.

3. In regular data centers an organisation typically has one set of Enterprise policies and organisation for separation of duties and control. But cloud services providers have to deal multiple enterprises so cloud polices have to be very well tailored. Our hospital might, for example, have stricter encryption standards than the service provider) 4. Patch testing and patch management is done one physical-platform at a time (one by one) in regular IT environments. With the cloud one command can update all your virtual machines saving time but also opening up a much larger potential for error.

But in the cloud everything changes…. As physical visibility is lost …. With the cloud, unlike a traditional data center, our concerns or questions arise: • Where is your data and where is processing performed? As a hospital you may have some issues sending

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sensitive information across geographies. For example the European Union Privacy laws place great restrictions on where an entity can store and/or process information • Who else can see your data? (More accurately who might be able to see your data – Remember our data is not housed in a single, secure physical data center anymore. And as you ask who has seen the data how do you know who has seen it? Do you have the right audit tools to confirm?

• Has data been tampered with in the cloud? Remember in the cloud we don’t have physical control so do we have the right tools and processes to understand if Data has been tampered with in the cloud?

• How is processing configured?

Who will manage this for you? Is your provider really managing your cloud processing as well as it claims?

How do you know if this translates into good security for your specific cloud?

• Does backup happen? How? Where?

3. What factors need to be considered while adopting a cloud-based solution?

We can make three different types of clouds based on the required service model: • Infrastructure as a service (IaaS) • Platform as a service (PaaS) • Software as a Service (SaaS)

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Differences among these three types of clouds are vitally important because they carry important ramifications for a wide range of operating and security requirements.

Infrastructure as a service (IaaS) includes the infrastructure resource stack from the facilities to the hardware platforms that reside in them and the logical connectivity to those resources.

So IaaS provides few if any applicationlike features, but enormous extensibility.

So for healthcare provider this generally means less integrated security capabilities and functionality beyond protecting the infrastructure itself. In short, this model requires that operating systems, applications, and content must be managed and secured by you the healthcare provider.

Platform as a service (PaaS) sits atop IaaS and adds an additional layer of integration by providing application development frameworks and middleware capabilities. These added functions include database and message queuing. PaaS is primarily used to enable in-house developers to build their own applications on top of the platform.

However built in security capabilities are still not fully complete because of this flexibility. So when using this model the hospital still assumes considerable risk but the risk is less than a pure IaaS model.

The final cloud variant is software as a service (SaaS). SaaS, in turn, is built upon the underlying IaaS and PaaS stacks. It provides a self-contained operating environment used to deliver the entire user experience including the content, its presentation, the application(s), and management capabilities. So SaaS provides the most integrated functionality built directly into the offering, but it has the least the least consumer (hospital) extensibility. And because of this, a SaaS provider must guarantee a relatively high level of integrated security. The SaaS cloud provider in essence bears a responsibility for most of your information security.

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The key takeaway for security architecture is that the lower down the stack the cloud service provider stops, the more security capabilities you, as the cloud consumers, are responsible for implementation and management 4. Do you think healthcare sector is better positioned to adopt cloud than others?

Actually every industry can be a beneficiary of the cloud. But Healthcare, which is often cost constrained and is more about doing societal good than profit, should be very receptive to its adoption.

5. How has the industry's initial experience with the cloud been?

There are clear opportunities and options for healthcare providers. The initial forays have been with Electronic Medical Records, and point solutions say for revenue cycle applications. Over time we expect many more applications to flourish.

6. Are there any cultural issues that could hinder the adoption of cloud?

First and foremost, the cloud presents those of us in information technology and security a once-in-a career opportunity to make information security better: faster, cheaper, more efficient and less intrusive. Because cloud platforms are still developing, we have unprecedented opportunities to embed information security processes and technologies deeper into the infrastructure. This requires a deep change in the cultural mindset of organisations used to a strong centralised IT function.

More critically your business units must also be ready to share the same infrastructure. For a cloud solution to make economic sense it has to have periods of high utilisation; otherwise, the resources will sit idle for long periods of time, destroying the return on investment.

7. There exist health information security and privacy concerns in the cloud; How can these issues be recognised?

The cloud forces user organisations to fully reexamine their methods for Data ownership and control. Therefore we may to revise our models for establishing trust and consequences and chain of custody, and how we provide access and authentication.

Providers of Cloud services must also have give user administrators (hospitals) the access and privileges needed to do their jobs. That is user organisations should clearly retain control over IT policies and assets, even if they don’t own or directly operate those assets.

One other important point: in the cloud Interactions between software and systems often equal or exceed those between people and machines.

Consequently, it’s imperative for IT and security processes to account for the reality that a ‘user’ in the cloud may more likely be a machine than a person (or a machine acting on behalf of a person). This has profound implications on how identities are provisioned, authenticated and managed

The ubiquity of fast networks for commercial use; a web enabled eco-system – standard protocols for sharing information; and the concept of the virtual machine provide a flexible pool of computing, network and storage resources, which loosely defined is the ‘cloud’.

8. What are the key steps to overcome/manage these issues?

In short, the best way to ensure security and privacy for the cloud is for enterprise customers to require maximum transparency into their cloud providers’ operations. You will be sharing resources with potentially lots of business units – external or internal – and you need to know what is going on Also as a CIO or Chief Security Officer you must change your mindset about information security. Several things are important: • Think of delivering security as a set of adaptive services that are delivered via programmable infrastructure to create adaptive zones of trust.

• Pressure incumbent security vendors to deliver their security controls in a virtualised form to more easily address secure cloud-computing requirements.

• Express security policy across physical and virtualised cloud-computing environments.

• Maintain separation of duties between security policy enforcement and IT operations in the transition cloudcomputing environments.

9. Any other comments?

There are many other cloud related issues that will affect users, IT managers and senior management. Consider one aspect, that of compliance. Many IT professional have to constantly worry about audits. Moving to the cloud means you will likely be inundated by audit such as systems reviews, transaction reviews, policy and procedure reviews and risk assessments. This is a heavy information dissemination, storage and analysis burden. It happens that information security is tied closely to information movement and will be among first compliance items we design for the cloud. So if we do this correctly for information security efforts, we can substantially improve other compliance needs in healthcare.

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Successfully Implementing Healthcare IT A health informaticianâ&#x20AC;&#x2122;s perspective IT is an enabler of change and not the change itself.

When customers look at IT as the one solution to all their problems, it is set up for failure from the beginning.

Introducing an IT system necessitates an in-depth study of existing workflows, roles and responsibilities and change management aspects in every speciality.

Thanga Prabhu, Clinical Director, GE Healthcare IT, India

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ealthcare IT implementation is complex, interlinked, domainsensitive and clinician-focused, thereby being different from other IT implementations. The generally high failure rate for IT implementations tends to be higher in healthcare due to this complexity3,4,5. Clinicians need to be involved actively from the requirements gathering phase and given ownership of clearly defined sub areas within the project to be successful. IT should be a tool to transform healthcare delivery

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model and not expected to be a solution by itself.

HCIT - Domain intensive Healthcare is an environment of trust wherein many actions are performed without being specifically asked for. The single point of focus for all clinicians is the patient and roles are synchronized, each one playing a small but significant part in the care process. A study found that when a patient walks into a healthcare facility, is registered, vitals taken

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by nurse, seen by doctor, takes medicine from pharmacy and walks out 50+ people have to work in harmony for this to happen successfully. Intensive training ensures that the personnel on the ground know exactly what is expected of them and they do that role with conscience. In contrast transactions in banking or the travel industry are simple and straightforward. Clinicians ranging from doctors, nurses, pharmacists, technicians in lab, operation theatres, dialysis centres, and emergency services have varying data needs and data recording responsibilities. When a doctor charts his patient for the first time he goes into details on illness, past history, allergies, drugs being taken by patient, builds a problem list, identifies / lists differential diagnosis, plans lab / radiology investigations and prescribes initial treatment. The methodology followed is standardized during his training and practice over the years ensures that it comes naturally while examining a patient. Nurses also train on similar lines to examine and document key information on the patient initially and then as patient moves through the system. The data that is recorded by each clinician is useful to take decisions for the patient and is used by the entire team.

As clinicians become experienced most

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of this data processing is done without actually recording it on paper and it is known that consultants record only key points in their patient records.

When HCIT requirements have to be gathered in such an environment they should be involved early as only clinicians understand the significance of each piece of information. Many tools are available to assist the clinicians during the course of their work and it is important to note that none of them are mandatory. HCIT is also a tool, which if not user-friendly tends to be ignored.

HCI (human computer interaction) has to offer better ways to input data as the traditional mouse/keyboard system does not fit into the busy healthcare environment. Speech recognition is now being used in radiology reporting and touch screen systems are being deployed in operation theatres and ICUs to gather data without the clinician having to actually sit and type.

in the operation theatres being expected to remove their sterile gloves to type can also jeopardize a project. Attitude is a subjective phenomenon and usually can be overcome by peer pressure and strict enforcement of policies. Once clinicians see the benefits they tend to voluntarily train their teams and the rate of knowledge transfer then goes up significantly.

This is after all the existing culture within healthcare where peer support and sharing of best practices is common.

Change management Clinicians have been known to be resistant to change for ages. As an example, usage of stethoscope amongst the medical community took almost 100 years. If the systems that they are expected to use in their day-to-day work is unfamiliar to them and takes too much of their time, without tangible benefit, there is a very serious risk of non-usage. Every clinician has to see clearly the benefit that will accrue to his / her work to adopt a new system. Resisting change is natural and it is seen in a greater degree within healthcare. ‘Clinician champions’6 have to be identified within the customer’s staff who will lead the implementation and support their colleagues later on.

The resistance to change is often because of three broad reasons: political, technical and attitude. If the new system upsets an existing hierarchy or even gives an impression of doing so, it can be a serious risk. Technical reasons such as lack of training, not being comfortable with using technology, HCI (human computer interaction) factors such as clinicians

Interoperability HCIT procurement should be done by knowledgeable personnel who see the big picture and can build a system incrementally. In the western countries it has been seen that departments usually acquire systems individually starting from radiology, cardiology then laboratory and finally the HIS / EMR. None of these systems are expected to communicate with each other initially and after significant cost, effort and time has gone into implementing it the results could be diverse systems that cannot communicate. Rather than follow a big bang approach it has been observed that incremental adoption with the larger picture in focus assures success.

It is imperative today that all systems communicate freely amongst themselves and also with external systems.

Most facilities have home grown basic billing HIS systems but clinicians are not exposed directly to these systems.

Technology savvy specialties such as Radiology, Cardiology, Anaesthesia and Lab medicine should be starting point

HCIT is no different from other IT implementations in that it is also force fitted on existing systems without understanding fully all the ramifications of doing so.

for a HCIT solution. Such pioneers are excellent ‘User Champions’ for future more complex specialties.

Benefits It is futile to incessantly discuss the many reasons of why HCIT solutions are not useful in healthcare. Success stories and proven benefits of HCIT implementation need to be highlighted to build customer’s confidence in adopting a HCIT solution. It has been seen that instead of trying to force fit a solution on existing workflows, a system that can adapt to and respond dynamically to end user needs is liked and used by clinicians.

Existing HCIT solutions have limitations on their configurability, nevertheless when products are extensively customized; it becomes difficult to maintain the product over time. A fresh approach to building HCIT solutions which are easy to customise, can be hosted on a cloud and paid for on a utility model (pay-asyou-go/case by case) and preferably allow clinicians to tailor on their own with minimum IT support is required. With the advent of Web 2.0 (Read and Write) and Web 3.0 (Read, Write and Run) technologies and customers using Facebook, Twitter, YouTube, Apple iStore etc. the same is now expected from HCIT vendors. Author has personal experience of Anaesthetists requesting data mining features with drag-drop tools to create queries/reports on their patient data which is then used for research and academic presentations.

Government initiatives The government has to play a regulatory role and help identify ‘EMR Interoperability standards’ after studying the globally available standards and identifying those that are relevant, affordable in the long run without any strings attached and mandate their use by HCIT vendors. Patient data has confidentiality and privacy implications which need to be covered by Government with a legal framework. The newly enacted addenda to IT Act 20001 which mandate vendors

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Learning from Aviation / Nuclear / Space industries We need to learn from our predecessors who have taken the failure bull by its horn and controlled what was given up as impossible earlier. Aviation industry had some depressing statistics before FAA (Federal Aviation Authority) stepped in to rein in the problem.

The FAA conducted due diligence and created open reporting mechanisms to identify problem areas which then went on to become starting points for other interventions. Nuclear industry by nature is risky and allows no scope for slip-ups.

Enforcing safeguards, defined protocols, on-going training to keep personnel updated on latest skills has resulted in safety. Space industry is intrinsically dangerous and failure rates were high initially. NASA today has managed to mitigate these risks and regularly sends rockets and shuttles to space. The key is to take a holistic view of systems and blame the system and not the user of that system when failures do occur.2 Transforming healthcare with IT IT is an enabler of change and not the change itself. When customers look at IT as the one solution to all their problems, it is set up for failure from the beginning.

Introducing an IT system necessitates an in-depth study of existing workflows, roles and responsibilities and change management aspects in every speciality.

IT is but another tool available to transform healthcare and when its role (and limitations) is understood the chance of success increases. A clinician who leads HCIT implementation on a full time basis starting with initial seeding of idea amongst clinicians, brainstorming with them implications of introducing the

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system into workflows, hand holding during the implementation and ongoing support post ‘Go Live’ should be minimum criteria in HCIT implementations.

Just mapping the paper based workflows to IT and replicating it does not allow clinicians to fully utilise the complete capabilities that IT brings in. New ways of working such as real time chat on social networking sites such as Twitter and SMS can allow clinicians to interact and mutually support each other while delivering care. Document once and reuse infinitely, auto calculating all variables, adding layers of security to ensure role based access are all possible only with HCIT. HCIT manpower The realisation that has dawned on health informaticians today and backed up by research is that HCIT implementation should not be treated as another IT implementation. The domain is complex, most work happens like clockwork without much communication (for example when a surgeon operates, the nurse assisting him knows exactly what instrument he needs next). Thus clinician-lead HCIT implementations are realising higher success rates. Medical Informatics workforce is non-existent today. A separate cadre of foot soldiers who can man the posts is required as bridging clinical and IT worlds, is difficult. ONCHIT is spending billions to encourage academic centres to churn out this workforce in USA. NHS in UK supports employees to acquire additional informatics skills as it is clearly required to practice in tomorrow’s healthcare world. India has the opportunity to recognise this need and use our excellent educational system in public and private sectors to train HCIT manpower at different skill levels using Author BIO

to take necessary and reasonably good measures to protect patient data is timely. Ownership of patient data is an unresolved question globally but the consensus has been to retain ownership of data with patient with government being a guardian for that data.

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modern teaching resources such as on demand learning and online delivery systems. The demand for this manpower has always been much higher than what the system has been able to provide.

Conclusion HCIT is no different from other IT implementations in that it is also force fitted on existing systems without understanding fully all the ramifications of doing so. The interlinked and mutually supportive healthcare environment where trust on peers and a single minded focus to work for one goal – patient care without direct orders is an amorphous beast to an outsider to healthcare: the IT person. A fresh approach to HCIT product development is required where the product can quickly meet the clinician’s need. Actively involved clinicians, HCIT trained manpower and HCIT aware clinicians can transform healthcare today; it is not an option but an idea whose time has come in 2011.

References:

1. Information Technology (Reasonable Security Practices and Procedures and Sensitive Personal Data or Information) Rules, 2011 under the existing Information Technology Act, 2000 2. Human error: models and management, James Reason, BMJ 2000;320:768–70 3. Rashbass J. The Patient-Owned, Population-Based Electronic Medical Record: A Revolutionary Resource for Clinical Medicine. JAMA. 2001; 285:1769 4. Kaplan B. Evaluation Informatics Applications: Clinical Decision Support Systems Literature Review.

International Journal of Medical Informatics. 2000; 64(1):15-37 5. McDonald CJ. The Barriers to Electronic Medical Record Systems and How to Overcome Them. Journal of American Medical Informatics Association. 1997; 4(3):213-221.

6. Lorenzi NM, Riley RT, Blyth AJC, Southon G, Dixon BJ. Antecedents of the People and Organisational Aspects of Medical Informatics.

Journal of American Medical Informatics Association. 1997; 4(2):79-93.

Thanga Prabhu has 20+ years of healthcare experience working in India, Abu Dhabi and United Kingdom. He authored a paper for the UK Parliament Health Select Committee in 2005 titled ‘The utilizations of telemedicine (telecare) and its future potential for improving services’. He heads the HIN (Health Information Network) of iHIND and is a member of the ‘EMR Interoperability Standards for India’ expert committee.

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Company....................................................................Page No. Healthcare Management Fleming Gulf.............................................................................05 Greiner Bio-One GmbH.............................................................03 IBC Asia (S) Pte Ltd........................................................ 09 & 23 International Biotech Park.........................................................31 HIMSS................................................................................... IBC Magenta Global........................................................................51 Messe D端sseldorf Asia Pte Ltd.............................................. OBC Medical Sciences Fotona d. d..............................................................................IFC Greiner Bio-One GmbH.............................................................03 International Biotech Park.........................................................31 Technology, Equipment & Devices Fleming Gulf.............................................................................05 IBC Asia (S) Pte Ltd........................................................ 09 & 23 International Biotech Park.........................................................31 HIMSS................................................................................... IBC Messe D端sseldorf Asia Pte Ltd.............................................. OBC

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SAVE THE DATE

SINGAPORE 17 – 19 SEPTEMBER 2012 WWW.HIMSSASIAPAC.ORG/12

LINKING PEOPLE, POTENTIAL AND PROGRESS On the week of the Singapore F1 we are holding HIMSS AsiaPac12.

It is the one healthcare IT event dedicated to connecting people and information in new ways to increase patient care and safety, reduce healthcare costs and improve quality of life across the entire continuum of healthcare.

FOUR HEALTHCARE INFORMATION TECHNOLOGIES CONFERENCES IN ONE HIMSS AsiaPac12 debuts a new annual conference format that is unlike anything you’ve ever experienced. You will have access four conferences all under one roof. s HIT X.0 s mHIMSS (Mobile Health) s Home Care s Standards and Interoperability The exhibition will showcase hundreds of products and services for your healthcare IT needs. Experience live demonstrations, technology updates, new products and services. And don’t miss the IHE Interoperability Showcase!

Conference & Exhibition 17–19 SEPTEMBER 2012 MARINA BAY SANDS S I N G A P O R E

Supported by

Held in

transforming healthcare through IT ™

MEDICAL FAIR ASIA 9th International Exhibition on Hospital, Diagnostic, Pharmaceutical, Medical & Rehabilitation Equipment & Supplies

12-14 sept 2012

Suntec Singapore

Asia’s definitive platform for innovative medical and health care technologies Book your booth space TODAY at

Concurrent event:

Held in:

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Sponsored by:

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Supported by:

Messe Düsseldorf / Organizer of

For enquiries, please contact:

Messe Düsseldorf Asia Pte Ltd 3 HarbourFront Place #09-02 HarbourFront Tower Two Singapore 099254 Tel : (65) 6332 9620 Fax : (65) 6337 4633 / (65) 6332 9655 medicalfair-asia@mda.com.sg

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