Asian Hospital & Healthcare Management - Issue 26

Sp e c ia l iss ue on technolog y

I s s u e 26

2012

w w w.asianhhm.com

Technology in Healthcare How data and mobility are taking centre stage

In Association with

The EHR Climbing the adoption curve

Evolving and Enabling Standards for Mobile Health Adoption

How ‘Meaningful Use’ and Health IT Collaboration are Enabling the Evolution of Healthcare

Foreword Healthcare’s Transformation Data and mobility lead the way Advancements in technology are at the heart of improved healthcare outcomes. Two such advancements that are currently in the spotlight deal with improved data management and mobile computing.

Electronic records are pervasive today. Twothirds (69%) of US primary care physicians reported using EMRs in 2012 a remarkable rise of 50% from 2009, while the EMR adoption rates shot up by 90% in Australia, the Netherlands, New Zealand, Norway and the UK, according to a survey of primary care doctors in ten countries by the Commonwealth Fund.

However, in many cases health records are still stuck in age old data management infrastructures. Crucial advances in the way data is stored and exchanged within and outside the organisation is changing this, and holds promise to improve patient diagnosis and efficiency of treatment.

On the front end of healthcare provision, mobile devices are empowering physicians and patients with access to data on the go.

Adoption is already on the rise thanks to rise in smartphone take up and related application. 'mHealth' applications are expected to predominantly be distributed through traditional healthcare channels. According to The Mobile Health Market Report 2010-2015 - The Impact of Smartphone Applications survey, 53% of the respondents believe that currently app stores are the best distribution channels followed only by healthcare websites (49%).

The mobile revolution has transformed industries such as banking already, and holds similar promise for healthcare. AS you will

read in the issue, it is becoming increasingly clear that patients are receptive to mHealth. In the EIU mHealth study, physicians and providers in China, India and the USA were asked what impact they expect mHealth would have on the current practice of medicine. Chinese providers also expected mHealth to have the most profound impact across the board, followed by India.

In this special issue of Asian Hospital & Healthcare Management, Jeanette C Schreiber from the College of Medicine, University of Central Florida, USA says that transforming healthcare will require a broad, interoperable Health IT system allowing healthcare providers to share and use patient data reliably and securely. Christopher Wasden and Rana Mehta from PricewaterhouseCoopers says that standards in IT, care delivery, payment and regulation must evolve more rapidly for mHealth to realise its full potential as one of the most disruptive movements in healthcare today. The issue also covers articles from industry experts focusing on new opportunities, issues and challenges facing healthcare IT. Hope you enjoy reading the magazine.

I thank all the authors for their support and contribution in making this issue possible.

Prasanthi Potluri

Editor

Advisory Board

Editor Prasanthi Potluri Copy Editors V Rashmi Divakar Rao Silpa Tummala Jenny Jones Debi Jones Art Director M A Hannan Project Managers Khaja Ameeruddin Prabha Nandikanti Jeff Kenney Breiti Roger Project Associate M Vinay Kumar Vineetha G Ben Johnson Veronica Wilson 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

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 Sankar Kodali Head - Operations S V Nageswara Rao

Peter Gross Senior Vice President and Chief Medical Officer Hackensack University Medical Center, USA Asian Hospital & Healthcare Management is published by

In Association with

A member of

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

Confederation of Indian Industry

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Contents

36 How an ICT-based System to Monitor Gait Can Make a Difference in Asia Diana Hodgins, Managing Director, European Technology for Business Ltd, Codicote Innovation centre, UK

40 Evolving and Enabling Standards for Mobile Health Adoption Christopher Wasden, Global Innovation Leader, PwC Rana Mehta, Partner, PwC India

46 Clinician Role Changes Delivering Patient-centered Workflow Barry P Chaiken, Chief Medical Officer, DocsNetwork, Ltd, USA

50 Liquid Data Fuel for collaboration on the road to innovation in healthcare Marc Perlman, Global Vice President, Healthcare and Life Sciences Industry Business Unit, Oracle

54 Can Animation Software Help Find Cures for Cancer and HIV? V R Srivatsan, Managing Director, ASEAN region, Autodesk Asia

56 Make Big Data Economical and Actionable for Faster and Better Healthcare 06 Connectivity in Healthcare - A Foundation for Quality Care Leveraging the 12 best practices for health IT to improve care and reduce costs

Yogesh Sawant, Director, Partner Sales and Field Alliance Organization, India, Hitachi Data Systems

58 Books

Kim Lamb, Executive Director, Oregon Health Network, USA

10 The EHR Climbing the adoption curve

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Ken Ong, Chief Medical Informatics Officer, New York Hospital Queens, New York

16 How ‘Meaningful Use’ and Health IT Collaboration are Enabling the Evolution of Healthcare Jeanette C Schreiber, Chief Legal Officer, College of Medicine, University of Central Florida, USA

22 Data Exchange and Analytics John D D’Amore Clinfometrics, Boston, MA USA Dean F Sittig, UT-Memorial Hermann Center for Healthcare Quality & Safety, School of Biomedical Informatics, University of Texas Health Science Center, USA

26 Accessing Health Data Striking a balance between security and usability Trevor Strome, Assistant Professor, Department of Emergency Medicine, University of Manitoba, Canada

31 Personal Connected Health The technology revolution in healthcare Chuck Parker, Executive Director, Continua Health Alliance, USA

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Connectivity in Healthcare A Foundation for Quality Care 12. Policy 11. Reimbursement 10. Credentialing and privileging 9. Recruitment and retention 8. Education 7. Measurement 6. Support 5. Information 4. Implementation 3. Connectivity 2. Collaboration 1. Strategy and vision

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T

he worldwide healthcare landscape is more complex and multidimensional than ever.

Over the past five years, acronyms, federal mandates, and funding streams have bombarded decision makers in a number of healthcare-related industries.

From core operational infrastructure systems to billing, scheduling, electronic medical records use and administration, healthcare has transitioned from a delivery system designed and managed within a silo to one that needs to communicate in real time to the rest of the policy-making continuum.

Healthcare executives, providers, and administrators, along with local and federal politicians, are charged with addressing the pressing healthcare, economic, and workforce needs of their

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Author BIO

Leveraging the 12 best practices for health IT to improve care and reduce costs

The healthcare landscape is more complex and multidimensional than ever. 12 health IT best practices developed will help healthcare executives, providers and administrators recognise the critical elements required to implement and support a viable health IT infrastructure.

Kim Lamb, Executive Director, Oregon Health Network, USA

constituents. These issues are increasingly difficult to deal with, particularly because decision makers are not given the broader context of health information technology to help them prioritise solutions. The new emphasis on patientcentered care requires collaboration and coordination at the federal, state, and regional level, as well as full interoperability at the hardware, software, payer system, and patient care levels.

Formerly reserved for those with money and resources to invest, today’s health IT is no longer optional: it is a core requirement for all providers and agencies playing any role in the healthcare continuum. Furthermore, its adoption and use go beyond the traditional quest for pure competitive advantage; health IT is truly the only effective means to not only survive, but to thrive.

Oregon Health Network (OHN) is building a statewide broadband telehealth network in Oregon with hopes that this

network model is then taken nationwide. OHN supports the Triple Aim, the revolutionary philosophy adopted by a number of key organisations, including the Office of the National Coordinator and the Centers for Medicare &

Kim Lamb is the executive director of the Oregon Health Network, manages Oregon’s first statewide health care network, designed to support all providers with an infrastructure and suite of services necessary to support the next generation of integrated care. As the face of OHN, she educates diverse audiences about the value of health information technology, OHN’s vision and the importance of collaboration in serving the Triple Aim goals of CMS.

Medicaid Services (CMS). The goals of the Triple Aim are to: enhance the patient experience of care (including quality, access, and reliability), improve population health, and reduce – or at least control – per capita costs.

12 Best Health IT Practices For Our Community These 12 health IT best practices are recommended guidelines for healthcare providers to understand what is required to achieve success, what they can influence (and what they cannot), and which partners and support systems are needed for success.

This framework is not based upon the latest grant, mandate, or technological advancement, but upon the proven business and technological expertise and resources required to develop a viable health IT programme.

1. Strategy and vision – Form follows function Until recently, the healthcare community did not have a commonly shared health IT solution goal. Decisions were made at the ground level, within the system walls created by providers, executives, and administrators.

But the recent adoption of the Triple Aim changes all that – there now is a framework to build from and within.

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The first step to any well-laid health IT plan is to take the time and effort to clarify your strategy and goals. Form must follow function. Think about your goals as a healthcare provider or facility: How do you (or will you) measure success as a result of your health IT strategy and plan? And even more importantly, how does your plan align with that of the surrounding communities, and within state and national plans?

Plan and build with the end in mind: an integrated healthcare delivery system.

2. Collaboration – Don’t reinvent the wheel Investing in—and integrating into— the national provider community is the most effective and affordable means to reduce costs and improve patient outcomes. Collaboration also addresses the pending healthcare provider shortage through expanded referral partnerships and supplements your health IT best practice areas.

Here in the USA, the Federal Communications Commission (FCC), the Office of the National Coordinator, and the Centers for Medicare & Medicaid (CMS) are working to improve and incentivize the quality of healthcare. These improvement efforts include mandating the meaningful use of Electronic Health Records (EHRs), funding Regional Extension Centers to assist physician practices in achieving meaningful use, and adding telemedicine services to the approved list of CMS services.

Like most healthcare organisations, the US federal government is in the early stages of facilitating true interagency coordination. This collaboration develops the programs and mandates that we work synergistically to support, not hinder, the transition from old to new. We are all in the same boat, and we need each other to achieve success. Each of us is empowered to play a positive role in transitioning to a better future: one strategy, decision, and sound investment at a time.

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The new emphasis on patient-centered care requires collaboration and coordination at the federal, state, and regional level, as well as full interoperability at the hardware, software, payer system, and patient care levels.

3. Connectivity – Building the infrastructure needed for success Regardless of whether we represent a public agency, a for-profit or nonprofit healthcare facility or provider, the pressure to do more and better with less is a common denominator. Under the developing new models, we’re all charged with thinking about how our facility, community, and state will connect to the healthcare delivery system via information technology.

The key to success in this new age of healthcare delivery is not only the interoperability of what is running on the network, but the broadband network or ‘highway’ itself on which health IT applications and hardware run. And once the network is built, it must be adequately supported and used.

Reliable, high-speed, high-quality connectivity is a crucial, but often overlooked, component for success. This is why Oregon Health Network is working to expand existing, and build new, broadband infrastructure across the United States to support the health IT requirements of the next generation healthcare delivery system.

4. Implementation – Answering the question of ‘how?’

What is your plan to serve your greater health IT strategy? What resources, tools

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(broadband internet, hardware, software, etc.) and supporting processes will be required to do so? And how will it be implemented to achieve success?

Success in this area requires more than funding; it also requires appropriate expectations based on measurable outcomes, research and measurement, and the right expertise to design a thoughtful implementation plan. While many of these plans are comprehensive in nature, a larger set is executed based on a specific use or application such as telemedicine / health, EHR, health information exchange, networking, video and others.

Consider this a critical ‘translation’ step of reconciling the approved strategy with the realities and limitations of the environment. These include, but are not limited to: access to resources (people, money, knowledge) and buy-in from leadership to set the implementation team up for success with their investment and awareness of all the 12 best practice areas.

5. Information – Quality improves outcomes The current HIT focus is on EHRs, but in the context of the other 12 best practices, it’s easy to see how EHRs plays an integral—but only supporting—role within the broader health IT framework. Our focus isn’t only about EHRs. It is about information. And more specifically, it is about getting the right information to the right person at the right time.

Why? At the risk of sounding redundant: to serve the Triple Aim. The demand for quality information will continue to increase worldwide. The key is to learn not only how to obtain and manage that information efficiently and effectively, but also to be able to share it easily and freely throughout the entire healthcare continuum.

6. Support – Making it work every day Once a network is designed and implemented, it is important to ensure that we have the resources needed to support

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the strategy and solution that have been implemented. There will be continuous modifications and subsequent investments that tie directly to the measurement and education of your solution.

It is paramount to ensure that you have the right people and resources to work well with your technical, business, and clinical staff. Support should be considered throughout the life-cycle experience: from the network level all the way through to the provider and patient or end user.

7. Measurement – Access realtime information for improved decision making The goal of gathering information is to reduce costs and improve outcomes.

Therefore, it is critical to regularly evaluate the success of health IT programmes and modify or adjust to meet those goals. The benefit of having access to ‘real-time’ information supported by health IT is that it provides organisational leadership with opportunities to adjust the course before you hit a wall. Consider it a proactive check and balance system. Therefore, it is not only important to allot time and resources for evaluating your programme’s success but also to measure performance in a way that directly aligns with clearly stated goals and metrics.

There is a wealth of information and metrics to gather, so be strategic and specific when identifying what you’re tracking and why. Here are some questions to consider • How has your new ENR system or telemedicine program served the Triple Aim? • How can you work with other healthcare providers and organisations to identify what and how the statewide community measures success?

• What action will you take if you discover your program is not living up to your expectations?

8. Education – Shortening the divide from ‘have’ to 'use’ Implementing new health IT solutions (from hardware to process refinement)

is just the beginning. To experience the full benefits and improved outcomes of health IT, you need to encourage users at all stages and phases of the process, from inside your organisation to outside (i.e. other providers and patients themselves) to make full use of the solution.

Targeted, simplified, user-focused communications are a core component of strong education programmes. Simplifying complex information is a challenge, particularly when you are required to ask the user to change existing behaviours such as how to enter or retrieve information in a new system. Because people absorb information differently, consider providing the materials and trainings in a variety of formats-hard copy literature, electronic files, visual representations, and in-person trainings.

9. Recruitment and retention – Increase, and then meet demand Strong health information technology is the number one incentive to attract higher wage-earning primary care physicians and other health professionals to a community. Keeping healthcare in local communities stimulates local economies by: • Increasing patient confidence (thus keeping the patient—and payment— local) • Increasing physician confidence (doctors across the region know that they have the support they need to answer some of medicine’s toughest questions, regardless of where they practice), • Retaining and recruiting doctors in historically underserved rural communities • Attracting higher-wage jobs.

10. Credentialing and privileging – Care without borders CMS and other organisations are working at the policy level to address the challenges faced with licensing, credentialing, and privileging for telemedicine. It’s important to keep an eye on progress, and to support the state and

national organisations lobbying to make the much-needed changes.

11. Reimbursement – Ensuring payment for the next generation of care Similar to licensing, credentialing, and privileging, making sure your physicians and clinicians are paid for the work they do via telemedicine (medicine across borders and facilities) is where the 'rubber meets the road.’ Thanks to several nonprofits, state agencies, and countless volunteers, Oregon is well on its way to overcoming reimbursement issues. However, work remains at the state and federal levels, and with insurance payers. This challenge can be overcome with innovation and collaboration, ensuring that all members of the healthcare continuum are reimbursed appropriately for all levels and types of care.

12. Policy – Top-down collaboration and support of the continuum Legislation and policy refinement at all levels is critical to helping providers invest in solutions that serve the Triple Aim. From broadband network deployment policy to licensing, credentialing, privileging, and reimbursement, local and national organisations are working on your behalf to reduce the barriers to full use and adoption of a national system. Your voice and support is critical to their ability to do so.

Resources to support best practices

All 12 best practices cannot—and should not—be performed by any one provider organisation. They require our community working together: provider, policy and funding sources, and nonprofits.

The key, as a healthcare provider business, is to consciously determine what you can feasibly address on your own, and where you need to look to others for assistance. Gone are the days of doing it alone; providers have a wealth of experience and resources to share with the healthcare community.

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The EHR Climbing the adoption curve

The electronic health record and its related technologies are new innovations that hold the promise of transforming healthcare. Nonetheless, all innovations encounter an uphill struggle of adoption. Meaningful Use and the HIMSS EMR Adoption Model are two complementary visions of how to make the promise of health IT a reality.

Ken Ong, Chief Medical Informatics Officer, New York Hospital Queens, New York

A

fter receiving more than one thousand public comments to its Notice of Proposed Rule Making, the US Centers for Medicare and Medicaid Services (CMS) is crafting the final rule for Stage 2 of meaningful use of the Electronic Health Record (EHR).

While we wait for CMS’s final rule, it is worth considering EHR adoption in the USA and those forward-looking

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nations that served as early adopters of this transformative technology.

Diffusion of innovations

Innovation in any field is a challenge.

Everett Rogers has studied the diffusion of innovations and explicated its mysteries.

Today it is common knowledge that scurvy is due to vitamin C deficiency and that a diet containing vitamin C

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will prevent scurvy. How we came to this understanding is a tale exemplary of the many twists and turns an innovation can make before it is finally adopted. The benefit of vitamin C containing foods like citrus in preventing and treating scurvy was discovered and re-discovered multiple times over hundreds of years.

Learning from the knowledge of the native people of the St. Lawrence River, the French explorer Jacques

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Cartier saved his men from scurvy in 1536. Decades later in 1601, Captain James Lancaster performed a controlled experiment in scurvy prevention.

The Captain supplied one of his ships with rations of lemon juice and none to his 3 other ships. One hundred and ten (110) of 278 sailors died of scurvy in the control group.

More than a hundred years later in 1747, James Lind, a physician in the British Royal Navy, repeated the experiment with similar results. Ultimately in 1795 the British Navy did require citrus fruits to prevent scurvy.

Everett Rogers popularized this historical lesson and pioneered diffusion of innovations theory. Mr. Rogers would not be surprised by the history of the EHR, which is no less remarkable.

IBM partnered with Akron Children's Hospital to create the first electronic medical record in 1962.

Demand for this new innovation was nascent until the Institute of Medicine issued a trifecta of revelatory reports that defined the computerbased patient record as an essential technology for healthcare (later known as the EMR and now EHR).

Meaningful use

Prior to the passage of the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009, physician and hospital adoption of the EHR in the USA was far behind Denmark, New Zealand, and Sweden. All three countries invested in economic incentives, regulations to foster interoperability, and



public-private partnerships to enable standardization.

The HITECH act replicated many of these critical success factors with telling results. The rate of office-based physician adoption of a basic EHR system rose from 10.5 per cent in 2001 to 33.9 per cent in 2011. Hospitals with any EHR system increased from 15.1 per cent in 2010 to 26.6 per cent in 2011.

In the USA, the journey continues. Evidence suggests EHR adoption among physicians over age 55 and those in non-primary care specialties, physician-owned practices, and small practices trail behind that of younger physicians, primary care physicians, and providers in larger practices.

A digital divide has developed among hospitals, as well. Small,

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non-teaching, and rural hospitals have adopted EHRs more slowly than their larger, teaching, and urban counterparts.

The proposed Stage 2 goals build upon and expand those from Stage 1.

Measures optional in Stage 1 will become required in Stage 2 (see Tables A to F).

Taking another step towards capturing and reporting quality measures from the EHR, a host of new clinical quality measures will be added to Stage 2.

Citing Professor Rogers, the American Academy of Family Physicians cautions against raising the bar of Stage 2 meaningful use too high: “We encourage HHS not to ignore diffusion of technology theory, which distinguishes the characteristics and capabilities of innovators and early adopters from the larger grouping of early majority, late majority, and laggards. The existing data on Meaningful Use adoption, in our opinion, is limited to innovators and early adopters. Their ability and efficiency in use of electronic health records are not likely predictive of the ability and efficiency of EPs who have yet to embrace meaningful use. We strongly urge HHS to use caution in assuming that outstanding performance on Meaningful Use measures, so far, indicates generalised success and that the bar should be dramatically raised. Successfully on-boarding later adopters is likely to require a gentler approach.”

Indeed, the challenge for policy makers is striking the right balance between the vision of meaningful use with the everyday realities of limited resources.

Beyond regulatory relief, diffusion of innovations theory offers a framework to further the work of adoption. The theory posits four main elements in the diffusion process: (1) characteristics of the innovation itself (2) how the innovation is communicated to its target audience (‘channels’) (3) processes that affect the time to adoption (e.g. innovation-decision and innovativeness and adopter categories) and (4) the social system (e.g. system norms, opinion leaders, change agents).

The EHR itself can and should be made more usable and reliable. In a recent report on health IT the Institute of Medicine viewed this as a patient safety issue. User-centered design and reliable software also positively affect clinician adoption. The proposed new Office of the National Coordinator for Health IT (ONC) EHR certification rule takes a step in that direction by requiring usercentered design and software quality improvement. A better EHR will speed adoption, improve patient safety and clinician satisfaction.

The HITECH-funded Regional Extension Centers (REC) have been charged to provide a variety of adoption services for physician practices

including e-newsletters, training, and on-site project planning and implementation. They are well-positioned to optimize services to promote adoption among small physician practices and small, non-teaching, and rural hospitals. Expanding and extending the RECs scope would help deepen adoption.

HIMSS EMRAM

Meaningful use serves as one path for EHR adoption. Another complementary model is the Healthcare Information and Management Systems Electronic Medical Record Adoption Model (HIMSS EMRAM).

HIMSS developed the EMRAM for hospitals in 2004 and for ambulatory care in 2012 (see Tables G and H).

The EMRAM serves as a tool for healthcare leaders to align IT initiatives with business strategy, develop a roadmap for future development, or ensure their organisations make the most appropriate use of funding. The HIMSS EMRAM permits healthcare providers and organisations to compare their IT budgets and level of adoption with their peers.

The HIMSS EMRAM has been used by hospitals in North America, Europe, and is expanding to the Asia-Pacific region. Launched June 2011, HIMSS Analytics® has collected data from hospitals from the Asia-Pacific (see Table I).

The Asia-Pacific’s first Level 7 hospital is Seoul National University Bundang Hospital (910 Beds) in South Korea. The area showcases another 13 hospitals that have achieved Stage 6.

It is all about transforming healthcare

Innovation is what drives health IT. Meaningful use and HIMSS EMRAM are dynamic, not stagnant models for health IT adoption. Both models will evolve as new innovations develop to engage patients, coordinate care, improve individual and community health, and make healthcare more effective and efficient.

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Table A

Stage 2 EP Core Objectives 1. Use CPOE for more than 60 per cent of medication, laboratory and radiology orders 2. E-Rx for more than 50 per cent 3. Record demographics for more than 80 per cent 4. Record vital signs for more than 80 per cent 5. Record smoking status for more than 80 per cent 6. Implement 5 clinical decision support interventions + drug / drug and drug / allergy 7. Incorporate lab results for more than 55 per cent 8. Generate patient list by specific condition 9. Use EHR to identify and provide more than 10 per cent with reminders for preventive / follow-up 10. Provide online access to health information for more than 50 per cent with more than 10 per cent actually accessing 11. Provide office visit summaries in 24 hours 12. Use EHR to identify and provide education resources more than 10 per cent 13. More than 10 per cent of patients send secure messages to their EP

14. Medication reconciliation at more than 65 per cent of transitions of care 15. Provide summary of care document for more than 65 per cent of transitions of care and referrals with 10 per cent sent electronically 16. Successful ongoing transmission of immunization data 17. Conduct or review security analysis and incorporate in risk management process.

Table B

Stage 2 EP Menu Objectives 1. More than 40 per cent of imaging results are accessible through Certified EHR Technology 2. Record family health history for more than 20 per cent 3. Successful ongoing transmission of syndromic surveillance data 4. Successful ongoing transmission of cancer case information 5. Successful ongoing transmission of data to a specialized registry.

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Table C

EP CQM Measures: 125 Potential Measures covering the categories of conditions / disease management, drug management, preventive care and medical practice: • ADHD • Adverse Event Reporting • Alcohol / Drug Dependence • Antibiotic Use: Pharyngitis, Bronchitis, Upper Respiratory Infection, Perioperative Care • Asthma • Blood Pressure • Cardiology: Heart Failure, Atrial Fibrillation, Coronary Artery Disease (CAD), Ischemic Vascular Disease (IVD), Myocardial Infarction (MI), Chronic Obstructive • Chlamydia Screening • Cholesterol • Colon, Breast, Prostate, Prostate • Complex Chronic Condition Assessment • Dementia • Dental Decay • Depression • Diabetes • Diagnostic Imaging Reports • Eyes: Cataracts, Glaucoma • Falls Risk • Hepatitis C • HIV / AIDS • Hypertension • Immunizations: Flu, childhood, pneumonia, HCV, HBV • Infection • Joints / Bones: Rheumatoid Arthritis, Osteoarthritis, Osteoporosis, Lower Back Pain, Knee / Hip Replacement • Kidney Disease • Maternal / Prenatal Care • Medication Reconciliation • Melanoma Diabetes • Oncology: Chemotherapy / Radiation / Pain, General Oncology, Breast, Cervical, Colorectal, Colon, Prostate, • Osteoarthritis (OTC Assessments) • Otitis Externa • Perioperative VTE Prophylaxis and Antibiotic Timing • Psychiatric: Major Depressive Disorder, ADHD, Bipolar Disorder • Pulmonary Disease (COPD) • Specialist Referral Loop Closure • Tobacco Screening • Urinary Incontinence • Use of High Risk Medications in Elderly

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• Weight Screening • Wound Care.

Table D

Stage 2 Hospital Core Objectives 1. Use CPOE for more than 60 per cent of medication, laboratory and radiology orders 2. Record demographics for more than 80 per cent 3. Record vital signs for more than 80 per cent 4. Record smoking status for more than 80 per cent 5. Implement 5 clinical decision support interventions + drug / drug and drug / allergy 6. Incorporate lab results for more than 55 per cent 7. Generate patient list by specific condition 8. EMAR is implemented and used for more than 10 per cent of medication orders 9. Provide online access to health information for more than 50 per cent with more than 10 per cent actually accessing 10. Use EHR to identify and provide education resources more than 10 per cent 11. Medication reconciliation at more than 65 per cent of transitions of care 12. Provide summary of care document for more than 65 per cent of transitions of care and referrals with 10 per cent sent electronically 13. Successful ongoing transmission of immunization data 14. Successful ongoing submission of reportable laboratory results 15. Successful ongoing submission of electronic syndromic surveillance data 16. Conduct or review security analysis and incorporate in risk management process.

Table E

Stage 2 Hospital Menu Objectives 1. Record indication of advanced directive for more than 50 per cent 2. More than 40 per cent of imaging results are accessible through Certified EHR Technology 3. Record family health history for more than 20 per cent 4. E-Rx for more than 10 per cent of discharge prescriptions.

Table F

EH / CAH CQM Measures: 49 possible measures covering the categories of conditions / disease management, drug management and medical practice 1. Antibiotics: Pneumonia, Perioperative 2. Asthma 3. Cardiology: AMI, HF 4. Emergency Department Throughput

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5.

6.

7.

8.

Home Management Plan of Care Immunizations: Pneumococcal, Flu Ischemic Stroke Labor / Delivery: hearing, elective births, surfactant, complications 9. NICU temperatures 10. PICU Pain Assessments 11. Pneumonia (antibiotics) 12. Surgical: VTE Prevention, Antibiotics, Catheter, Hair Removal 13. VTE Prophylaxis.

Table G

Table I EMR Adoption Model Stage

Cumulative capabilities

Stage 7

Complete EMR; CCD transactions to share data, Data warehousing; Data continuity with ED; ambulatory, OP

Stage 6

Physician documentation (structured templates), full CDSS (variance & compliance), closed loop medication administration

Stage 5

Full R-PACS

Stage 4

CPCE, Clinical Decision Support (clinical protocols)

Stage 3

Nursing / clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology

Stage 2

CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging, HIE capable

Stage 1

Ancillaries – Lab, Rad, Pharmacy

Stage 0

All Three Ancillaries Not Installed

Table J

The HIMSS Analytics® Asia Pac EMR Adoption Model (EMRAM) was launched in June of 2011.

HIMSS Analytics Asia Pac is focused on collecting EMR adoption data in the following countries

Singapore Malaysia South Korea China Thailand Taiwan Hong Kong India Australia New Zealand Saudi Arabia UAE

References are available at www.asianhhm.com

Author BIO

Table H

• • • • • • • • • • • •

Ken is Chief Medical Informatics Officer of New York Hospital Queens, a member of the New YorkPresbyterian Healthcare System.

The second edition of Ken's award winning 'Medical Informatics: an Executive Primer' was published 2011. He is Chair of the Informatics Council of NYPHS and a Member, Board Directors of HIMSS.

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How ‘Meaningful Use’ and Health IT Collaboration are Enabling the Evolution of Healthcare Transforming healthcare will require a broad, interoperable Health IT system allowing healthcare providers to share and use patient data reliably and securely. This article outlines how US programs are supporting essential Health IT building blocks and how community Health IT partnerships can enable innovative programs for healthcare improvement.

Jeanette C Schreiber Associate Vice President, Medical Affairs and Chief Legal Officer, College of Medicine University of Central Florida, USA

A

s America embarks on improving healthcare, Health IT must be the bedrock for this transformation.

While political debates rage over what a better healthcare system should look like, all proposed improvements will require a broad, interoperable Health IT system that allows healthcare providers to share patient data in a reliable and secure way and to use that information to improve the health of all.

Dr Donald Berwick (formerly of the Institute for Healthcare Improvement and U.S. Centers for Medicare and

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Medicaid Services) has summarised the goals of healthcare reform as the ‘Triple Aim.’ These three goals are better care for individuals, better health for populations, and reducing per capita healthcare costs. Health IT tools are critical building blocks for reaching these goals.

Whether the initiative is to track quality and measure comparative effectiveness of treatments; share lab reports and images to avoid duplicate testing; mine public health data to discover and track diseases; expand managed care to new populations; implement

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standardised protocols to enhance safety and efficiency; employ home monitoring technology and telemedicine; or engage patients through portals, personal health records and employer-sponsored wellness programmes, Health IT tools are essential.

Essential building blocks

The basic Health IT essentials include: Broad-scale adoption of Electronic Health Records (EHRs), with: • Common standards for interoperability, functionality, data transmission

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and patient identification • Privacy and security best practices Health Information Exchanges (HIE) across separate providers, communities, states and nations, ultimately creating a network of networks and community data sources. These exchanges require: • Governance models for sharing information and use of community data • Common standards for interoperability • Models for economic sustainability • Portals and patient engagement.

Creating this IT backbone for health reform will require an extended and concerted effort, the talents and expertise of many, and an investment of resources.

This article will outline ways that US Health IT programmes are providing essential fuel for this journey and how partnerships across communities can build essential resources and enable innovative programmes for healthcare improvement.

Building block I- adoption, meaningful use and regional extension centers

Congress recognised the need for incentives and assistance to help hospitals and physicians adopt electronic health records when it enacted The Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the 2009 American Recovery and Reinvestment Act (ARRA). This legislation, designed to promote adoption and meaningful use of health information technology, provided over US$20 billion in incentives through Medicare and Medicaid for hospitals and physicians who adopt ‘certified’ EHRs that meet national standards. Eligible physicians can receive up to US$44,000 each from Medicare or US$64,000 from Medicaid to help defray the costs of establishing a certified electronic health record system. To receive these funds, doctors must certify they have achieved ‘meaningful use’ of EHRs, including

use of e-prescriptions and documenting certain quality measures and functions.

The U.S. Department of Health and Human Services, Office of the National Coordination for Health IT (ONC), announced that as of June 2012, over 100,000 healthcare providers have received incentive dollars for adopting electronic health records, totaling more than US$5.7 billion.

The incentive program is helping spur change. In 2002, only 17.3 per cent of physicians across the United States had adopted electronic health records.

In 2011, that number had increased to 56.9 per cent, with many more in process. In 2015, Medicare will begin reducing payments to doctors who have not implemented EHRs as a further incentive for adoption. Assistance in adopting electronic records comes from 62 federally funded Regional Extension Center (REC) programmes, which help eligible primary care providers acquire and use

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UCF Medical Students: ‘Digital Natives’ At the University of Central Florida College of Medicine in Orlando, medical students who grew up on computers and video games learn to practice medicine using simulation tools such as virtual patients that can be programmed to exhibit any symptom, behavior or diagnostic test result. These new doctors will demand the latest technology to support best medical practices in the 21st century. For that reason, M.D. students are issued iPads and computers and begin using electronic records from their first days in medical school, and the college is a national leader in the use of interactive, digital learning tools. UCF’s Health Sciences Library is 98 per cent digital, meaning faculty and students can get information in any location 24/7 on any electronic device. Most importantly, UCF medical students are selected for their humanistic desire to care for patients: they learn that technology is an essential tool, but that excellence in care for patients is the real goal.

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EHRs. The RECs provide hands-on, vendor-neutral assistance in selecting, implementing and achieving ‘meaningful use,’ of EHRs and enable providers to obtain Medicare or Medicaid incentive funds.

A model in Central Florida

As of 2009, less than 20 per cent of physicians in the greater Central Florida area had adopted electronic health records. In 2010, the University of Central Florida (UCF) College of Medicine established a REC to help physicians in seven Central Florida counties adopt electronic health records and work towards the ‘Triple Aim’ of health reform. UCF has been awarded US$8.6 million through the American Recovery and Reinvestment Act funding to support the REC.

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The initial local goal was to assist 1363 primary care providers with adoption and ‘meaningful use’ of EHRs. As of June 2012, UCF has signed on over 1300 primary care providers, and over 750 have ‘gone live’ on certified electronic systems. REC staff members help physicians and their practices achieve more efficient workflows by integrating the new technology, assist with privacy and security best practices, and have become trusted advisors to these providers. A recent customer survey found that 92 per cent of the physicians in the programme rated the REC’s work as exceptional and also helpful in minimising disruption of the practice while implementing an electronic system. The UCF programme is now expanding its services to specialists and dentists. The ultimate success of REC programmes across the nation will be measured as adoption rates increase and patient care quality and safety are improved. But this is only the first building block: as healthcare providers complete implementation of electronic records, they are asking, “When can I join the Health Information Exchange?”

Buildingblock II- health information exchange

A Health Information Exchange (HIE) is a data hub or repository that enables the sharing of clinical data among a patient’s different healthcare providers, bringing more complete and accurate information to the treating clinician at the moment of care. In addition to hospital and physician data, HIEs can include labs, pharmacies, imaging, home healthcare agencies, long-term care providers, and even insurance companies and other payers.

By bringing together a patient’s entire medical history, these exchanges are a critical tool in building continuity of care and eliminating duplication of tests, a primary concern among patients. Recent studies are beginning to document the cost savings of information sharing, such as in emergency departments, where duplicative testing and unnecessary

A network of community, state, national and international HIEs must be created to link hospital systems, community physicians, ancillary and post-acute providers, and ultimately health plans.

hospitalisations can be prevented. HIEs are increasingly used inside large health systems, linking hospitals and physicians within that system. However, these health system exchanges generally do not integrate patient information from community providers outside their particular system. A network of community, state, national and international HIEs must be created to link hospital systems, community physicians, ancillary and post-acute providers, and ultimately health plans.

A coordinated system of health information exchanges will save lives, time, and money and can provide community data resources.

HITECH funding was allocated to many states for establishing HIE’s, but no single model has yet emerged for HIE technology, functionality, governance, geography, or economic sustainability.

Central Florida builds a community HIE model

In Central Florida, two large competing health systems, Orlando Health and Florida Hospital, have partnered with each other and with other community stakeholders to build a non-profit health information exchange known as the Central Florida Regional Health Information Organization (RHIO).

The organisation is committed to “Building a Healthier Community Through Connectivity” and just completed a successful pilot project that collected over 27 million records on over 1 million distinct patients. The pilot is used in 14 Central Florida emergency departments run by the two hospital systems. With the patient’s consent, emergency physicians can immediately access the patient’s clinical records from the exchange, which may include information on allergies, lab results, or an entire diagnostic workup performed at a different health system. The HIE access is structured for physician convenience and carefully imbedded into the physicians’ workflow,

Figure 1

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resulting in high use rates (ranging from 62 per cent to 87 per cent of available records searched.)

In a recent evaluation, 72 per cent of participating physicians said that because of the Central Florida RHIO information exchange they are ordering fewer lab tests, and 85 per cent said they are ordering fewer imaging studies.

A study will be designed to measure the cost savings.

The Central Florida RHIO is now working to onboard additional hospitals, physicians, and ‘safety net’ providers who care for low-income patients. Plans are underway to have physicians currently served by the UCF Regional Extension Center join the health information exchange, and discussions are beginning regarding expanding the exchange to involve insurers and other payers.

The organisation’s Board of Directors represents community stakeholders

such as hospitals, physicians, consumers, managed care companies, employers, ancillary providers, community foundations, and the University of Central Florida. This partnership has successfully tackled most of the common impediments for a community health information exchange, including technology, governance, privacy and security, and trust among competing providers. It is now working toward implementing a sustainable revenue model.

The commitment to creating a healthier Central Florida and the economic value of a centralised regional health information exchange and data resource are driving strong community collaboration in Health IT. Ultimately this partnership will deliver better quality healthcare, improved population health for the region, greater efficiency, and opportunity for economic development.

Figure 1 depicts the collaboration that is at the core of the Central Florida Regional Health Information Organisation’s vision Building block III – next steps

With electronic health records and health information exchanges in place, analytics and other data-use tools can be added to help monitor and manage diseases, improve services, coordinate care across communities, and in other ways help providers collaborate and achieve the ‘Triple Aim.’ This new technology is great medicine for a fractured, disjointed healthcare delivery system that is re-engineering payment incentives to reward positive outcomes, efficiency, value, managing chronic conditions, and staying healthy. For example, emerging uses of health information exchange can include programmes to identify gaps in care, demonstrate the

Building a Medical City and IT Infrastructure The University of Central Florida College of Medicine is a founding anchor of the emerging Medical City at Lake Nona, adjacent to Orlando International Airport. Medical City’s vision is to be a global healthcare destination providing state-of-the-art medical education, research and patient care. Medical City partners include the Sanford – Burnham Medical Research Institute, the Nemours Children’s Hospital, and the Orlando VA Medical Center, which will be a national center for surgical simulation. UCF and Medical City have established a ‘no limits’ IT infrastructure to support emerging and yet unimagined clinical, research and commercial uses and recently helped launch US Ignite, a national initiative to deploy broadband at 100 times current speeds and accelerate creation of new applications.

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imagine a single point for you to communicate with all of your healthcare providers, access your own health information and manage healthcare finances for yourself or your family member.

Exchange portals can also tie in homebased technologies to support better management of chronic conditions like diabetes or high blood pressure day-today. With these types of portals, accessing your healthcare information could become as easy as banking.

The US government’s HITECH investment is driving Health IT adoption. Widespread adoption of electronic Author BIO

most successful treatments, develop early intervention for at-risk populations, and improve care management (such as sending alerts to physicians when a patient is hospitalised or goes to the emergency department). Exchanges can enable use of data to identify threats to public health earlier and determine more successful solutions for high-risk conditions. In addition to improving quality of care, information shared through health information exchanges can help in identifying healthcare fraud and abuse, handling pre-admission hospital approvals and coordinating payments.

Some health information exchanges are also improving the way healthcare providers communicate with patients.

They are developing portals so that patients and their families can access patient data, submit information and communicate consents. As a patient,

health records and a network of interacting health information exchanges can support emerging uses of technology and data, better communication and coordination among caregivers, better care for patients and more efficient delivery of services. Communities wishing to improve healthcare delivery and population health can collaborate to develop Health IT resources. Successful Health IT alliances can grow into broader community health partnerships, bringing together stakeholders, finances and human capital to improve healthcare for us all.

Jeanette C Schreiber is Associate Vice President for Medical Affairs and Chief Legal Officer at the University of Central Florida, College of Medicine in Orlando, Florida. With a Harvard law degree and over 25 years of healthcare experience, she helps build community partnerships, oversees the College’s Regional Extension Center, and chairs the Central Florida RHIO Board of Directors.

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T

he adoption of Electronic Health Records (EHRs) ushers in several improvements for practising clinicians. Charts are readily accessible, illegible documentation is reduced and clinical decision support improves patient safety. While these all improve individual care, digital data are rarely used to their potential for population health. Two factors cause this. First, most countries worldwide have multiple commercial EHRs that compete for utilisation by health providers. This isolates medical information in separate databases, making it difficult to track the same patient across care settings. Second, EHRs have historically prioritised

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episodic disease treatment over continuous health maintenance. As health leaders seek to manage escalating costs while also improving care quality, they need better data exchange and analytic tools to enable population health.

A key technology to advance data sharing between different EHRs is EXtensible Markup Language (XML).

While XML was approved as a web standard fifteen years ago and is broadly used on the internet, its adoption in health information technology was limited until recently. This changed in response to several national initiatives, most notably Meaningful Use in the USA which requires healthcare provid-

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ers to share patient data maintained in EHRs outside of their organisational boundaries. To accomplish this, EHR developers adopted a standard data interchange format and XML document generation capability into their technology. A major advantage of XML over past standards is that data natively encoded with associated vocabularies can be shared (Figure 1). This allows recipients of XML-formatted documents to aggregate data from many sources without having to pre-arrange and build a specified format for each new partner involved in a transmission. Applications of XML clinical data transmission in the Asia-Pacific region include the

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The use of clinical information beyond the patient encounter is decisively lacking. To create an environment where organisaions achieve continuous health maintenance, new tools that leverage data exchange and analytics are needed.

This article presents three examples using a standardised, extensible format to improve the outcomes of health systems.

John D D’Amore Clinfometrics, Boston, MA USA Dean F Sittig UT-Memorial Hermann Center for Healthcare Quality & Safety, School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, USA

reporting of infectious disease in China, pre-admission data entry in Australia and as a potential backbone for a nationwide EHR in Japan.

Tools for population health, however, also need the right content to be effective.

A leading candidate for XML-formatted clinical data is the Continuity of Care Document (CCD). The CCD was established as a harmonized standard in 2006 and includes normalised data on patient problems, allergies, medications, laboratory results and procedures. While these elements do not encompass all EHR data, they represent a workable subset that can be used for public health, medical research and quality measurement.

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Assembling the right clinical data from multiple EHRs enables the development and widespread distribution of provider tools for population health.

Such tools are like applications on a smartphone. While no single smartphone application meets all user needs, the constellation of many has unleashed a mobile revolution. In parallel, provider tools can be customised to a specific disease or clinical practice. They can be offered as services through health information exchanges or sold as software for integrated health systems. Together, they can help transform current provider-patient interactions into continuous health management. Three examples in this article explore how such analytic tools can improve care-readmission prevention, disease documentation and comprehensive quality measurement Readmission prevention

Departing an acute care hospital is a precarious time for patients. Medications need to be reconciled; Nurses must educate patients about their illness; Multiple clinicians need to coordinate appropriate services and timing for ambulatory follow-up; Patients must comply with a range of post-discharge therapies; Failure in any step increases the likelihood that suboptimal care will cause a relapse of previous illness leading to a costly readmission to an acute care hospital.

Not every discharge, however, shares the same risks. Patients with multiple medications, co-morbidities and severe disease stand a larger chance of being readmitted to a hospital. While clinicians know this, nurses and physicians are not particularly good at identifying patients at elevated risk of readmission.

The reason is that readmission prediction requires a highly multivariate model where dozens of factors contribute to overall risk. Using a sample of 8,000,000 discharges, one readmission model found over 50 significant variables that contribute to readmission risk. Humans are not efficient data gatherers or calculators for

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As health leaders seek to manage escalating costs while also improving care quality, they need better data exchange and analytic tools to enable population health.

such complex data manipulations, but computers are.

Using clinical data extracted from an electronic health record, software can instantly calculate an individualised risk profile for each patient at discharge.

This can identify high-risk patients for whom specific interventions can reduce the readmission likelihood by 20-30 per cent. Moreover, data sharing and analytics post-hospitalisation can identify when care steps, like medication fulfillment and physician follow-up, have been missed. The goal is to create an environment where care is individualised to patient need and actively surveyed to ensure compliance. Together, these practices can reduce the number of costly re-hospitalizations and save billions in annual medical expenditure.

Disease documentation

Having complete and accurate documentation of a patient’s medical condition in the EHR is vital. Clinicians need to quickly internalise a patient’s problems when considering therapeutic options.

Clinical decision support requires disease-specific care to be verified with guidelines to ensure patient safety. Quality measurement and risk adjustment algorithms rely on patient problems

IS S Ue - 26 2012

to provide meaningful measurement.

Moreover, for nations with insurer-based reimbursement, a complete diagnosis list is the cornerstone to accurate provider reimbursement.

Research has demonstrated, however, that problems lists are often inaccurate, incomplete and inadequately maintained. Clinicians often prioritise time for clinical care over documentation and it is easy to omit one aspect of a patient’s condition when they have many complicating problems. One way to improve problem documentation is for analytic software to continuously screen medical data from the EHR to find potentially missing diagnoses. Such software can look for evidence-based definitions of disease and flag individual records for follow-up.

For example, if a patient has a highlevel of B-type natriuretic peptide, a strong marker of heart failure, and is receiving furosemide, a common heart failure prescription, the patient is highly likely to have heart failure. If that diagnosis is not present on the patient’s problem list, software can alert the clinician. This process is often called problem inference or clinical inductive reasoning and can be applied to a large set of diseases. One recent clinical trial found that problem

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Quality measurement

A pervasive concern in medicine is that provider payment and care quality are often unrelated. In a world where the data needed for quality measurement are recorded on paper in unstructured text, quality measurement is tedious and expensive. This was a major reason why providers have historically not been paid for the quality of care they provide. With interoperable EHRs, however, this can change.

Many quality measures are calculated by comparing all patients with a condition to a fraction who have achieved a desired outcome. With diabetes, for example, it is desirable to have patients regularly manage their glucose levels, which can be measured through a lab result called HbA1c. If a diabetic’s HbA1c is under a certain threshold over time, this is indicative of consistent glucose management and correlates with fewer adverse outcomes. For the healthcare system, it would be advantageous to reward physicians who have more patients with good glucose control. Of course, such metrics only apply to physicians managing a large group of diabetics and should include factors to adjust for patient compliance, but the value of such measures is clear.

While many EHRs natively calculate quality metrics like HbA1c management, they may be missing critical data.

What if a patient’s lab result was not

incorporated into the source EHR? What if the patient’s glucose control deteriorates when they go to see a specialist using a different EHR? To overcome such challenges, it is valuable to measure quality by aggregating data across care practices. Research has demonstrated that comprehensive quality measures can be calculated from clinical data extracted through XML from EHRs. In addition, health information exchanges have shown that reporting through a large network can increase the care quality for patients in a region. Building outcomesoriented health systems requires health information exchanges with robust quality surveillance, and new standards in EHR data and interoperability will make this possible.

Discussion

These examples demonstrate how analytics can improve care quality and advance disease management, but EHR vendors are unlikely sources for development of such functionality. To re-visit the smartphone analogy, the power of mobile computing spans thousands of useful applications, of which few were developed by smartphone manufacturers.

Instead, motivated companies empowered through an interoperable environment applied their creative talents.

XML-generated clinical extracts and interoperability could provide a similar ecosystem where innovation leads to increased efficiency and effectiveness for health providers. The need for such tools is evident today and their reach will grow

Author BIO

counts increased by over 100 per cent when such alerts were added to an existing EHR. While problem inference has significant potential to improve care today, its importance will grow as digital records are increasingly shared. Reconciling and maintaining problem lists will be a priority with health information exchange so that patients are continually matched with the right resources for their medical condition. Better documentation thereby results in improved care, robust communication, and in some circumstances, increased reimbursement.

as new modalities, like telemedicine and remote monitoring, are incorporated into EHRs. The other element that can accelerate the growth of such tools is health information exchange. As the examples illustrate, comprehensive data contributes to better metrics and better analytics. While health information exchanges expand the infrastructure for data sharing today, they can also leverage third-party tools to become value-added resellers. HIE case studies have already documented how analytic solutions play a supportive role in becoming financial sustainable.

Technology alone will not transform healthcare. It requires the right direction from governments, hard work by clinicians and innovation from an array of emerging health technology companies.

Once these forces are aligned, population health tools that use XML-based clinical data will be a natural path to an outcomes-oriented health system.

Health leaders will need them to manage the large tasks which lie ahead.

Conclusion

Creating the next generation of outcomes-oriented health system will rely on the use of data and analytics to improve care delivery. Using emerging interoperability standards provides a logical means to build an ecosystem of health information tools. These tools will accelerate the transition to continuous health management that will save monies and lives worldwide.

References are available at www.asianhhm.com

John D’Amore focuses on improving healthcare operations through clinical and financial analytics. He currently serves as President of Clinfometrics, a company developing population health tools and predictive analytics as highlighted in this article.

His research focuses on medical data interoperability, and he holds degrees from Harvard College and the University of Texas.

Dean Sittig studies the design, development, implementation, and evaluation of all aspects of clinical information systems.

Dr. Sittig is working to improve our understanding of both the factors that lead to success, as well as, the unintended consequences associated with computer-based clinical decision support and provider order entry systems.

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Accessing Health Data Striking a balance between security and usability

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M

any healthcare administrators, clinicians, and analysts consider information security to be realm of Information Technology (IT) professionals working behind the scenes to protect computer networks and servers from unauthorised access by nefarious outsiders. This common but narrow view belies both the many ways in which sensitive health-related information can be exposed and the many countermeasures available and necessary to mitigate the threat of information breach.

Health data must be managed and utilised wisely or analysts / users may risk losing access to the very information that is vital to improving healthcare.

Data stewards must apply industry best practices to secure the hardware and software on which data resides and is accessed, and analysts / users must ensure their own behavior does not pose a risk of information breach.

Trevor Strome Assistant Professor Department of Emergency Medicine University of Manitoba, Canada

The collection and storage of private and health-related information is growing as more Healthcare Organisations (HCOs) adopt Health Information Technology (HIT) such as Electronic Medical Records (EMRs). As more data becomes available, its use for other than purely clinical needs (such as quality and process improvement initiatives) is also increasing.

HCOs from around the globe are actively engaging in quality and performance improvement initiatives in hopes of transforming into more efficient and effective providers of care.

Teams engaged in such initiatives are utilising methodologies such as Lean and Six Sigma to ensure a measured, structured approach to improving quality and performance. Most improvement efforts are data-intensive, using available information to determine baseline values, monitor ongoing performance, and detect changes as a result of process improvements. To be of most value, data must be accurate, timely, and readily available to the teams charged with improving processes.

This growing volume of electronic health and personal data being amassed in databases, coupled with the fact that more people have legitimate need to access and use data for myriad needs, results in an increased risk of a breach of health information. A breach of security has the potential to result in an unauthorised release of an individual’s (or, more likely, many individuals’) private health information. The information at risk commonly ranges from name and birthday to detailed credit information and private health matters.

Electronic health information can be made almost entirely secure.

The trade-off, though, is that nobody would be able to access it. An ongoing dialogue between healthcare providers, researchers, administrators, and information stewards is necessary so that appropriate levels of privacy and security can be maintained. This is required so that information that needs to be

shared can be shared, without risking wide-scale leaks. It is the responsibility of all who may have stewardship over and / or have access to health information to ensure that the accessibility, confidentiality, and integrity of the information remains protected from unauthorised access, modification, and / or disclosure.

Scope of the problem

The statistics on health information breaches are quite startling. According to the United States Department of Health and Human Services, in 2009 and 2010 (when information on health information breaches was first collected by the Department), the personal medical information of approximately 7.8 million people had been exposed improperly (1). Incredibly, a single case involving the theft of 1.7 million records from an unlocked van of a records management company was reported.

According to the “2012 HIMSS Analytics Report: Security of Patient Data” survey (2) released in April 2012, 27 per cent of the 250 leading healthcare organisations who participated in the survey indicated their organisation experienced a security breach within the previous 12 months. This was up from 19 per cent in 2010 and 13 per cent in 2008. Of those HCOs that reported a breach, 69 per cent experienced more than one. Interestingly and somewhat worrisome, 18 per cent of respondents were not aware of whether or not a data breach had been experienced by their organisation in the previous 12 months.

Causes of information breach

The 2012 HIMSS Analytics survey noted that 56 per cent of respondents stated the source of security breach was unauthorised access by an employee, whereas three per cent of breaches were caused by a network breach by an outsider. Twenty-two per cent reported breaches due to theft of laptops or handheld devices, and 10 per cent reported breaches due to data being housed by a third-party vendor.

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The US Department of Health and Human Services has identified several types of incidents resulting in large breaches (which involve more than 500 records): Theft The theft of personal health information can occur when traditional paper records or electronic media such as laptops, tablets, and memory devices are stolen.

Deliberate theft is the largest category of breach reported by the Department of Health and Human Services.

Loss A breach of health information can occur due to the loss of records. Such incidents include the loss of paper records or the loss of electronic media (i.e., laptops, tablets, or memory and backup devices).

Intentional unauthorised access There is an upswing in deliberate attempts to gain access to sensitive computer systems through the use of ‘phishing,’ hacking, or similar methods to gain login / password information.

In these cases, individual computers and / or network servers are accessed by unauthorized persons to obtain private health information of others.

Human or technological error Information breaches can occur as a result of a failure to take adequate care of protected health information. These types of errors include misdirected shipping / mailing of paper records (due to an incorrect mailing address, for example). This can also occur if unencrypted information is inadvertently emailed to an incorrect and / or unauthorised recipient.

Improper disposal This could happen either by paper records not being properly disposed of, or electronic information not being completely obliterated, and may result in an information breach.

Preventing information breaches

Understanding how information breaches occur is necessary when developing and implementing effective countermeasures.

Governments at all levels are working to

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implement effective legislation aimed at improving information security. Driven by both the need to maintain regulatory compliance with legislation, and the desire to protect the privacy of their patients, HCOs are developing policies and procedures to safeguard this data.

Information security, however, ultimately depends on how well the data is physically protected via technology and responsible human behaviour.

Legislation To combat data breaches, governments at all levels around the globe have introduced (or are introducing) legislation aimed at curbing the unauthorised access to personal and health information. These regulations typically dictate how health information can be collected, used and disclosed.

They also specify how such data ought to be protected throughout its lifecycle and allow for the accessing and sharing of data for legitimate purposes (such as improving quality or providing care). Most legislation attempts to strike a balance of protecting sensitive data without over-burdening healthcare providers with excessive measures to actually access information.

In the Canadian province of Alberta, for example, the Health Information Act (HIA) sets out rules to protect the privacy of an individual's health information and stipulates how and when information can be collected, used and disclosed. The legislation requires that information custodians (such as healthcare providers) and affiliates (such as employees and contractors who work for a custodian) are only to obtain, utilise, and share private health information in the most limited manner possible, with the highest degree of anonymity possible, on a need-to-know basis.

Another example of legislation is the United States Health Insurance Portability and Accountability Act of 1996 (or HIPPA). HIPPA provides guidelines for the protection of personal health information while balancing the need to disclose such information if and when

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An ongoing dialogue between healthcare providers, researchers, administrators, and information stewards is necessary so that appropriate levels of privacy and security can be maintained.

it’s needed for the delivery of patient care and other legitimate purposes.

The HIPPA guidelines also specify the administrative, physical, and technical safeguards that must be in place to help ensure that private health information remains confidential and that the integrity and availability of the information is maintained.

International standards The International Standards Organization (ISO) has taken an interest in the protection of health information. It’s most recent standard for health information, ISO 27799:2008, applies directly to health information in all its aspects.

The standard outlines controls for managing health information security and identifies best practice guidelines for protecting and maintaining the security of health information. The intent of this standard is to assist HCOs ensure a minimum requisite level of information security appropriate to their size and how they intend to use the data.

Data encryption – protection at the source Perhaps the best approach protecting private health information is to encrypt it at the source. Encrypting sensitive information on source databases (or other data files) will help prevent unauthorized access or disclosure should the database be directly accessed. Legislation and other guidelines commonly mandate encryption of health information

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is limited to authorised users, and those users are only able to access applications and data that they are authorized to see.

One very common threat to information security is password sharing (or ‘generic’ logins). Although it might be convenient for clinical staff to share a password, or access computers via others’ login credentials, such practices can leave the door wide open to information breaches.

Responsible use As more clinical systems (and thus more data) become available, there are many ways in which information is used throughout modern healthcare organisations. Healthcare dashboards, scorecards, and other forms of aggregated de-identified information pose little risk of privacy breach (provided that the data sources are sufficiently protected). There is an increasing ‘gray area’, however, in which de-identified information may be required for 'seemingly’ legitimate purposes. Many audits, critical incident reviews, and quality improvement projects may request information that is de-identified to handle a complaint or to develop contact lists for infection control.

Healthcare professionals in the position to request and / or provide data that might reveal private health information must consider if the request can be handled without disclosing the sensitive information. Once private health information is released (even via legitimate request), it is possible that a breach may occur even by accident. Health research has long been subject to the scrutiny of ethics boards to ensure that no unnecessary private health information is released (even if it’s ‘nice to have’, but not essential to the study). Quality improvement projects internal to the healthcare organisation seem not to be subject to Author BIO

(especially when passing health information over an open network, or sharing files). There are many types of encryption algorithms in use by HCOs (such as, DES, 3DES, RSA, AES). An appropriate choice of encryption algorithm for an HCO is one that balances overall system and encryption performance with necessary security precautions based on the type of data being encrypted and applications for which it is being used. For some organisations and / or applications, encryption at the source is not a viable option (for cost and / or performance reasons). For this reason, data should always be encrypted when it leaves the confines of the network for transport or analysis.

Responsible handling and storage Some of the most common causes of privacy breaches are loss and theft of portable devices (such as laptops, tablets, memory sticks, and now even ‘smart phones’) used to store health information. Avoiding the storage of health information on such devices (in favor of the use of encrypted network connections such as Virtual Private Networks, or VPNs) reduces the risk of privacy breach if such devices are lost or stolen. When absolutely necessary to transfer health information on such devices, both the data and device storage medium should be encrypted and the device itself should be protected with a secure log-in. Many government laws mandate a significant financial or other penalty when loss or theft of a mobile device occurs; properly encrypted data and storage devices may protect organisations from such penalties under provisions of certain legislation.

Network security & Access controls HCOs are becoming increasingly interconnected, and now rely on networks to share information throughout and between organisations. Properly implemented network security is essential to keeping information secure, especially now that ‘phishing’ and hacking attacks into healthcare networks are an increasing concern. The basic premise of network security is to ensure that access

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the same scrutiny, yet represent a very real risk of data breach. Users of health information have the responsibility to use what is only absolutely necessary.

Summary As more health information becomes available electronically, and as the need for such information for clinical care and healthcare improvement continues to grow, there will always be a need to balance data security and usability. If health information is not kept secure in multiple ways (via encryption, secure hardware, and responsible use), the unauthorised exposure of private data will continue to occur. If these breaches continue to occur, especially on a large scale, the likely response will be a tightening of access to health information for everything but pure clinical care.

Information security is not really about technology and industry best practices – it is about the patient. When a patient presents to a healthcare facility, they are expecting healthcare professionals ‘to do no harm.’ In the modern era, doing no harm now includes protecting the patient’s privacy in addition to their health. A balanced approach to information security and usability will ensure that both are possible.

References 1. Annual Report to Congress on Breaches of Unsecured Protected Health Information (For Calendar Years 2009 and 2010). U.S. Department of Health and Human Services, Office for Civil Rights.

URL: http: / / www.hhs.gov / ocr / privacy / hipaa / administrative / breachnotificationrule / breachrept. pdf 2. 2012 HIMSS Analytics Report: Security of Patient Data (Commissioned by Kroll Advisory Solutions). April 2012.

URL: http: / / www.krollcybersecurity.com / media / Kroll-HIMSS_2012_-_Security_of_Patient_ Data_040912.pdf

Trevor Strome is responsible for developing and implementing innovative analytics tools for use in healthcare quality improvement initiatives. He has broad experience in health informatics implementations, healthcare quality improvement initiatives, and healthcare analytics development.

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Personal Connected Health The technology revolution in healthcare

High costs, inconsistent quality, disparities in access, and resource inefficiencies are creating pressure to adopted connected health. Remote patient monitoring is showing positive results and the market for health technologies is growing. However, connected health faces a major hurdle, interoperability, necessary for flexibility and convenience. This is illustrated by a recent disaster response program in Japan.

Chuck Parker, Executive Director, Continua Health Alliance, USA

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he Internet, personal computers, smartphones and other electronic devices make information sharing and communication easy, instant, secure and widely available. It is now common to use the Internet for banking, making retail purchases, managing investments, booking travel, or reading a newspaper.

Virtually any activity that involves interaction with a customer can be transacted online.

While the practice of medicine is rife with specific technical solutions, healthcare is one of the last industries to use technology to connect with and improve the experience of its customers: patients. However, unsustainably high costs, inconsistent quality and outcomes, disparities in access to services, and resource inefficiencies are changing that. Today, hospitals, providers, insurers, employers and policy makers are

looking to health information technologies to better engage patients, deliver consistent high quality, improve adherence to medication and care plans, create new efficiencies and ultimately, improve clinical outcomes.

The tools of this new healthcare technology revolution-smartphones, computers and simple remote health monitoring tools, are engaging patients, facilitating better patient-doctor communication and delivering care where the patient is, when the patient needs it. This new form of healthcare delivery has been dubbed ‘personal connected health’.

Remote patient monitoring

Among the more mature applications of technology in connected healthcare is remote patient monitoring, in which telecommunications and health management devices are deployed by healthcare

organisations to collect and share accurate, individual patient physiologic data (i.e. blood pressure, weight, heart rate or blood glucose levels), and quality of life data such as sleep patterns and daily activity. The benefits to patients include remaining or returning to home rather than hospitalisation; ongoing awareness of their health status, which encourages understanding and engagement in health self-improvement; and avoidance of office visits and / or emergency room visits. Remote monitoring also creates a platform for more meaningful discourse between patients and providers. For providers, remote monitoring represents the ability to be alerted automatically of significant changes in a patient’s health status, maximising the time available for preventive action and preserving physician resources for the most serious cases.

These types of programmes are showing

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positive outcomes in managing chronic diseases such as diabetes, cardiovascular disease, stroke and hypertension, which often require ongoing attention to a proper diet, exercise and a care plan.

The Whole System Demonstrator Programme, conducted by the Department of Health in England, looked at the effect of telehealth on hospitalisations and mortality in more than 3,200 people with diabetes, chronic obstructive pulmonary disease, or heart failure. In addition to telemonitoring with biosensors, patients received symptom questions and educational messages from the telehealth unit or a television set top box. Results from a twelve-month analysis, published in the June 2012 issue of British Medical Journal, show that • 44.5 per cent fewer patients in the intervention group than in the control group died during the study period • Hospital admissions were 10.8 per cent lower in intervention group • Emergency Room visits were 14.7 per cent lower, and ER visits were down 20.6 per cent, in the telehealth intervention group • Hospital bed days were 14.3 per cent lower per head in the telehealth group • Estimated costs savings were 7.7 per cent lower per health in the patients that received telehealthcare.

Since 2006, the Center for Connected Health (CCH) at Partners HealthCare has operated the Connected Cardiac Care Program (CCCP) to non-homebound patients with heart failure. More than 1,000 patients have been enrolled. To date, the programme has demonstrated a reduction in hospital readmission rates of close to 50 per cent and 84.7 per cent of patients reported they were able to gain control over their heart failure while in the programme.

The US Department of Veteran Affairs’ (VA) DiaTel study, published in Diabetes Care (March 2010) compared home telemonitoring together with active medication management with monthly care coordination calls, looking at changes in glycemic control in veterans

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Mobile apps, remote blood pressure cuffs, pedometers, glucometers and computer networking systems that relay and store vital patient information must all have the ability to work interchangeably.

(analysis group=137) with type 2 diabetes and poor glycemic control. The group receiving telemonitoring and active medication management demonstrated significantly larger decreases in A1C at three months (1.7 vs 0.7 per cent) and six months (1.7 vs 0.8 per cent; p< 0.001 for each) versus those receiving a monthly care coordination telephone call.

A related study published in Journal of the American Medical Information Association (May 2012) re-enrolled some DiaTel study participants to probe the intensity and duration of telemonitoring required to sustain results achieved in the original study. For veterans who had received home telemonitoring or active medication management for six months in the DiaTel study, results were sustained six months later despite receiving less intense subsequent interventions. mHealth and adherence

According to a 2003 report published by the World Health Organization (WHO), in developed nations, only 50 per cent of patients with chronic diseases take their medication as prescribed and the number is even lower for developing nations. Poor adherence can reduce the effectiveness of medications, jeopardise patient health and lead to burgeoning healthcare costs.

While some of the factors that contribute to poor compliance are unlikely to be influenced by mobile health (such as the cost of medication), mobile devices

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capable of compliance tracking, electronic reminders and simple medication management are demonstrating potential to help stem the tide of lost opportunity due to poor adherence.

In March 2012, researchers from the Stanford Prevention Research Center reported that smartphone applications raised awareness of how to improve health in a group of 31 adults, ages 45-77, who had never used a smart phone before the study. Study participants were supplied with phones pre-loaded with an application targeting one or more objectives: increased walking decreased sitting time or improved diet. The participants were trained and instructed to use the phones for eight weeks. Three-quarters of the participants reported that the apps helped track the target behaviour, and twothirds said they were motivated to make improvements. More than 96 per cent said the smartphones were a fast, efficient means of gaining information.

Other studies have shown that simple text messaging programs can improve adherence to antiretroviral therapy regiments for people with HIV / AIDS and asthma medication in teens. Another study improved prenatal care for at-risk pregnant women.

Connected health technology market

The global mobile health applications market is expected to grow at a compound annual growth rate of 24 per cent from 2010-2014, according to research by Technavio, while a 2011 report published

by ABI Research predicted that, fueled by the use of connected wearable devices, there will be more than one billion health-related mobile app downloads annually by the year 2016. Berg Insight reported that, globally, approximately 2.2 million patients used a home-based remote monitoring device as of the end of 2011 (not including devices that connect via smartphones or PCs) and estimated the number to reach 4.9 million by 2016.

In addition, they predict the number of home health monitoring devices using

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cellular connectivity will hit nearly 2.5 million in 2016. In terms of the market as a whole, MarketsandMarkets projects the global healthcare IT market will reach US$162.2 billion in 2015, a 10.2 per cent compound annual growth rate from the 2010 value of US$99.6 billion.

The good news in connected health is that patients are using technology to manage their health, connect with their healthcare providers and participate in supportive, interactive communities in record numbers.

Interoperability: A challenge to the vision

While there is still much research to be done, plenty of support exists for remote patient monitoring, texting programmes and other forms of connected health.

Further, by many accounts the availability of connected health technologies is growing by leaps and bounds. However, a

fundamental vision for connected health is that usersâ&#x20AC;&#x201D;be they providers, payers, employers, or consumersâ&#x20AC;&#x201D;will be able to create novel, customized systems for health management according to their specific needs. With the number of devices, apps and services being introduced, it is a major challenge to ensure that technologies are interoperable. Users must be able to easily connect different types of devices and technologies as well as swap out devices that perform the same function for a different model or manufacture. A lack of interoperability between technologies could thwart adoption as well as limit the efficiency and effectiveness of technology-enhanced care. Examined from another perspective, interoperability is a necessary technological underpinning of a robust connected health market, and more importantly, successful clinical programmes. A remote monitoring programme developed to

help survivors of the Great East Japan Earthquake illustrates this point.

Disaster Cardiovascular Prevention network (D-CAP)

Following a disaster, medical support for survivors must shift from emergency medical treatment to daily disease management to mitigate health risks associated with stress and environmental changes (Noji 292). Experience from the 1995 Kobe earthquake in Japan shows that 14 per cent of fatalities were realized after victims had initially survived the event (Hays). Further, living in an evacuation camp is associated with several factors that can increase cardiovascular risk (WHO 42), and studies have demonstrated increases in cardiac events in the immediate hours and weeks after an earthquake. Long-term impacts of disaster on cardiovascular events has also been observed: researchers at Tulane University

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concluded in a study published in January 2010 that chronic stress following Hurricane Katrina contributed to a 300 per cent increase in heart attacks in New Orleans—more than two years after the event.

After the Great East Japan Earthquake of 2011, Dr Kazuomi Kario, Chairman of Cardiovascular Medicine at Jichi Medical University in Tochigi, Japan, was concerned about elevated cardiac risk in survivors. He contacted medical device manufacturer A&D Medical about developing a remote monitoring programme for evacuees at a camp in the town of Minami-Sanrikucho, in the Miyagi Prefecture, which had suffered enormous losses in the earthquake and subsequent tsunami.

Complicating care at Minami-Sanrikucho was the fact that the disaster site lacked basic services such as electricity, water and sewer for the first three months, limiting the capability to monitor and treat patients and access medical records to assess pre-existing cardiovascular disease. A rapid solution was needed.

The Disaster Cardiovascular Prevention Network (D-CAP) was developed to remotely monitor the blood pressure of evacuees in campsites, with a goal to prevent cardiac events in survivors identified as “high risk.” The program consisted of examinations and risk assessments to stratify high-risk patients, defined as having systolic blood pressure above 180 mmHg. Screening of 1,500 evacuees identified 400 people with elevated cardiac risk, who were enrolled in the D-CAP program (26.6 per cent of screened evacuees). Patients with persistent symptoms were evaluated by physicians and prescribed oral medications as needed.

D-CAP registrants received electronic identification cards and were encouraged to measure their own blood pressure at automated stations within the evacuation camp. The data were sent via wireless communication to a data server and relayed to Jichi Medical University, about 200 kilometers away. Clinicians

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monitored the data and alerted on-site physicians by phone of any significant developments. Subsequently, high-risk patients were moved from the evacuation camp into temporary housing provided by the government and provided with individual blood pressure monitors that store a month of readings. Data can be downloaded at the hospital and then uploaded to D-CAP’s data center.

Participating companies and their component devices include A&D Medical - Automatic blood pressure monitors; Alive Inc. - Gateway firmware; Ryoto Electro Corp. - data server; Panasonic – PC; Toppan Forms - Patient ID Cards; Qute - Web application development; Intel - Project coordination. An important aspect of the program’s launch was pre-existing interoperability between all devices. The component products had been certified by Continua Health Alliance, a global non-profit organisation that publishes guidelines for plug-and-play connectivity of personal health devices and services. The guidelines conglomerate technology standards in use on an international scale.

The most important outcome of this program is that D-CAP has been credited with saving lives. Every one of the 400 ‘high risk’ D-CAP evacuees is still living today and the program remains in operation.

Pre-existing interoperability among the component products facilitated a time from conception to launch of just two weeks, or 12 man-weeks, at a cost of US$27,000. In interviews conducted with participating companies, representatives from Intel and Panasonic estimated that without pre-existing interoperability, launching the D-CAP program would have taken twelve weeks, or 72 manweeks, at a cost of US$166,000. According to these estimates, deploying interoperable technologies reduced launch time by 84 per cent, or ten weeks, and saved US$139,000.

While the cost savings were certainly significant, it is the 10-week launch advantage that is clinically important in light

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of documented elevated cardiac risk in earthquake survivors and people living in evacuee camps. D-CAP has not provided estimates for cardiovascular events averted or lives saved, but one can easily conceive of the risk to these 400 earthquake survivors had they received no specialized screening or cardiac monitoring—or the additional care that resulted from screening and monitoring—for two and a half months following the event. Further, the cost savings derived from pre-existing interoperability in the D-CAP program would fund five additional programs of the same size (without accounting for economies of scale), providing monitoring for another 2,000 patients.

The D-CAP program speaks to the clinical advantages, and even necessity, of interoperability—and allows us to envision the thorny challenges of implementing connected health in a market lacking interoperability.

Achieving interoperability

In order to maximise the potential of technology-enabled health and wellness, a rich and varied ecosystem of interoperable personal connected healthcare devices is necessary. Mobile apps, remote blood pressure cuffs, pedometers, glucometers and computer networking systems that relay and store vital patient information must all have the ability to work interchangeably, to ensure adoption, retention and maximum results for patients and providers. Further, electronic home healthcare solutions must offer consistent and simple connectivity so that they function together with any device or within any network.

Continua Health Alliance is working to establish a global, secure, plug-andplay market in connected health for more effective health management, patient engagement and better outcomes. In addition to publishing standards-based guidelines for interoperability and security, Continua certifies and provides brand support for connected health products, sponsors events and collaborations to support technology and clinical

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the vital role of interoperability in the connected health revolution.

Acknowledgements

Continua wishes to acknowledge Dr. Kazuomi Kario, Professor and Staff Physician at the Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan, for his responsiveness and creativity on behalf of survivors of the Great East Japan earthquake, as well as D-CAP participating physicians and companies, without which this program would not have been possible.

Author BIO

innovation, and works with employers, payers, governments and care providers as a facilitator.

The need for interoperability seems to be most evident to organisations that serve large numbers of people, such as governments and NGOs. Continua is working closely with two national, government-run telehealth programs, recently welcomed a division of the U.S. Department of Defense as a new member, and was welcomed to the United Nations agency International Telecommunication Union. But the pressure to bring plugand-play connected health technologies must also come from private-sector healthcare buyers.

With new opportunities come new challenges. The clinical evidence is mounting in favor of connected health, but the healthcare industry and its partners in the telecommunications, medical device and pharmaceutical industries must address

References 1. Hays, Jeffrey. “Kobe Earthquake Death and Damage.” Facts and Details, 2009. Web. 3 July 2012 http: / / factsanddetails.com / japan.php?itemid=863 &catid=26&subcatid=161 2. Noji, Erik K. “Disaster Epidemiology.” Emergency Medicine Clinics of North America, 4.2 (1996) 292.

Print.

3. Tulane University. “Post Katrina Stress, Heart Problems Linked.” Tulane University. 2012. Web. 3 July 2012 http: / / tulane.edu / research / discovery / story-katrina-heart-attacks.cfm 4. World Health Organisation, Western Pacific Region. The Great East Japan Earthquake: A Story of a Devastating Natural Disaster, a Tale of Human Compassion; March 11, 2012, WHO, 2012. Print.

Charles (Chuck) Parker was previously with Masspro and VHA, Inc. and has served organisations such as CMS, Bridges to Excellence and the Office of the National Coordinator for Healthcare IT. He holds a Master of Science in Healthcare Informatics.

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How an ICT-based System to Monitor Gait Can Make a Difference in Asia A gait screening tool used in a variety of applications is described. Details of a longitudinal study on elderly people attending an exercise class are provided.

Results show that simple information to the individual and person running the exercise class helped improve their gait and reduced their risk of falling.

Diana Hodgins, Managing Director, European Technology for Business Ltd, Codicote Innovation centre, UK

M

aintaining mobility is important to both individuals and healthcare providers as it is a fundamental aspect of living a healthy, active lifestyle. Gait analysis is recognised as a clinically useful tool for identifying problems with mobility yet clinical use is still not routine. This is due to

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limitations with existing technologies, namely: length of time and costs required for performing a gait test and difficulty in interpreting the results.

However, with advancements in ICT it is now possible for individuals of every age to be monitored regularly using a sensor based-gait screening tool. One

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such system, gaitSMART, provides accurate data in a simple, easy to understand format within minutes, overcoming the barriers that are present using existing technical approaches. This originated from a European project, Healthy Aims, with the overall goal to develop a range of medical implants and diagnostic equipment.

If a person grows up with a poor gait then compensatory gait deficits may introduce musculosketal pain in different parts of the body, or osteoarthritis later in life, whereas a good gait will reduce the risk of joint problems later in life. For the generation where joints are already causing problems and replacement surgery is required, good recovery to a normal gait profile will help to prolong the life of the implant. For those active in sports, good recovery from injury is essential. And for the elderly, where falls are a major concern, identifying those with a problematic gait and monitoring through exercises or treatment improves mobility and reduces costly falls.

This paper describes how the gait screening tool has been used in a variety

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of applications and then provides details of a two year longitudinal study on a group of 11 elderly people attending a weekly exercise class. The findings are that providing simple information to the individual and the person running the exercise class helped improve their gait and reduced their risk of falling.

Why it is important to measure gait

Identifying the precise abnormality within the gait profile is essential if it is to be corrected, either by training, exercises, drugs or surgical intervention. If identified early enough, exercises may be sufficient, alleviating pain and reducing the likeliness of surgical intervention.

An unstable or uneven gait can result in a worsening in a medical condition, or in the elderly it may result in a fall.

Gait profiling as part of a medical diagnosis makes it possible to quantify the gait abnormality for individuals, identify problems early and prescribe the best course of treatment. For example, if early stage knee osteoarthritis (OA) can be detected then therapy may be an option, whereas late stage knee OA generally dictates replacement surgery. The elderly may be offered a set of exercises to strengthen particular muscles and help reduce their risk of falling.

The gaitSMART system

GaitSMART is a sensor-based system that accurately monitors the lower limb movement through the gait cycle. It does this using four Inertial Measurement Units (IMUs), which collect acceleration and rotational data in six Degrees of Freedom (DOF) at 100Hz. The sensors are mounted onto the thigh and shank of each leg using custom designed straps with integral pockets, which are light enough not to affect the limb movement. All units are synchronised in time prior to the test and data is stored onto an SD card for the duration of the test, which typically lasts a few minutes. Once the test is complete the IMUs are linked to a laptop, the data is automatically downloaded and the thigh and shank

easy to understand, for example knee range of motion (flexed to straight).

It is recognised that there are many intervention strategies that can be used to help prevent falls, but there is no standard process for monitoring the longterm benefits of these on an individual basis.

movement, knee flexion and stride duration are calculated. These values are presented on the screen in simple graphical form and the user can then prepare a simple report with graphical and tabular output, all within minutes, making it suitable for use in a clinical setting. In addition, the values are automatically compared to normalised data and amber or red warning indicators given on any parameters that are outside the limits.

The gait cycle can be described as the movement of the lower limbs in 3D space over time. Using sensor technology, the orientation of each limb segment can be quantified and plotted in time.

In any test there will be a number of strides, or repeat gait cycles. These can be automatically calculated and individual strides identified, from which the typical stride can be determined. This can then be compared to normalised data, and values which are outside range can be highlighted. This approach overcomes one of the major barriers with previous gait systems, where normalised data is not readily available or referenced.

The data presentation is also important as both the client and person responsible for treating the client need to be able to understand the results.

The simple graphics in the gaitSMART system report show movement of each segment and the knee angle through the gait cycle, which visually highlights differences between the left and right. A table identifies specific values which are

Health applications using the gait monitoring system

The system has been validated against an optical system and data on healthy people over the age range 18-97. This data forms the normalised data used to identify and highlight any values outside the normal range. It has also been used in a variety of health applications over the last two years. These include: Sports clubs It has been used in rugby and football clubs to help ensure that injured players recover correctly and do not overwork the injury during training or when playing. Regular gait screening has enabled the physiotherapist to adjust training so that players remain match fit.

Orthopaedic clinics It has been used in both the NHS and private sector as part of the diagnosis process for knee problems and monitoring the rehabilitation phase after treatment. This has included ACL reconstruction, meniscus tear repair, treatment of knee osteoarthritis, and knee replacement surgery. It is evident from these studies and other published studies that pain is not a good indicator for the severity of the problem and individuals are unaware of their gait defects. It is also evident that if no quantifiable objectives are set during rehabilitation, the outcomes may be poor, particularly for total knee replacement. Individuals will often not work through pain unless they can see the benefits, and so gait screening would improve the long term outcome.

Therapy clinic Knee OA is one of the most common causes of knee pain, and therapy can alleviate the pain if the condition is detected at the early stage. Specific gait parameters quantified using the gaitSMART system relate to knee OA and hence the condition can be detected early. This is also applicable to the orthopaedics sector, where less invasive treatment could be offered.

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Helping the elderly remain active One of the main concerns with elderly people is their risk of falling.

If a fall occurs it can lead to hospitalisation, joint replacement, a reduction in their quality of life, or even death. In the year 2000, it was the second most common form of accidental death in Asia, and the prevalence of falls in those over 60 was over 10 per cent, rising to 30 per cent in some regions. The annual cost of falls varies across Asia, for example $500 million in Australia and $17 million in Japan. It is recognised that there are many intervention strategies that can be used to help prevent falls, but there is no standard process for monitoring the longterm benefits of these on an individual basis. One of the most common reasons for falling is tripping and this is directly related to knee flexion in swing.

The gait system has been used in a longitudinal study on a group of elderly people attending a weekly exercise class, age range 68-91 (Figure 1). Many of the class members have trouble walking and some use walking aids. The study was to test the hypothesis that providing gait data to the individuals and the class teacher in a simple to understand format on a regular basis would result in an improved gait and lower the risk of falling. The gait profiles from healthy individuals over the same age range were used for comparison purposes.

Details of the 11 class members 1 Age 91 at start, monitored for 93 weeks.

Healthy at start, poorly for 6 months at end 2 Age 74 at start, monitored for 71 weeks.

Suffers from emphysema 3 Age 70 at start, monitored for 93 weeks.

Healthy throughout 4 Age 80 at start, monitored for 88 weeks. Had a brain tumour removed when 74 5 Age 72 at start monitored for 28 weeks.

Healthy at first, early signs of dementia at end 6 Age 80 at start monitored for 88 weeks. Had a stroke which affected her right side 7 Age 83 at start monitored for 50 weeks. Walks with sticks and is registered as blind 8 Age 91 at start monitored for 6 weeks, arthritis in both knees and walks with 2 sticks 9 Age 76 at start monitored for 6 weeks.

Healthy but occasionally loses balance when standing up 10 Age 76 at start monitored for 6 weeks. Had right hip replaced 18 months ago 11 Age 68 at start monitored for 78 weeks. Lower limb prosthesis on the left leg Table 1

The average knee range of motion (ROM) and asymmetry in knee ROM over time have been plotted in Figures 2 and 3 respectively for 11 members of the class.

Figure 1: Test on two elderly people at the weekly exercise class.

White straps house the sensors.

The study started in September 2010 and the gait system was taken to the exercise class location every 2 months. All those in attendance at each session were monitored, with each person leaving the class for less than 5 minutes. This ensured minimal disruption to the class activities and ensured all people were tested and results fed back before the end of the class.

As their progress was monitored their history data as well as current data was provided. The age, health status and time of monitoring for 11 class members is summarised in Table 1.

Figure 2: Average knee ROM for 11 class members

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As can be seen from figure 2, seven of the members were above the normal limit throughout. Two other members were below the normal limit but above the danger limit. The final two members were below the danger level. These were the person with the lower limb prosthesis and the one walking with sticks. Positive intervention was provided in the way of focused exercises for all 11 members, particularly when their own values were reducing significantly. This can be seen from the cyclic motion in the plots.

Figure 3: Asymmetry in knee ROM for 11 class members

For the symmetry between the left and right leg, eight of the class members retained symmetry within the normal limits and none of the class members were outside the limit consistently. Of those members where symmetry was sometimes an issue, corrections were made by focusing exercises on the less active knee.

The knee ROM was chosen as this directly relates to toe clearance, which is important to avoid tripping on objects. Minimum toe clearance occurs around peak knee flexion and small variations in knee angle can result in noticeable changes in minimum toe clearance. A limit of 40â ° is seen as the danger level, whereby below this value toe clearance may not be adequate to clear small obstacles on the floor. The two class members were aware of the dangers and applied extra vigilance, but occasionally a fall would occur. None of the other nine members experienced falls.

Asymmetry is seen as important as this can cause problems with balance. The worst class member was the one who had a stroke. When the asymmetry went outside limits, extra exercises for the poor side were given and the asymmetry reduced accordingly.

The benefits of gait monitoring

Mobility is crucial for a good quality of life. In our early years this may be hampered by injury and it is important that recovery is complete otherwise problems such as osteoarthritis can occur later. As people get older, joints often suffer and less invasive treatment such as exercises or drugs may suffice. Left untreated until the problem becomes critical often results in joint replacement surgery. And finally as they get older they may have problems moving as effectively and if this is not addressed it may lead to falls and ultimately complete loss of mobility. With this new technology it is now possible to monitor gait profile, so problems can be identified early enough and corrective action taken. This will lead to a more active lifestyle, an improved quality of life and ultimately lower health costs.

Author BIO

References are available at www.asianhhm.com Diana Hodgins has a PhD in Solid State Physics and was awarded an MBE for her services to SMEs. Diana is now Managing Director of European Technology for Business (ETB) Limited and from 2003- 2008 she was the Project Co-ordinator for Healthy Aims, a 23Mâ&#x201A;Ź EC funded project on medical systems.

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Evolving and Enabling Standards for Mobile Health Adoption Although providers see mHealth's promise to increase productivity in the healthcare system, they still exhibit reservations in moving quickly to adopt this new technology for several good reasons.

Providers are looking for guidance in identifying, creating and adopting best practices in care delivery and are waiting to manage the broad array of challenges that this disruptive innovation creates.

Christopher Wasden Global Innovation Leader, PwC Rana Mehta Partner, PwC India

M

obile health or mHealth has the potential to change the practice of medicine by increasing access and improving quality of care while decreasing costs. Yet lack of regulatory standards is limiting the rate and breadth of worldwide adoption. According to Emerging mHealth: Paths for growth, an mHealth study conducted by the Economist Intelligence Unit (EIU) and commissioned by PricewatehouseCoopers (PwC), 47 per cent of providers surveyed indicated that mHealth applications will not work with their organisation's IT, while 45 per cent of payers and providers said the lack of regulatory standards is stifling adoption.

Based on these and similar findings, it would appear that standards in Information Technology (IT), care delivery, payment and regulation must evolve more rapidly for mHealth to realise its full potential as one of the most transformational movements in healthcare today.

In this article, PwC will provide additional insights about the mHealth marketplace and identify the standards required in six key areas that will enable the mHealth market to continue its upward trajectory of growth and success.

Our productivity problem

Healthcare systems, regardless of their level of economic, technical and clinical development face a common problem: they lack the necessary resources to deliver the same

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standard of care to those that require it in the future. Almost all regions globally face the following five constraints: Patient population growth is outpacing economic growth In developed countries, a rapidly ageing population is prompting the need for more healthcare services since 75 per cent of all healthcare costs occur in the last five years of life. In rapidly growing economies the problem is centred on the rise of chronic disease—often referred to as diseases of affluence—as standards of living for the population improve.

Fewer healthcare professionals Shortages of healthcare professionals created by a combination of economic progress, ageing populations and retiring clinical professionals make it difficult to deliver care in the same manner as in the past. A recent survey of physicians in the USA indicated that one in three doctors plan to retire in the next 10 years. No country has the ability to produce enough healthcare professionals to close existing and future shortages without a radical change in the practice of medicine.

Insufficient healthcare facilities Shortage of hospital and institutional facilities, combined with budget constraints that limit the ability to build more means that care must be delivered in alternative locations such as the home, office, and distributed retail locations. Emerging countries, like China and India, with their very low hospital density ratios and rapidly growing and ageing populations, cannot keep up with the demand for hospital services to manage acute conditions. In developed markets, such as the USA or the UK, chronic diseases are usually treated and managed in existing hospitals, which represent 75 per cent of their spending.

Budget shortages With fewer resources to finance healthcare services, credit rating agencies have sounded the alarm that a failure to address future healthcare costs will result in downgrading a country’s credit rating. For example, according to the

Organisation for Economic Co-operation and Development (OECD), Japan, which has the lowest spending on healthcare as a percentage of GDP among developed countries at 9.5 per cent in 2010, expects this figure to double in the next decade due to their ageing population. In the US, on the other hand, the figure in 2010 was already over 17.6 per cent and the US government expects it to reach 20 per cent by the end of the decade. These growth rates are viewed as potentially unsustainable and demand increasing levels of productivity to reduce them.

Complex adaptive system Command and control through topdown hierarchical structures will not solve the healthcare challenges. To deploy transformational change in a complex system among diverse, semi-independent and autonomous agents (doctors, hospitals, patients, etc.) requires a networked model of delivery as opposed to a hierarchical hospital-based system.

IT fuels this complexity and requires us to rethink the structure and nature of a healthcare delivery system.

These five constraints make it clear that the status quo is unsustainable and productivity must increase, not incrementally but radically. Technological innovations, such as mHealth, have the ability to help overcome these challenges.

The case for mobile technology productivity

Mobile wireless technologies have already begun to transform other industries such as media, entertainment, music, publishing, banking, travel and retail.

Consumers typically experience greater convenience, lower prices, more control and greater empowerment as a result of mobile adoption. Non-traditional companies have entered these nonhealthcare markets with new innovations that have challenged the status quo and threatened the very survival of industry leaders. mHealth has the potential to do the same in healthcare.

Yet while patients are receptive to mHealth, providers tend to be less enthusiastic, and opinions vary based on region of the world surveyed. In the EIU mHealth study, physicians and providers in China, India and the USA were asked what impact they expect mHealth would have on the current practice of medicine (see Figure 1). Among providers in these three markets, Chinese providers expected mHealth to have the most profound impact across the board, followed by India. What is interesting is that US providers think mHealth will be less transformative than providers in these emerging markets despite the ubiquity of mobile technology in the US among other industries and the US' dominance of mHealth applications and services over other markets. However, when these responses are viewed in light of the five constraints listed above, it's clear that they are more acute in emerging markets like China and India. Since necessity is the mother of innovation it is unsurprising that providers in those markets see such mHealth innovations more useful and essential to address their healthcare challenges than providers in the US. When trying to understand the difference in interest among providers and patients, we see that the key drivers for providers differ from consumers. According to the same EIU survey, patients across all three countries agreed on the four key drivers for patient adoption of mHealth: lower costs, greater convenience, better information and increased control over their own health.

Yet among providers, the key drivers varied considerably across countries, as seen in Figure 2, and were primarily focused on the benefits mHealth can provide to the provider, not to the patient.

This gap seems to exist between patient and provider largely because providers don’t view patients as a consumer.

They, therefore, miss the opportunity to create new consumer-oriented value propositions by leveraging this new technology.

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Physician view on the impact of mHealth on current practies No substantial impact*

Internal only

44%

24%

21%

35%

18%

*No noticeable impact

22%

Patient only

Impact all aspects

U.S.

16%

9% 7%

21%

INDIA

19% 4%

22%

CHINA

25%

Internal only

13%

Impact all aspects

*Minor communication improvement, no real impact

Patient onlt Figure 1 Source: PwC analysis and Economist Intelligence Unit

Standards needed to close the gaps

Although providers see mHealth's promise to increase productivity in the healthcare system, they still exhibit reservations in moving quickly to adopt this new technology for several good reasons.

Providers are uncertain how to address the many new issues that arise from mHealth adoption and are looking for guidance in identifying, creating and adopting best practices in care delivery.

In short, they want mHealth standards to manage the broad array of challenges that this disruptive innovation creates.

The following are some key guidelines and standards that providers should establish to allow mHealth to be appropriately leveraged to transform their practice.

Medical training and education standards Very rarely are physicians or nurses trained on how to deliver mobile care as a standard practice. For this reason, academic medical centres need to create an mHealth curriculum for existing students as well as alumni through Continuing Medical Education (CME) programmes. For example, the Veterans Health Administration (VHA) in the US had to create its own CME programmes to educate providers on these new care delivery technologies and practices. So far it has trained thousands of healthcare providers in its system.

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To help subsidise this type of course, medical schools can partner with the private sector to enable real-life applications to be taught. For example, in the US, a global mobile technology company has helped fund the creation of an mHealth program at a Scripps Research Institute in La Jolla, California.

Clinical and economic efficacy research standards Clinicians are scientists. They demand research and empirical evidence that this new mHealth paradigm creates greater clinical and economic value than the existing one. To address this requirement, some organisations are documenting the necessary structures, practices and processes to quantify the economic value of telehealth and mHealth services. This research has then been used by others, such as the National Health Services in the UK, to develop their own programs.

Similar research, such as that published by the Mayo Clinic on e-visits, demonstrates that remote care can eliminate over 40 per cent of office visits without compromising the quality of care and substantially decreasing the associated costs. Similar studies, such as the hospital-at-home program recently published in the Annals of Internal Medicine show that moving patients into their home from the hospital can decrease costs by 30 per cent and

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improve the quality of life and care, with significant reductions in infections. As more research designs combine the dual outcome measures of cost and quality it will provide a standard for value that clinicians can use.

Data collection and integration standards Healthcare is rapidly becoming an information industry, accelerated by the move to incorporate genomic information and patient generated data. Data and information growth in healthcare now exceeds that of all other industries, with volumes doubling every six to nine months. A key challenge, however, is that the focus on digitising existing medical records has left little time and resources to determine the best way to incorporate the data. As a result, much of this information, when generated and collected, is merely filed away with little thought to integrating it into other EMR or EHR records. This makes it very difficult for clinicians to use the information in a systematic way to diagnose, treat and manage patients.

In an effort to try and address this integration issue, some providers are aggregating the data through interoperable technologies and using intelligent algorithms to empower nurses and social workers who can do the type of work that was traditionally limited to physicians. This enables greater use of medical staff, increases staff capabilities, provides better patient care and decreases associated costs.

Solution and deployment standards One of the greatest frustrations from those that have attempted to incorporate mHealth, remote patient monitoring, telecare, telehealth and telemedicine is that there is no â&#x20AC;&#x2DC;one size fits allâ&#x20AC;&#x2122; standard for solutions. Factors such as disease, acuity, age, education, geography, culture and demographics all have an impact on treatment. Consequently, organisations that have attempted to create a templated, hierarchical and inflexible mHealth approach have been frustrated by failure.

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Provider Drivers to adopt mHealth

Figure 2 Source: PwC analysis and Economist Intelligence Unit

Various standard-setting organisations are critical to establish consistency for all the players in the healthcare system so they can deliver the best solutions for each problem. Some healthcare systems in countries such as Denmark and Japan have adopted interoperability standards to support a move to a more complex, adaptive system. More markets should do the same in healthcare just as they have done so in adopting telecommunication standards, to enable a thriving ecosystem.

Payment and reimbursement standards Too often we have seen arguments that claim all we need for doctors to adopt mHealth is to pay them for it. While that helps, the fact is that the issues raised above generally pre-empt the payment

Author BIO

The complex nature of healthcare requires the application of a simple solution based on several simple and common rules. An optimal approach tends to be consumer-centric, flexible, interoperable, and highly configurable and adopts the principles of personalised medicine.

Technology interoperability and integration standards Sony's mobile division (formerly Sony Ericsson) in a presentation made at Capital Markets Day in Stockholm on 5 May, 2010, estimated that the number of sensors collecting data will explode from 6 billion to 50 billion over the next decade, with many of these being biosensors associated with human health. At the same time, the cost of these sensor and data aggregation technologies is dropping. Remote patient monitoring technologies that cost $5,000 just five years ago can now be had for less than $1,000, representing more than an 80 per cent reduction in costs. As the data collected from these sensors and mobile devices explodes, interoperability and integration as well as intelligent analytics will have to expand in order to use the information such that all the various components of any solution are 'plug and play'

discussion. If standards are not already in place to serve as a foundation then providers are uninterested in discussing reimbursement.

After studying various mobile technology business models from other industries, and the way and pace in which they have rolled out, some important lessons have emerged 1) Digitisation of content enables new business models 2) Transactions will move to subscriptions 3) â&#x20AC;&#x2DC;Freemiumsâ&#x20AC;&#x2122;, whereby services or products are offered free of charge, encourage consumer experimentation 4 Paid searches provides free services 5) There is greater fragmentation in production but consolidation in distribution 6) Purchasing services / products allows for greater freedom and flexibility.

It is never all about the technology

While technology is a powerful enabler, it is only one element among a host of requirements. A number of standards must be in place before the case can be made that mHealth is a viable and sustainable solution in improving productivity and addressing many global healthcare challenges. A mutually supportive ecosystem of standards across all aspects of mHealth will enable a new paradigm of healthcare that addresses the acute needs in all countries for all people.

Chris Wasden is the Global Healthcare Innovation Leader at PwC. He has led nine startups, is a named inventor on 20 patents, and has authored over 20 reports on innovation. He has a doctorate in human and organisational learning from George Washington University in Washington, DC. Rana Mehta is an executive director in the Healthcare Advisory Practice of PwC India. In his career spanning 15 years, he has been responsible for strategising, planning, commissioning and running over 50 hospitals in South Asia. Dr. Mehta holds a Master of Hospital Administration degree from the Tata Institute of Social Sciences (TISC), Mumbai and MBBS degree from the Medical College of Kolkata.

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Clinician Role Changes Delivering Patient-Centered Workflow For information technology to play a valuable role in reducing healthcare costs while enhancing quality of care, it must be deployed within newly defined workflow that completely reinvents how care is delivered, professionals provide the care, and technology is leveraged throughout care delivery.

Barry P Chaiken, Chief Medical Officer, DocsNetwork, Ltd, USA

I

n the design of successful Healthcare Information Technology (HIT) implementations, patients matter.

Although the importance of addressing the workflow needs of clinicians cannot be overstated, focusing on patient needs helps ensure newly designed workflows leverage the full capabilities of information technology tools. In addition, this delivers the clinical and financial outcomes desired by organisations.

Entities that ignore the needs of clinicians in designing HIT driven workflows can expect to experience either low levels of HIT adoption among clinicians, suboptimal patient care results, or both. Focusing on patient care provides a framework in which to create effective workflows that leverage new technology to deliver promised value to caregivers and their patients.

The Institute of Healthcare Improvement (IHI) —started by former administrator of the United States’ Centers for Medicare and Medicaid Services, Don Berwick, MD—displays this mantra throughout its facility: “Every system is perfectly designed to achieve exactly the results it gets.”

Therefore, organisations that utilise new information technologies to mimic

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the existing workflow of clinicians deliver results no better than outcomes previously reached. In some cases, the inherent complexity of the information technology when deployed within a paper-based workflow can deliver results worse than originally obtained.

To effectively implement HIT, organisations must understand in-depth the capabilities of the available information technology, the requirements of the practicing clinicians, and the expected outcomes of all impacted stakeholders (i.e. patient, clinician, organisation).

Teams built from a cross-section of disciplines and perspectives hold the greatest promise in designing effective workflows. Building a comprehensive workflow across caregivers allows for efficient use of resources to achieve specific patient goals.

Workflow defined

Workflow is defined as any task performed in series or parallel by two of more members of a work group to reach a common goal. ‘Tasks’ refer to any activities or actions undertaken by individuals. ‘Series or parallel’ implies tasks performed one after another or simultaneously. ‘Work group’ means a

IS S Ue - 26 2012

team of individuals working on the same project. Finally, ‘common goal’ indicates that a group’s various activities are performed in concert to contribute to a well-defined and agree on outcome.

At a granular level, workflow functions to (1) deliver information to the appropriate people, (2) organise information to be immediately useful, (3) ensure that the information is acted on, and (4) file information and record actions taken.

The specific needs of the healthcare industry make it an ideal match with workflow concepts. Healthcare involves complex procedures that include both clinical and administrative tasks. As a result, workflow increases efficiency and effectiveness through the maximal integration and use of relevant, timely information. Due to its heavy reliance on information, healthcare is in a unique position to take advantage of the information benefits provided by the implementation of workflow concepts.

Creating a particular workflow requires the stringing together of various healthcare tasks, both clinical and administrative, to achieve a desired outcome in the most efficient manner possible. Patient-centered workflow fuses clinical and administrative protocols by sequencing care tasks, coordinating medical and nonmedical care resources, and establishing a defined timeline for completion of set tasks.

Patient-centered workflow involves: • Identifying a target process (e.g. patient care post myocardial infarction) • Defining both clinical and admin-

Special issue on technology

•

•

• •

•

•

istrative tasks to be performed by a work group Breaking down tasks, in some cases, into more specific actions that can be performed by different individuals but which, when completed together, accomplish the original tasks Deciding on the skill set required to perform each task or action (e.g. skills of a physician, nurse, technician, receptionist, patient) Understanding the sequence in which the tasks are to be performed Recognising and applying conditional rules and logic branching, so that only necessary and indicated tasks are performed Planning the sequence of tasks, assigning the tasks to individuals, and then documenting the process so that others can understand and follow it Creating the forms, documents, and instructions needed by individuals at each step to perform the tasks (e.g. patient hospital discharge instructions).

Invaluable new technologies

Readily available healthcare information technologies offer invaluable tools such as Single Sign-On (SSO), roaming desktops, location awareness, and fast-user switching to support impactful patient-centered workflows.

For example, let us consider an inpatient post-myocardial infarction diabetic patient on the day of discharge. Administration of medications requires a nurse sign-on to multiple HIT applications including a medication administration system to obtain a list of prescribed medications and an electronic medical record system to document patient care.

SSO allows for rapid access to multiple systems through the use of a single two-factor authentication process: who you are (e.g. proximity identify card) and what you know (e.g. password).

As the nurse previously reviewed the patient’s record at the nurses station,

roaming desktop technology permits rapid access to the identical desktop in the patient’s room without needing to open or position the required applications on the display screen. With such technologies, devices function independently allowing for the use of computers and tablets interchangeably during the continuum of patient care workflow.

As some applications may be inappropriate for display in a patient’s room—email, human resource systems, web searches—location awareness technology filters only information that is relevant to the patient. Such filtering allows for the use of dual displays that deliver simultaneous viewing of clinical information by the clinician and the patient. In addition, location awareness directs the convenient printing of relevant documents, in this case, patient discharge instructions at the patient’s bedside printer.

Lastly, fast-user switching facilitates the use by multiple clinicians of the same HIT platform (e.g. bedside computer) by rapidly presenting userspecific displays, as defined by role (e.g. nurse, physician, specialist). The technology eliminates the need for frequent complete sign-out or sign-in by each user, a ghastly clinician offputting process.

Patient-centered workflow requires stringing together individual steps, the linking of processes, and the bridging of activities by multiple caregivers to create an effective and efficient orchestration of resources to enhance the health of the patient. Technology provides only the tool kit to achieve these workflows. Knowledgeable professionals from multiple disciplines synergistically working together hold the potential to build efficient models for care. By focusing on the patient, rather than the technology or any individual participant in the workflow, provides the greatest opportunity to achieve successful outcomes that benefit the clinician, organisation, and patient.

Innovative use of HIT needed

In addition, healthcare systems require a HIT revolution, a drastic change in the way care is delivered by utilizing information technology in new and innovative ways. As already noted, deploying HIT, to replicate the processes and workflows that currently deliver poor results on so many measures, only guarantees continued suboptimal and unacceptable clinical and financial outcomes.

We must focus on three key areas: 1) Information technology tools, 2) Processes and workflows, and 3) Healthcare provider tasks, duties and responsibilities.

Solutions come from an in-depth understanding of tools, and creative thinking around what each healthcare professional can do and how best to deploy an individual’s skill. Valued HIT solutions offer these professionals information technology tools that leverage their unique skill, while organizing the processes and workflows to deliver a consistently high quality, safe, and efficient healthcare outcome.

Clinical decision support expands access

Clinical decision support at the point of care plays a significant role in expanding the number of clinicians available to provide primary care. Through such HIT tools, best practices—those that we know from scientific evidence offer the highest probability to produce the best healthcare outcome—can be delivered to each patient by healthcare professionals educated, guided, and ‘double-checked’ by the HIT tool.

Currently, patient delivery depends upon an unreliable system formed from poorly integrated and highly variable human participants. Solutions integrating clinical decision support provide needed adjunct tools that increase the reliability of the human components, while integrating these components through effective processes and efficient workflows.

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In addition, as best practices change, they can efficiently be delivered through the existing workflow by simply changing the knowledge contained in the clinical decision support tool. Currently, changing practice patterns requires the inefficient, and mostly ineffective, method of targeted medical education.

Clinical decision support at the point of care plays a significant role in expanding the number of clinicians available to provide primary care.

Changing what clinicians do

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deciphering of puzzling diagnostic challenges or devising significant changes to therapeutic plans. Reducing the number of these types of patients seen by physicians, frees them up to care for patients requiring higher levels of service.

Expanding the capabilities of all clinicians through the deployment of clinical decision support increases the availability of primary care providers while ensuring high levels of quality care.

The revolution for healthcare providers is inherent in the dramatic change needed in what professionals do and how they do it. Therefore, effective change management techniques must be utilized to facilitate the acceptance of new responsibilities and duties in addition to the new processes and workflows required of these new roles.

Focus on incentives

Before the expansion of clinician roles achieves widespread adoption, reimbursement policies for all types of providers must be addressed. Currently financial disincentives exist for some physicians who ‘outsource’ visits to

Author BIO

Deployment of clinical decision support within HIT systems fundamentally changes what physicians, nurses, and other healthcare professionals do. Physician activities become more challenging on a cognitive level as other routine tasks such as drug dose recall, use of best practice order sets, and drug-allergy checking become automated. Physician expertise is assigned to more important tasks including solving difficult diagnostic problems, devising customised patient treatment plans, and influencing patient adherence to chronic disease care regimens.

Work for nurses and other healthcare professionals changes dramatically too.

More tasks, formerly done by physicians or healthcare specialists, are completed by these professionals guided by intelligent processes and workflows that include meaningful HIT. Therefore, the number of qualified clinicians available to deliver quality care increases to meet the demands of expanding populations in need to care.

Clinical knowledge and experience, normally obtained only through years of study and work, can now be codified in clinical decision support tools that less trained clinicians can apply to their patients. The delivery of care is now standardized around a high level of quality, with outlier patients—those identified as having unusual medical problems and in need of more complex care plans —referred to primary care physicians or physician specialists.

As uncomplicated patients make up the majority of an ambulatory medicine practice, many visits engender monitoring of a patient’s medical condition or treatment for simple ailments rather than

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physician extenders. Payors must team with both large physician groups and small independent practices to construct reimbursement models that allow for the increase in non-physician primary care clinicians while preserving incomes for physicians. These models must include the use of clinical decision support tools embedded in the workflow of deployed electronic medical records.

Perhaps the interest in capitated models now seen in accountable care organisations and medical home projects being deployed in the US indicates that innovations already exist in this area.

These projects offer models that can be adopted by governments or other types of payors throughout the world.

For information technology to play a valuable role in reducing healthcare costs while enhancing quality of care, it must be deployed in a way that completely reinvents how care is delivered, professionals provide the care, and technology is leveraged throughout care delivery.

In 2012, progressive organisations will effectively allocate their investment in HIT by utilising clinical decision support and modifying workflows to expand the effective and efficient use of their clinical staff, while delivering enhanced outcomes to patients.

References Chaiken, B. P., & Thompson, M. A. (1997).

Enhancing quality / controlling costs: Using Internet technology to apply workflow to healthcare.

Journal of Healthcare Information Management, 11(3), 73-80.

Workflow. (2012, June 19). In Wikipedia, The Free Encyclopedia. Retrieved June 19, 2012, from http: / / en.wikipedia.org / w / index.php?title=Workflow& oldid=498357506 Chaiken BP. Clinical Decision Support Revolutionizes Delivery Of Care. The Top 10 Health IT Trends For 2011, p. 12-13.

Barry Chaiken has more than 20 years of experience in medical research, epidemiology, clinical information technology, and patient safety, Chaiken is board certified in general preventive medicine and public health and is a Fellow, and former Board member and Chair of HIMSS. Barry currently serves on the Advisory Boards of Aventura, the Digital Healthcare Conference, the Institute of Healthcare Technology Transformation, and PanGenX.

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Liquid Data

Fuel for collaboration on the road to innovation in healthcare Predictive, preventive, pesonalised and participatory are the 4Ps of next-generation healthcare. This approach shifts the emphasis from reactive to preventative and from disease to wellness. This article talks about the role information plays in enabling this advancement.

Marc Perlman Global Vice President, Healthcare and Life Sciences Industry Business Unit, Oracle

I

n the global economy, healthcare challenges and issues rise to the top, irrespective of the country or region. The lack of medical availability to significant numbers of citizens, escalating costs, and growing influence by governments, further exacerbated by the desire for consumer control and access, has created a serious crisis.

According to the Frost and Sullivan Asia-Pacific Healthcare Outlook 2012-2015, the healthcare sector in Asia Pacific (APAC) is growing quickly, spurred further by an increased spending on health, the liberalisation of investment policies, growing medical tourism activity, and high adoption of new technologies. Accounting for over 60 per cent of the world's total population, this region alone presents significant growth opportunities to meet the increasing needs of a rapidly growing and ageing population. In 2011, the APAC healthcare market held 27.5 per cent of global healthcare market share and by 2015, this is expected to grow to 33.1 per cent.

Due to the sheer opportunity in the healthcare industry, there is no question that we need to collectively move forward to innovate and transform how we manage our health.

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What is the vision for next-generation healthcare? This fundamental question can be answered with four wordspredictive, preventive, personalised, and participatory. Known as P4 medicine, this approach shifts the emphasis in healthcare from reaction to prevention and from disease to wellness. P4 medicine promises to improve outcomes, reduce costs, and empower patients to take a more active and informed role in their care. The opportunity for reduced medical errors and improved patient safety is another key element that will encourage the adoption of IT systems for next-generation healthcare.

Information is the key to realising the potential of P4 medicine â&#x20AC;&#x201C; whether flowing from healthcare providers to pharmaceutical organisations for the development of more personalised therapies, exchanged between providers to improve care coordination, delivered to the point of care for more informed decisions, or communicated directly to patients to enable them to assume a more active role in their personal health.

Liquid data turning into actionable information is essential

Our journey toward the next generation of healthcare requires the rethinking of

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the overarching technology, interoperability, processes, and people that will need to be in place to support it. The first critical step in this journey is to focus on the fuel that will propel us and subsequently pave the path to innovationliquid data.

The amount of data that todayâ&#x20AC;&#x2122;s healthcare systems are gathering is staggering. However, sheer volume does little to advance care if it remains isolated. We have many of the systems and foundational elements in place to generate the raw data needed to move forward â&#x20AC;&#x201C; such as Electronic Health Records (EHRs), clinical information systems, and Computerised Physician Order Entry (CPOE) systems. The critical data from these systems, however, remains largely frozen. Our data must become liquid to provide the most benefit for healthcare patients and practitioners.

Simply put, liquid data is information that can flow to where it is needed in a form that can be easily accessed, is semantically interoperable, and ultimately actionable. It requires trusted and secure access and exchange, and drives the ability to recombine data at a secondary level to drive new insights.

On the road to personalised medicine and improved population health,

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22-23 March 2013

Grimaldi Forum, Monaco

Healthcare providers seeking international patients should take advantage of this unique platform to showcase the services and facilities to an international gathering of purchasers and facilitators of cross border healthcare. Potential investors and buyers attending will discover the latest innovations and services on offer in this dynamic market.

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Learn from the medical travel experts IMTEC 2013 will provide the opportunity to knowledge share and discuss best practice on the many factors influencing the patient decision-making process on getting treatment abroad.

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trusted data from many systems that reference the entity with different identifiers or names.

Robust applications drive informed decisions

Liquid data is essential, but cannot alone transform healthcare. To gain actionable insight and drive transformation, we require powerful software applications for both physicians and patients. Liquid data must be engaging, useable, interactive, and provide clear direction to the physician and patient.

Further, if health IT is to become the next ‘participant’ in healthcare, it must be intelligent enough to be an ‘advocate’ in helping patients reach their health goals while driving personalised care around the clock.

Increasingly sophisticated decision support systems and analytical applications are emerging and will be fundamental to realising P4 medicine. We are seeing the emergence of next-generational clinical decision support systems that guide decisions at the point of care, as well as analytical applications that enable providers to better evaluate outcomes as well as facility operations.

For example, Oracle Enterprise Healthcare Analytics helps healthcare organisations gain expanded clinical and business intelligence through an integrated picture of clinical, financial, administrative and research informa-

Author BIO

our next milestones as an industry will be supported by the ability to better assess performance and outcomes, clinical effectiveness, and comparative effectiveness. Liquid data is essential in achieving each of these goals, but while it may sound simple enough, we have, and continue to face some hefty roadblocks along the way – including competition amongst those providing and consuming healthcare information that has led to data lock-in.

To get liquid, the healthcare industry as a whole must strongly consider four foundational tenets when evaluating solutions: 1. Open Standards 2. COTS-based (Commercial-Offthe-Shelf ) 3. Interoperable 4. Integrated A key enabling technology to achieve the liquidity needed in our healthcare data is interoperative information exchange that will aggregate and normalise data from core transactional systems, and seamlessly enable healthcare providers and researchers to act on it.

Oracle is on the front lines of helping healthcare organisations achieve this important goal, offering complete, standards-based solutions to facilitate integration and automate processes across multiple systems in the healthcare enterprise.

For example, Oracle Health Information Exchange provides a suite of extensible, open, standards-based solutions built upon a reliable technology infrastructure for the secure exchange of electronic health information. These solutions help to empower healthcare entities globally to reduce costs, enhance revenues, and most importantly, improve patient care. The Oracle Healthcare Master Person Index provides a single point of reference to information about a patient, clinician, payer or other healthcare entity within and across healthcare organisations, ensuring the availability of unified,

IS S Ue - 26 2012

tion across the enterprise. This holistic view can truly help ‘close the loop’ in healthcare intelligence, allowing for the right clinical information and best treatment practices to be placed at the point of care ensuring the best decision by the doctor and patient when needed most.

Applications will also be essential to fostering greater patient engagement.

Integrated or ‘accountable’ care is gaining momentum, but will only succeed if consumers can play a more active role in their care. Personal Health Records (PHRs), which enable patients to have access to information related to their care, will help set the stage for increased engagement and collaboration in a more efficient and streamlined manner.

Initial adoption remains slow, but as we develop more technologies to bring personal information together and integrate it into a provider’s workflow, consumer empowerment will increase as they gain the capability and knowledge to positively affect their care.

To be truly beneficial long term, however, technology must deliver information to the physician, and ultimately the patient, in a proactive, timely, and secure manner through preferred communication channels.

We find ourselves at an exciting time in the history of modern medicine, as we look forward to what the next generation of healthcare will bring. Building the right infrastructure to support data collection, integration, and transformation is essential to enable new insights and accelerate our journey toward highly effective and efficient personalised care.

Marc Perlman is Global Vice President for Oracle's healthcare and life sciences responsible for driving strategy and industry solutions across the organisation. He leads the Healthcare Customer Industry Strategy Council and serves as executive lead with some of the top healthcare and life science companies. With more than 30 years in the healthcare industry, he brings deep global experience.

Special issue on technology

Vendor Neutral Archives Solving the challenges of medical information management The efficient management of medical information lies at the heart of effective patient-centred care. The industry is turning to Vendor Neutral Archives (VNA) to solve this challenge, but what does the industry buzz word mean and how can it really help?

Peter Wilkop, VNA Product Leader, EMEA At GE Healthcare IT, we define VNA is a 4 level model for medical information management that meets a hospital’s requirements to store information in a cost effective way, consolidate access to patient data, provide service continuity, preserve investments and comply with data protection regulations, while supporting the wider objective of improving patient diagnosis and treatment.

Our VNA product is an ‘Open standard’ which means it adheres to the IHE industry standards, it supports our wider vision for integrated patient care – a patient driven, outcomes driven method of delivering healthcare - and it can be developed over the long term to meet the evolving healthcare requirements of the future.

The four levels of VNA offered by GE can benefit a healthcare system in a number of ways and offer incremental benefits when adopted simultaneously. Level 1 accommodates independent radiology PACS systems from different vendors. Level 2 adds the ability for enterprise imaging (e.g. rad and cardiology) systems from different vendors so that different departments can be archived together and the life cycle of images

A VNA distributes patient’s clinical data to physicians and clinicians to help improve productivity and patient experience.

Patient Information Viewer – A zero-footprint clinician viewer providing anywhere, anytime access to patient clinical records and part of the VNA suite of products.

stored on the archive can be managed automatically thereby contributing to reduce, control and manage costs.

Level 3 adds enterprise medical documents and media access which makes it possible to store all kinds of media produced in the hospital or medical department on one archive making it accessible to all departments of the hospital. This means a holistic patient history is available resulting in improved diagnosis and therapy.

Level 4 takes the archive outside of the confines of the hospital and connects the patient history across the region providing a gateway to regional image exchange.

There is no doubt that the face of healthcare and the way that we diagnose and treat patients is changing.

In particular we are seeing a trend where numerous specialists from across the country can be involved in the treatment of one patient and a scalable solution like the GE VNA is the key to enable this effective collaboration, both now and as things evolve. It is an extremely powerful tool bringing a host of benefits across the organisation to the IT department, the physician and the patient. And the good news is that in order to take advantage of these benefits there is no need for additional IT infrastructure or a hefty capital outlay – everything is contained within the VNA, it is just a question of accessing it to its full potential.

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Special issue on technology

Can Animation Software Help Find Cures for Cancer and HIV? Visual effects software is more commonly associated with the movie and gaming industries, but is today being used in pharmaceutical and life science research laboratories to digitally visualise, simulate and replicate micro biological processes that may bring us closer to solving some of humanityâ&#x20AC;&#x2122;s most pressing medical problems.

V R Srivatsan, Managing Director, ASEAN region, Autodesk Asia

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hile 3D animation and visual effects have traditionally been associated with the movie and gaming industries, the same software used to create blockbuster games and movies is now moving beyond the silver screen: into the research laboratories of the leading players in the healthcare, pharmaceuticals and life sciences industries.

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Enter the era of bio-visualisation â&#x20AC;&#x201C; where the tools used by the likes of Disney and Pixar studios are used to bring complex biological data to life, making it possible to digitally visualise, simulate and replicate micro biological processes on a molecular level, in far greater detail than possible with traditional equipment.

While not yet prevalent in the life sciences industry, these new techniques

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and technologies are gradually being employed to communicate complex concepts, research, and models in the biological sphere in a manner that is visual, immersive and engaging. Within the scientific community, animation is gaining prominence and value due to its ability to aid communication, both among industry experts as well as nonspecialist audiences.

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With Maya recently available for free to educators, the next generation of scientists and researchers stand to benefit immensely from the power of software.

Beyond the research laboratory, the use of visualisation software and tools is almost essential to communicate effectively with broader audiences, many of which are critical to the growth of the scientific community. Visual communication becomes yet more crucial when new findings in the field develop into products or techniques that are ready to hit the market, in helping to inform and eventually secure buy-in from investors, marketers, regulators and even end-consumers about the product in a way that is easy and engaging for non-technical audiences to consume.

Visualisation software is also gaining ground in the field amongst educators, who are using these tools to make learning more accurate, wholesome and exciting with many of the intricate biological structures, techniques and processes being illustrated and animated in realistic 3D. Already, special plug-ins exist for Maya users to download special “Molecular Maya” toolkits, designed specifically for professionals in the biological field, to download data from scientific databases that can be automatically translated into 3D models. Pioneered by Dr Gael McGill, Director of Molecular Author BIO

Among industry experts, Hollywood’s tools of the trade are particularly useful in the research process, helping researchers to accomplish their work in a matter of months rather than years.

For example, being able to visualize and analyse new drug formulations on a molecular level, and thereby simulate adjustments and how these affect medical effectiveness can have profound effects on the time taken for the drug to make it to the market. The added benefit of having digital visualisations of a complex research project also mean that findings can be easily communicated amongst expert team, even across borders, enabling greater collaboration and coordination to ensure commercial success.

Already, moviemaking technology has had a hand in enabling significant scientific breakthroughs in experimental medical studies, including that of cancer research. Using a plug-in called CADnano, built on the Autodesk Maya platform, researchers from the Wyss Institute for Biologically Inspired Engineering at Harvard University have achieved encouraging results with a technique called DNA Origami. The plug-in uses the powerful capabilities of Maya software, a staple in visual effects in the entertainment industry, to model individual strands of DNA into a complex web of patterns that perform “smart” functions in what the team calls a “nanorobot”. In trials conducted at the Wyss Institute, the nanorobots created were able to target specific pathogenic cells, releasing a payload of antibodies on contact with leukemia cells with little collateral damage to surrounding healthy tissue.

These findings, while still in an early stage, provide an encouraging development in the field of the life sciences.

With the open-source plug-in available for researchers the world over, scientists can now leverage the power of 3D visualisation tools to explore yet more exciting possibilities with DNA Origami.

Visualisation at Harvard Medical School and founder of Digizyme, a multimedia biotech company specialising and educational and promotional animations for life sciences applications, the toolkits integrate the Rutgers Protein Database into Maya’s code base so that users no longer need to build molecular animations from scratch. With Maya recently available for free to educators, the next generation of scientists and researchers stand to benefit immensely from the power of software used by Hollywood’s largest production houses to take medical pedagogy to the next level.

This technology has allowed McGill’s team to develop accurate animations of scientific processes that remain hidden to the human eye, because the structures involved are too minute, or the timescales of the processes – rapid like the conformational changes of a protein, or prolonged as with ecological and evolutionary shifts – are beyond the perception of the human senses. His work includes visualisations on the process of viral infection, where viral surface protein spear target cell membranes – which may hold potential keys to unlocking better understanding on how to treat fatal infections like HIV. In equipping not just industry experts, but also young medical students with new ways to explore and discover the natural world, scientists and educators of today can help create an environment that not only promotes better understanding of the life sciences field, but also opens up avenues to pursue and investigate new scientific breakthroughs that may hold the secrets to unlocking cures for some of the world’s most deadly illnesses.

V R Srivatsan has over 22 years of experience in the IT industry, helming various leadership roles with multinational organisations with SAP and Oracle. He is responsible for the overall strategy and growth of Autodesk’s business in the ASEAN region across the various geographies, industries and product segments.

Building strategic partnerships across the region will also be his key focus area.

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Make Big Data Economical and Actionable for Faster and Better Healthcare Yogesh Sawant Director, Partner Sales and Field Alliance Organization, Hitachi Data Systems, India

I

n today’s Healthcare and Life Science (HLS) environment, healthcare big data is everywhere. For example, most physicians now provide consultation and diagnosis by reviewing a patient’s history in Electronic Medical Records (EMR); radiologists make treatment decisions with medical images such as x-rays, ultrasounds, Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) scans; and life science researchers study disease through high-resolution digital images of tissue biopsies, and examine digitalized genome sequencing patterns..

With the extensive adoption of healthcare big data at every step of the healthcare and lifescience process, the volume and variety of big data has become mind-boggling, and continues to expand relentlessly. To understand the scale of this data expansion, think of it this way: a single CT image contains approximately 150 MB of data, while a genome sequencing file is about 750 MB, and a standard pathology image is much higher, close to 5 GB. If you multiply these data volumes by a population’s size and life expectancy, a single community hospital or a mid-size pharmaceutical company can generate and accumulate terabytes and oftentimes petabytes, of structured and unstructured data.

Two sides of the same coin

Naturally, for many HLS organisations, trying to control the spiraling costs, complexities and risks associated with big

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data has become a critical issue. However, from another perspective, healthcare big data can produce benefits that are far beyond the costs required to manage it, such as unlocking new sources of medical value, improving the accuracy and speed of diagnosis, forecasting disease and health patterns, and gaining fresh insights into life science innovations. US management consulting firm McKinsey Global Institute (MGI) estimated that if the United States’ healthcare industry were to effectively use its growing volume of big data to drive efficiency and quality, it could create more than US$300 billion in new value every year. Moreover, in the developed economies of Europe, government administrators could use big data to save more than €100 billion (US$149 billion) in operational improvements alone.1 Every coin has two sides. It’s true that healthcare big data creates many challenges regarding data management, storage, distribution and protection. For the majority of successful organisations, however, the use of big data has also become a key strategy forunder-pinning productivity, improving patient care, enhancing competitiveness, and accelerating growth and innovation.So, how do we balance these two sides, or even create a situation where the benefits exceed the costs?

The answer lies in Data Economics –namely, how to make the processof extracting value from data costless than the resulting value. If we can effectively

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minimize the costs of storing, processing and protecting data and then harness sophisticated techniques to transform that data into actionable information that supports clinical and business growth, we achieve the highest Data Economics.

Healthcare big data volume and complexity

The problem, however, is that effectively minimizing the costs of big data storage is a fundamental challenge for business and IT leaders, especially for contentdriven HLS businesses. This is because, apart from the proliferation of data volumes and modalities, healthcare data is also subject to longer and longer retention periods. A patient’s medical records may need to be stored for 70 or 80 years, perhaps even longer. In many cases, medical records must also be preserved in the original format on a permanent basis in order to meet compliance and legislative requirements. Similarly, life science organisations are increasingly opting to retain and maintain decade’s worth of data, in the hopes that it could be a source of new research.

Furthermore, in today’s ever-changing environment, many HLS organisations are already struggling with strained resources, continuous business growth, and the rise ofnew medical technologies.

This often leads to the unplannedexpansion of storage architecture resulting in disparate systems and tools, which makes management and administration

Special issue on technology

The ideal Storage Infrastructure for HLS organisations

all healthcare big data, regardless of whether it is structured or unstructured, to enable centralized management and better resource allocation.

To consolidate big data across different hospital departments, or across disparate life science systems and enable optimal information search and sharing, the ideal storage architecture must be an integrated system for block, file and content with powerful capacity, performance and throughput to main-

Author BIO

even more complicated. Indeed, accelerated storage consumption, and poor utilisation of storage assets, as well as the continuous demand for more floor space, and higher power and cooling costs, all driveup storage TCO. As if this situation is not dire enough, for a hospital, failure to locate information can also create compliance issues and may result in legal penalties and even fines. For a research organisation, data access is at the core of innovation and competitive success. Itâ&#x20AC;&#x2122;s no wonder managing the costs and complexities of file-based data growthhas been named asone of the top five most difficult issues facing Global 5000 companies today.2

tain a sense of operating coherency in handling, moving and accessing multiple large datasets and vast amounts of data, frequently in the range of terabytes and even petabytes. To minimise storage costs and alignthe system with clinical and business needs, it must also enable a level data interoperability that will support clinical innovation. It must provide intelligent tiering to automate data placement based on frequency of access, clinical value and the actual cost of the storage. This dynamic tiering function helps further improve capacity utilisation and resources allocation, which holistically optimizes the costefficiency of the storage resources.

In addition, HLS organisations require massive storage headroom and dynamic scalability to handle their unpredictable and growing amounts of data and images, as well as a high level of compliance for enforcing policies regarding long-term data retention, integrity and protection. Crucially, a suitable storage system must beable to provide a content-awareness capability to enable the transformation of data into actionable information. Contentawareness describes a set of capabilities that dynamically classify inforÂŹmation and assign policies to unstructured data files, turning unstructured data into valuable intelligence so they can enforce best practices, make decisions faster, and protect sensitive company data.

1. Source: Big data: The next frontier for innovation, competition, and productivity, McKinsey Global Institute, June 2011 2. Source: http: / / www.busmanagement.com / article / The-Challenge-of-File-based-Data-Storage /

Yogesh Sawant is responsible for driving the Hitachi Partner program and enabling the partner eco-system in India, with over 20 yearsâ&#x20AC;&#x2122; experience in the industry, Sawant has been with Hitachi Data Systems since September 2011, prior to which he worked for organisations such as Oracle India, Sun Microsystems, Dell Computer India, Hewlett Packard, Compaq and Digital Equipment India where his contribution has been highly respected.Yogesh Sawant is an engineering graduate from the University of Pune, specializing in industrial electronics.

To achieve the highest level of Data Economics, the key is to integrate

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Books

58

Medical Equipment Maintenance: Management and Oversight (Synthesis Lectures on Biomedical Engineering)

Transforming Health Care: The Financial Impact of Technology, Electronic Tools and Data Mining

Editor: Binseng Wang No of Pages: 86 Year of Publishing: 2012 Description: The book opens with a foundational summary of the laws, regulations, codes, and standards that are applicable to the maintenance and management of medical equipment in healthcare organizations. Next, the core functions of the team responsible for maintenance and management are described in sufficient detail for managers and overseers. Then the methods and measures for determining the effectiveness and efficiency of equipment maintenance and management are presented to allow performance management and benchmarking comparisons.

The challenges and opportunities of managing healthcare organizations of different sizes, acuity levels, and geographical locations are discussed.

Extensive bibliographic sources and material for further study are provided to assist students and healthcare leaders interested in acquiring more detailed knowledge.

Editor: Phil Fasano, Jack Cochran No of Pages: 224 Year of Publishing: 2013 Description: Transforming Health Care combines healthcare, technology, and finance in an innovative new way that explains the future of healthcare and its effects on patient care, exploring the emergence of electronic tools that will transform the medical industry.

Explaining how technology, not politics, will lead the future of the healthcare revolution, author and healthcare technology expert Phil Fasano presents real-life examples that show how the next generation of medical breakthroughs will come from the instant exchange of information across the world • Explores how new technologies will radically change the future of healthcare by making it easier to share information rapidly • Explains what the future of the high tech medical industry means for investors and entrepreneurs.

Asi a n H o s p i t a l & H ea lt hcar e M a n age me n t

IS S Ue - 26 2012

Health Communication in the 21st Century Editor: Kevin Wright, Lisa Sparks, Dan O'Hair No of Pages: 360 Year of Publishing: 2013 Description: This popular and engaging text on health communication is now revised and updated in a second edition that incorporates recent research and boasts new material on topics such as crisis communication, social disparities in health, and systemic reform.

• Fully revised second edition of this popular and authoritative text • Includes fresh material on topics such as crisis communication, health care reform, global health issues, and political issues in health communication • New case studies, examples, and updated glossary keep the work relevant and student-friendly • Provides effective strategies for healthcare organizations and individuals in communicating with patients.

Special issue on technology

Innovation with Information Technologies in Healthcare (Health Informatics)

Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures

Information Technology Solutions for Healthcare (Health Informatics)

Editor: Lyle Berkowitz, Chris McCarthy No of Pages: 320 Year of Publishing: 2012 Description: The Editors and their carefully selected group of contributors, ranging from multi-hospital organizations to small clinics, have assembled a book that describes successful cases covering EHR, Telemedicine and other health IT experiences, in which brilliant and innovative uses of healthcare IT have improved quality, efficiency and value. Each case chapter includes a story about the impact of these HIT innovations on patients, an explanation on the origin of the innovation, details on how the innovation evolved from idea to reality, the real world results of the innovation and lessons learned along the way. Additionally, each of these chapters conclude with thoughts on future HIT innovations from each contributor.

This book provides an extensive review of what innovation means in healthcare, with real-life examples and guidance on how to successfully innovate with IT in healthcare.

Editor: Pradeep K. Sinha, Gaur Sunder, Prashant Bendale, Manisha Mantri, Atreya Dande No of Pages: 376 Year of Publishing: 2012 Description: With the EHR (Electronic Health Record) being central to most health informatics applications, several countries have initiated programs for implementing national EHR infrastructures. Building and implementing such a national EHR infrastructure requires an understanding of healthcare standards, coding systems, and standard frameworks, each of which may vary across borders and / or come from a myriad of sources.

With this in mind, the authors compiled their study and analysis results in a groundbreaking single-source guide to fill the void in this area for the benefit of others working in similar areas.

Editor: Krzysztof Zielinski, Mariusz Duplaga, David Ingram No of Pages: 370 Year of Publishing: 2012 Description: This book presents the current and future trends in the transformation of healthcare services in the Information Society Era and is of great relevance to informatics professions, clinical managers and all clinicians using these new technologies as part of their practice. Information Technology Solutions for Healthcare addresses the priorities within international informatics and presents a thorough survey of the most promising e-health technologies, including internet-enhanced healthcare services and mobile technology via modern wireless technologies. It is illustrated with case reports identifying real applications of the techniques and focused on providing an integrated overview of e-health and medical, sociological and technical aspects of the application of e-health technologies.

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