Asian Hospital & Healthcare Management - Issue 27

I s s u e 27

2013

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Medical Tourism Redefining Patient Experience

In Association with

Facing the Future The growing burden of adult congenital heart disease

mHealth Improving opportunities for better care

Can Banks Offer Digital Keys for Healthcare?

Foreword Medical Tourism

Enhancing patient satisfaction Since the time of Roman Britain, when patients travelled to the Hot Water Springs in the hope of curing their diseases, medical tourism has grown in scale with high quality treatments and cost-effective care packages available.

Healthcare providers are now moving to the next level in medical tourism and international patient management. The objective now is to gain patients’ trust and satisfaction by focusing on quality and safety.

grow rapidly and have a significant impact on patients and service providers.

In this scenario, meeting the changing expectations of global medical tourists is as important as providing care with good standards and procedures. Hospitals and care professionals need to get accredited because this is likely to become a requirement. Creating high quality and cost-effective medical care at all stages is the key challenge healthcare organisations need to concentrate on.

In other articles, K Ganapathy, President, Apollo Telemedicine Networking Foundation, India talks about challenges involved in incorporating digital health into the healthcare delivery system to achieve the necessary radical transformation; Sir John Oldham, National Clinical Lead for Quality and Productivity, UK talks about the challenge and the technological opportunity involved with multiple long term conditions; Robert Junk and Tobias Gilk from RAD-Planning, USA, talk about radiology facility design standards.

Medical tourism industry has been growing with a double digit CAGR in Asia and is expected to reach US$8.5 billion by 2013. Medical tourism contributed nine percent of global GDP (more than US$6 trillion) and accounted for 255 million jobs in 2011. Medical tourism industry—with organised structures and standards, certification of hospitals in addition to accreditation and better defined quality with improved communication—is expected to

The cover story of this issue, by Claudia Mika, Angeliki Katsapi and Hashem Al-Fadel from Temos International GmbH, talks about the essential quality criteria and patient satisfaction factors for international patients. It also explains international patient care / service cycle and phases involved in international patient management.

Prasanthi Potluri

Editor

Contents

04 Quality in International Patient Management For the well-being of patients Claudia Mika, Managing Director, Temos International GmbH, Germany Angeliki Katsapi, Director, Temos Aegean Ltd, Greece Hashem Al-Fadel, Regional Director, Temos Middle East, Jordan.

Healthcare Management 11 Reforming Healthcare Delivery in the Commercial Market Ann Boynton, Deputy Executive Officer, Benefit Programmes Policy and Planning California Public Employees’ Retirement System, USA

TECHNOLOGY, EQUIPMENT & DEVICEs 29 The Dose Makes the Poison!

Can we apply Paracelsus´ paradigm to technology-driven medical therapies?

MEDICAL SCIENCES

Joerg Vienken, BioSciences, Fresenius Medical Care Bad Homburg, Germany

16 Facing the Future The growing burden of adult congenital heart disease

K Ganapathy, President, Apollo Telemedicine Networking Foundation, India

32 Can ICT Make a Difference in Providing Healthcare?

Kenneth Guo, Associate Consultant, Department of Cardiology, National Heart Centre, Singapore Ju Le Tan, Director of Adult Congenital Heart Disease Program, Department of Cardiology, National Heart Centre, Singapore Koichiro Niwa, President, Asia Pacific Society for Adult, Congenital Heart Disease, Japan Ariane Marelli, Professor of Medicine, McGill University, Canada

information technology

22 Long-term Conditions The challenge and the technological opportunity

40 Medical Technology Innovations Enhancing healthcare delivery

Sir John Oldham, National Clinical Lead for Quality and Productivity, UK

GSK Velu, Vice Chairman, Metropolis Health Care Limited, Chennai, India

Diagnostics

44 mHealth Enhancing healthcare delivery

26 Radiology Facility Design Standards Cookie cutters and football pitches

Jeanine Vos, Executive Director, mHealth, GSMA

36 Can Banks Offer Digital Keys for Healthcare?

John Casillas, Senior Vice President, HIMSS, USA

special features

Robert Junk, President, RAD-Planning, USA Tobias Gilk, Senior Vice President, RAD-Planning, USA

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Advisory Board

Editor Prasanthi Potluri Copy Editors V Rashmi Divakar Rao Jenny Jones Art Director M A Hannan Product Managers Khaja Ameeruddin Prabha Nandikanti Jeff Kenney Breiti Roger Product 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

Compliance Team P Bhavani Prasad P Shashikanth Sam Smith Steven Banks CRM Yahiya Sultan Naveen M Subscriptions incharge Vijay Kumar Gaddam

Sandy Lutz Director PricewaterhouseCoopers Health Reseach Institute, USA

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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Quality in International Patient Management For the well-being of patients The medical tourism and tourism medicine market is an increasing but also challenging market. Patients have particular needs when undergoing treatment abroad. Pre-, on-site- and post-treatment take place in different countries and need to be managed to assure high quality and cost-effective medical care during all phases of the treatment process.

Claudia Mika, Managing Director, Temos International GmbH, Germany Angeliki Katsapi, Director, Temos Aegean Ltd, Greece Hashem Al-Fadel, Regional Director, Temos Middle East, Jordan.

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nternational patient management for expatriates, residents, and (business) travellers receiving healthcare services abroad and the processing of medical tourists are issues significantly raised in the past decades. These patient categories are characterised by unique requirements and needs when undergoing treatment outside of their own country. Pre-, on-site- and post-treatment take place in different countries and need to be adequately managed in order to assure high quality and cost-effective medical care at all stages of the care cycle.

Another important point is that the medical service structure and the operational and quality levels differ among countries depending on each country’s living standards, current regulatory, financial and organisational conditions.

Moreover, quality is always relative due to the individual perception and culture and also due to the scientific or professional standards that are implemented.

Furthermore, difficulties in international patient management arise as a result of cultural differences, language barriers but also legal issues, different

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understanding of medicine or an interruption of cross-border procedures, for example, in the frame of the provision of reliable information and documentation in the pre-treatment stage.

The processes and procedures associated with the treatment of international patients need to be defined, implemented and realised in the frame of the healthcare facility’s Total Quality Management System (TQMS).

Treatment results and outcome data should be evaluated based on the medical facility’s quality criteria, Key Performance Indicators (KPIs) and data obtained from patient satisfaction surveys.

The importance of such elements for quality in international patient management beyond accreditation will be highlighted. Also emphasis will be made on the processes during the cycle of medical tourism from patient’s departure from their country, throughout medical care and treatment in the hospital until returning home.

Furthermore, the following article summarises the essential quality

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criteria and patient satisfaction factors for international patients. The necessary tools for Continuous Quality Improvement (CQI) for medical tourism will be discussed to achieve a quality healthcare culture beyond accreditation and beyond boarders.

These principles and best practices are based on certification experience from hospitals with large numbers of international patients and from the involved Temos assessors working with different hospitals in different countries internationally.

Quality culture beyond accreditation in healthcare services

Quality and safety are the most essential requirements for providing an optimum healthcare support for accreditation and QMS systems. Since it relates to medical tourism, a third dimension is needed, concerning the quality culture with all its aspects of medical and non-medical operations. As such, hospitals in some countries within the frame of the medical tourism industry have been competing recently for quality culture to capture

The international patient care / service cycle Cross-border healthcare involves different stakeholders from different countries offering their services at different times and different levels in the patient’s treatment process – the so called “international patient care / service cycle”.

From the patient’s perspective the international patient care / service cycle can be divided into the following parts:

At home The patient’s research about treatment options abroad begins via the Internet or is based on advertisements on radio, TV and newspapers. Agencies, facilitators, and other intermediaries usually offer support and the personal experience of friends, relatives, and neighbours are other means of research in deciding where to go for medical treatment.

Pre-travel arrangements in cooperation with the hospital are done either by the patient him / her-self and the hospital or by the inclusion of intermediaries like medical tourism tour operators (facilitators, agents, brokers, etc.) and travel agencies or airlines.

Individualised and effective planning of the patient’s treatment prerequisite is needed. An exchange of information

concerning the patient’s medical history, diagnostic test results and relevant data essential for the medical and clinical services are to be provided and respective services are to be scheduled for international patients.

On-site At this stage, travel and arrival services for the medical tourist and accompanying relatives / friends are completed.

Admission, diagnostics, medical and non-medical services are offered and provided. Discharge procedures and posttreatment options are to be defined, planned and organised.

On-site / at home Concierge and post-treatment services after discharge are to be scheduled followed by the aftercare in the home country which needs to be realised.

All involved parties have to be aware about their roles and the challenges associated with this ‘cycle’ from the quality, safety, and medical point of view. The patient usually expects the highest level of quality and safety after his / her decision was made.

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the attention of international patients, health insurance and facilitator companies. However, at the end the objective of healthcare organisations should be the gain of trust and then meet or even exceed inbound patient expectations and satisfaction.

Looking at the overall picture of international patient care, accreditation standards cover the main departments of the healthcare organisation for the minimum requirements of healthcare services. However, for medical tourism, additional criteria and elements are required

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to cover inter-cultural boundaries. These elements include culture sensitivity of the personnel including nurses, doctors and involved administrative staff, language skills, food quality and flexibility, and the procedures before, during and after the treatment followed by discharge policies and, importantly, adequate documentation in the required language.

The whole objective is to achieve optimum multicultural services for the highest quality of care and safety with adopted cultural elements. Besides the non-medical dimensions of health-

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care, the clinical or medical outcome of the service itself progressively becomes an objective measure for competition among healthcare providers worldwide.

Different hospitals promote their clinical effectiveness and high rates of ‘extraordinary’ effects of various treatments or diagnostic procedures and those points seem to be rather persuasive when it comes to patient’s decision in the choice of a medical service provider.

Thus, accreditation is an important part of the establishment of a general and basic quality culture for healthcare service

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providers. For medical tourism and international patient management, healthcare providers need to go a step further.

On-site

Challenges for quality management in medical tourism

International patient management is confronted with a number of challenges to achieve higher patient satisfaction rates. When a patient travels to get treatment abroad, he or she expects to have a high level of quality healthcare services, a minimal risk of medical mistakes or malpractice, and safe, effective and appropriate treatment.

From the patient’s side, there may be different barriers. These include unsure quality, unknown physicians and hospital personnel skills, different and unknown food, different culture and language, different religious handling of deceased patients, questionable infection control levels, uncertainty regarding surroundings and adjustment to the environment as well as difficulties in the continuity of care. Furthermore, billing and accounting might be a challenge for the patient who is not familiar with the local system.

From the hospital’s side there are also significant factors to be properly handled which include unknown real conditions of the patient and the respective medical history, infection control issues, difficulties in the follow-up and after-treatment care, payment of services after discharge and other related issues.

• Research

• Arrival

• Travel

• Provision of docs

• Treatment

• Post treatment

• Decision

• Discharge

• Follow up

• Pre-travel

• Invoicing

• Feedback...

• Travel

• Travel

At home

At home Figure 1: The international patient care / service cycle

In any case, proper management of international medical tourist services, which include internal and external communication, the implementation and realisation of guidelines as well as internal protocols, can bridge the gap between the international patients’ demands and the hospital’s requirements for the provision of these services. At the end both sides will benefit by achieving their objectives.

Positive impact of quality management in medical tourism for the country

Despite the above mentioned requirements and challenges for the management

of international patients, there are positive impacts to the nation receiving international patients by properly managing their discrete needs for special services.

Effects might include social, financial and industrial impact. On the social front, international patient management experience leads to more employment opportunities in the country, more positive competition between hospitals to provide effective and affordable healthcare in addition to industrial growth.

From the financial aspects it promotes industries, foreign investment business experts, and foreign currencies and contributes positively to the GDP. On the industrial side, several industries

Phases in international patient management: Challenges for the hospital's quality management system

Preparation

Pre-travel

Travel

On-site Treatment

Travel

Post Treatment

Follow up

Figure 2

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are significantly impacted by its growth and development; these include the hotel industry, tourism, pharmaceutical and other private and public sectors. On the other hand, there may be negative impact to the nation in case relevant risks are not well managed and treated. These include possible communicable diseases, constrains on the country healthcare for its own citizens and uncertain reimbursement to the hospitals that can be due to political situations.

Examples of best practices in international patient management services

The experience of the Temos assessors in auditing different hospitals of

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different categories all over the world has shown that system planning and a respective structure are usually based on the currently existing situations. These are related to local residents depending on a particular pre-defined model for potential needs or required services.

International patients are expected to be covered through the existing operational systems not taking under consideration the particularities accompanying the international patient. In the frame of the Temos certification process, healthcare providers have the opportunity to learn basic methodologies and the importance of risk assessment procedures in the direction of defining the most suitable system to

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adequately meet international patients’ needs including and combining the local and international perspective for high quality services.

The most typical example from the hospitals' perspective is the infection control system which has to integrate pre-screening guidelines and protocols for the admission of patients depending on the country of origin and provenance. Furthermore, the existing infection control system might need to be extended due to the fact that pathogenic germs travel with the patients and do not stop at the border.

Since most of the international medical tourists are laypersons regarding the validation of the medical

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Conclusion and future outlook

International patients’ travel for treatment abroad is on the rise with a rapid pace in some countries. Other healthcare providers or even countries may not profit from these developments.

The experts’ opinions differ. Does this industry which is one of the newest in this decade significantly contribute

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Quality and safety are the most essential requirements for providing an optimum healthcare support for accreditation and Quality Management Systems.

to improving the well-being of patients and help them financially? Are the benefits for hospitals and nations with a medical tourism industry convincing and practicable?

The realisation of the following five points may already help to regulate the market to the good / benefit of the patients and the service providers: 1. Supporting but also regulating the industry within the country and between countries.

This can include service requirements, pricing, payments and monitoring of the services but also regional conferences to continuously address the challenges in medical tourism 2. Ensuring the availability of legal medical liability in the country receiving international patients

3. Establishing medical tourism clusters that include hospitals, governments, hotels, tourism and other stakeholders to define interfaces, improve and optimise services 4. Emphasising on certification of hospitals for medical tourism in addition to accreditation. International patient management certification can give assurance to patients and the receiving country in terms of neutral assessment and the provision of best services to the patients. It also helps hospitals improve the service quality for the international patient-based on best practices in the industry 5. Emphasising on communication between the service providers and the patient during all phases of the patient’s care cycle by maintaining a multi-language, interactive and service website, and a communication system within the hospital system and to all externally involved parties.

These points, as well as quality management, and continuous quality improvement programmes are essential to ensure patient safety and formulate an optimal international patient management in this new industry.

In the end, patients will decide about the future of this evolving and ‘alternative’ market.

Claudia Mika is the Managing Director of Temos International, a German-based international certification body specialised in medical tourism and tourism medicine. Her expertise in quality management and medical tourism processing is in great demand, not only among hospital managements around the globe but also governmental institutions and ministries.

Author BIO

quality, the non-clinical services are mainly the determining factors for patient satisfaction. Beside others, nursing services, availability of doctors, cultural sensitivity and also food are important factors for patients' satisfaction. Many healthcare providers experienced in medical tourism are aware of these factors and have implemented such measures in their TQMS programmes.

Risk assessment methodologies derived from the Temos certification quality criteria framework are considered as the basis for every standard operational procedure and / or programme.

This is usually scheduled and mostly implemented either within the medical or non-medical and supportive services of the healthcare provider. Hospital professionals throughout the certification process become aware of the significance of risk identification in order to plan and execute particular measures for the effective and direct management of risks with regards to the international patients’ physical and general safety.

Moreover, during the certification process and preparation of the hospital, it is realised that promoting the healthcare services in the international market requires enhanced evidencebased competitive factors. These factors include measuring and continuous monitoring of clinical effectiveness, medical staff credentials for specialisation and experience as well as proven and documented hospital policies and procedures regarding Continuous Medical Education (CME) programmes and specified internal training programmes.

Angeliki Katsapi is the Temos Aegean Ltd Director and a certified Assessor. She holds an Msc in Health Management and Informatics.

She held several senior management positions in the Greek Health Ministry and participated as a Member of Workgroups and Review Committees in e-Health projects.

Hashem Al-Fadel is a Healthcare Consultant and hospital surveyor with extensive experience working in Jordan, Gulf, USA and China in quality management and healthcare technology. He is a certified assessor, and currently a shareholder with two hospitals in Jordan and the regional director for Temos in the Middle East.

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CaseStudy

Reforming Healthcare Delivery in the Commercial Market Over the years, CalPERS has implemented numerous strategies to help reduce cost increases without jeopardising coverage and quality. We know that in order to make systemic changes there has to be reform and improvement of the prevailing models of healthcare delivery. New models have to be developed and their growth nurtured to reduce costs and maintain quality of care. Driving system changes that lead to improving our members’ health is most important to us.

Ann Boynton, Deputy Executive Officer, Benefit Programmes Policy and Planning, California Public Employees’ Retirement System, USA

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s one of the largest healthcare purchasers in the country, the California Public Employees’ Retirement System (CalPERS) is on the front line of finding better, more cost-effective ways of providing quality healthcare for its members. CalPERS provides healthcare benefits to active and retired members and their families, more than 1.3 million covered lives, at a cost of more than US$7 billion a year. We have two Health Maintenance Organization (HMO) plans provided by Kaiser Permanente and Blue Shield of California, and a self-funded Preferred Provider Organization (PPO) plan using Anthem Blue Cross as our third party administrator.

Over the years, CalPERS has implemented numerous strategies to help reduce cost increases without jeopardising coverage and quality. Still, we realise that the current rate of cost increases is unsustainable. The Kaiser Family Foundation reports that healthcare costs in

the US were close to US$2.6 trillion in 2010. Those costs have grown at seven to eight per cent annually, exceeding the rate of inflation. Net premium payments have risen seven to 10 per cent per year.

We know that in order to make systemic changes there has to be reform and improvement of the prevailing models of healthcare delivery. New models have to be developed and their growth nurtured to reduce costs and maintain quality of care. Driving system

changes that lead to improving our members’ health is most important to us.

The complexity of the California’s healthcare market makes change challenging. There exist a myriad of commercial and non-commercial coverage plans, insurers, providers, physician payment methods and pharmacy benefit plans, and that is before considering compliance with numerous state and federal regulations.

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Reference pricing—a set price for a specific procedure—is another strategy we employ. Our Value-Based Design (VBD) purchase pricing strategy involves making changes with providers to deliver efficient, high-quality services at lower costs, for health plans to create access to value-based purchasing, and for our members to make betterinformed, wiser purchasing decisions.

For example, we found that within our PPO health plan, facilities cost for elective knee and hip replacement surgeries ranged between US$15,000

Author BIO

As a major healthcare purchaser, CalPERS has been able to overcome some of those hurdles by implementing market innovations to improve the current healthcare models and keep us on a road to more cost-effective, quality healthcare. Many of those innovations are based on a health benefits purchasing initiative CalPERS developed that includes strategies designed to influence healthcare delivery, improve health outcomes, and deliver sustainable programmes.

We have incorporated efficient networks of care, began incentivised value-based purchasing programmes (reference pricing), implemented integrated healthcare systems and sponsored worksite wellness projects. Following are examples of some of the steps taken to improve care delivery and make it more effective for our members.

In January 2005, CalPERS initiated an exclusive provider network within our Blue Shield of California Health Maintenance Organization (HMO) plan. This ‘narrow network’ of providers included only hospitals that met certain efficiency and quality standards. We removed 24 high-cost hospitals from the network, used lower-cost, high quality centers of care, and saw savings of US$31 million in 2005 and as much as US$45 million in ongoing savings.

In January 2008, we offered our CalPERS Blue Shield HMO and Anthem Preferred Provider Organization (PPO) subscribers new plans that provided an option of using smaller, lower-cost, high performance provider networks. The networks included in the Blue Shield NetValue and Anthem PERS Select plans met criteria showing they could provide quality physicians and maintain high quality care at a lower cost. Members subscribing to these plans reduced their premiums without sacrificing coverage or quality.

Through 2011, CalPERS has achieved an estimated health programme savings of US$68 million using this model.

and US$110,000. In 2011, based on the average costs for such surgeries (US$31,000-US$33,000), CalPERS set a threshold of US$30,000 and identified 46 high-quality facilities— designated as ‘value-based purchasing centers’—that performed these surgeries at or below that threshold. When members use a designated hospital, they incur only the usual co-payment and co-insurance costs. Should they choose a non-designated facility, they are responsible for any charges in excess of the threshold.

Ann Boynton Boynton provides executive leadership for health policy and planning, health policy research, health plan contracting and administration, retirement research and planning, and the CalPERS Center for Innovation. She also oversees CalPERS Information Technology Services Branch. Her work experience includes almost twenty years as a management consultant in the private sector.

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CaseStudy

The result was a cost reduction of just over 26 per cent, or about US$9,000 less per allowed surgical charge from 2010 to 2011. At least five other hospitals have revised their pricing for us and joined the programme since then. We implemented a similar programme within our Blue Shield HMO plans for the 2012 benefit year.

Equally important, however, is the fact that the programme got the attention of orthopedic surgeons, some of whom had no idea how much each hospital charged for those surgeries.

It helped encourage the surgeons to become more engaged in understanding how greatly they influence the cost of healthcare. It had the catalytic effect of people paying attention to the fact that healthcare purchasers have to figure out the hospital financing question overall.

Continuing the reference pricing / value-based design strategy, in 2011 we established a programme with Anthem

that encouraged our members to use lower-cost ambulatory surgery centers for colonoscopies, cataract surgeries and arthroscopies. As a result, the costs of colonoscopies were down 10 per cent, cataract surgeries nearly 20 per cent, and arthroscopies 3.5 per cent, for a savings of about US$7.6 million for 2011.

We believe very strongly in the value and benefit of worksite wellness, and have invested much time and effort in developing ways to test and deliver these programmes. Worksite wellness programmes have resulted not only in better overall employee health, but also in lower employee absenteeism, improved morale and higher productivity.

One successful worksite wellness example is the collaborative endeavor we embarked upon with Santa Cruz County in central California called “Cruzin’ to Health.” The California Association of Physician Groups was a primary sponsor

of this 12-week project in which county employees modified their exercise and diet behavior. The participating employees dropped an average five pounds, lost an average 1.4 inches from their waistlines and reduced their potential for chronic diseases. Key to the success of this programme was the enthusiastic response of county employees who began to take more responsibility for their own state of health. An estimated 88 per cent of the participants continue to follow their fitness regimens.

Looking at the rising cost of prescription drugs, CalPERS took steps to emphasize using lower-cost, evidencebased generic substitutions for selected prescription drugs wherever feasible. In 2009, we launched California’s largest electronic prescription initiative, working with participating physician and pharmacists to determine and employ the best ways to use e-Prescribing technology.

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In 2011, we specifically examined nine classes of drugs and, using benchmark prescribing patterns, we identified a potential savings of 44 per cent, or US$56 million of US$128 million spent on prescriptions.

CalPERS also initiated pharmacy benefit changes that increased the brand name copayments for certain preferred and non-preferred drugs, and instituted a 'member pays the difference' programme. Under this programme, when a doctor prescribes a brand name drug—and a U.S. Food and Drug Administration (FDA) approved generic equivalent is available—the member will pay the difference between the costs of the brand name and the generic drug.

The member will also have to make the generic drug co-payment.

The aforementioned strategies have been effective for CalPERS. However, we have found the greatest promise in creating integrated healthcare systems that align financial incentives, focus on improving outcomes and reduce redundancies inherent in the delivery system.

A recent study released by Catalyst for Payment Reform indicated that only 11 per cent of payments to doctors and hospitals were tied to their performance. All of the providers covered by that number were either given financial incentives (43 per cent) or put at financial risk for their performance if they didn’t meet certain quality and cost goals.

CalPERS used that type incentive when we initiated a pilot partnership project in 2010 between Blue Shield, Dignity Health and Hill Physicians Group. The partners committed to improved communications and data sharing. They agreed to achieve costreduction through service initiatives.

Additionally, they integrated care delivery, implemented evidence-based practices, increased generic drug use and streamlined administrative processes.

Crucial to the success of this exciting partnership was an agreement to share the financial risk. CalPERS goals for

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CaseStudy

Looking at the rising cost of prescription drugs, CalPERS took steps to emphasize using lowercost, evidence-based generic substitutions for selected prescription drugs wherever feasible. the partners were to create a sustainable model, grow membership and deliver cost savings. We wanted them to keep our 2010 costs the same or lower than they were in 2009. The partners would share in the savings or loss.

The strategies employed were integrating the delivery of care; implementing evidence-based practices; streamlining the administrative processes between the partners; increasing population management; reducing physician variation in clinical care and resource use; increase use of generics and establishing drug purchase strategies; and have all the physicians adopt and effectively use the technologies and tools available.

Our members benefited from improvement in key areas of care: • Readmissions fell by 15 per cent • The average length of stay for patient admissions dropped from 4.13 days to 3.65 days • Emergency room / urgent care admissions were down nearly 8 per cent • Inpatient stays of 20 or more days dropped 15 per cent • The number of discharges with no medical group follow-ups fell from 93 per cent in 2009 to 60 per cent in 2010.

The Blue Shield plan also added more than a thousand new CalPERS enrollees, and we expanded the integrated healthcare model six other counties in northern, central and southern California. To top it off, our programme model received national attention and

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was lauded by the U.S. Department of Health and Human Services as an example of an innovative share savings model.

CalPERS will continue on its path of innovation, even as we engage in procuring future health plan services.

We are in the midst of a health plan procurement process, seeking companies to fulfill a five-year contract to provide healthcare for our members beginning January 2014. Because we know that it will enable us to better control costs of services as well as quality, we are pursuing a strategy of selffunding our HMO programmes in the same way that we currently self-fund our PPO health plans.

In addition, as part of our contract requirements we are requiring the winning bidders to share risks and align their incentives with CalPERS health initiatives and offer options to address our purchasing needs. The bidders had to show that they were willing to incorporate transparency, pricing and performance guarantees, and health and disease management into strategies aimed at reducing costs and improving our members’ health outcomes.

We have found our plans and providers to be enthusiastic partners with us in these endeavors. We believe that the active involvement of the healthcare purchaser is key to bringing about systemic change. We have also understood that a crucial element of our success in implementing healthcare innovations is including early input from our members and their representative constituent groups, discussing and considering their input on the possible impact of any changes made in the design and operation of our health benefit plans. Looking ahead, we will seek to expand the ways we can influence coordination of care, alignment of incentives and long-term reduction of cost without reducing coverage or restricting access. Delivery model reform is not only possible, it is imperative.

Facing the Future The growing burden of adult congenital heart disease

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MEDICAL SCIENCES

The field of complex congenital heart disease has evolved greatly, allowing more patients to survive into adulthood.

Their healthcare issues are multifaceted, mandating a multi-disciplinary approach. Forward planning and resource allocation for manpower and infrastructure development, based on accurate demographic data, will undoubtedly help countries face this growing challenge.

Kenneth Guo, Associate Consultant Department of Cardiology, National Heart Centre, Singapore Ju Le Tan, Director of Adult Congenital Heart Disease Program Department of Cardiology, National Heart Centre, Singapore Koichiro Niwa, President, Asia Pacific Society for Adult Congenital Heart Disease, Japan Ariane Marelli, Professor of Medicine, McGill University, Canada

A

ccording to the World Health Organization (WHO), a well-functioning healthcare system requires a robust financing mechanism, a well-trained workforce, and importantly, reliable information on which to base decisions and policies. The knowledge of adult prevalence of congenital heart disease can estimate the need for specialised services. As the field of congenital heart disease matures, we are beginning to recognise a new era of changing demographics that must be matched with services and infrastructure that commensurate with its growth.

Changing demographics of Congenital Heart Disease (CHD)

The annual worldwide birthrate of 150 million births during the 1990 had already corresponded to 1.35 million live births with CHD every year. With advancements in pediatric cardiac care and improvement in socio-economical circumstances in developing countries allowing for an increased survival of these patients into adulthood, the burden of adult congenital heart disease is only expected to grow. By the beginning of the 21st century, adult survival is expected to reach 75 years. This is an increase of 15 years as compared to the period of 1987 to 1993. In Ireland, the percentage of CHD patients surviving into adulthood is over 90 per cent.

Where previously scant, empirical and contemporary data is now available on the epidemiology of CHD in the general

adult population. This landmark paper published in 2007 had characterised the problem, incidence, prevalence and distribution of adult congenital heart disease in the province of Quebec, Canada. It helped inform public health research, priority setting and program monitoring. In this population wide study, severe lesions accounted for 9 per cent of the CHD population. The median age of all patients with severe CHD was 11 years (interquartile range, 4 to 22 years) in 1985 and 17 years (interquartile range, 10 to 28 years) in 2000 (p < 0.001). The prevalence of severe CHD increased from 1985 to 2000, but the increase in adults was significantly higher than that observed in children, suggesting that this population has yet to stabilise. In addition, in the year 2000, there were nearly equal numbers of adults and children with severe CHD. Asia reported the highest CHD birth prevalence with 9.3 per 1000 live births (95 per cent confidence interval: 8.9 to 9.7), with relatively more pulmonary outflow obstructions and ventricular septal defects. In Japan, based on the death certificates of CHD registered with the Japanese government, a total of 622,800 patients (49 per cent were children and 51 per cent adults) were estimated to be alive in 1997. From 1997 to 2007, there has been an estimated increase of 9,000 adults annually, with 454,000 adults estimated to be alive in 2013. Likewise, adults made up a substantial proportion of the total CHD population in Korea (22-26 per cent), Taiwan (20 per cent), and Thailand (32 per cent). Adults with CHD of moderate or greater severity made up 36.6 per cent and 32 per cent of patients in Korea and Japan, respectively. In Singapore, the number of adults with CHD (about 15,000) was higher compared with children with CHD (about 5,000) in 2008. This trend of increasing adult CHD patients in the Asia-Pacific region mirrors what has been observed in North America and Europe.

Mortality rates in the CHD population in Quebec, Canada, were noted to have decreased in all age groups below 65 years during July 1987 to June 2005. The largest reduction was noted in infants with a mortality rate ratio of 0.23. In adults between the ages of 18 and 64 years, the mortality reduction was similar to that of the general population with a rate ratio of 0.84. The differences in mortality between the industrialised and third world countries are striking: from 3-7 per cent to 20 per cent respectively. Furthermore, the mortality from CHD is likely under-reported in third world nations because access to diagnosis is more difficult, and the great majority of studies only report data from patients in tertiary centres.. In addition, a difference in mortality due to CHD is also seen between different socio-economic groups in developed countries. For instance, an analysis of death certificates by the Centers for

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Disease Control in the United States has shown that mortality from CHD is generally higher in blacks than in whites, despite the incidence of CHD being slightly lower in the former per cent.

Disease burden in adults

CHD patients are at increased risk for chronic renal disease, epilepsy, stroke, transient ischemic attack, secondary erythrocytosis, diabetes, hypertension, heart failure and cancer. Atrial arrhythmias occurred in 15 per cent of adults with CHD. The lifetime incidence increased steadily with age and was associated with three times the risk of cardiac intervention, a doubling of the risk of adverse events, and a near 50 per cent increase in mortality. A diagnosis of pulmonary hypertension in adults with CHD is associated with more than double the risk for all-cause mortality and a three times increase in health services utilisation (inpatient and outpatient service, such as cardiac catheterisation and coronary / intensive care hospitalisation), reflecting a high level of morbidity. The need for valvular interventions has also increased from 42 per cent to 63 per cent in the last two decades in CHD patients. The complexity of the cardiac anatomy and the myriad of problems associated with this group of patients mandates that this growing burden must fall on the shoulders of a multi-disciplinary team led by qualified adult congenital heart disease specialists.

Country by country, life expectancy will eventually follow a path of uninterrupted but slowing increase. Asian regions will grow fastest to the west, slowest to the east, but in every case with growth rates, at least up to 2100.

Between 2100 and 2300, the proportion of world population 65 years and older will increase by one-third; the proportion 80 years and older will double, and the proportion 100 years and older will increase by nine folds. Afilalo et al. described the geriatric CHD population in the Quebec population from 1990 to 2005. The prevalence of CHD

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Table 2. Facility survey for Asia-Pacific countries Institution

Auk GL

ABCI

RPA

Shirir

NUHS

NHCS

Established

1995

1998

1992

1998

2003

2005

Active patients

1,200

3,000

1,000

700

1,500

1,000

Adult cardiologists

1

0

2

2

1

1

Pediatric cardiologists

2

1

2

2

1

2

Cardiovascular surgeons

3

1

1

3

1

1

Specialty nurses

0

0

0

1

2

1

Personnel

AukGL: Starship Hospitals, Aukland/ Green Lane, New Zealand ABCI: Adolph Basser Cardiac Institute, Childrenâ&#x20AC;&#x2122;s Hospital, Sydney, Australia RPA: Royal Prince Alfred Hospital, Sydney, Australia Shirir: Siriraj Hospital Mahidol University, Bangkok, Thailand NUHS: National University Hospital Singapore NHCS: National Heart Centre Singapore

in older adults was about 3.8 per 1000 indexed to the general population.

The distribution of lesions in the adult CHD population varies, depending on the location where the proportions are taken, as well as the age group concerned. Patients with severe lesions made up about 9 per cent of the CHD population in Quebec, Canada. In the geriatric age group, the most common types of CHD lesions in older adults were shunt lesions (60 per cent), followed by valvular lesions (37 per cent) and severe CHD Table 1. Adult CHD (3 per cent). Type of CHD and CHD-related complifacilities in the Asia-Pacific cations had a minor impact on mortality, which was region predominantly driven by acquired co-morbid conditions. The most powerful predictors of mortality in Country Number of this age group were dementia, gastrointestinal bleed, adult CHD facilities and chronic kidney disease.

The financial burden of congenital heart disease is Japan 14 receiving increasing attention. Garson et al. described Korea 3 a multi-center assessment of lifetime cost of care for China 2 children with CHD in 1994. Average charges of Taiwan 1 care from birth to 40 years of age varied from US$ Philippines 0 47,515-73,606. Services included in this study were Australia 3 that of routine clinic visit, complex clinic visit, hospital admission for medical admission, hospital admisNew Zealand 2 sion for surgical treatment, hospital admission for Thailand 1 interventional treatment, hospital admission for paceSingapore 2 maker implantation, and number of years the patient Indonesia 1 has taken cardiac medication. It however does not Malaysia 1 take into account non-cardiovascular care for these Vietnam 0 children, cost to the family (loss of income for parents, costs of uncovered medical services and drugs, costs India 1 of psychologist). Also not included are societal costs Pakistan 0 associated with loss of work, increased healthcare Turkey 1 needs, and increased educational services. In contrast, Hong Kong 1 updated data on hospitalisations for individuals with Total 33 congenital heart defects in the U.S. in 2004 were about

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US$1.4 billion, and severe CHD defects accounted for about US$511 million (18), or about 37 per cent of the hospital cost associated with CHD defects.

In 2005, for privately insured population in the U.S., estimated medical care costs for an infant with any CHD defect was merely US$100,000, and costs were higher for those infants with a severe CHD defect. We can only expect this cost to further increase in time to come.

Hospitalisation rates for patients with CHD were higher than the general adult population in Quebec (relative risk of 2.08). In addition, patients with severe CHD have higher adjusted rates of outpatient cardiologist care, emergency department utilisation, hospitalisation and days in critical care than patients with other congenital cardiac lesions. In Singapore, CHD patients were found to not only require longer length of hospital stay for both cardiac and non-cardiac related medical conditions, but also required interdisciplinary resources.

Life insurance remains an important component of financial planning. Despite recommendations from cardiac societies, availability of insurance varies considerably not only between but also within countries, with surprising discordance between insurance policies and available outcome data. Health insurance, in particular, may exclude treatment for the cardiac condition in certain countries. In Germany, one survey found that more than 30 per cent of CHD patients were refused life insurance. The U.S. had taken the lead by passing the Patient Protection and Affordable Act in 2010, alleviating the unfair discrimination that besieges CHD patients. Singapore, in its recent revision of its policy from March 2013, has also taken a step forward by extending its nationwide insurance to include newly diagnosed CHD and neonatal conditions. With such sterling examples, this should be a consideration for countries when formulating their healthcare policies.

Healthcare delivery - Meeting the challenge

A strong relationship is a must between the paediatric cardiologist and adult congenital heart disease specialists to ensure a smooth transition of the patient to adult care. This relationship, in addition to suitable policies, will prevent a gap of care should the patient be lost to follow up. In Quebec, Canada, for example, law mandates all paediatric cardiologists to transfer the care of their patients to an adult institution by the age of 18. Predictors of lack of cardiology follow up in adulthood included male gender, non-severe lesions, and a history of follow up outside a university hospital setting. Improved communication with primary care physicians may reduce the proportion of patients lost to cardiac follow up. More trained imaging specialists are needed in the field of echocardiography, computed tomography and magnetic resonance imaging to achieve accurate diagnoses, and guide treatment. The impact of the increased use of fetal echocardiography and pregnancy termination on reduction of CHD birth prevalence is expected in the next

time period. Intervention will need to be executed through the hands of experienced interventionists and cardiothoracic surgeons, who are familiar with the peculiarities of complex CHD. Cardiac chambers often enlarge and arrhythmias are more common. Ventricles tend to develop systolic dysfunction, resulting in the main causes of death as that of progressive heart failure and sudden cardiac arrest. This brings in the heart failure team and the electrophysiologists. Patients with unrepaired complex cyanotic congenital heart disease are repeatedly advised to avoid pregnancies, given the extraordinarily high risks to both mother and the child. The obstetrician and gynecologist are needed to counsel on contraception and surrogacy. The need for screening any patient should be individualised based on type, likelihood, level of potential exposure, as well as time of gestation during which the exposure had occurred. It is also important to include the obstetric history. If and when they do get pregnant, we need them to run the highrisk pregnancy clinics in tandem with the congenital heart disease specialists.

In the Asia-Pacific region, CHD facilities and resources are in the midst of development. In developing countries, CHD care whilst available, is very basic, sub-optimal and likely inaccessible. Thus far, thirteen countries in this region have at least one outpatient clinic for CHD (Table 1), an improvement compared to seven countries in 2007. Looking at the ratio of congenital heart surgeons to each continentâ&#x20AC;&#x2122;s population, very large disparities have been identified. In North America and Europe, there is approximately one congenital heart surgeon for 3.5 million individuals, whereas in South America, this ratio is one in 6.5 million.

However, in the Asian continent, this ratio drops to an alarming figure of one in 25 million, worse in Africa (one in 38 million). This information does not include the lack of trained CHD specialists and the accompanying team and infrastructure.

Table 2 depicts the constitution of the CHD team in various centers across Asia.

As our region grows and matures, we will likely experience an unprecedented rise in the CHD population. Unless sustainable strategies can be implemented in developing countries to stay abreast and make specialised case accessible, the gap in standard of care will only further deepen. With the breath and depth of the issues defined, countries can now formulate a clear road map on manpower and infrastructure development, based on accurate demographic and epidemiologic data. This, together with effective healthcare policies, will put us in good stead to shoulder the growing burden of the CHD population.

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be considerably higher than in nonconsanguineous parents, suggesting an important genetic influence. Data about alcohol usage, hard drugs or cigarette smoking during pregnancy are insufficient to determine risk for CHD. More research is required in this area.

Inclusion of next of kin and family may allow for better continuity of care and follow up. The patient must be empowered to be involved and in charge of their care, and thereby giving advanced directive in their overall healthcare plan. Support must also be given for the caregiver to reduce the incidence of caregiver fatigue. For patients with unrepaired complex disease, the congenital heart disease team should broach the idea of palliation to prepare the patient and their family at the appropriate time. This care is shared with the palliative care team so that the patients can face the burden of their illness and possible demise with dignity.

Access to healthcare across countries, groups and individuals, is largely influenced by social and economic conditions as well as the healthcare policies in place.

Countries have different policies and plans in relation to the personal and population-based healthcare goals within their societies. The exact configuration of the healthcare system varies from one country to another. One of the more recent CHD studies in Thailand reported 0.41-1.05 prevalent cases of unrecognised CHD for every 1000 elementary-age students.

This variation was due to the topography and the limitation of medical staff and facilities in the study area. In a recent study in Mozambique, a pattern of late presentation accompanied by high rate of complications was found. Of the 534 CHD patients studied, about half were diagnosed after the age of two. Preventable complications were present in 29 per cent at the time of diagnosis. All references are available at www.asianhhm.com

Kenneth Guo is an Associate Consultant with the Department of Cardiology at the National Heart Centre Singapore. He is currently a completing a Fellowship in Adult Congenital Heart Disease at the McGill Adult Congenital Heart Disease Centre (MAUDE Unit) at McGill University.

Author BIO

They will need to tackle issues on whether to terminate the pregnancy or continue with a clearly defined plan worked out with the anesthetist and the intensive care team.

A dedicated nurse is needed to educate the patient and their caregivers about the disease, how to cope with their disabilities and ensure that they remain within the healthcare system and are not lost to follow up. Add on the fact that these patients frequently suffer from emotional and psychological trauma associated with the high level of anxiety about the underlying heart condition and prognosis, difficulties with social interaction, specific issues about employment, insurance and physical activities and poor self-esteem, psychologists and medical social workers will be needed to act as advocates for the patients who may face unfair discrimination.

Promoting multicenter research remains pivotal to fill the growing knowledge gaps. Epidemiology, outcomes research and genetics are rapidly advancing. Multicenter registries will allow for further prospective and retrospective studies to be done.

Patient-centered care and education involves not only learning more about each diagnosis of CHD that we have, but also refining and adding to the current pool of knowledge. This can only be achieved through research.

There is a need to teach fellow healthcare workers and the public about the disease as well as the avoidance of risk factors for CHD. Known risk factors include maternal pre-gestational diabetes mellitus, consanguineous marriages, phenylketonuria, febrile illness infections, various therapeutic drug exposures, vitamin A use, marijuana use, and exposure to organic solvents.

The high total CHD birth prevalence found in Asia could partly be attributed to high consanguinity rates in some study populations. CHD birth prevalence amongst children with consanguineous parents was found to

Tan Ju Le is the Senior Consultant Cardiologist specialising in Adult Congenital Heart Disease and Echocardiography at the National Heart Centre. Dr Tan has gone for further training in Adult Congenital Heart Disease at the Royal Brompton Hospital in London from 2003 to 2005. Main interest is in the care of adults with congenital heart disease, management of cardiac disease in pregnancy and pulmonary hypertension.

Koichiro Niwa is the President of Asia Pacific Society for Adult Congenital Heart Disease, Japan.

Ariane Marelli is a Professor of Medicine at McGill University. She obtained advanced fellowship training in Adult Congenital Heart Disease at the University of California in Los Angeles where she was the first person to graduate from the first adult congenital heart disease program in the US. She completed an MPH at the Harvard School of Public Health.

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Long-term Conditions The challenge and the technological opportunity The healthcare systems in most countries will be rendered unsustainable by the rise in people with long-term conditions like having not just a single disease but multiple conditions. Current strategies will make healthcare unsustainable in all those countries. A model of care and finance to mitigate this problem is outlined.

Sir John Oldham, National Clinical Lead for Quality and Productivity, UK

O

ver the next 40 years, most healthcare systems worldwide face a tsunami of need from people with long-term conditions (diabetes, chronic airways disease, circulatory diseases). There will be a rise of 252 per cent by 2050; the mathematics is inescapable. The majority of people will not have a single disease but multiple morbidity (see Figure 1).

In England now, this group of patients use 76 per cent of activity and cost in the health and social care system. They are disproportionately higher users of health services â&#x20AC;&#x201C;representing 68 per cent of specialist outpatient attendances, 72 per cent of inpatient bed days, 58 per cent of emergency department attendances, 55 per cent of GP appointments and 59 per cent of practice nurse appointments.

The consequences are equally inescapable for most countries. Firstly, if healthcare systems continue to manage people with Long Term Conditions (LTCs) as they do now, they will not be sustainable. Secondly, the way that a country manages people with long-

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term conditions will, given the proportion of GDP that this will consume, be a determinant of the competitiveness of that countryâ&#x20AC;&#x2122;s economy. For example, if the U.S. continues its current model of LTC management, and given the built in demographic drivers, by 2065 itwill spend 100 per cent GDP on healthcare. In one sense this is a nonsense statistic. Thirdly, disease specific pathways of care, and hospital-based care are a redundant strategy for the multimorbidity future. Some countries with a greater balance between ageing and working populations, particularly some in Asia, will fare better, but for everyone status quo is not an option.

Data from the Scottish School of Primary Careâ&#x20AC;&#x2122;s Multimorbidity Research Programme Guthrie et al.

Universally, patients say that they wish to be treated as a whole person and for the health and social care system to act as one team. Despite this, those people who have more than one condition, particularly older people, face a fragmented response. Long-term condition

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Morbidity (number of chronic conditions) by Age Group 100 90

0

80

1

70

2

60

3

50

4

40

5

30

6

20

7

10

8+

Age Group(years)

85+

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0-4

0

Figure 1

• The majority of over-65s having 2 or more conditions, and the majority of over-75s having 3 or more conditions • More people have 2 or more conditions than only having 1.

‘needs’ transcend the organisational boundaries of social, primary, community and secondary care. The current system fragments care for individual patients and this lack of continuity often leads to poorer outcomes and hospital admissions. There now needs to be transformational change in the culture and operating model to ensure a step change in innovation so that healthcare can be a viable entity for the future.

That step change is from ‘see, treat and discharge’to‘ identify, integrate care and co-manage’ patients, with technology at the heart of that change.

Model of care

The population care model described below is based on a wealth of international evidence;it has been shown to improve clinical outcomes and to reduce length of stay and unscheduled hospital admissions. The three primary drivers are: • Systematic risk profiling of the population • Integrated locality care teams including social care, community services, allied health professionals and general practice • Systematised support for patients to co-manage their conditions

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• Systematic risk profiling of the population This uses a validated risk profiling tool to support commissioners to understand the needs of the population and manage those at risk. A risk prediction tool will identify patients that are at high and medium to high risk of accessing healthcare services. Targeting the latter with proactive care will assist in slowing disease progression and will allow for interventions to be prioritised.

Understanding the population in this way also facilitates the identification of the future resource need and its utilisation. Research evidence shows that 20 per cent of patients identified by risk stratification would not be identified in any other way. This improved access to care for these people has also been shown to improve the quality of outcomes. There are several such tools commercially available. The algorithms are not dissimilar, but there are differences in accuracy and search capability.

Integrated locality care teams including social care, community services, allied health professionals and general practice Healthcare systems and mechanisms traditionally focus around the body

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parts of people for which the different clinicians feel responsible (see Figure 2). This has created fragmentation and duplication, particularly when dealing with people with multiple problems.

For the patient it is often just confusing.

We also know the outcomes are poorer.

The system change that is required is the creation of functionally integrated holistic teams at a neighbourhood level.

These teams should include community services, allied health professionals, social care services and specialist nurses and should be linked to the lead clinical provider. The integrated health and social care teams should be based around a neighbourhood (experience suggests a population size of 30,000) to provide integrated and personalised services.

Neighbourhood care teams will provide a single main point of contact for patients and carers. Each patient should have a key worker within this team to coordinate their care. Combined with risk stratification, this integrated proactive management of patients will improve their lives. A large randomised trial in the U.S. showed that this sort of approach, for this cohort of patients, resulted in 52 per cent fewer inpatient days, 17 per cent fewer emergency department visits and 49 per cent fewer readmissions. 16 other studies have also showed significant reductions in length of stay, unscheduled admissions and ED attendances.

Systematising support for patients to self manage

In the model described here, care is delivered by a multi-disciplinary, prepared and proactive workforce that actively seeks to move patients away from being passive recipients to becoming informed and activated people who are able to co-manage their conditions.

Self-management support becomes a clinical responsibility and an integral part of the delivery system, not just an add-on. Professionals can have the view that ‘patients can’t manage their own condition’. The reality is that most

MEDICAL SCIENCES

Within current service models care can be fragmented and duplicated Team A

Team B

Team C

admissions, and a 45 per cent reduction in mortality for some categories of patients. Much other literature also shows that empowered patients who co-manage their condition have better clinical control and outcomes. And this is not simply the better educated, higher income patients. Most people are interested in their own health, most can contribute to its management in some way, and increasing numbers have access to the internet via smart phones.

Team D

Figure 2

above are features of many telehealth systems. These are remote monitoring systems where people input data which is reviewed at a central location. The best systems have two way communication and mobile platforms. Sadly many don’t. Many telehealth projects simply use the electronics as an add on to the existing method of delivery, rather than as a means of transforming the care model. For example, appointments might still be made in the same way, nurses might still visit in the same way with the same protocols, and he patient data duplicated by professionals or ignored in consultations. In short the investment is wasted. The mantra has to be: change the system first, put the kit in second. However, there is strong evidence that if technology is used to involve patients in their own care as part of a wider system change, there are reductions in unscheduled admissions, and even mortality. The whole system demonstrator project evaluated in England covered 6000 patients who used telehealth. The results showed a 20 per cent reduction in unscheduled Author BIO

people with long-term conditions have to do precisely that for some 7900 hours in a year, and only interact with professionals for an average of 4-5 hours.

Unscheduled admissions are often driven by one of two things: anxiety in patients about how to handle an exacerbation, or failure to recognise deterioration in condition before a crisis occurs.

It makes sense to enable patients to gain knowledge in a structured way to give them greater confidence about their diseases. Many people look up information anyway on the internet. We need to harness that natural inquiry and interest as part of the care system.

It is this element where technology can play a significant part. Imagine a situation where as a patient you can input your own recorded blood pressure (eliminating white coat syndrome) or blood sugar, or weight into an app.

You can track your data in a time series graph and that graph is automatically available to your clinical provider.

There can be automated responses if the readings are outside your personalised norm. This response might refer you to your pre-organised electronic care plan, and prompt your provider to call you.

This is not the future, but exists now in 2013.

The key to facilitating co-management by patients is the availability of electronic and remote support. Less sophisticated versions of what is described

Summary

The rise in the number of people with multiple long-term conditions threatens to overwhelm most healthcare systems. Care based around individuals in the community, rather than hospital, is the only fiscally rational option—and produces better outcomes.

A key shift in mindset is required for the most under used resource in healthcare to be utilised as part of the care system —the patients. Embracing technology catalyses that shift. Fears from professionals’ Patients don’t have the knowledge, ‘It is unsafe’, ‘It undermines my status’ are ungrounded in experience and often mask a vested, and sometimes economic, interest in status quo.

But status quo is not an option, and the volume of demand is such that professional livelihoods would not be affected.

The truth is that the digital revolution will come to healthcare, just as it has to other service industries. Patients will be able to seek the service they want from outside their national boundaries and the resistance of some professionals and organisations will be by-passed. Better, instead, to get ahead of the curve, and recognise the inevitable.

Sir John Oldham is an internationally recognised expert on large scale change not just in health care but other areas. A primary care clinician by background he has keynoted at many international conferences and also presented at the World Economic Forum in Davos. His recent role has been as National Clinical Lead for Quality and Productivity at the Dept of Health England.

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Radiology Facility Design Standards Cookie cutters and football pitches This article identifies one of the major challenges in managing growth and modernisation of radiology facilities, that of appropriate design and construction. Particularly with the wide variety of contracting options, without specific facility design standards for radiology, imaging projects can force lifelong costs and operational inefficiencies.

Robert Junk, President, RAD-Planning, USA Tobias Gilk, Senior Vice President, RAD-Planning, USA

W

e have designed hundreds, if not thousands, of imaging suites. For each one, we seek to identify the unique technical, operational, and clinical demands that each facility will need to support.There are similarities among many of them, but no two are identical. We absolutely shun cookie cutter rigidity in design, but that doesn’t mean that we don’t operate on a set of standards. In fact, a quality outcome is virtually impossible without them.

Let us take something ubiquitous, a football pitch, and imagine how it would be designed to suit the desires of different people.

• Goal keepers would probably want the goal to be shorter and narrower • On the other hand, strikers would like to see the goal frame a meter taller and as wide as half the scoreline • Defenders would like to see the penalty area extend nearly to midfield, and have the pitch narrowed by 20 meters

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The U.S. Department of Veteran Affairs publishes a set of imaging design guides, which can help a bit in terms of defining relationships among various elements of a department plan, but again these are not helpful in defining what is the appropriate mix of equipment and support spaces to meet particular needs.

• Forwards would limit the penalty area to just the 6-yard box, and shorten the field • Club owners would want the whole pitch on a tilt-table, so that the home club was always playing ‘downhill’ • Television broadcasters would probably make the field smaller in all dimensions, so that it better fit into the frame of a TV picture • Sponsors would want to see their logos indelibly mowed into the turf • Fans would want seats to be even closer to the action.

In short, if you let one party control the outcome based on their personal interests, you are likely to get a pitch that does not look much like any other pitch you may have seen.

Let us switch back to radiology. We are seeing tremendous variability in the ways in which radiology facilities are being procured: tenders for separate design services, tenders for combined design-build services, and comprehensive turn-key services including imaging equipment, site construction, and design services. While each contracting option comes with its own benefits, they also come with their own set of biases. If providers want consistent results in their physical facilities that reflect their unique priorities—and not monuments constructed to a particular vendor’s bias—then there needs to be a metric against which to measure the end product.

It is a lot less expensive to build an MRI suite that does not have staff support areas, or patient waiting, or inpatient holding, or dressing booths, or I.V. prep, or induction / recovery areas. But an MRI facility without these features will be horribly inefficient to operate. And if the scanner is being placed in a women’s hospital, but there is no room for a biopsy system and the clinicians to operate it, then room layout decisions will have perpetual negative impacts on the clinical care that the hospital can provide.

Without a defined set of common standards that identify, communicate, and verify the hospital’s design and construction expectations, competitive tenders can quickly turn into a ‘race to the bottom’. If there is no minimum standard for support spaces such as dressing booths or staff areas, then these will likely become casualties to the low-bid pressures.

Yes, in many cases designers, builders, and turn-key vendors ask the appropriate questions about what spaces and support services should be included.

But when getting tenders from multiple vendors, no two vendors will independently include the same items.

Many times, what is the best solution for the hospital is not the lowest cost for the competitively-bidding vendor.

We recently reviewed designs for a radiology suite which had an inpatient holding area that could also double as an anesthesia induction / recovery area.

However, the design did not provide any means for the technologists to observe patients in the holding area.

When it was suggested that an observation window be installed, the design and construction team declined because there was not a standard that required observation of the holding area by the technologists. The design team indicated that they would be penalised for a change that added cost to the construction project.

Instead they indicated that they would inform the hospital that a nurse

would need to be stationed in the holding area. A small one-time cost for a window (which would have been attributed to the design and construction team) was not presented to the hospital which, instead, had to assume the much higher recurring cost of an additional nurse.

Another example is radiology changing rooms: a simple low cost space that can have a major impact on the operation of an imaging facility. Everyone can agree that a changing room is necessary, but the issue of how many, what size and where to locate the changing rooms can vary greatly from facility to facility. The facility ought to clearly identify its needs, based on patient demographics and cultural needs.

It appears as though sometimes facilities issue tenders, specifying only quantities of the imaging equipment, to multiple vendors as if the tender responders have magic telepathic powers to determine the specific needs of the facility. This typically turns out to be less than ideal for all parties involved. The majority of equipment vendors want to provide what the client has explicitly asked for; but without specific direction beyond the quantities in the tender, it becomes a guessing game as to what else should be included. In an effort to keep their price as competitive as possible they only include the bare minimum, which frequently results into diminished functionality for the facility.

At a minimum, a radiology facility design standard for a hospital or health system should help define current needs.

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The Facilities Guidelines Institute publishes a healthcare design code which describes basic elements within most areas of a hospital, but building codes are of limited value in determining what you need.

Their primary purpose is to define the minimum characteristics of a space, should a hospital decide to include it. Building codes can be helpful, but only as a second or third line of reference.

codes and space planning criteria, which may be helpful starting points, but an existing standard may not be appropriate to a hospital’s use.

Moreover, given how quickly both radiology technology and clinical practice are evolving, the useful shelf-life of a published standard on imaging facility planning is only a few years. Some existing standards are still struggling to remove references to chemical darkrooms for modalities that are, today, universally digital. If the publication date is more than three years old, treat it with an extra level of skepticism for imaging design guidance. In many ways, an outdated standard is worse than no standard at all!

Another caution about borrowing other design standards is their lack of economic or cultural relevance. In countries where most imaging procedures are paid for by private insurance,

Author BIO

To prevent instances of individual bias from interfering with a hospital’s goals and mission, the facility or healthcare system should have radiology design standards which define the minimum acceptable criteria. This is not ‘standards for the sake of standards’, but rather to define a benchmark against which radiology facility solutions can be measured. By capturing and recording institutional knowledge alongside best practices, every subsequent project can benefit from prior lessons learned in the establishment of minimum acceptable standards.

At this point, having advocated strongly for radiology design standards, it bears repeating that these design standards should not be “standard designs” – cookie cutter prototypes replicated robotically in different locations or in different clinical settings.

Yes, some critical areas or functions are well served by prescriptive standards (e.g. ‘the MRI scanner room will be at least 5.5 meters wide and 7.4 meters long and should be located on an exterior wall.’), but the quantity and composition of spaces should be determined by the particular circumstances.

Let us take this back to our football analogy.

In competitive football, the goal is of a uniform size, 7.32 m by 2.44 m, everywhere. This makes sense as teams travel to different venues, the basic parameters of putting the ball past the keeper remains consistent. But the overall length and width of the pitch are permitted to vary by tens of meters, allowing for a sanctioned field even in locations with variable siting conditions.

This is how radiology facility design standards should be structured: defining, explicitly, the most critical elements of the game (modality scanner rooms, control areas, equipment rooms), while allowing a range of acceptable options for other required elements, such as patient waiting, dressing booths, etc.

There are existing radiology design

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it had been that the more technologically advanced scans (particularly CT and MRI) were very generously paid, leading to a generation of inefficient facility design precedence. Similarly, social issues such as privacy and gender separation, are more appropriately addressed regionally, than from borrowed international standards.

Radiology facility design standards can be as modest or as boundless as a hospital wishes them to be. They can focus on a single modality, for a single facility, as their forecasted needs indicate, or can promote regional or national standards that address siting criteria for each type of imaging equipment.

At a minimum, a radiology facility design standard for a hospital or health system should help define current needs and anticipate the changes that nearfuture changes will bring. It should help define what equipment is needed, and in what numbers, to meet patient care goals. For each imaging modality, the standards should help define space needs based on clinical needs, including support and preparation spaces.

The development of a set of radiology facility design standards can be a substantial undertaking and should be seen as an investment in the future.

One needs to look no further than the cost of imaging and therapy equipment to recognise that the maximisation of that capital investment deserves a well thought through radiology plan.

Robert Junk is a recognised leader in radiology and imaging suite design. Rob has been involved in healthcare design and medical imaging for over 25 years. His firm, RADIOLOGYPlanning has developed standardised design guidelines for radiology and imaging services setting the standard for care within the industry, winning an AIA Best Practice citation.

Tobias Gilk has been practising architecture for more than 15 years with a dedicated focus on radiology and imaging facilities.

He has written imaging design standards and guidance for the Facilities Guidelines Institute, several US Federal Government agencies, the American College of Radiology and the American Society of Healthcare Engineers.

TECHNOLOGY, EQUIPMENT & DEVICES

The Dose Makes the Poison!

Can we apply Paracelsus’ paradigm to technology-driven medical therapies?

The success of medical therapies depends on drug dosage. The dose of medical devices, however, is complex because their contribution must be seen under a systems approach concept. Hemodialysis represents an ideal model for the dosage of medical systems, because affected uremic patients are repeatedly exposed to this treatment for longer periods of time. Thus results of treatment parameters can be attributed to system parameters.

Joerg Vienken, BioSciences, Fresenius Medical Care Bad Homburg, Germany

M

edicinal drugs are administered according to medical needs. A practising physician defines the dose of a pain killer, an ACE-inhibitor or an antibiotic to be compliant with a therapeutic outcome.

The condition for approval of medicinal drugs also implies clinical investigations in which for instance Phase II trials serve to find the optimal drug dosage and its efficacy. To date, ‘individualised therapies’ are in the focus of drug research. They are based on gene analyses of individual patients and allow for a highly specific dosage and application.

In contrast to the pharma approach, medical devices are typically developed for multiple cohorts of patients, such that we literally define this approach as ‘personalised medicine’.

Medical devices are very heterogeneous and cannot be categorised easily.

When looking from the medicinal drug

perspective at medical devices, several questions arise: 1. Can dose-related effects also be used for the application of a medical device?

2. Is there a specific dose for the use of a pacemaker, an orthopedic shoe, an implant or of spectacles?

3. Do we need to normalise patient cohorts, for example, by referring the application to a standardised body surface area of 1.75m² and define an appropriate exposure time?

In this article, I´d like to discuss the specific situation of a therapy that continuously uses medical devices for the treatment of patients with kidney failure. Hemodialysis with artificial kidney represents a success story in the realm of biomaterials and medical technology, because currently worldwide, more than two million uremic patients owe their lives to this treatment.

Patients suffering from kidney failure are exposed to this therapy three times a week, mostly by applying single-use devices, such as syringes, tubing and filters. Recent clinical investigations have shown that patients survive better once a specific therapy dose is applied (see below). Therefore, a short description of the treatment might be helpful to better understand the discussion circulating around the optimal dialysis dose.

In hemodialysis, blood from the forearm vein of a patient is guided through a set of tubing and the artificial kidney (dialyser) under the control of a dialysis machine. Such a dialyser contains more than 10,000 tiny capillaries with an internal diameter of about 200µm and a membrane wall of ca. 40µm.

When blood passes by these capillary membranes, uremic retention solutes may leave the blood stream across the

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Author BIO

TECHNOLOGY, EQUIPMENT & DEVICES

Joerg Vienken is a Chemical Engineer with a doctoral degree in Biophysics & Engineering. He currently works as Vice President ‘BioSciences’ at Fresenius Medical Care in Bad Homburg, Germany with special focus on biomaterials, medical device technology, and artificial organs.

membrane wall and blood purification occurs. Under standard conditions, this treatment lasts for about four hours.

The patient is then disconnected from the dialysis system and will return for this treatment two days later.

The dose concept for dialysis is borrowed from drug treatment, where physicians manipulate the levels of a single compound: increase the dose and the levels in the body will rise. If the treatment removes a substance, like in hemodialysis, the direction must be reversed: increase the dose and levels in the body should fall. This notion has led to many controversies during the last decades. The search for representative molecules to define an optimal surrogate marker for the efficiency of the therapy, combined with investigations on device and treatment efficiency is still ongoing.

In the early 1970s, Babb and colleagues found out that the pres-

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ence of so-called middle molecules play an important role in uremic toxicity and could be attributed to uremic neuropathy. Prevention of neuropathy was dependent upon an adequate hour of dialysis per week rather than on maintaining a certain pre-dialysis level of serum urea and creatinine. The removal rate of these small molecules falls towards the end of dialysis because the concentration gradient responsible for the diffusive removal declines.

Thus, prolonging dialysis time does not contribute to their increased removal.

However, the removal of those molecules that diffuse slowly would benefit from extending dialysis time (taken as a dose). The consequence of these observations was the introduction of a dialysis dose, known as the ‘square meterhour hypothesis’. Dialysis efficiency was defined to be dependent on the surface area of the dialysis filter and the hours of application. Despite being convinc-

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ing, patient-specific properties were not included in this hypothesis.

This disadvantage was overcome about a decade later, when Gotch and Sargent introduced the concept of ‘Kt / Vurea’ as a dialysis dose. These authors based their analyses on the findings of a nationwide study on dialysis in the USA in the late 1970s. Here, the dialysis dose was defined by the clearance of urea multi¬plied by dialysis treatment time and normalised for distribution volume ‘V’ of urea in the patient. ‘V’ can be calculated in a first approximation as the amount of water present in the patient´s body i.e. about 60 per cent of his / her body weight. This approach was supported by observational studies that demonstrated an association between Kt / Vurea and patient survival.

It showed for the first time that dialysis dose should be assessed as a systems approach i.e. by the combined use of those factors that control the therapy

TECHNOLOGY, EQUIPMENT & DEVICES

namely the patient (Vurea in a single pool), the engineer who had designed the device (k) and the physician responsible for the treatment time (t).

A value for Kt / V between 1.2 and 1.4 was considered to be the target for an optimal therapy. It is still the basis for the reimbursement of dialysis therapy in many countries to date. However, this rather simple equation has led to the assumption, that treatment time ‘t’ can be shortened to 2.5 to 3.5 hours, once ‘K’ is adequately increased. In contrast, reports on superior patient outcomes have been attributed to longer treatment times, e.g., in Tassin / France (24 h / week,) or subsequently with long nocturnal hemodialysis in the home in Toronto / Canada, and finally also to more frequent daily dialysis in Minneapolis / USA. The question arises whether ‘treatment time’ as a parameter for the dose of dialysis has become the most prominent parameter? A physiologist would welcome such an approach and explain it by the kinetics of diffusion-driven processes that represent a slow mobilisation of uremic retention solutes from body compartments other than blood, such as tissue.

Recently, further high tech research added to the complexity of uremic retention solutes and their efficient removal.

Proteomic analyses of the ultrafiltrate in high-flux dialysis have shown that more than 1,400 different polypeptides with increased molecular weight can be found here. Without knowing both, the precise toxic potential of these polypeptides and their possible synergistic effects in causing uremia-related pathology, it will become difficult to define an appropriate parameter for the dose of dialysis.

Moreover, one has to assume that it is not sufficient to remove only a single retention solute during dialysis, such as urea or phosphate. Focus should be on the removal of groups or families of molecules with common features such as a comparable conformation, a similar charge or an identical molecular weight, to name only a few. As a consequence,

A short description of the treatment might be helpful to better understand the discussion circulating around the optimal dialysis dose.

convective rather than diffusive transport mechanisms look more promising for the removal of such groups and thus should be applied. Why is that so?

It has long been known that convective transport of solutes across membranes decreases less rapidly as the solute size increases than does diffusive transport. Sieving coefficients of membranes are less dependent on the molecular size than are diffusion coefficients. A large ultrafiltration volume, defined as a dose, allows for the convectively driven removal of large molecular weight solutes. A large ultrafiltration volume can be provided by an ideal technique called hemodiafiltration (HDF). The EUDIAL group defines hemodiafiltration as follows: “HDF is a blood purification therapy combining diffusive and convective solute transport using a high-flux membrane characterised by an ultrafiltration coefficient greater than 20 mL / h / mm Hg / m2 and a sieving coefficient (S) for β2-microglobulin of greater than 0.6.

Convective transport is achieved by an effective convection volume of at least 20 per cent of the total blood volume processed. Appropriate fluid balance is maintained by external infusion of a sterile, non-pyrogenic solution into the patient’s blood”. A series of clinical trials have been performed in recent years that tried to confirm the advantage of HDF mostly without showing a clear-cut advantage, or advantages only after subgroup analyses. Obviously,

and in light of a recent publication in Cataluña / Spain published in 2013, the convective dose in terms of ultrafiltration was simply too small.

This study showed that survival of dialysis patients significantly improved when HDF and an effective convection volume exceeding 20L was performed with HDF and a substitution volume provided online from the dialysate circuit. Data of this study represent an impressive background. More than 900 patients were followed for three years in a two arm scheme. The trial compared high-flux dialysis (n=450) with high efficiency hemodiafiltration (n=456). All-cause mortality was reduced by 30 per cent, if high efficiency HDF with an ultrafiltration volume of more than 20L was administered. The authors concluded that the estimated number needed to treat suggested that switching eight patients from high-flux hemodialysis (low volume HDF) to high efficient HDF (high volume HDF) may prevent one annual death.

To conclude, the definition of dialysis dose for an optimal therapy of uremic patients has changed. Parameters, such as duration or frequency of dialysis therapy as well as the physical performance of the filtering device (clearance) have come out second and have been replaced by high ultrafiltration volumes. At first sight, this looks surprisingly simple. However, the concept of high exchange volumes in hemodiafiltration implies two issues: efficient transport capacity for molecules with increased molecular weight and a deeper insight that a single culprit molecule has not yet been identified, that can be made responsible for the pathology of kidney failure. As a consequence, an unspecific blood purification therapy has come out to be most successful.

The search for similar parameters in other applications of medical device technology will certainly go on.

References are available at www.asianhhm.com

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TECHNOLOGY, EQUIPMENT & DEVICES

Can ICT Make a Difference in Providing Healthcare?

This article reviews the necessity for digital health to be incorporated into the healthcare delivery system to achieve the necessary radical transformation. The challenges in executing this and the necessity to address 'WiiiFM' (What is in it For Me) is discussed in the setting of the inevitable evolution of Homo Digiticus.

K Ganapathy, President, Apollo Telemedicine Networking Foundation, India

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ighty per cent of Indiaâ&#x20AC;&#x2122;s specialist doctors live in urban India. 700 million Indians living in rural India have to travel 50 to 100km for secondary care. While we have outstanding medical centres of excellence, the great majority of Indians cannot access them. With an increasing population, rise in life expectancy, higher purchasing power due to rising income and increasing literacy levels, expectations of the healthcare 'consumer' are reaching an all-time high. Life style and noncommunicable diseases are now becoming a public health hazard. Living in an information age, knowledge empowerment is also becoming a reality. It should therefore be no surprise that the recession-proof healthcare industry is expected to touch US$27 billion in 2016-17. The annual average revenue growth during the last five years has been 20-25 per cent. With 78 per cent healthcare expenditure in India being out of pocket, there is a large market for health insurance. Growth in the

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TECHNOLOGY, EQUIPMENT & DEVICES

healthcare industry has to be exponential not incremental, if the urban rural health divide is to be bridged and if we are to reach even the minimum prescribed WHO standards. Realising this, the Government of India has committed to double its contribution from 1 per cent of the GDP, to 2 per cent in the 12th five year plan. Over the next five years, India will require investments of INR6 lakh crores to attain the global median of 24 beds per 10,000 persons from the present.

The ICT Scenario

The growth in Information and Communication Technology has been exponential. Though the use of personal computers and broadband penetration is still predominant in urban India, rural tele-density in India is approaching almost 65 per cent. The Govt. of India in its National Telecom Policy envisages even a ‘Right to Broadband’ scenario by 2020. The United Nations has already declared access to the Internet a human right. A government funded fibre optic network to connect 250,000 Panchayats in India was launched in October 2011, under the Universal Service Obligation Fund (USOF), to increase broadband penetration in rural and remote areas.

This will improve delivery of public services and empower village residents, who constitute 70 per cent of India's population. It will change eGovernance, education, and agriculture. Delivery of healthcare could truly be transformed.

These Panchayats will have a cell tower and other related infrastructure. Public and private operators will share facilities for providing last mile wireless services to rural customers. Broadband wireless access will consist of a mix of 3G / 4G cellular, mesh WiFi, and WiMAX. With a projected cost of INR30,000 crores, this is scheduled to be operational by 2014.

Introduction to eHealth

Given the Health and ICT scenario outlined above, it follows that the

growing health divide between the advanced countries and emerging economies, could be quickly bridged by adopting eHealth. The World Health Organization broadly defines eHealth as the transfer of health resources and healthcare by electronic means”. eHealth is all about ensuring the delivery of the right health information about the right individual, to the right person at the right place and the right time, in a seamless, cost-effective manner, using appropriate need-based Information and Communication Technology with a view to enhance health outcomes and improve system efficiency. eHealth is about modernising health system methods and technologies to increase the quality, safety, timeliness, and efficiency of health service. eHealth is a long term project requiring clarity, ownership of direction, strong collaboration and accountability among all key stakehold-

ers, with attention to specific achievable deliverables. To promote digital health, strong leadership is required to solve conflicts between and within organisations. Skill development and adoption of new practices would be a challenge. ICT portals could improve patient-provider communication, contain cost, provide reliable health information, reduce medical errors and enhance efficiency by enabling access, utilisation and collaboration. Introduction of ICT curriculum in all health training institutions and retraining of already qualified medical practitioners should become mandatory.

Allotment of budget for ICT is critical to ensure sustainability. Unlearning and Relearning by all users is more critical than choice of technology. An information intensive sector, improvements in healthcare can occur only if e-health technologies are applied as enabling tools for re-organisation, supported by the

Homo digiticus As one born as homo sapiens, initially a spectator, but slowly entering centre stage, it has been my privilege to see the new species Homo digiticus evolve. Marty Cooper inventor of the cell phone and Sir Timothy John Berners-Lee creator of the World Wide Web could never have foreseen that they would disprove Charles Darwin.

According to Darwin’s hypothesis, it has taken tens of thousands of years for a new species to evolve. Marty and Timothy reduced this to four decades.

Interestingly the speed of mutation is more in the emerging economies.

Today, 5.5 out of 7 billion homo sapiens have become homo digiticus.

To me, chips were something one ate, discs were part of the spinal column, tablet was something a doctor prescribed, semiconductors were people wishing they were heading an orchestra and out of sight was out of

mind – to homo digiticus these have a totally different connotation. We are living in a stage of transition. The homo digiticus uploads 24 hours of video content every minute or three billion videos per day. If the homo digiticus watches videos for 24 hours a day it would take 1000 years to see all videos presently on YouTube.

Facebook has 90 billion photos. 168 million emails are sent per minute in addition to 12,000 new e queries every second. That we are in the midst of a digital upheaval, which is truly transforming the society of yesteryears, is obvious. A Ph.D student from the USA insisted, that her apparently normal India based mother, consult me for a brain scan, because there were too many new errors in the e-mails she was now receiving. The scholar was right.

A benign tumour was diagnosed.

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TECHNOLOGY, EQUIPMENT & DEVICES

necessary skills. The biggest advantage for emerging economies is that we need not follow the West or even piggy back, we can directly leap frog. In so far as eHealth is concerned the digital divide is not insurmountable.

What is Digital healthcare?

Can the digital revolution lead to better healthcare? There is only one answer to this question and that is an emphatic Yes. As every sixth human and every fifth mobile phone are in India this discussion will be India centricâ&#x20AC;&#x201D;after all, if it is doable in India it should be doable anywhere.

Digital Health Care (DHC) is the use of Information and Communication Technology to encompass all aspects of healthcareâ&#x20AC;&#x201D;preventive and curative. DHC is particularly useful in promoting wellness, not merely curing illness.

One has to accept the fact that worldwide, particularly in the developing countries, there is and will always be a major shortage of basic infrastructure to provide healthcare. 20th century solutions cannot be used for 21st century issues.

DHC can considerably extend the reach of the healthcare provider and also assist the individual to get expert opinion thousands of miles away.

Illustrations on how digital technology can better health outcomes

Advanced Computer Assisted Systems, Virtual Reality (VR), and imaging systems could eventually minimise the usage and dependence on expensive and complicated invasive diagnostics as well as surgical procedures. Also, amalgamation of medical VR and CAS holds the potential to improve medical outcomes in a cost-effective manner by increasing the accuracy in diagnosis and surgery. Several procedures will eventually be shifted from the operating room to radiology centers and outpatient surgery rooms. Increased use of mobile digital X-ray systems will make it easier to transmit images across the internet. The physical absence of radiologists in suburban India can be replaced by their virtual presence. Sophisticated computer programmes will serve as knowledge-based systems, attempting to replicate the performance of a human expert on some specialised reasoning tasks. These expert systems can be used for disease diagnosis. Knowledge can be stored and manipulated to help the user to solve a problem or make a decision.

Teleconsultations

The author has overseen 75,000 teleconsultations in 25 different specialities from 95 telemedicine centres mostly located in suburban and rural India. Home telecare and electronic house visits have been initiated. Skype is being used for teleconsultation from patients homes. In Karnataka hundreds of family physicians, small clinics and hospitals have been connected to tertiary cardiology centres where

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ECGs are interpreted and opinion given with a turnaround time of 30 to 45 minutes. eICUs are being planned where smaller ICUs will be connected to highly trained experienced intensivists. High risk newborns in rural India have their retinas evaluated by super specialists hundreds of miles away. 60 VSAT enabled Hospitals on Wheels provide specialist consultations in different villages EMR / HIS

EMR is slowly being introduced not only in tertiary corporate hospital groups but also in selected remote government run primary health centres. At the 3rd international conference on Transforming healthcare with ICT held in

mHealth With 920 million phones, mBanking, mEntertainment, mCommerce and mGovernance are slowly becoming a reality, but mHealth today is conspicuous by its absence.. This untapped potential is enormous. Pilots and proof of concept studies in various aspects of mHealthare are abounding in India. In fact, there are more pilots in mHealth than in the Indian Air Force.

Hundreds of thousands of SMSs sent every day by government health departments, NGOs and the private sector are ensuring better adherence and compliance be it for immunisation, vaccination, ante natal counselling, or blood sugar evaluation.

For the past one year 24 / 7 sophisticated medical call centres are providing authenticated validated health information for INR40 on mobile phones. Hundreds of applications on various health issues can now be downloaded on a smartphone.

Video conferencing through mobiles using 3G and eventually 4G is on the anvil.

TECHNOLOGY, EQUIPMENT & DEVICES

Hyderabad from Aug 31st to Sep 1st 2012 more than 400 stakeholders in Digital Health spontaneously affixed their signatures to the Cyberabad Declaration, requesting the government to take regulatory steps and provide the necessary infrastructure and support to make eHealth a reality in India. Obviously the time has come.

This augurs well for the future.

More than 500 grand rounds have been carried out between the various tertiary Apollo hospitals using multi point video conferencing. The Ministry of Health, Govt. of India has a programme of eLectures linking hundreds of post graduate medical training centres, using VSATs supplied by the Dept. of Space. Using the National Knowledge Network Simulation Skills Laboratories using 1 Gigabyte per sec bandwidth will become available- this is the new vibrant India giving birth to digital healthcare. The Dept. of Telemedicine, Apollo Hospitals Chennai is one of the 10 super speciality hospitals in India connected to 39 countries in Africa under the Government of India Pan African e-Network project. About 2500 lectures have been delivered for doctors in Africa thro this network.

Challenges in introducing digital health

These challenges include evaluating the appropriateness of existing Healthcare ICT applications, based on impact and effectiveness of the delivery of health services, standardisation, interoperability, reliability and robustness. Human resource development and skills in information systems design and implementation is critical to successful application of ICT in healthcare. These skills need to be staged and nurtured preferably locally.

Building competencies finding and retaining skilledpersonnel, enhances access to information and resources resulting in empowerment of patients

to make informed healthcare decisions, and improves quality, value and patient satisfaction. Users want credible reliable information, convenience, accessibility, and the assurance of privacy. All these can be provided digitally. Issues to be considered in deploying ICT in healthcare would include the availability of data-related standards, regulatory and legal frameworks, electronic content that is relevant, applicable and culturally appropriate and options to ensure continuity and sustainability of ICT projects. The technology should be simple, relevant and local, built on what is already available and in use.

Users need to be involved in the design by demonstrating benefits that would accrue to them. Experience shows that there is no single solution that will work in all settings. The complexity of choices of technologies and the complexity of needs and demands of health systems suggest that the gradual introduction, testing and refining of new technologies, would be the way forward.

Conclusion

Anyone, anytime, anywhere at afford-

Author BIO

Tele education

All people, no matter where they live, have a right to access high quality, affordable healthcare.

able cost, making geography, history and distance meaningless will be the new mantra. This is what digital health is all about. In India, mHealth could be the specific answer to improve the quality of care, without significantly increasing costs. The most important enabler to make these breakthroughs come true, is not further advances in technology, but meticulous attention to WiiiFM for every single stakeholder in the entire ecosystem. The question 'what is in it for me' has to be satisfactorily answered if digital health is to be incorporated into the healthcare delivery system. A solution is not a solution unless it is universally accepted.

Digital health should produce not just customer satisfaction but customer delight. Creating awareness aggressively with success stories is a prerequisite. Lars Leksell the inventor of the Gamma Knife, had remarked half a century ago - I quote â&#x20AC;&#x153;a fool with a tool, is still a foolâ&#x20AC;?. He also observed that when one has a hammer everything around you looks like a nail, particularly when the hammer is expensive. Technology should not go in search of an application. We should develop a technology for a pre-conceived application. Digital technology should be viewed as an enabler to achieve an end, not an end by itself.

As one belonging to the BC (Before Computers and Before Christ are one and the same) era, I strongly feel we should not become slaves to technology. TLC should continue to be Tender Loving Care not only telephone or TV linked care.

K Ganapathy is a Senior Consultant Neurosurgeon at Apollo Hospitals and President of Apollo Telemedicine Networking Foundation. A Past President of the Telemedicine Society of India, he was a Member of the National Task Force on Telemedicine; He was a former Secretary and Past President of the Neurological Society of India, Former Secretary General of the Asian Australasian Society of Neurological Surgery and Former Honorary Consultant and Advisor in Neurosurgery Armed Forces Medical Services. He is also President of Indian Society for Stereotactic & Functional Neurosurgery.

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INFORMATION TECHNOLOGY

Can Banks Offer Digital Keys for Healthcare?

In the quest to implement electronic health records, healthcare stakeholders have uncovered an obvious but unanswered challenge–how to implement patient identity and integrity solutions. Medical banking, or the convergence of banking and heath IT systems, is spawning new ideas that could impact this difficult area. Redefining a ‘bank’ based on core competencies, the article looks at three areas (1) the ‘identity theft arms race (2) innovations in payment processing and (3) consumer engagement, and suggests that, as banking and healthcare systems converge, digital identity may become the ‘new money.’ This realisation may find banks fully engaged in helping healthcare overcome the challenge of patient identity and integrity.

John Casillas, Senior Vice President, HIMSS, USA

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n 2001, HIMSS Medical Banking Project outlined a health Information Technology (IT) strategy linking banking and healthcare platforms to form new, inter-organiSational systems that streamline administrative costs in healthcare. Commercial banks responded by accelerating investment in treasury management operations, where the idea has driven demonstrable impact. For example, a world renowned healthcare system implemented a ‘medical banking’ programme that transformed processing four million payments from paper to electronic. Annual cost savings can be roughly estimated by multiplying volume by two, or US$8 million per year.

While this business practice is still in its infancy, and ways are emerging to harness the efficiency of electronic payments that circumvent the lockbox, the idea of tighter technology linkage between banking and health IT has spawned new areas of thinking. These areas may be summarised as: (1) integrated healthcare administrative technologies, such as the example cited above (2) ‘health-wealth’ portals that consumers can use to manage spending in healthcare, and (3) bank-managed digital

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identity and integrity for healthcare.

Though distinct, these three emerging capabilities overlap and may be portentious of our healthcare financial network of the future. This article will focus on the third area only – using banking technologies for ‘identity assurance’, referred generally as a ‘digital key’.

Dialogue around this issue is still quite new. ‘HIMSS G7,’ a cross-industry thought leadership assembly focused on business innovations in healthcare, actively involves banks to explore solutions around emerging issues in healthcare. Objective recognition of medical banking ideas appears to be gaining ground. In early January 2012, six editors at American Banker searched the US marketplace to find the ‘biggest ideas’ in banking. The creation of a ‘healthwealth’ portal made number one on the list. Later in July, Treasury & Risk magazine compiled a global listing of the ‘Top Influential People in Finance in 2012’ where medical banking ideas were again recognised.

Of all the ideas that have evolved from the convergence of banking and health IT, none may drive more impact, and debate, than using bank identity

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management mechanisms for healthcare; specifically, digital keys that link a patient with his or her electronic health records. Events like AsiaPac12, Summit for Health Information and Financial Technology (SHIFT) at HIMSS annual conference, the mHealth Summit, Digital ID World Africa and others, allude to a new dialogue that suggests we are fast moving toward bank-managed digital identity for consumers of health services.

In fact, it would not at all be surprising if some projects have already connected the dots around this area.

As our world turns digital the need for identity management has become foundational, and this is true not only in first world countries but in developing areas where mobile finance is making strong inroads (i.e. mPesa, others). A study

by Unisys found that among consumers, the most trusted venue for digital identity management is the commercial bank. As banks redefine their value proposition—a process that has escalated since the 2008 global credit crisis—the notion that ‘identity is the new money’ is resonating. In a digital world, consumers are digital ‘entities’, who may or may not be who they say they are. For banks

Author BIO

INFORMATION TECHNOLOGY

John Casillas founded the Medical Banking Project in 2001 that was later acquired by HIMSS to form the HIMSS MBProject in 2009. He is considered a pioneering authority in the convergence of banking and healthcare. In 2012, John was appointed the first Global Health IT Fellow for the World Bank and was, in addition, named one of the top 100 most influential people in the world of finance in 2012 (Finance & Risk Magazine).

that are re-imagining service portfolios, a compelling product pathway is emerging that places them within an identity management value chain.

One aspect of a bank-driven digital key lies in prevention of medical identity theft. The numbers are daunting and tantamount to a universal wake-up

call. The World Privacy Forum declared in 2006 that medical identity theft is the fastest-growing form of identity theft. In 2010, according to the Ponemon Institute, more than 1.4 million people were victimised by medical identity theft, and the average cost to resolve their cases was approximately US$20,000.

Over half of these people report having to pay for medical coverage they did not receive in order to restore their health coverage. In fact, nearly one third indicated their health premiums increased after they were victimised.

Yet the financial fallout of medical identity theft is not the worst part.

Authorities suggest the impacted health record could lead to dangerous situations. Imagine reliance on a medical record where the blood type has been changed or where the history of treatments is mixed with the criminal’s illgained procedures. This is where digital ID ‘integrity’ comes into full view.

Patient identity and integrity are inextricably linked. They go together. And if bank-managed digital identities are in our future, it follows banks could be involved in some form of integrity of records as well.

These facts illuminate a fundamental dialogue society is wrestling with today: how will we protect our medical identity in a digital world? We may have a key part of the answer already but the global dialogue hasn’t yet acknowledged the notion of using banking systems for identity assurance. Many view banking and health IT as separate. But the medical banking domain is yielding cross-industry innovation that is blurring the lines. Can patient identity and integrity be addressed using finely tuned programmes deployed by banks? Can banks offer digital keys for healthcare?

As we discussed how a bank can redeploy core competencies to drive growth, we quickly concluded that for a bank this size, the best ideas need both a large market and global scale.

Building a capability just within the US would not work. Viewed from this

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angle there are several good reasons to strongly consider banking technology for healthcare. Here are just three: Core Competency #1 The ‘Identity Theft Arms Race’ As electronic health information technology advances there is a need to fully understand a hidden, but considerable cost for keeping medical identity private. Consider that the banking industry is locked into an ‘identity theft arms race’ with the criminals–individuals and organised crime syndicates who are trying to rob the system 24 hours a day, 365 days a year. Addressing this persistent threat requires significant investment, strong stakeholder engagement among competitors and authorities and futuristic thinking, so that emerging threats are envisioned way out in the horizon before they actually become reality. There is no comparative capability within the healthcare system that mimics this banking resource. We may well ask if we need to reinvent it for healthcare.

Policy development has morphed around this area. For example, the Obama Administration in the United States announced a new cybersecurity plan to protect national interests. As commerce moves from paper money exchange to digital transfers, identity and access management is rising in importance. As medical identity theft grows, new technologies are now embedded in financial systems to deal with financial identity theft and have already cross-pollinated into healthcare systems, especially in payment channels.

It stands to reason that as best practices in identity management in banking are much more evolved, keeping our money safe, that linkage with health IT is inevitable.

Core Competency #2 Innovations in Payment Processing An area that brings together identity and access management in banking and healthcare is cash management. The convergence of banking and health IT impacts the finances of the enterprise,

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practice and individual. Accessing this cash flow requires a growing portfolio of trusted identity protocols (i.e., multi-factor authentication, site stamping etc.). The technical development ‘glidepath’ brings banking and healthcare systems into a mutually valuable inflection point.

Consider that in healthcare, payments processing is much more involved than transferring funds between the healthcare stakeholders. Accompanying these funds is a detailed description of what the payment is for, and many times, what is partially paid or not paid at all. This information helps the enterprise to optimise reimbursement; the physician who is trying to get paid and the patient who wants to know what his or her portion of the bill is, and if it was calculated accurately.

This data is also individually identifiable and highly confidential, presenting a line-by-line description of each medical treatment and its associated cost. When using banking systems for managing payments that have accompanying ‘explanation of benefits’ that go through a lockbox (as many hospitals and large practices do), this data crosses the boundaries of the healthcare provider and enters the banking system. This is the reason why banks that provide these types of services are impacted by health data protection laws in the USA, such as HIPAA, and those in other countries as well.

An axiom in medical banking is that

the evolution of health data protection laws will necessitate ever tighter linkage between banking and health IT. This is because the marketplace is relentlessly driving best practices to optimise efficiency yet gaining this efficiency requires IT convergence between banking and health IT systems. Because of this, compliance regulations in healthcare (HIPAA, HITECH) and banking (GLB, FACTA, PCI) are converging in the payments area. While there are other avenues for transferring remittance data, such as health data clearinghouses, in the end the remittance needs to be linked to the payment. This is a function that the bank is uniquely positioned to perform; after all, the banks are processing the payments.

In the USA, the ‘X12 835’ transaction is used transfer a payment and remittance. Use of this transaction in banking systems has been hampered for many reasons, however, banks are catching up and there is active discussion today about implementing ‘straight through processing,’ that moves the funds and the data together to end point, in healthcare.

Moving funds alone is highly commoditised and so there is growing interest in this area, where banks can provide greater value to healthcare stakeholders.

The product evolution seems apparent. Banks, through which this data will progressively move, will provide platforms that help their customers to process the data, whether through cash management

Redefining banks While peering through a window high above the three rivers that converge in Pittsburgh, Pennsylvania, I was struck by remarks made by a senior executive at a major bank. At the time, the bank was managing over US$ 21 trillion in assets across the world. The executive began to reflect on the components of a bank and what really makes it tick from a global perspective. The bank, he suggested, provides unique competitive strengths in the area of consumer trust and engagement, privacy and security, persistent investment in administrative technologies and other welldefined areas. These ‘structural building blocks’ can be configured in different ways to pursue margin and mission.

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platforms for the enterprise that streamline workflows, or, online banking platforms that serve up near real time data to the individual so they can manage their healthcare spending…all instantly portable to a mobile device. Clearly, access to this data stream is controlled using a banking identity and access management mechanism. It stands to reason that as banks are highly invested in this area, including the nascent development of ‘legal entity identifiers,’ that healthcare stakeholders won’t need to reinvent the wheel.

Imagine a consumer who establishes a bank account being assigned a lifelong digital key for authorising access to financial and personal health records. The key could also be deployed into interoperable healthcare networks to accurately collate electronic records at point of request (online, card swipe, etc).

Yes, this is far easier said than done but the point of reflection remains the same – should health stakeholders engage the banking community for the digital key component or re-develop this capability? How will it be paid for to keep the criminals continuously at bay? Will a separate effort yield the same, or better, security than we find in banking? What if we could bypass this area and turn our collective attention to other difficult tasks to build interoperable health data networks?

Core Competency #3: Consumer Engagement A Witman, P and Roust, T (2008) Balances and Accounts of Online Banking Users: A Study of Two US Financial Institutions. International Journal of Electronic Finance 2(2) (April, 2008) conducted by professors at California Lutheran University corroborated another that was done early by Digital Insight; both trying to show cost savings of moving banking customers from offline to online banking. Yet the studies revealed something different. The cost savings were slight, but a major finding indicated the ROI for online banking customers is three times more

A study by Unisys found that among consumers, the most trusted venue for digital identity management is the commercial bank.

than offline customers. Online banking customers typically have larger and more account balances.

Realising this, banks have developed a multi-pronged approach for moving people from casual users to offline, then online banking, and now, mobile banking. They target the ‘unbanked,’ such as healthcare targets the ‘underserved’ (those uninsured or underinsured who fall through the cracks). Doing this is not as easy as one might suspect.

There is a business cost to move consumers from what feels comfortable today to new technologies. For example, there are generational gaps in the use of technology. Some prefer going to a bank branch to speak to a live person. Others prefer an ATM. Still others go online or use a mobile phone. Targeted marketing and consumer segmentation is vital for changing consumer behavior. Grandma likes sending checks in the mail, while the kid brother prefers his iPad. There are also language barriers that must be addressed so that consumers are educated in their own language. Sensitive cultural norms must be recognised…the list goes on.

Banks have built this capability into their business models. Will the healthcare stakeholders do the same? Wouldn’t it be easier to add a new service category in online banking – click here to visit your ‘digital medical home’? Are healthcare stakeholders able to pay for changing consumer behavior given other priorities, like clinical excellence?

Of course, before we can realistically walk down the path of a digital home for medical records, the user experience must become more robust.

Health records located in disparate systems need to be brought together and presented in an inviting, easy-touse format. To this point, some say a broad and interoperable system may never happen, and consumers simply need to buy a personal health record and load it manually or, if available through their healthcare provider, electronically.

Moreover, once this is done, tomorrow’s consumers could monetize their records, selling them in a very controlled way using an authorised format. However accomplished, whether self-managed, through an interoperable network or both, integration with a commercial bank is good idea. Funds from the ‘digital medical home’ could be swept into a savings account, as consumers learn to exercise new legal rights around an asset they’ve always had but with far too little control.

Conclusion

Looking through the lens of medical banking it is easy to envision a future state that finds banks offering identity assurance solutions. If ‘identity is the new money’ and banking systems continue to integrate technologies that help health stakeholders to reduce operating costs, it seems inevitable that a common IT convergence point will become using bank identity management ‘engines’ for healthcare – both in terms of criminal-resistant technology and widespread promulgation of digital keys, through persistent investment that changes consumer behavior from offline to online engagement. Getting two for the price of one may become a viable policy and technology decision in the near term as healthcare goes digital. The healthcare leadership should actively bring banks into the identity assurance dialogue and strongly consider use of existing systems to meet this critical need.

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Medical Technology Innovations Enhancing healthcare delivery

Globally, nations are struggling to meet healthcare costs. This is a challenge that we need to meet without compromising on the sustenance of the business. The medical technology industry has been thriving on innovations. While the focus has been on better outcome and quality of life, it is time that the focus also includes affordability.

GSK Velu, Vice Chairman, Metropolis Health Care Limited, Chennai, India

W

ith the convergence of many scientific and technology breakthroughs, the pace of medical invention is accelerating, inspiring hope for better clinical outcomes with less invasive procedures and shorter recovery times, all in lower cost settings thereby creating tremendous value.

These changes can drive demand for new lower cost diagnosis, monitoring and treatment procedures.

Globally, nations are struggling to meet healthcare costs. This is a challenge that must be met without compromising on the sustenance of the business. The medical technology industry has been thriving on innovations. While the focus has been on better outcome and quality of life, it is time that the focus also includes affordability.

Medical technology encompasses a wide range of healthcare products (devices, equipment as well as Consumables / supplies) that are intended by its manufacturer to be used specifically for diagnostic and / or therapeutic purposes.

It encompasses any instrument, apparatus, appliance, implant, in vitro reagent, software, material or other article, which is used, alone or in combination, for the following purposes: • diagnosis, prevention, monitoring, treatment or alleviation of disease

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• diagnosis, monitoring, treatment, alleviation of or compensation for an injury • investigation, replacement, modification or support of the anatomy or of a physiological process • supporting or sustaining life • control of conception • disinfection of medical devices • providing information for medical or diagnostic purposes by means of in vitro examination of specimens derived from the human body which does not achieve its primary intended action in or on the human body by pharmacological, immunological or metabolic means, but which may be assisted in its intended function by such means.

Medical technology plays a strategic role in fostering the change of healthcare delivery towards better health outcomes.

According to EUCOMED (the European medical technology industry association), Medical Technology extends and improves life. It alleviates pain, injury and handicap. Its role in healthcare is essential.

Incessant medical technology innovation enhances the quality and effectiveness of care. Billions of patients world wide depend on medical technology at home, at the doctor’s, at hospital and in nursing homes.

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With the convergence of many scientific and technology breakthroughs, the pace of medical invention is accelerating, resulting in better clinical outcomes, less invasive procedures and shorter recovery times, and thus improving overall health of people.

Medical technology in India

There can be no better example than India to illustrate the need for medical technology for improving healthcare delivery. The majority of India’s population cannot afford anything better than the most basic healthcare. There is a need to use medical technology effectively to address the yawning gap between demand and supply of healthcare services in India. Innovative products and business models are needed to make healthcare affordable and accessible to a larger percentage of the population.

Indian medical technology market An overview

India’s medical equipment market—valued at US$2.7 billion in 2008—is Asia’s fourth largest (behind Japan, China, and South Korea) and is projected to reach US$6 billion by 2015. Domestic production supplies only 29 per cent of the market. Imports account for

INFORMATION TECHNOLOGY

What would be the countryâ&#x20AC;&#x2122;s vision today, if you have numerous PhD scientists, a steady supply of biomedical and electronics engineers, and medical device manufacturing facilities at its disposal? Would its vision change from what it was a year earlier, or would it remain the same? Could it be an untapped opportunity, knowing that the best people in the field, a supporting infrastructure, and an ecosystem of entrepreneurs raring to not only develop unique solutions for the local market but also put Indian medical technology industry on the global map?

Importing to innovation - A paradigm shift

about 71 per cent. Medical technology is seen as one of the three key drivers of increasing healthcare accessibility. It is estimated that 35-40 per cent of a hospital project is allocated to medical technology. Therefore, it is imperative to devise ways to rationalise this cost by adopting some innovative methods including reducing the cost of medical technology research and development, encouraging indigenous production of medical devices, devising innovative ways of dealing with obsolescence, testing the new and upcoming business models of technology services etc.

Some pertinent questions

How did the Indian automotive industry become a self-sustaining industry?

How did the information technology industry become a force to reckon with globally? How did the pharmaceutical industry turn a high-import country of drugs to one of the largest exporters of drugs in the world? By taking lessons from such successful models, can the Indian medical technology industry grow and in the process, make India (a country that imports 71 per cent of its medical devices) self-sufficient based on indigenous innovation?

Some key recommendations Establishing an appropriate government channel focused on medical devices - A separate governing body that caters to the industry is required to oversee certification, approval, or monitoring of medical devices Specific policy initiatives - Lack of a clear policy for the industry has discouraged the private sector from participating actively. To encourage investment, financial incentives must be offered to local manufacturing units

to offset the high capital required for new projects. Additionally, separate manufacturing zones must be identified for export-oriented units.

Need for a dedicated regulatory body - The Indian medical technology industry requires a similar approach in establishing a central agency that oversees all functions and addresses the specific needs of this industry.

Establishing India-specific quality standards and a device monitoring and certification body

Almost 71 per cent of the medical devices used in India are imported into the country. Most have not seen India as a primary low-cost labor destination or center of excellence for certain business operations. Companies can drive growth and position themselves for success by venturing into new markets beyond Tier 1 countries, and by pursuing breakthrough product and business model innovation. Such innovation among companies in India has been scant to date, although a few, such as Trivitron Healthcare, GE Healthcare and B. Braun, have done so. For example, Trivitron has established an innovation center within IIT Madras campus focused on cardiology, IVD, renal care, critical care solutions for India and emerging markets of the world, GE has developed a portfolio of innovative diagnostic imaging products etc. Some companies are also establishing and integrating their India operations with their global low-cost R&D and manufacturing organizations to attain higher quality.

As companies expand their market presence, it is often necessary to customise or tailor existing products to address new customer segments or unmet needs and to differentiate offerings from those of international and domestic

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competitors. This may include simplifying products by removing features that are less valuable, substituting materials with comparable but lowercost options.

Impediments for indigenous medical technology manufacturing and innovation and industry growth

Author BIO

India’s medical technology industry needs to innovate to meet the demand of the local markets. The potential for growth lies in creating a huge talent base, targeted government policies, a central regulatory body, collaboration between research bodies such as IIT, and establishing quality standards.

Some of the steps that Govt. can take include: 1. Establishing MT manufacturing joint ventures in India 2. To recognise medical technology as a separate & significant entity of healthcare 3. To form a Department of Medical Technology (like dept. of Pharmaceuticals) under Ministry of Health or Science & Technology.

4. Powerful financial incentives 5. Create our own supportive regulatory system 6. Supportive investment capacity (Subsidised loans for medical technology manufacturing / innovation).

Innovation in medical technology faces a lot of challenges that need to be addressed by government.

The challenge in medical technology innovation space can be addressed by creating a medical technology innovation eco-system which requires

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(1) An education system that nurtures creativity (2) An R&D culture and value system which supports both basic and applied research and technology development (3) An industry culture which is keen to interact with the academia (4) Government support (5) A policy framework which encourages young people to enter scientific careers.

The Indian medical technology innovation eco system will include engineering, medical institutes, government (DST / DBT / ICMR) and domestic medical technology companies. A collaboration of industryacademia for innovative solutions will foster high levels of productivity. Creation of a central authority for holistic development of industry in India to drive non-regulatory and commercial growth (Dept. of MT under Ministry of Health or Science & Tech), sharing industry best practices and encouragement of overall development of industry are a few other notable steps to be taken by government and others in the eco-system.

To sum up, indigenous medical technology manufacturing and innovation is the key to bring cost-effective medical technology solutions specific to India and emerging markets of the world. Hence, significant efforts are needed for all participants in the medical technology ecosystem to stimulate innovation in, so that opportunities provided in the market can be capitalised up on by domestic companies and the consumers of healthcare services are benefited.

G S K Velu has over 20 years experience in the diagnostics and healthcare industry. He was awarded Rajiv Gandhi Shiromani award in 2007 and The Entrepreneur of the Year award in 2006 by GE & Modern Medicare. He is also the only person in the healthcare industry to receive ‘The ITM University Awards for Corporate Excellence for the year 2006. He has also published scientific papers in ‘Journal of Interfacial & Colloidal sciences’, USA and ‘Journal of Biophysics and Biomedical sciences’, USA.

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Book

Healthcare Information Technology Innovation and Sustainability: Frontiers and Adoption Editor: Joseph Tan No of Pages: 355 Year of Publishing: January 31, 2013 Description: Healthcare Information Technology Innovation and Sustainability: Frontiers and Adoption presents research in the emerging field on information systems and informatics in the healthcare industry. By addressing innovative concepts and critical issues through case studies and experimental research, this reference source is useful for practitioners, researchers and academics aiming to advance the knowledge and practice of these interdisciplinary fields of healthcare information. development.

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Being the current major trend, is mHealth's promise to change the practice of medicine being met?

One of the biggest challenges facing societies worldwide is how to make high-quality healthcare afforable and accessible for all.

As the population expands in developing countries and ages in developed countries, the world is spending an increaingly high proportion of its Gross Domestic Product (GDP) on healthcare Governments, individuals and private insurers worldwide are urgently seeking more cost-effective ways of preventing and treating chronic diseases and other debilitating conditions.

The widespread use of mobile connectivity in healthcare, called mHealth, could significantly cut costs, increase the reach and accessibility of healthcare services and reduce the impact of illness on peopleâ&#x20AC;&#x2122;s lives.

The GSMA tracks mobile health deployments around the world, and our database today counts over 800 services and over 200 mobile health devices. However, I would still not yet classify mHealth as having reached large scale adoption.

Barriers still remain, for example, being a new innovative service, it is not always clearly understood how existing regulations apply to mHealth, and only few solutions are being reimbursed by insurers or govern-

mHealth

Improving opportunities for better care Mobile technologies are making a significant contribution to addressing the enormous challenges of healthcare provision worldwide. As the market for mobile healthcare solutions reaches the next stage in its development, greater consideration is being given to the regulatory frameworks that will govern their promotion and use.

Jeanine Vos, Executive Director, mHealth, GSMA

ments. Also, awareness of mobile health solutions by healthcare practitioners and people working in the pharmaceutical industry remains low, and mHealth is at present not regularly prescribed.

The GSMA commissioned end-user research to investigate what healthcare practitioners and patients currently consider main challenges in managing chronic conditions today, and what they see would be the role and potential benefits of mHealth.

The research was conducted among 2,000 end users in India, China, US and Brazil.

What I found interesting is that, on the one hand, an impressive 89 per cent of healthcare professionals believed mHealth had significant benefits to improve healthcare outcomes and reduce costs. On the other hand, almost 90 per cent of patients indicated that they are not using mHealth solutions at the moment, simply because their healthcare practitioners do not recommend them.

In India, the number one barrier stated by patients to their increased use of mHealth solutions was lack of healthcare practitioners prescribing them. Therefore, I still see significant work needs to be done before real scale will be achieved.

What is your take on the existing regulatory standards for mHealth?

Mobile technologies are making a significant contribution to addressing the enormous challenges of healthcare provision worldwide.

As the market for mobile healthcare solutions reaches the next stage in its development, greater consideration is being given to the regulatory frameworks that will govern their promotion and use.

Mobile health brings together healthcare and telecommunications industries, which both have specific policy and regulatory environments. This raises questions and uncertainties, such as, how do medical device regulations apply to mobile health solutions? How can existing legislation for data protection in telecom networks be translated into a healthcare setting?

Medical device regulation is essential in assuring patients’ and users’ safety. Safety for end-users is and should be at the centre of mHealth solutions and is essential in

creating the foundations to ensure trust in services. It is, therefore, important to ensure it is clear how this regulation applies to mobile health.

The use of standards has been a key element in establishing medical device regulations. The GSMA strongly embraces the adoption of global, consensual standards. Markets for mHealth are increasingly global and interdependent. Global standards are, therefore, key to ensuring economies of scale can be achieved and innovation can flourish. We encourage adoption of current medical device and software standards when developing mobile medical products.

Overall, I would encourage constructive discussion between industry and national regulators to help bring clarity and make sure that these new technologies can enter the market swiftly to deliver on the benefits to patients and healthcare professionals.

Are the existing applications of mHealth serving the purpose?

The GSMA research showed that almost 50 per cent of healthcare practitioners believe that patients lack full understanding of their condition, with 42 per cent of patients identifying that they are struggling to achieve their disease goals and now looking for help. mHealth offers a portal to address this need. Real-time data capture and analysis, increased access to information, increased patient ownership and understanding of their condition, support with diet / lifestyle changes, improved compliance with medications; these perceived benefits of mHealth solutions all go towards improving the overall quality and efficiency of patient care.

One of the mHealth applications is called DiabetesManager®, launched by AT&T mhealth Solutions and WellDoc® in 2011. Through this application, a patient can enter their blood glucose readings, medication information, and other lifestyle information into DiabetesManager®, which through the use of a clinical

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What kind of technology backbone needs to be in place for a successful mHealth strategy? Are legacy systems a major hurdle?

The history and success of the mobile industry is built on the application of common standards. This has been underpinned by a commitment to interoperability from multiple network operators and equipment suppliers.

The nascent mobile health industry will benefit from applying these same principles to accelerate market growth and increase the value it delivers.

The GSMA has explored several standards that already exist within the health information arena. Through discussions with industry experts, the GSMA has identified four key functional areas that could benefit from further standardisation: • Communications: Consisting of the raw communications protocols and services • Data and records: Consisting of the mechanisms to codify clinical information and also store this information in an organised health-record format • Identity and Access: Consisting of the non-functional components around patient identity, patient confidentiality and consent, and security around the solutions • Service and Application: consisting of the functional healthcare specific application components that interface with existing systems and business functions • To accelerate the development and

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adoption of mHealth devices and solutions, the GSMA is engaging with the wider ecosystem and working with key players to understand their needs and to reduce the barriers to adoption.

What are the key challenges in deploying mHealth and how can these be managed?

GSMA has identified number one key barriers that need to be addressed in order to unlock the latent potential of mHealth. The main barriers are limited awareness of mHealth by healthcare professionals and patients, lack of clear policy and regulatory frameworks, lengthy reimbursement processes and change management requirements by healthcare providers.

To address these barriers the GSMA is bringing together its mobile industry members and health stakeholders to collaborate to enable scaled integration of mobile and information and communications technology into health systems. GSMA has regularly organised working groups and workshops, as well as provided resources and support to identify and diagnose opportunities and bring solutions to scale.

What is the scenario in Asia?

We have seen a significant increase in different mHealth solutions being deployed – ranging from decision support tools or remote diagnostics for healthcare professionals in remote communities, health hotlines where individuals have a first advice on primary care questions, to remote monitoring solutions for chronic patients.

Figures from the GSMA, developed in collaboration with PricewaterhouseCoopers (PwC) for a

Author BIO

analytics engine provides automated, real-time feedback on the patient’s specific data. This way, the patient can take immediate action to help manage their disease. This valuable patient information is also made available to nurses, case workers and doctors who can review the information through an enterprise portal and provide additional communication to the patient, if needed, about what action he or she needs to take.

global report entitled ‘Mobile Health – Enabling Healthcare’, indicates that the Asia-Pacific mobile health market is expected to continue to grow significantly, to almost US$7 billion in 2017 at a CAGR of approximately 70 per cent. The largest opportunity across the region include monitoring services, with a 55 per cent market share in 2017, and diagnostic services, with a 24 per cent market share.

China is expected to have the biggest mobile health market in 2017, driven by growth in monitoring and diagnosis that will facilitate the delivery of effective healthcare to a widely spread population who have limited health access at present. In India it is expected that mobile diagnostics solutions will create the biggest opportunity due to the large proportion of the population living in rural areas.

Any other comments?

As shown in the GSMA end-user research, healthcare providers believe that mHealth solutions offer the opportunity to improve the quality of patient care, improve efficiency of work and reduce costs per individual. For the pharmaceutical industry, mHealth solutions offer the opportunity of improved adherence to medicines, thereby allowing their true value to be seen, as well as opportunities to work more closely with HCPs and patients, to explore new ways of working together to improve health. Other benefits include supporting clinical trials to obtain real world data and helping to advance research and development.

The possibilities and opportunities that mHealth can offer in all countries are enormous across both public and private healthcare providers.

Jeanine Vos is leading the global mobile health (mHealth) programme at the GSMA which aims to stimulate the development and take-up of sustainable and scalable mHealth solutions. Jeanine is responsible for defining strategic direction of the programme, working closely with member companies and stakeholders across healthcare ecosystem.

ISSUe - 27 2013

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Venus Remedies Ltd. 00-91-172-2565577,2561244 www.venusremedies.com Viasys Healthcare Inc. (610) 862-0800 www.viasyshealthcare.com Waves Surgicals +91 11 23693185 / 23693187 wavessurgicals@yahoo.com www.wavessurgicals.com ZOLL Medical Corporation +1-978-421-9655 info@zoll.com www.zoll.com

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Books

Oncology at a Glance Editor: Graham G Dark No of Pages: 132 Year of Publishing: 2013 Description: This book explores both relevant scientific content and key human issues, including communication and palliative care. Oncology at a Glance • Provides an accessible overview of the scientific foundation of cancer medicine • Covers the common cancers as well as key information on presentation and approaches to investigation and management • Includes young adult oncology, the multidisciplinary team, clinical trials in oncology, approach to treatment and response assessment, management of nausea, and end-of-life care • Was developed with students for students, to ensure it contains exactly what students need to know

50

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

Clinical Hematology-Oncology 2013 Editor: C G Weber No of Pages: 1341 Year of Publishing: 2012 Description: An extensive reference text on the presentation, diagnosis, treatment and differential of Hem-Onc conditions.

Topics include: most cancers, Oncologic Emergencies, DVT, pulmonary embolism, the anemia's, lead toxicity, sickle cell, prophyria, cancer syndromes & tx, blood cell abnormalities, transfusion medicine, bleeding disorders, DIC... Features: illustrations and hyperlinks. Detailed workups and extensive treatment options. Edited by a board certified Hematologist-Oncologist. This text contains numerous illustrations and is fully referenced. No other text on the market provides such a collection of succinct and clinically relevant material that can be accessed at the bedside.

ISSUe - 27 2013

Essentials of General Surgery Editor: Peter F Lawrence, Richard M. Bell, Merril T Dayton, James C Hebert No of Pages: 608 Year of Publishing: 2012 Description: For nearly 25 years, medical students and faculty alike have chosen Essentials of General Surgery and its companion textbook, Essentials of Surgical Specialties, for authoritative coverage of surgical information that every physician in training should know. The Fifth Edition incorporates current research from the field; new sample questions, answers, and rationales; and new tables and algorithms. A new art program presents concepts and images— including an Appendix with 50 burn images—in full color for optimal learning and retention.

Diagnostic Imaging: Chest Editor: Melissa L Rosado-deChristenson, Gerald F Abbott No of Pages: 980 Year of Publishing: 2012 Description: Diagnostic Imaging: Chest is the much-anticipated update to the bestselling first edition by Dr. Melissa Rosado-de-Christenson and her large team of chest radiology experts. This new edition features an expanded section on infections, including discussion of various infections not included in the first edition. It also adds two new subsections to the chest imaging section. The first of these is an illustrated terminology section, which includes medical illustrations of important visual identifiers such as “honeycombing.” The second new subsection describes various radiographic and CT signs, such as the “finger-in-glove” sign. Also fresh in this edition is a new section devoted entirely to atelectasis, which features expanded discussion of this important topic.

The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care Editor: Eric Topol No of Pages: 320 Year of Publishing: 2012 Description: For the first time we can capture all the relevant data from each individual to enable precision therapy, prevent major side effects of medications, and ultimately to prevent many diseases from ever occurring. And yet many of these digital medical innovations lie unused because of the medical community’s profound resistance to change.

In The Creative Destruction of Medicine, Eric Topol—one of the nation’s top physicians and a leading voice on the digital revolution in medicine—argues that radical innovation and a true democratization of medical care are within reach, but only if we consumers demand it. We can force medicine to undergo its biggest shakeup in history.

This book shows us the stakes—and how to win them.

The Strategic Application of Information Technology in Health Care Organizations Editor: John P Glaser, Claudia Salzberg No of Pages: 288 Year of Publishing: 2011 Description: Description: This new edition of The Strategic Application of Information Technology in Health Care Organizations offers a peerless guide for health care leaders to understand information technology (IT) strategic planning and implementation. Filled with illustrative case studies, the book explores the link between overall strategy and information technology strategy. It discusses organizational capabilities, such as change management, that have an impact on an organization's overall IT effectiveness, and a wide range of IT strategy issues. The book covers emerging trends such as personalized medicine; service-oriented architecture; the ramification of changes in care delivery models, and the IT strategies necessary to support public health.

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SuppliersGuide

Company................................................................... Page No. Cura.......................................................................................IFC www.cura.in Global Data ........................................................................... IBC www.globaldata.com Greiner Bio One . .................................................................. OBC www.greinerbioone.com Healthex 2013..........................................................................21 www.healthex.co.in India Med Expo........................................................................15 www.indiamedexpo.in Medicall...................................................................................43 www.medicall.in Medtec India............................................................................09 www.medtec-india.com

To receive more information on products & services advertised in this issue, please fill up the "Info Request Form" provided with the magazine and fax it, or fill it online at www.asianhhm.com by clicking "Request Client Info" link.

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

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