Asian Hospital & Healthcare Management - Issue 30

I s s u e 30

2014

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In Association with

Next Wave of Investments in Southeast Asia

Emerging Technology Trends in Asian Healthcare Organisations www.asianhhm.com

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Foreword eHealth Revolution New paradigm for healthcare information technology “…We are moving towards a digital era, where more and more things are electronic so more so than ever before, the healthcare provider needs to know everything about it.”

- Kurt Long, CEO, FairWarning

Continued technological innovations are helping the healthcare industry to deliver better care outcomes.

Innovations in the area of electronic healthcare (eHealth) are having a positive impact on care delivery. eHealth allows application of information and communication technologies improved for healthcare delivery. eHealth is a rapidly expanding field serving providers and consumers alike in many ways. To name a few, eHealth is used as an electronic patient administration system, laboratory and radiology information system, electronic messaging systems, monitoring system, patient management system, medical records and electronic prescribing system, etc. However, it is also important that all the key stake holders work in coordination for implementing these new, patient-centric technologies.

Growing incidence of chronic diseases, ageing population, and rising healthcare costs are regulating the global telehealth market. A report by RNCOS Business Consultancy Services predicts 18.5 per cent annual growth in telehealth worldwide through 2018, with the US outpacing the rest of the world. eHealth encompasses the usage of power of IT, eCommerce and ePractices in healthcare systems; it can enable efficient and effective care delivery. eHealth is also termed as an important tool for governments to address issues relating to inefficient healthcare systems.

The Ministry of Health and Family Welfare, Government of India, also announced that it is planning to start an ‘eHealth service’ to build up health awareness in rural India.

The global eHealth market is estimated to grow to US $160 billion by 2015 at an average growth rate of 12-16

per cent, and the global m-health market will be worth approximately US$23 billion by 2017, according to GSMA. Issues related to cost, privacy and usage remain challenges in eHealth adoption.

Growing adoption of mobile applications is getting patients involved in the delivery of care. Sixty-nine per cent of providers use a mobile device to view patient information and 36 per cent use mobile technologies to collect data at the bedside, according to HIMSS survey of 170 individuals.

Asia-Pacific is the fastest growing region for healthcare information technology (healthcare IT) solutions. With changing demographic factors and favourable government policies and legislations, advanced IT tools are entering the market.

In the cover story for this issue, Stephen Chu, Adjunct Professor, Multi-Media University, Malaysia opines that while health information technologies offer considerable administrative efficiency gains and cost-savings, empirical evidences available so far indicate that any clinical costsavings realised from health IT systems adoption are likely to be marginal. Stephen suggests that Health IT should be used as strategic and quality improvement tools, and not directed at clinical cost cutting.

Prasanthi Potluri

Editor

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Contents TECHNOLOGY, EQUIPMENT & DEVICES

44 COVER STORY Stephen Chu, Adjunct Professor Multi-Media University, Malaysia

20 Medical Device Research at a Regional Health System The Mercy experience Joseph P Drozda, Director, Outcomes Research, Mercy, US Timothy R Smith, Vice President-Research, Mercy, US

26 Preventing Medical Errors with Proven Bar-Code Technology Mark Neuenschwander, President, The Neuenschwander Company, US

FACILITIES & OPERATIONS MANAGEMENT 32 Using Operational Planning Studies To improve planning and design in healthcare facilities Marvina Williams, Lean Black Belt, Healthcare Clinical Operations Expert Perkins+Will, US

38 Designing Navigation Friendly Hospitals Debajyoti Pati, Rockwell Professor, Department of Design, Texas Tech University,US Sipra Pati, Research Coordinator, HKS, Inc., US

INFORMATION TECHNOLOGY 52 The Future of Healthcare New innovative technologies delivering more measurable outcomes

HEALTHCARE MANAGEMENT

Arjen Radder, President, Philips Healthcare, Singapore

05 Achieving Transformational Care

58 Emerging Technology Trends in Asian Healthcare Organisations

Adam Chee, Chief Advocacy Officer, binaryHealthCare, Singapore

Sash Mukherjee, Asia Pacific Research Manager, IDC Health Insights, Singapore

09 Improving Local and Community Care for Older People Helen Tucker, Researcher, Independent Consultant & Vice-President Community Hospitals Association, UK

special features 18 Books

13 Next Wave of Investments in Southeast Asia Amit Varma, Managing Partner, Quadria Capital, India

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Diagnostics 17 Molecular Diagnostics – LEADERS’ ANALYSIS Stephen Bustin, Professor, Anglia Ruskin University, UK Gemma Johnson, Postgraduate Medical Institute, Faculty of Health, Social Care and Education, Anglia Ruskin University, UK Chee Gee See, Biomarker and Genetics, Programme Manager, Roche Products Limited, UK Chris Chamberlain, Global Head, Medical Genetics, Roche Products Limited, UK Natarajan Sriram, Director, Tulip Group, Orchid Biomedical Systems, India Albert Cheung-Hoi Yu, Chairman & CEO, Hai Kang Life Corporation, Hong Kong Lok Ting Lau, COO & General Manager, Hai Kang Life Corporation, Hong Kong

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Advisory Board

Editor Prasanthi Potluri Editorial Team Grace Jones Sasidhar Pilli Art Director M A Hannan Product Manager Jeff Kenney Senior Product Associates Ben Johnson Veronica Wilson Circulation Team Naveen M Sam Smith Steven Banks John E Adler Professor Neurosurgery and Director Radiosurgery and Stereotactic Suregery Stanford University School of Medicine, USA

Subscriptions In-charge Vijay Kumar Gaddam IT Team Krishna Deepak James Victor Head-Operations S V Nageswara Rao

Sandy Lutz Director PricewaterhouseCoopers Health Reseach Institute, USA

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 Confederation of Indian Industry

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

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Vivek Desai Managing Director HOSMAC INDIA PVT. LTD., India

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

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HEALTHCARE MANAGEMENT

Achieving Transformational Care ‘Achieving Transformational Care’ clarifies misconceptions, shares insights, best practices and strategies on how to optimise existing resources, redefine workflow and utilise technology to achieve quality and meaningful patient-centred care that is sustainable as opposed to ‘current common practices’ of applying stopgap measure to symptoms.

Adam Chee, Chief Advocacy Officer, binaryHealthCare Singapore

What is Transformational Care?

A common request I get from consulting clients on ‘transformational care’ projects is for a ‘standard template’ to help stakeholders in their ‘implementation’.

Unfortunately, while there are fundamental principles and concepts that one should be familiar with before undertaking such an initiative, there is definitely no cookie-cutter solution that one can take and hit the ground

running. Before I elucidate the core knowledge, there is one very important hurdle to clear – understanding what is transformational care?

So what exactly does transformational care constitute of?

Is transformational care achieved by adopting technology?

Is transformational care attained when a healthcare institute achieves HIMSS EMRAM Stage 6 or Stage 7 recognition?

The main point here is if you don’t know where you are going, you will never get there and this is the fundamental ‘Achilles Heels’ of many healthcare organisations in their quest for transformational care, resulting in unhappiness among relevant stakeholders (that usually develops into a vicious cycle of disgruntlement so watch out there).

Now back to the question - what exactly does transformational care constitute of? Well, keep this question

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in the back of your mind; we will revisit it in the middle of this article.

Transformational Care Guidelines

For the purpose of this article, we will examine five simple guidelines that scratch the surface of this subject (it is a very big topic).

1.There is no Cookie-Cutter Solution The first and perhaps most important guideline is - there is no cookie-cutter solution and I cannot emphasise this enough. To read deeper into this, it really just translates to - there is no utopia.

Hence it is paramount that one stop looking for the perfect technology / product / workflow / staff at zero cost while expecting additional freebies to be thrown in. But seriously, it is important to stop looking for solutions that do not exist and start focusing on how to solve the underlying problem.

There is no such thing as ‘better, faster, yet cheaper’, compromises are at many times, a harsh reality of life so the earlier one learns to deal with it, the better.

2.Fix the Problem, not the Symptom This is perhaps the most common mistake people make (regardless of situational context) when trying to fix a problem – mistaking the symptom as the problem. This poses many downstream problems since the underlying cause was never rectified.

Hence the next time a problem is identified (be it workflow or technology related), spend some time analysing the issue at hand. If time permits, perform a Root Cause Analysis to determine the real problem. This will minimise BandAid solutions from being applied.

3.Technology is an Enabler By technology, I refer to both IT and Health Informatics (yes, they are different) but in order for ‘an enabler’ to work, there must be something for it to enable.

This is the reason why the term GIGO (a phrase in the field of computer science) is such a popular

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catchphrase among techies. GIGO stands for Garbage In, Garbage Out, which essentially refers to the fact that computers (or in this case, technology) operate by logical process and will unquestioningly process unintended, even nonsensical, input data (Garbage In) and produce undesired, often nonsensical, output (Garbage Out).

To further illustrate this point, I will use power tools as an example; • Power-tools in the hands of a novice will not result in great by-products • Power-tools in the hands of a kid will result in disaster – maybe even to the kid too.

The main point here is, if you are implementing health informatics as part of your transformational care strategy (which you will), get a real Health Informatician.

The frequent mistake healthcare organisations make is thinking that Health Informatics is the same as IT – it is not. As a matter of fact, health informatics is a very different discipline that happens to use IT as a tool (just like the banking industry, the logistical

It is important to stress that healthcare organisations must learn to optimise workflow in order to achieve sustainable, contextually effective adoption of technology (be it IT or health informatics) to aid their transformational care initiatives.

industry or even the food and beverage industry).

It is important to get a real Health Informatician, not someone using second hand knowledge.

Note: For more information about the differences between ‘IT in Healthcare’ versus Health Informatics, please refer to the article Excuse Me, Are You a Thought Leader?1 Lastly, before you get attracted by the bells and whistles of any technology, work on getting your Health Informatics Standards right to achieve Semantic Interoperability.

This is crucial in enabling Clinical Decision Supports, Analytics, EMR adoption etc.

4.Semantic Interoperability is Fundamental From a technical aspect, Interoperability refers to the ability of two or more systems or components to exchange information and to use the information that has been exchanged.

The ‘systems or components’ in this case refer to the health / healthcare entities, be it people or organisations.

Loosely speaking, there are three levels of Interoperability: Physical Interoperability • Refers to the medium of connectivity or the physical connection • For example, ethernet cable, a thumb drive or wireless network etc.

Syntactic Interoperability • Refers to the standard formatting adopted to enable machine-tomachine exchange of data • For example using pre-agreed / defined industry standard format like XML or SQL etc.

Semantic Interoperability • Refers to the ubiquitous use of standardised vocabularies so data can be exchanged and the meaning kept intact To better illustrate my point, I would need to quote Charles Mead1 available at http://binaryhealthcare.files.wordpress. com/2009/03/excuse-me-are-you-a-thought-leader.pdf

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‘Syntactic interoperability guarantees the exchange of the structure of the data, but carries no assurance that the meaning will be interpreted identically by all parties’.

So why is semantic interoperability important? For starters, clinical classification & terminologies are pretty confusing and without semantic interoperability, a computer will have difficulty interpreting problem list, procedure list & results, progress notes, diagnosis, medication etc.

As mentioned earlier, semantic interoperability is crucial in enabling Clinical Decision Supports, Analytics, EMR adoption etc. and you will need to (properly) adopt healthcare informatics standards and terminologies to facilitate

Eight Dimensions of PatientCentered Care

semantic interoperability. This is not an easy feat so be sure to engage a real health informatician2.

5.The ‘Secret Ingredient’ is Workflow Workflow can ‘make or break’ many things, be it the healthcare organisation’s daily operation, technology adoption and yes, even attempts to achieve transformational care, but what exactly is workflow?

I have realised over the years that people (especially those who have never worked in any clinical settings) tend to confuse workflow with use-case and/or process, while the three concepts are 2 For more information about “Semantic Interoperability”, please refer to the YouTube video Generating Healthcare Data for Transformation through Crowds, available at http://www.youtube.com/watch?v=W8Z257a_Bxs

somehow related; they are definitely not synonyms of the same concept3.

It is important to stress that healthcare organisations must learn to optimise workflow in order to achieve sustainable, contextually effective adoption of technology (be it IT or health informatics) to aid their transformational care initiatives.

So, What is Transformational Care?

After covering the five simple guidelines (do note that while we only covered 3 Note: To illustrate the differences between workflow, usescases and process would require an article in its own right, please refer to the article Use Case vs. Process vs. Workflow, available at http://binaryhealthcare.files.wordpress. com/2009/03/workflow-the-secret-ingredient.pdf

Access to Care Patient's Preference

Family & Friends

Emotional Support

Overall Evaluation of Care

Physical Comfort

Coordination of Care

Information & Education Continuity & Transition

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Patient-Centred Care

To initiate a conversation on patientcentred care, we need to first examine provider-centred care, which is also known as the common model of care.

Provider-centred care is an acute / incident-based care model with the following attributes: • Is costly • Provides care for patients when they are sick (not proactive care) • A physician model with customer experience • Little coordination amongst health facilities, each contained in its own silo, patients receive no continuity of care.

Patient-centred care on the other hand, is a primary care practice where a partnership is established among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs and preferences. Patients’ input on the education and support are also

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The frequent mistake healthcare organisations make is thinking that Health Informatics is the same as IT – it is not.

point out that patient-centred care is not the same as patient-centric care, which refers to the utilisation of wireless technologies, built around the premise that personalised data and interactions (that emanate from the patient) are managed by both the patient and the provider. Health organisations can utilise patient-centric care concepts while adopting the patient-centred care model.

A Word on Innovation

solicited as they need to make decisions and participate in their own care.

In other words, health organisations adopting patient-centred care integrate patients as active participants in their own health and well-being. This is the fundamental differentiator between other models of care. The focus on wellness, patient education and active participation results in lower long term cost as patients are kept well (proactive health) and health outcomes are improved.

Patients are empowered with the tools and support needed for certain aspects of self-care and monitoring while being cared for by a physician who leads a medical team that coordinates across aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology.

To illustrate how patient centred this care model is, we need to review the eight dimensions of patient-centred care. At this point, it is important to

Author BIO

five, there are many more guidelines), we need to revisit the question – What is Transformational Care?

Briefly described, healthcare organisations imbued with principles of transformation care would deliver quality health services that improve the experience of their patients as well as their family and visitors. Such experiences are achieved by creating and delivering values that not only improve patient’s health outcomes but also the way health services are accessed as well as how patient care is delivered.

As one can see from the illustration above, transformational care is not better customer service, nor is it just treating the patient with respect, rather, it encompasses all these and more.

Importantly, involving the patient as a partner in managing their own health and well-being.

Transformational care is achieved via the adoption of patient-centred care.

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The second most common request I get from consulting clients on ‘transformational care’ projects is to provide training on ‘Innovation’ since this plays a big role in transformational care. While innovation itself is a major topic, it is important for me to provide a few insights pertaining to innovation.

• Innovation is not just about technology, it is about how to improve ‘everyday life’ • Innovation need not be delivered in a ‘Big Bang’ manner.

Incremental innovation resulting in effective workflow can be achieved when one is able to utilise the capabilities of existing solutions in their environment, suiting their contextual needs – the key lies in understanding the workflow involved and utilising existing resources to achieve transformational care.

Disclaimer This article serves as a prelude to the upcoming book of the same title. For more details pertaining to the book, please visit www.binaryHealthCare. com.

References are available at www.asianhhm.com

Adam Chee is the Chief Advocacy Officer of binaryHealthCare, a ‘purpose-driven’ boutique consulting firm offering training, advisory on technical and business strategies, specifically addressing the eHealth domains within (but not limited to) the APAC and Middle East region while serving to ‘Bridge the eHealth Divide’ by empowering stakeholders in both developed & LAMI counties on effective, sustainable adoption of Health IT as an enabler for ‘better patient care at lower cost’.

HEALT HCARE MANAGEMENT

Improving Local and Community Care for Older People The challenge for health services in the UK is to create capacity in the community for the increasing number of older people, so that they can be cared for close to home. Local community hospitals attract strong support from their communities and are successfully extending their role to meet increasing needs.

Helen Tucker, Researcher, Independent Consultant & Vice-President, Community Hospitals Association, UK

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he new Chief Executive of NHS England, Simon Stevens, has announced that he believes that ‘small hospitals have a big part to play, especially for older people’. This statement signals a shift in emphasis from a centralised and highly specialised service towards a more local, generalised and holistic service. The National Health Service in the UK is responding to changes in the population and its health needs by recognising the increase in older people who are typically frail, have comorbidities and complex care needs, and who require both health and social care. Where possible, the NHS aims to care for patients in their own homes or close to home facilities such as community hospitals rather than in specialist, acute care hospitals.

Community Hospital Services

The 450 community hospitals in the UK are well placed to provide many of the required local services. Originally called ‘cottage hospitals,’ they were created to provide a safe and clean environment of hospital beds for the treatment of patients living in rural and remote areas.

They have expanded their original service scope and have diversified with many of

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them now offering extended services and facilities to meet a wide range of health and social care needs.

Community hospitals are described as small local hospitals serving a defined population. Most of the facilities have less than 30 beds but the range varies from 10 to 100 beds. The hospitals have nurse-led services with medical support provided by local family doctors. There are no resident doctors. Communitybased staff have direct access to services, unlike the system with acute care hospitals that operates by ‘referral only’.

The community hospital is often described as a health and social care ‘hub,’ where many different healthcare providers deliver services. There is a wide variation of services in community hospitals, but key service areas include in-patient care, clinics, minor injuries units, diagnostics, therapy services and ambulatory care.

Community hospitals offer community beds that are not designated to any speciality but are used according to need. Patients can be admitted for inpatient care such as rehabilitation, assessment, sub-acute care or end of life care. Patients, on an average, stay for around two weeks, although assessment may just require a short stay and patients with complex rehabilitation may need to stay longer. The in-patient beds offer intermediate care, and help achieve the ambition of reducing unnecessary admissions to specialist District General Hospitals (DGHs).

Research on intermediate care in the community hospitals has demonstrated the care to be appropriate, effective and associated with greater independence. In particular, post-acute rehabilitation at community hospitals has been assessed as cost-effective and is appreciated by patients.

Community hospitals are now offering a range of clinics such as rapid access clinics for older people, audiology, rheumatology, mental health services and many more. It has been shown that the availability of clinics such as rapid

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Community Hospital Typical Services & Facilities In-Patient Ward

Minor Injuries Unit

Rehabilitation End of Life Care Maternity

Injuries / Ailments

Therapy Services

Clinics

Physiotherapy Occupational Therapy etc.

Specialist Community

Ambulatory Care

Diagnostics

Day Surgery Transfusions

Xray & Ultra Sound Phlebotomy

Facilities Meeting Rooms - Community Groups Catering - School Meals and Community Cafe

access clinics help reduce admissions to hospital, resulting in only 15 per cent of patients seen in the clinic being admitted to a DGH. ‘One stop clinics’ are also offered, where practitioners concerned with a particular condition or illness work together with feasible clinic times for patients so that they may be seen by different practitioners as required in one visit. A diabetic one-stop clinic would include a consultant physician, a diabetic specialist nurse, a podiatrist or chiropodist, an ophthalmologist and a dietician. This integrated way of working has proved to be effective for the patient and for the service providers.

Most community hospitals have ‘minor injuries’ units, some of which also attend to minor ailments. These offer swift access to clinical assessment followed by treatment, referral or discharge. In some areas these services are being expanded in order to try and

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relieve the workload and pressure on the emergency departments in DGHs. The diagnostic services usually include X-ray, ultrasound and phlebotomy. Some hospitals offer CT scanning and may offer day procedures such as gastroscopies. Ambulatory services also include blood transfusions and intravenous treatments. A number of community hospitals have services such as maternity, kidney dialysis and day surgery. Services for older people include memory clinics and dementia care units.

The range and scope of the service provision continues to expand beyond healthcare offering social, welfare, leisure and wellbeing services. Their role in health education, health promotion and involvement in the wider community through work in schools, colleges and public services, has led them to being described as part of the social fabric of their community.

HEALT HCARE MANAGEMENT

Characteristics

Three of the key characteristics of the community hospital model are described below: local medical care, integrated working and support from the local communities.

A feature of community hospital care is the role played by local family doctors. Local family doctors work in the hospital offering intermediate care, which is described as a bridge between primary care (general practice) and secondary care (DGH). GPs work as part of a formal multi-disciplinary team with nurses, physiotherapists, occupational therapists and social workers, with additional practitioners invited to join as required.

Joint working is a strong feature of the community hospital model. A study on ‘joint working’ across disciplines, sectors services and staff demonstrates that services are provided through partnerships. Partnerships that were particularly evident were those between the community hospital other health sectors (primary and secondary care), and agencies (third sector, social services and councils). Integrated care is a global priority in healthcare. The study shows that community hospitals can provide evidence of a long tradition of a long tradition of integrated working for patients of all ages and conditions.

Another feature of the community hospital model is the level of involvement and support from local people. Community hospitals were created through public donations of land and finance, and have a long tradition of providing care for over 100 years. Each hospital has an organised group of local people known as the League of Hospital Friends who support the hospital through activities such as fund raising and organising volunteers to work with the hospital. Funds are used for overall patient benefit, and for equipment furnishing, staff training and improvements to buildings. Local people are fiercely loyal to their local hospitals, and demonstrate it through highly active

campaigns if there is any suggestion of reducing or closing services.

Improving Care for Older People

Older people express satisfaction with the service, and cite features such as a high quality care that they can trust, including accessibility, familiarity of the hospital and staff and continuity of care.

Community hospitals can help improve care for older people by providing a service that they can be confident about, knowing it can offer a range of services to meet their changing needs. The community hospital often has a good reputation, and has been trusted by its community over many years. The tradition of care over generations is deemed important and local communities often speak of trusting the quality of care at ‘their’ hospital. This sense of ownership is a feature, and is visible in many aspects of the way the hospital operates.

Community hospitals are more domestic in size and scale than the specialist centralised acute hospitals, and are therefore less daunting and disorientating than large hospitals with long corridors and multiple clinical spaces. Patients, when asked, value the fact that the hospital is close to home, they can park easily and it is accessible for patients and visitors alike. For patients who are frail and vulnerable, and who may have compromised

Community hospitals are now offering a range of clinics such as rapid access clinics for older people, audiology, rheumatology, mental health services and many more.

mobility and cognitive limitations, these considerations are important.

Patients value the fact that they are being cared for by staff that they know.

Community nurses and therapists provide home-based care as well as care within the hospital, and so patients may see familiar staff who live locally, including their own family doctor.

It is known that older people appreciate being cared for by those who already know them, and know not only their medical conditions but also their social circumstances. This has been referred to as holistic care by staff, and complies with the person-centred care approach.

Patients can be supported in their local hospital throughout the progression of recovering from an illness, condition or from an incident or intervention such as an operation. The model of care ranges from helping patients to retain or maintain their independence, while supporting those who are living with long term conditions; monitoring and supporting those with deteriorating conditions and life threatening illnesses, and also patients requiring palliative care and end of life care. There is a challenge for staff working in small hospitals with such a wide remit which requires a wide range of skills, although clinical support and training is provided to generalist staff by specialist nurses and consultants.

Shared Learning

The Community Hospitals Association (CHA) for England and Wales supports staff and organisations that are providing community hospital services by developing a network of members for sharing good practice, offering advice and promoting community hospitals. The CHA is working with research institutions to further develop an evidence base to support informed decision-making for the future of community hospitals.

Community hospitals were originally established in the UK over 100 years

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Case Studies 1. Local Care Mr Smith, aged 85 years was transferred to his local community hospital after he had spent a day in a very busy assessment ward in a DGH, 35 miles away. He was assessed as he had a fall and was immobile and confused.

He was diagnosed with urinary infection and had a history of prostate cancer. He arrived in the evening, exhausted, confused, dehydrated and unable to move. He agreed on his plan of care, and after several days of medication, nutrition, physiotherapy and occupational therapy and nursing care, he declared that he felt like a new man and is now able to

walk across the room. He said that only when he got to his local hospital could he start to recover. He appreciated having his own doctor looking after him. He also said that it helped his wife visit him as he was close to home.

2. Community Initiative A group of volunteers for the community hospital who were members of the League of Hospital Friends were concerned about the high incidence of hip fractures in older people in their town. They consulted the GPs, and decided to purchase a dexa scanner for the hospital to enable early detection of osteoporosis. The group also funded staff training and support. They talked to GP practice staff and local groups, promoted the service and supported auditing of the service.

3. Life Stories A community hospital day unit provided support for older people including those with dementia. Staff wanted to create a project that would help older people to remember and celebrate their lives. They decided to encourage school children to offer to work with patients to create their ‘life stories.’ The resulting life stories were presentations illustrated with photographs and the patient’s favourite music. This intergenerational project is a feature of the local hospital being part of the community and was granted an ‘Innovation and Best Practice Award’ by the Community Hospitals Association.

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This demonstrates that features of the model may be replicated elsewhere, adapted and located within other health systems.

Conclusion

In summary, community hospitals in the UK have been providing care that is person-centred, integrated, and highly valued by the communities they Author BIO

ago. Over time many of the original hospital buildings have been extended, redeveloped or replaced in order to meet required clinical and quality standards.

However there are still community hospitals that require financial investment in buildings and this represents a challenge. Providers of community hospitals also face challenges in managing complex contractual arrangements for services, involving multiple partners. The partnership model has helped to create some innovative developments however, such as with social care and housing.

The model of the community hospital can be found outside of the UK, such as in Norway and the first community hospital in the Netherlands.

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serve. There is evidence of effective care for older people, particularly with outcomes for rehabilitation.Studies show that savings can be made for the health economy by providing more care locally. With an increasingly ageing population such local services will become more important and valued.

The service therefore not only meets national health policy, but it also fulfils the needs of patients, care providers and their communities.

References are available at www.asianhhm.com

Helen Tucker is a Researcher and Independent consultant specialising in community hospitals and integrated care. Helen is Vice President of the Community Hospitals Association, and has been working with community hospitals for 30 years. She is on the editorial board of the Journal of Integrated Care.

HEALTHCARE MANAGEMENT

Next Wave of Investments in Southeast Asia Technology-enabled healthcare has the potential to revolutionise the way people receive and manage care, by collaborating technologies, analytics and process innovation. This will drive the next wave of investment in the South East Asia region. The real value of Healthcare IT is derived only by continuous innovation in both product and service based technologies.

Amit Varma, Managing Partner, Quadria Capital, India

O

ver the past two decades, the Southeast Asian region has witnessed rapid growth and development, making it the hot bed for global investments. Most countries have prospered and the population has benefitted from the same. However, this prosperity has not percolated across all countries and sections of the society

and so is bereft of an inclusive growth model.

One sector that has been directly impacted by disparate growth and income levels is the healthcare sector. In a region that shelters approximately nine per cent of the global population and is expected to have eight per cent of world’s non-communicable deaths, healthcare

in the region attracts a miniscule six per cent of the global healthcare expenditure pie.

Furthermore increasing population, rising incomes and increasing prevalence of chronic diseases and comorbidities have put additional pressure on region’s healthcare systems to keep pace with the demand of more reliable professional and sophisticated healthcare services.

As a result, we have an ageing, underdeveloped and over-stretched healthcare systems in most of the Southeast Asian countries. The number of beds per 1000 people stood at 0.6 and 2.1 in Indonesia and Thailand respectively against 3.0 in the United States and the United Kingdom. The number of physicians per thousand stood at 0.3 and 0.4 in Indonesia and Thailand as compared to 2.4 each in USA and 2.7 in UK.

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HEALT HCARE MANAGEMENT

The gravity of the problem becomes apparent when looked at deeply. Due to significantly high proportion of patients paying out of pocket, most of the doctors prefer to practice in economically viable regions which creates further shortage of physicians in rural areas creating inequitable access of care.

While the region has seen an increase in investments in healthcare sector in the past few years, it is still not enough to keep up with the growing needs of a fast growing population. Much needs to be done, especially in ensuring uniform access to preventive and curative care and delivering increased value to patients at a given level of cost. As different countries try to re-structure care delivery model and promote efficient use of resources, a clear trend is pointing towards technology enabled healthcare as means to revolutionise the way people receive and manage care by collaborating technologies, analytics and process innovation. Promotion and introduction of technology in various spheres of healthcare infrastructure allows a leapfrog jump in healthcare provision for majority section of the population in an affordable and effective manner.

As a result of this, in my view, products and services that focus on leveraging technology to create an affordable and effective healthcare ecosystem will drive the next wave of investments in Southeast Asia region. The principal targets for such investments will be Technology Principals: Companies developing, manufacturing and selling medical technology products and services Technology Aggregators: Delivery platforms aggregating technology to provide healthcare services.

Both the above target segments are critical components of business models that will cater to the unmet demand in the most cost effective and efficient manner.

Technology Principals: These constitute of manufacturers and service providers who are driven by innovation,

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improvisation and affordability in the medical technology space.

They form a part of the US$ 4 billion medical technology industry in this region, with the 65 per cent current contribution from Malaysia, Thailand and Indonesia. While the market and its growth is dominated by MNCs, there is an encouraging contribution from local players. These local players, who are aggressively vying for a large share of this market, are supported by the market’s demand for low cost and low value products and hence will thrive on frugal innovation to achieve the aim.

Most of the device companies are focused on the chronic diseases segment, led primarily by diabetes, cardiovascular diseases and cancer. Today, Asia is home to 55 per cent of the world’s diabetic population and more than 50 per cent of the global elderly population.

Additionally, more than 50 per cent of deaths due to cardiovascular diseases and cancer happen in Asia. With expected increase in an ageing population and prevalence of chronic diseases the number of people affected by these diseases is bound to increase.

The indigenous medical device manufacturers in this region have long focused on the low-to-mid-market segment such as the surgical glove manufacturing in Malaysia. The local manufacturers are now shifting focus from low end rubber-based products, such as gloves and catheters, to manufacturing non-rubber-based and more advanced medical devices such as diagnostic imaging equipment, orthopaedic devices and implantable devices. Additionally, with the boom in medical tourism of major surgical procedures and standard medical care soaring in the region, it will further boost the sale of medical devices.

The medical devices and consumables market is expected to double to US$ 8 billion by 2017.

While an increasing number of MNCs are setting up R&D and manufacturing sites, some are also going ahead and partnering with local

ISSUe - 30 2014

medical technology firms. The local manufacturers, over the years, have built significant capabilities to develop innovative products. In the process, they have gained insights into customer demands and local dynamics and built efficient sourcing and distribution capabilities without increasing the overhead costs. Additionally, with better understanding and easy compliance with regulations, these firms are becoming a choice for partnering. A growing number of local manufacturers are also establishing themselves without partnering with MNCs, since they are now capable of developing products that can cater to needs of general physician as well as specialist both in urban as well as remote places.

Singapore is one country that has encouraged innovation in technology through tax breaks, financing and infrastructure. On the other hand, Malaysia has created a robust eco-system for production of advanced medical products. Indonesia and Vietnam support the region with basic materials for production.

As a result, the region has started attracting investments from both strategic and financial investors. In the recent past, Hong Kong based Comfort Enterprise acquired Ogawa World Berhad, a Malaysia-based medical equipment company. In March 2014, Employee Provident Fund of Malaysia acquired stake in Supermax Corporation

Products and Services leveraging technology to create an affordable and effective healthcare ecosystem will drive the next wave of investments in Southeast Asia region Technology Principals and Technology Aggregators will be the principal target for such investments.

HEALTHCARE MANAGEMENT

Berhad, a Malaysian company that manufactures, distributes, and markets medical gloves. Earlier, Southern Capital Group, a Singapore PE firm has acquired Aventa Bhd for US$165 million.

Other components of technology that will see a growing use are the IT enabled healthcare products and services such as Electronic Health Records (EHRs), Computerised Physician Order Entry (CPOE) and applications to manage care. Until now, IT was applied more to support the non-clinical functions such as accounting, procurement, human resources, admission, discharges, etc. However, the providers are now increasing the applications of IT across various functions, including clinical functions, due to its ability to save costs as well as improve the quality of clinical care. They also help reduce medical errors by mapping patient history with current prescriptions. These technologies also assist the physician review of the patient’s medical history and in accurately diagnosing the condition. As a result of IT applications in ancillary activities such as scheduling for doctors, staff, equipment and assets, healthcare services will transition to an online system allowing administrators to analyse various trends to minimise wastage of resources and optimise labour.

The changing environment in product and service innovation, is also witnessing support from governments in terms of improved regulatory situations in the regions. In some cases, like Singapore, the government has gone ahead to set up funds to encourage growth of medical technology start-ups.

The other segment of technology that is expected to attract investment is the technology aggregator space.

Technology Aggregators are companies that are seeking to leverage technology to create a platform solution for healthcare delivery services. Technology aggregators, commonly referred to as e-health companies, aggregate and offer services like Emergency Medical Response Systems (EMRS), m-health, telemedicine and remote patient monitoring.

Currently Asia has an average 5.9 physicians and 10 beds per 10,000 population. e-health the use of electronic processes and communication to deliver medical information, access or record data, or provide clinical services-has the potential to significantly bridge the huge gap between demand and supply of basic healthcare.

The e-health industry, across the Asia Pacific region, generates a revenue of ~U$8.5 billion and this is expected to grow exponentially. Various platforms

Underserved Region With Growing Healthcare Needs Hospital Metrics

Hospital Beds (per 1000) 4.0

Doctors (per 1000) 3.0

2.7 2.4

3.0

2.5 1.9

2.0 1.2

2.0 3.0

2.0

2.1

1.8

0.8 Malaysia

Thailand

Vietnam

Singapore

USA

UK

0.4

Source: WHO

1.5 1.0

0.3 1.0 Philippines

2.0

1.0

0.0

1.3

Indonesia

3.0

1.2

0.5 0.0

under e-health are expected to play an increasing role in delivering healthcare outside of the conventional clinical settings. These services are improving and accelerating access to care for people who otherwise might not have access to care or might have to travel to receive care. All these factors provide a strong foundation for adoption of technology by a majority of the people.

88 per cent of Southeast Asian countries reported the usage of emergency toll-free telephone services while 75 per cent of Southeast Asia uses mobile devices for emergency communications. 62 per cent of Southeast Asia reported adoption of mobile telemedicine initiatives. These numbers seem quite promising and are definitely a step in the right direction as countries try to provide better healthcare to people in this region.

Amongst the various components of e-health. m-health is expected to enjoy the highest growth due to surge in usage of mobile internet and availability of inexpensive devices. But the key to its growth will lie in support from other technology-driven services. These include improved patient management systems to store and analyse patient information, improved integration between diagnostic devices and mobile phones to record and transmit data to physicians remotely and a platform that facilitates care coordination & patient engagement channels.

This transition towards m-health provides an opportunity for various stake-holders, such as payers, physicians and med-tech companies to develop certain critical assets and capabilities.

Med-Tech Companies: These companies are working with physicians to increase the interaction and reach of the physicians with patients. They are designing and developing less expensive devices/technology that create and deliver value for an expanded set of customers. The aim is to reduce “total cost of care� rather than trying to minimise one time transaction costs.

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HEALT HCARE MANAGEMENT

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

Fast Growing ASEAN Medical Devices Market ASEAN Expenditure

ASEAN US$ 4 Billion

ASEAN US$ 8 Billion

2012

2018

in control; With Patients, they are trying to leverage technology to obtain more data and improve their selection and premium calculation process. Quite a few are encouraging patients to use self-monitoring devices as a means to constantly manage their wellness. This is done by gifting self-monitoring devices to patients and offering discounts on insurance premium who are constantly using these devices • Another trend that might be seen in the near-term is building capabilities for technology solutions, such as m-health and tele-medicine to take on the dual role of payer and provider.

With the growing potential, the e-health industry is seeing a rise in investment. In 2013, Geob International Sdn that manufactures a device that measures the skin’s humidity and temperature levels and displays the readings on the screen of the smartphone, received seed funding from Star Accelerator fund. While currently,

Author BIO

Providers and Physicians Providers and physicians fear the risk of losing patients and revenues to the ‘out of hospital care model’. Some of them fear getting obsolete, while quite a few of them believe that integration of technology would require major changes to both infrastructure and mind-sets of physicians.

• Technologies, such as m-health and tele medicine, will help increase the hospital reach for the patient, increases the utilisation of resources and augment revenues • Most of these technologies don’t require significant changes in workflow of the hospitals, apart from building a comprehensive patient management system. e-ICU, a concept that is growing particularly in India and could be extrapolated to this region, is one of the many examples of leveraging clinical expertise, processes and high-end technology for the benefit of the hospital as well as patients. In a country like India, that has more than 5 million ICU admissions every year, there are only approximately 5000 critical care physicians. An e-ICU is aimed at taking adequate critical care to patients at peripheral systems and minimising patient dislocation and disruption. The e-ICU can also train staff at peripheral care centres to treat critical patients in real-time and thereby improving critical care delivery. With most of the technology and manpower requirements standardised, an e-ICU spoke centre can be set up in less than three weeks. Hence, minimising the disruption of hospital operations.

Payers: Payers have now realised that technology will drive healthcare access in this region and hence will need to tweak their business model to keep up with the change. Very few have, however, gone ahead and are in the process of altering the dynamics with both the doctors and the patients.

• While with doctors, they are finding the right set of incentives to improve outcomes while keeping costs

ISSUe - 30 2014

most of the investments are happening at seed stage we do see big investments coming in to set up e-health platforms.

Going forward, maximum value may be realised by understanding what the patients want and how a more seamless care experience can be delivered. With each stakeholder wanting to find a place at the table to be a part of the technology growth story, will need to focus on developing and delivering products and services that create superior health outcomes based on evidences at affordable prices.

The above factors will push technology to the centre of healthcare planning in public and private sectors and therefore create greater opportunities for all stakeholders. And consequently, it augurs well for investors to focus on this segment of the healthcare market and participate in creating an inclusive growth in one of the most critical services for any society.

References are available at www.asianhhm.com

Amit Varma has over 20 years of private equity, strategic & operational leadership and board level experience with healthcare organisations across USA, Asia and Australia. Previously, he served in various roles including managing and operating P&Ls, procurement of medical supplies, strategy and quality of healthcare organisations, and recruitment of key physicians for organisations such as Fortis (Director of Critical Care), Narayana Hrudayalaya Private Limited and Manipal Heart Foundation.

Leaders’ Analysis

Molecular Diagnostics Diagnostics Rapid Evolution of Technologies Holds Out Much Promise Stephen Bustin, Professor, Anglia Ruskin University, UK Gemma Johnson, Postgraduate Medical Institute, Faculty of Health, Social Care and Education, Anglia Ruskin University, UK

Molecular diagnostics comprises a rapidly evolving range of assays for the detection and analysis of nucleic acid sequences and proteins. These enable the detection of pathogens, estimation of viral loads; help with the selection of antibiotic and antiviral therapies, diagnosis of cancer and other diseases and offer prognostic assessments as well as assistance with treatment selection and drug treatment efficacy monitoring. Inappropriate use of molecular technologies is also leading to serious issues with the clinical relevance of many molecular biomarkers in use today. There is an urgent need for standardisation of assay designs, laboratory practices, measurement methods and data management.

Human Genome and the Molecular Diagnostics Market Chee Gee See, Biomarker and Genetics, Programme Manager, Roche Products Limited, UK Chris Chamberlain, Global Head, Medical Genetics, Roche Products Limited, UK

Within the in vitro diagnostics industry, molecular diagnostics is the fastest growing segment. In little more than a decade, the clinical market for molecular diagnostic products has surged from $50 million to over $1 billion in the US, and is anticipated to reach a global market of $35 billion by 2015. These are astonishing exponential figures and they are an indication of the profitability of the molecular diagnostics market. Even more indicative is the market belief that a major portion of this will be attributed to advances in genetics, genomics and proteomics. It is therefore clear that molecular technologies will drive the expansion in market size and the range of applications in the molecular diagnostic market.

Challenges and Constraints in the Developing World Natarajan Sriram, Director, Tulip Group, Orchid Biomedical Systems, India

Currently, molecular diagnostic platforms that allow direct detection of target DNA / RNA of the infecting organism require instrumentation, trained manpower, special storage conditions, special laboratory infrastructure etc. and hence are not ideal for the developing countries. However, the future is likely to see the development of novel, simple and inexpensive molecular platforms and other technologies such as microfuidics and nanotechnology that could be used for better disease management in developing countries.

Need to Incorporate New Technologies that Help in Fighting Emerging Diseases Albert Cheung-Hoi Yu, Chairman & CEO, Hai Kang Life Corporation, Hong Kong Lok Ting Lau, COO & General Manager, Hai Kang Life Corporation, Hong Kong

Molecular diagnostic tools have been around for years and are advancing with time. They have allowed us to discover diseases that may appear new but have been loitering around for some time. Molecular diagnostics are sensitive, can be performed more rapidly with high throughput and at a lower cost. However, molecular diagnostic tests are not commonly used and virus culture still remains the method of choice. Also, most technicians in developing countries are not well trained to use molecular diagnostic tests. At the moment, microarray technology is developing rapidly but it still lacks the sensitivity for direct application to clinical specimens. Nevertheless, these new technologies are an option and through the availability of portable machines for conducting tests, they may change the face of diagnosis of emerging diseases in the future.

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17

Books

Principles of Molecular Diagnostics and Personalized Cancer Medicine Editors: Dongfeng Tan, Henry T Lynch No of Pages: 992 pages Year of Publishing: January 9, 2013 Description: The role of molecular genetics in the treatment of malignancy continues to grow at an astonishing rate. Today’s subspecialised multidisciplinary approach to oncology has incorporated advances in targeted molecular therapy, prognosis, risk assessment, and prevention - all based at least in part on molecular diagnostics and imaging. Inside this cutting-edge resource, readers will explore broad, comprehensive perspectives on the current trends in molecular diagnosis of cancer and personalized cancer medicine.

Authoritative discussions share insights from noted experts in cancer research, clinical trials, molecular diagnostics, personalised therapy, bioinformatics, and federal regulations. From the basic mechanisms of carcinogenesis to the most advanced molecular screening, staging, and treatment technologies, readers will discover clear and straightforward discussions directly relevant to patient diagnosis and care.

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Molecular Diagnostics: Current Research and Applications

Next-Generation Sequencing & Molecular Diagnostics

Editors: Jim Huggett, Justin O'Grady No of Pages: 260 pages Year of Publishing: May 1, 2014 Description: The application of molecular technology in clinical diagnosis is a rapidly developing area and is predicted to greatly improve the speed, efficiency, and accuracy of diagnostic medicine. The editors of this book have commissioned an excellent series of chapters representing two key molecular diagnostic areas: cancer and infectious diseases. The cancer section deals with the challenges in identifying genetic, epigenetic, and transcriptomic biomarkers. The infectious disease section describes the current clinical applications of molecular diagnostics for the detection of viral, bacterial, and fungal pathogens, as well as an example of the use of molecular diagnostics outside the clinic environment. A cautionary tale describing what can go wrong when molecular methods are applied incorrectly is also provided and makes fascinating reading. A substantial component of the book is dedicated to the process of translating a preclinical test to the bedside and describes the progress in the near patient point-ofcare molecular diagnostics market.

Editor: Dimitrios H Roukos No of Pages: 116 pages Year of Publishing: February 13, 2013 Description: In striving to improve healthcare, the field of genome sciences is rapidly evolving into clinical genomics.

Changes in the structure, regulation and function of the human genome define disease pathogenesis. Fast and accurate DNA sequencing at a genome-wide scale, at a relatively low cost, has revolutionized life science and research. Nextgeneration sequencing (NGS) technologies coupled with advanced microarrays referred together as high-through-put technologies (HTs) enable new identification of mutations and deeper exploration of the functional principles orchestrating the function of genes, genomes and cells. Translating these complex genomic discoveries into clinical medicine offers substantial benefits as we move toward clinical personalized health management.

In this book, internationally renowned experts explore the power and challenges for the integration of NGS into the clinic.

ISSUe - 30 2014

What’s causing it

will it get worse i s m y d i ag no s i s co r rec t

am I sick

which woman is at highest risk of

how can we prevent strokes

and save millions

what diseases do I have

who should manage

cervical cancer

her heart disease

how can I reduce my post-operative hospitalisation costs

who is t he b es t c an d i d a te

is he suffering for treatment

Is something

wrong with me

a heart attack

do I have cancer

did my pap miss

Am I at risk

something is he HIV+

will this patient

recover quickly

after surger y

I s my ba b y

healthy

is my treatment

working

can I

still get

pregnant

I know I

am not at risk

we caught it early

I know I am ok

I know the tre a tmen t

will work I am in control

my baby is fine

I KNOW WE CAUGHT IT EARLY THE POWER OF KNOWING Roche Diagnostics Pte. Ltd. www.roche.com

Roche Diagnostics gives you The Power of Knowing that you're using accurate information to make the right decisions today, so your patients can experience a healthier tomorrow.

CaseStudy

TECHNOLOGY, EQUIPMENT & DEVICES

Medical Device Research at a Regional Health System The Mercy experience

Mercy’s research department develops information from electronic information systems to support quality improvement and operational efficiencies that generate revenue. A major research effort was a Unique Device Identifier (UDI) project which resulted in operational efficiencies and a database that is being used for comparative effectiveness and safety analyses.

Joseph P Drozda, Director, Outcomes Research, Mercy, US Timothy R Smith, Vice President-Research, Mercy, US

I

n 2009, Mercy made the decision to embark on a research programme involving implanted medical devices by employing Unique Device Identifiers (UDIs). Mercy is a four-state regional health system headquartered in St. Louis, Missouri that serves communities in Arkansas,

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Kansas, Missouri, and Oklahoma through 40 hospitals ranging from small, critical access facilities to large tertiary medical centres. In addition, Mercy employs over 2,000 physicians specialised in multiple disciplines and generates in excess of US$4 billion annually.

ISSUe - 30 2014

Mercy’s Information Journey

In 2006, Mercy began implementing EpicCare (Epic, Verona, WI) Electronic Health Record (EHR) in all of the system’s hospitals and employed physician practices - a process that took over six years to complete which resulted in a ‘fully connected’ health

TECHNOLOGY, EQUIPMENT & DEVICES

system generating a significant amount of clinical data across the healthcare spectrum. Despite this success, Mercy continues to face challenges in turning these data into actionable information due in part to free-standing clinical and administrative databases such as those contained in the cardiac catheterisation laboratory (Cath Lab) software and the Enterprise Resource Planning (ERP) solution. These ‘data islands’ make it difficult to establish a comprehensive view of administrative, clinical processes and of patient outcomes necessary for Mercy leaders to manage in the changing healthcare environment created by US Affordable Care Act (ACA).

New Business Environment and Need for Actionable Information

As healthcare reforms proceed, Mercy must learn to deal with US Centers for Medicare and Medicaid Services (CMS) programmes such as valuebased purchasing, and public reporting of hospital and physician performance, along with different delivery models, such as patient centered medical homes and Accountable Care Organisations (ACOs). Mercy’s Springfield ( Missouri), network is participating in CMS’s ACO programme building on experience gained from the network’s successes as part of the earlier CMS Physician Group Practice demonstration. Finally, CMS is also working on new reimbursement strategies meant ultimately to replace fee for service. These include shared savings; bundled payments; and, potentially, monthly payments per assigned beneficiary (capitation). All of these changes will require an in-depth understanding of both the clinical and administrative aspects of the business and how the two interrelate.

Overall Data and Information Strategy at Mercy

To gain the in-depth business intelligence needed by an American hospital system in a post-ACA world, Mercy has undertaken a comprehensive

The field of implanted medical devices is an area where both clinicians and administrators will require in depth information and analysis if patients are to be provided with high quality care that is affordable.

data strategy that begins with optimising data flow through all of its electronic information systems organised around the individual patient. This data is then channeled through a data warehousing solution called the Integrated Patient Datamart (IPD) from which data sets can be created that contain information from multiple source systems being available for analysis and use at the point of care. As a means of extending and strengthening this strategy, Mercy is developing data partnerships with national registries such as the American College of Cardiology’s National Cardiovascular Registry (NCDR), and with like-minded health systems, such as the Healthcare Transformation Group (HTG), which, in addition to Mercy, is composed of Geisinger Health System, Intermountain Healthcare, KaiserPermanente, and Mayo Clinic.

Through this comprehensive data strategy, Mercy is achieving a number of patient care and business goals.

Mercy is improving care quality and gaining clinical efficiencies by bringing actionable information to clinicians at the point of care and by performing sophisticated clinical analyses. Detailed knowledge of costs in relationship to clinical outcomes greatly assists Mercy leaders in working with clinicians

to optimise resource utilisation. The knowledge gained includes results of comparative effectiveness research of various diagnostic and therapeutic approaches including the use of expensive technologies as employed by Mercy clinicians. Finally, the data constitutes a business asset which is of value to third parties presenting a revenue generating business opportunity. In summary, the Mercy information strategy is designed to help ensure that the system thrives in any business environment.

Mercy’s information strategy is enabled by automated capture of high quality data and by rigorous attention to data standards. This includes control points embedded within care processes enabling better decision making and improved documentation. One outcome is the creation of integrated data sets through IPD that are highly scalable.

Medical device information as prototype

Mercy identified implanted medical devices as a priority area for converting data into information since these devices are not only expensive but the appropriateness of their use and their in-vivo performance also has

Examples of outputs from Mercy’s information strategy • Internal patient registries to manage gaps in care • Point of care decision support and shared decision making tools • Analytics to assist in understanding the drivers of readmissions • Creation of risk models to guide patient management • Comparative effectiveness of medical devices.

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TECHNOLOGY, EQUIPMENT & DEVICES

Mercy

33 Acute care hospitals

4 Heart hospitals

2 Rehabilitation hospitals

2 Children's hospitals (include in acute care)

1 Orthopedic hospital 40,000 Employees 2,108 Employed physicians 875 Employed advanced practitioners 5,515 Medical staff members $4.38 Total operating revenue (in billions)

significant implications for the quality of patient care. Several groups of Mercy stakeholders identified information needs relative to medical devices.

Mercy’s supply chain leaders were concerned that the premium prices attached to some devices within a class, were not supported by data establishing superior effectiveness when used in the real world by Mercy physicians. Clinical support personnel in Mercy’s Cath Labs faced obstacles in managing inventories of implanted devices because of highly manual processes that were cumbersome and inefficient. Physicians faced a number of challenges when caring for patients with implanted devices.

They often did not have ready access to critical device information needed

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for diagnostic and therapeutic decision making. When devices were recalled, physicians found it difficult to determine which of their patients, if any, were affected by the recall. Finally, physicians faced challenges in reporting adverse events related to devices because of lack of ready access to device information.

Mercy’s Research Department identified a need for device data infrastructure to support health services and comparative effectiveness research along with safety surveillance. The requisite infrastructure would include automated capture of significant clinical and device variables along with linkage to external databases such as Health Information Exchanges (HIEs) and national registries. In summary, robust device information

ISSUe - 30 2014

would support three of Mercy’s fundamental goals: superior patient care experience including outcomes, care provider satisfaction, and optimal financial performance.

Mercy assembled a multi-disciplinary team under the leadership of the Research Department to create a system for tracking implanted medical devices from product receipt through implantation to post-implant patient follow up. The team included clinicians, information system architects, and supply chain and performance optimisation personnel.

The new system was to be modelled after one that was already in use at Mercy for tracking medications and that was built on National Drug Codes (NDCs) which are specific to individual drugs.

TECHNOLOGY, EQUIPMENT & DEVICES

FDA Demonstration Project

In 2012 Mercy had the opportunity to accelerate its medical device information strategy through participation in the U.S. Food and Drug Administration’s (FDA) Medical Device Epidemiology Network (MDEpiNet). As a subcontractor to the MDEpiNet Methodology Center at Harvard University, Mercy performed a demonstration project whereby UDIs were integrated into Mercy’s electronic information systems. Details of the demonstration project are described in detail elsewhere. 1 A UDI is a unique numeric or alphanumeric code that contains 2 types of information: a Device Identifier, which is specific to a device model, and a Production Identifier, which includes the current production information for that specific device, such as the lot or batch number, the serial number and/or expiration date.

The FDA requires product labellers to put UDIs on most medical devices beginning from September, 2014, with the highest risk devices (Class

III). UDIs, then, have the potential to function for devices as NDCs do for medications. Additionally, the FDA has also created a database of device attributes (the Global UDI Database or GUDID) linked to the UDIs. To achieve the demonstration’s aims the Mercy team accomplished a number of tasks. The first was to create Draft UDIs since the project was carried out before the FDA’s UDI requirements were in place and to associate them with the attributes in the FDA’s GUDID. This was accomplished with the cooperation of the coronary stent manufacturers (Abbott, Boston Scientific, and Medtronic) using GS1 barcode standards (GS1, Brussels).

The FDA supplied Mercy with GUDID information since the database was not fully functional during the time of the project.

Mercy also worked with an expert panel of cardiologists to create supplemental attributes to be stored in a reference database (supplemental UDI database or SUDID). These attributes

Mercy Demonstration Project aims to • Implement a coronary artery stent UDI-based surveillance system in the EHR in a multihospital system • Identify obstacles to implementation of UDI in clinical information and to characterise the effectiveness of interventions to overcome them • Assess the validity and utility of data obtained from the EHR and incorporated UDIs for purposes of post-market surveillance.

are specific to coronary stents and significantly affect device performance but are not found in the GUDID. Mercy system architects then created a UDI data flow through ERP to Cath Lab hemodynamic software to EHR and ultimately to a UDI research

UDI Example

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TECHNOLOGY, EQUIPMENT & DEVICES

UDI Phase 2

During the demonstration, Mercy’s HTG health system partners helped ensure the project’s generalisability with the intent of expanding the work to include all five systems at some point. The plan for UDI Phase 2 is to replicate Mercy’s UDIR at each of 3 additional HTG

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systems (Geisinger, Intermountain, and Mayo) and to create a distributed data network using the CathPCI Registry as the hub with the NCDR providing network coordination, business rules, and a common data model to support analytics. The distributed data model has been advocated by the U.S. Agency for Healthcare Quality and Research (AHRQ) for data sharing and research by provider networks. It has the advantage of keeping sensitive information behind the ‘firewalls’ of the data owners while still being available for combining with data from all network members for research purposes. The resulting robustness of the combined datasets greatly enhances their ability to answer questions on product performance and safety as compared to the smaller datasets from individual health systems.

In order for Phase 2 to be successful, an alliance of key stakeholders will be assembled. Besides the HTG health systems, these include national medical societies (ACC and the Society for Cardiovascular Angiography and Interventions), the pertinent national registry (NCDR), coronary stent manufacturers (Medtronic, Abbott, and Boston Scientific), and consumer groups representing patients. Mercy utilised a similar partnership during the demonstration project and found that no system of device surveillance and research is viable without the active participation of these important constituencies. The intent is to employ the template created

Author BIO

data set (UDIR) generated by the IPD and useful for research and safety surveillance. The data flow is hinged on implementation of a Cath Lab barcode scanning, point of use system (OptiFlexsm, Omnicell, Mountain View, CA). The UDIR contains device attributes drawn from the GUDID and SUDID together with clinical data from the hemodynamics software and EHR and mortality data obtained from the Social Security Death Master File. Patient data isadded to the UDIR on a weekly basis to enable longitudinal patient and device follow up.

Mercy also worked with the NCDR to create UDI fields in the NCDR’s CathPCI Registry. Mercy’s Cath Labs report their coronary stent cases to the CathPCI Registry, which captures in excess of 85 per cent of such procedures performed in the United States. This was an important task for two reasons. It was the first step in developing a system for automated reporting to the registry, which now requires manual data entry.

Secondly, Mercy’s goal and that of its partner health systems is to create a data network using the CathPCI Registry as the hub.

Once the UDIR was in place Mercy researchers performed studies to demonstrate the validity and reliability of data. The plan is to publish results in the near future. Finally, Mercy has also identified obstacles to incorporating UDIs in our electronic information systems, explored solutions, and will publish these findings as well. In the meantime, Mercy is taking the learnings from this project and beginning implementation of a point of use system in its operating rooms.

ISSUe - 30 2014

and tested in Phase 2 for developing similar systems for use with all implanted medical devices using national registries when they are available.

Summary and Conclusions

As other American hospital systems have also discovered, Mercy recognises that actionable information for all members of the healthcare team is critical in this new era of healthcare reform and accountable care with its emphasis on improved patient experience, improved health of communities, and lower per capita costs. With these exigencies in mind, Mercy has embarked on a strategy of information creation and analytics to take advantage of the vast amount of data it is capturing in its electronic information systems. The field of implanted medical devices is an area where both clinicians and administrators will require in depth information and analysis if patients are to be provided with high quality care that is affordable. With that in mind, Mercy and its HTG partners have embarked on an ambitious programme of UDI-based device surveillance and research that is anticipated to yield many operational and clinical benefits.

Reference: Tcheng JE, Crowley J, Tomes M, Reed TL, Dudas JM, Thompson KP, Garratt KN, Drozda Jr JP. Unique device identifiers (udis) for coronary stent post-market surveillance and research: A report from the FDA’s Medical Device Epidemiology Network (MDEpiNet) udi demonstration, American Heart Journal (2014), doi: 10.1016/j. ahj.2014.07.001.

Joseph P Drozda is a Cardiologist and Director, Outcomes Research at Mercy. His group at Mercy performed an FDA demonstration on incorporation of Unique Device Identifiers (UDIs) into Mercy information systems for purposes of surveillance and research. He leads a team from 5 health systems developing an extension of the demonstration.

Timothy R Smith is Vice President - Research at Mercy. His enterprise - level research leadership provides strategic and tactical support for Mercy’s Unique Device Identification project. His team of researchers and other personnel provide support for database development, analytics, research conduction and investigator development Mercy-wide.

TECHNOLOGY, EQUIPMENT & DEVICES

21st International Exhibition and Conference

India's No. 1 Trade Fair for Hospitals, Health Centres and Clinics

21–23 March 2015 Halls 11, 12, 12A Pragati Maidan New Delhi, India

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Santacruz (West) _ Mumbai 400 054 _ India Tel.: +91 (0) 22 6678 9933 _ Fax: +91 (0) 22 6678 9911 Mr. Suraj Ullal Email: UllalS@md-india.com

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TECHNOLOGY, EQUIPMENT & DEVICES

Preventing Medical Errors with Proven Bar-Code Technology Bar-code technologies, which have proven effective at points-of-sale in stores and during order-fulfillment in warehouses are preventing errors at points-of-care and during medication preparations in hospitals.

Mark Neuenschwander, President, The Neuenschwander Company, US

A

US television commercial for Berlitz language courses begins with a senior officer briefing a draftee on how to man the station before leaving him on his own.

No sooner had the officer left than a desperate call crackled over the radio: ‘May day! May day! Hello! Can you hear us? We are sinking. WE ARE SINKING.’ The novice slowly and deliberately replies in his second language, ‘Hello, zis iz za German coast guard.’

With no time to spare, the party in peril fires back, ‘We are sinking. We are sinking!’ To which the young radio pal replies, ‘What are you zinking about?’

Admittedly, I speak only English and many (perhaps most) reading this article have English as their second language. Please bear with me as I use my language to share a few things we

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

are learning in the US about improving patient safety.

I’ve been thinking about how easy it is to get things wrong.

At my grocery store, the 1 per cent and non-fat milk containers sit next to each other in the cooler. They look alike except that one label is a lighter shade of blue than the other. Don’t ask me which one. I can’t remember. More than once, I’ve arrived home with the wrong product.

The same is true for medications in hospital pharmacies. Not only the containers but the names also often look and sound alike.

According to a 2006 survey by the American Society of Health-System Pharmacists (ASHP), the number-one fear gripping patients (61 per cent) entering hospitals is that they will be given the wrong medication. Their

ISSUe - 30 2014

fears are reasonable. According to the Institute of Medicine1, one in five medication administrations involves an error, resulting in as many as 1.5 million adverse drug events each year.

An estimated seven thousand of these errors result in death, roughly the 1 To Err Is Human, Institute of Medicine, Nov 1, 1999.

TECHNOLOGY, EQUIPMENT & DEVICES

equivalent of 6.5 plunging Titanics, or an AirBus 330 crashing every three weeks. If planes and ships went down at this rate, we would all stay home.

For over a decade, The Joint Commission’s (TJC) yearly National Patient Safety Goals have had the same number-one goal: ‘Improve the accuracy of patient identification,,

requiring hospitals to use ‘at least two patient identifiers when providing care, treatment, or services.’ TJC’s third perennial patient-safety goal: ‘Improve the safety of using medications,’ requiring hospitals to annually review a list of look-alike/soundalike medications and to ‘take action to prevent the interchange of these

medications.’ This short list illustrates their point: Cerebyx vs. Celebrex Cedax vs. Cdex Dioval vs. Diovan Diovan vs. Darvon Dobutamine vs. Dopamine Epinephrine vs. Ephedrine

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TECHNOLOGY, EQUIPMENT & DEVICES

Can you read the paragraph below?

Apaprenlty, the oredr of the ltteers in a wrod deosn’t raelly matetr that mcuh.

The olny iprmoatnt tihng is taht the frist and ls a tltteer be in the rghit pclae. The human mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Evreywrod in tihs paragrahp wtih fuor or mroe letetrs is missepled.

For all those whose first language is English, the paragraph above was an easy read. This suggests that the more familiar a person is with drug names, the greater the possibility of getting confused with them. Did you notice with the drug names above how not just the first and last letters were the same but also the first and last syllables were similar?

As a lay person, the drug names on the above list do not look alike to me, nearly as much as they do for pharmacists or nurses who know them well.

The same confusion happens with patient names. Not only do some names look and sound alike (e.g., Smyth, Smith); some patients in the same hospital may have similar or same names. Nearly five million people in the US have the surname Smith or Jones. In China, around 180 million people are surnamed Wang or Li. Even with rare names, mix-ups occur. On his way to surgery in a 200-bed hospital, my uncle had a medical chart on this chest bearing his name. My aunt complained that someone used the wrong middle initial.

‘It’s N,’ she protested, ‘not A.’ Turns out that David N Neuenschwander was heading to surgery accompanied by a chart belonging to one David A Neuenschwander.

No patient wants to be affected by a medical error, nor does a caregiver.

During a typical business day, nearly six billion bar codes are scanned around the world with virtually no errors. Prior to point-of-sale bar-code scanning, IBM studies involving the review of cash-register receipts from customers leaving supermarkets showed that one in ten entries had an error.

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Scanning at the point-of-sale was born in the United States forty years ago on June 24, 1974. The first bar code read by a scanner on a retail product was a pack of Wrigley’s Juicy Fruit chewing gum. Within ten years, virtually all items in grocery and drug stores had bar codes. Soon, dresses at department stores and wrenches at hardware companies had bar codes.

Scanning was being used to track packages, identify cattle and luggage, and admit fans to concerts and football matches. Bar codes were everywhere on everything - except on patients and drugs in hospitals.

Two decades after the Juicy-Fruit scan, a nurse named Sue Kinnick was vacationing in Seattle. Upon returning a Hertz car at the airport, she was impressed that the agent could retrieve her rental record just by scanning the bar code on the windshield. In fact, she

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According to the Institute of Medicine, one in five medication administrations involves an error, resulting in as many as 1.5 million adverse drug events each year.

was so impressed that she nearly missed her flight to Kansas by asking questions.

Upon returning to work, she asked the medical centre’s IT department if they could create something like this for positively identifying patients. In 1995, bar-code scanning at the point-of-care (BPOC) was born. To make it work, the hospital had to apply its own bar codes to all drug packages, an ominous and high-risk practice.

Bar codes did not appear on hospital drugs until 1991 and then only on a dozen products. It would take another fifteen years before all drugs would have bar codes but not without

TECHNOLOGY, EQUIPMENT & DEVICES

first convincing the US Food and Drug Administration (FDA) to issue a rule requiring drug manufacturers to include them on all immediate packages effective April 2004. This proved to be the tipping point for the widespread adoption of scanning at the point-of-care.

Safe practice requires comprehensive bar coding at the source, which rarely happens voluntarily. In most cases, source labelling requires government regulations.

Today nearly two-thirds of US hospitals are scanning patients and most medications and the results are impressive.

A landmark study from the Brigham and Women’s Hospital in Boston, published in the New England Journal of Medicine, demonstrated the benefits that other ‘bar-coding’ hospitals had claimed to experience:

41 per cent reduction in non-timerelated medication errors 51 per cent decrease in non-timerelated potential adverse drug events 27 per cent decrease in time-related medication errors Scanning medications is but the nose of the camel that we need to shove into the bar-code tent. Expect to see more and more hospitals implement scanning at points of collection to properly label and track blood, stem cells, specimens, biopsies, x-rays, and mother’s milk. Scanning will be increasingly utilised for matching patients with transfusion, implant, meal, TPN, medical device, and other medical service requirements, as well as for matching babies with mothers and ensuring that caregivers have the right documents for the right patients.

The list is endless.

The next gap we are addressing in US hospitals is upstream in the medicationpreparation process. While most medications can move from the loading dock through the pharmacy to the point of care intact with manufacturer bar-coded labels, some medications require preparation and compounding.

These include the higher-risk drugs like chemotherapy, often involving high-risk patients (e.g. paediatrics, oncology, etc.)

In my lectures, I show a quick video clip of my topping off a paper cup with Dr. Pepper at a self-service soda fountain. Then I ask the audience what was in my cup. Not everyone pays enough attention to get the answer right.

So I show the clip again. Knowing the question, they pay close attention, and everyone gets it right. Actually, everyone sees that they were wrong when I show them the full video, in which I randomly add ten sodas into the cup before I reach Dr. Pepper. In the US, we call this drink a ‘suicide.’

Then I show an IV bag that has been prepared in a pharmacy and ask, ‘What’s in the bag?’ They don’t know, of course, and neither do nurses. They must trust that their pharmacies have followed the orders.

BPOC cannot determine if bags have been compounded and labelled correctly. And the fact is, a significant portion is not. I’ve seen studies falling under the 5 to 10 per cent error range.

What if FedEx were to have as high an error rate? They would not be in business. But even when FedEx gets the right-labeled boxes to the right customers, what if Amazon has filled 10 per cent of these boxes with wrong items in the warehouse? Amazon would be out of business.

The fact is when Amazon fulfils orders, they have an error rate of .001 per cent, which is achieved with bar-code order verification systems.

Scanning at the point-of-care cannot fix compounding errors, but scanning ingredients in the pharmacy can prevent compounding errors.

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TECHNOLOGY, EQUIPMENT & DEVICES

2 “In the Clean Room: A Review of Technology-Assisted Sterile Compounding Systems in the US,” Mark Neuenschwander and Jerry Fahrni, PharmD. www.hospitalrx. com

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Bar codes did not appear on hospital drugs until 1991 and then only on a dozen products.

error types, the most repeated of which involved wrong selection of products.

While these data are frightening, the fact that BCMP technology intercepted the errors in pharmacies before reaching patients is encouraging.

For years, I have argued that bar coding at the point-of-care is to patient safety is like what seatbelts are to passenger safety—not the only thing but a salient thing. Cars must have good brakes, clean windshields and drivers should be sober, and drive defensively.

Caregivers must be well rested, highly trained, undistracted, and attentive.

But when everything is said and done, accidents happen and bar coding can keep caregivers and patients from flying through windshields.

I will not rest until we view scanning the patients in hospitals as important as buckling up before putting our cars in gear. I will press on until we view failure to scan infants before administering heparin as horrifying as driving off without having secured them in safety seats.

A 2012 study by the Automobile Association of America revealed that

Author BIO

Though presently fewer than 5 per cent of US hospitals are using bar-code enabled medication preparation (BCMP) systems to compound sterile products, I expect most will do so by the nd of this decade.

A colleague and I have just completed an extensive report on BCMP technologies available in the US, reviewing over a dozen products, including2 semi-automated manual and highly robotic systems. Both types use bar-code scanning to verify ingredients and to produce final order-specific bar-code labels for scanning prior to administrations.

Semi-automated manual systems utilise a combination of imaging and gravimetrics. Cameras capture images of drug vials and drawn syringes during compounding, which pharmacists may view when checking completed orders. Some systems utilise gravimetric verification tools, which require compounding technicians not only to scan products to ensure they have the right drugs and diluents but also to weigh vials, syringes, and bags before and after draws and injections. These steps verify that the right amounts of ingredients have been used. This is analogous to self-checkout grocery stands. One-by-one, shoppers scan products and place them in bagging stations. If the weights don’t match the items scanned, shoppers cannot proceed.

With highly automated robotic systems, technicians must manually place drugs, diluents, and containers onto staging platforms from which robotic arms retrieve items and complete the compounding process.

One leading BCMP provider compiled data from several million IV preparations, which revealed a consistent product selection error rate of nearly 5.5 per cent distributed across 14 different

ISSUe - 30 2014

three of four infant safety seats are improperly installed in automobiles.

Many parents, committed to the welfare of their children, have the illusion that their little ones are safe. Kids may be properly placed in car seats, but if those seats have not been installed correctly, the seats and the children are at risk of going through windshields.

Taking things full circle, scanning at the point of care may likewise have a false sense of safety if the hospitals are not utilising bar-code safety systems when compounding medications in their pharmacies.

As hospitals attempt to make their ships safer for patients, I hope they will also consider the benefits to other invaluable passengers on board.

In 2010, here in Seattle, a loving nurse, with 25 years of exemplary service, accidentally overdosed an infant with sodium chloride. Six months later, unable to endure the grief, she took her own life. Four years earlier, on her second birthday, Emily Gerry’s life was lost as a result of a compounding error in the hospital’s pharmacy. The pharmacist on duty was charged with a felony, spent time in jail, and lost his license to practice his life calling and passion. Such mistakes could have happened to any nurse or pharmacist.

Both could have been prevented by using proven bar-code systems, one at the point of care, the other upstream during the preparation process. These deaths were unnecessary.

We owe everyone on board the safest journey possible—patients and caregivers alike.

That’s what I’ve been thinking.

What do you think?

Mark Neuenschwander, President of The Neuenschwander Company is a leading authority and consultant on barcoding in healthcare, frequently lecturing throughout the US and around the world. In 2010, he was awarded the Institute of Safe Medication Practices’ Lifetime Achievement Award

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FACILITIES & OPERATIONS MANAGE MENT

Using Operational Planning Studies To improve planning and design in healthcare facilities This article highlights case studies in the use of lean principles and operational planning that impact the plan and design of healthcare facilities. The role of operational studies on determining facility size, operational efficiencies, process improvement, and innovative approaches, delivery of care and patient / staff experience and satisfaction is demonstrated.

Marvina Williams, Lean Black Belt, Healthcare Clinical Operations Expert Perkins+Will, US

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FACILITIES & OPERATIONS MANAGEMENT

O

perational planning studies play a vital role in healthcare facility planning. It assists clients in obtaining goals of improvised quality, efficiency, and experience. Lean operational planning is a methodology that draws upon the ability to specify details on objectives that can be achieved and carried out by front line staff. Both operational planning studies and lean operational planning work in tandem to provide the ability to optimise operations and impact design.

Organisation's commitment to operational planning

Where does the organisations willingness lie in accumulating resources needed for operational planning? It takes commitment to organise and help user groups to participate in operational planning to provide data for studies and create, for example, value stream analysis or develop process maps for existing and future state processes. Looking at best practices for evaluating the clinical productivity in an area can also seem threatening to staff. Creating an overall understanding of the connections between an organisation’s strategic objectives and its assets of people, process, and facilities can help reduce fears and obstructions in the operational planning process.

Helping the client identify guiding principles and goals accurately by evaluating options to make decisions from good information that involves envisioning a sustainable plan is one of the main objectives in operational planning. It takes an overall view to offer adaptable solutions to operational problems. Lean operational planning helps deliver more by minimising wastage in designing buildings and areas with improved efficiency and quality.

Operational Tools

There are many tools that can be used in healthcare planning studies. Some use lean methodology, lean six sigma

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FACILITIES & OPERATIONS MANAGEMENT

or other combinations. Observational studies, process maps, value stream mapping, fishbone diagrams, process analysis, event planning, and simulation modeling are just a few when choosing what tool or tools to use for a particular study. Tool selection focus depends on what is needed by a particular client and how that tool will help increase the value delivered. Operational studies help create innovative approaches, value and improve the healthcare facility planning and design in facilities. Lean methodology is used frequently and is a dynamic process that strives for continuous improvement.

Opertaions Space Efficiency and Flexibility Lean Design Study for Surgical Services:

OPERATING SUIT MODEL Legend Surgeon

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Scrub Nurse

Circulator

CMS Tech

PRE OP

Operational Planning Case study #1: Simulation Modeling as a Method for Determining Size of Prep/Recovery and PACU:

In a large academic hospital, ten extra prep/recovery beds were added to the interventional program at the request of the staff. A simulation modeling study was the tool utilised in the operational planning to determine if the number of Prep/recovery and PACU spaces are adequate for the OR needs if the ten beds are removed from the program.

Simulation modeling is a great tool to assess patient flow, wait times, and analyse capacity.

Data for the analysis was obtained from the facility and includes OR average length of stay by service. The surgical specialty data provided minimum, average, maximum procedure duration in minutes. Next, recovery room average length of stay by service was evaluated.

OR process time by service included % of patients to recovery, % of patients to PACU, and % of patients to ICU. The whole data was reviewed to ensure information accuracy before running the simulation models.

Several scenarios were developed with assumptions made such as: 1. Number of projected procedures 2. Total number of scheduled surgeries 3. Number of days per year, and hours

Anesthesiologist

OR Suite Census

Pre OP Census

Clean Case Carts

OR1

OR2

OR7

OR8

OR3

OR4

OR9

OR10

OR5

OR6

OR11

OR12

Soiled Case Carts

Recovery Census

RECOVERY

Use simulation modeling to determine if the number of Prep/Recovery and PACU spaces are adequate for the OR needs if the 10 holding beds are removed from the program

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FACILITIES & OPERATIONS MANAGEMENT

per day the surgical department will operate 4. Percentage of surgical cases performed outside of a normal day 5. Prep and recovery rooms flexing of space Each of the scenarios employed simulation software to inform key design decisions by comparing the efficiency of various design and operational concepts. The interesting part of simulation is experimenting with scenarios using different variables. The models are dynamic enough to handle the variables. The client was presented the simulation modeling with the various scenarios. The tool concluded that the spaces planned were adequate to handle the OR needs if the number of beds is reduced by ten as requested.

This creates a US$1.5 million savings on ten rooms. The client could now make an informed decision on whether to maintain the program with the ten beds or to reduce the program size.

Operational Planning Case Study #2: Influence of Operational Planning on an Emergency Department’s Triage Process:

Use of lean operational planning and best practices in handling lower ESI in an Emergency Department created innovative ideas for a community hospital. Emergency Severity Index (ESI) is a five-level tool. Emergency Department staff uses the levels to rate patient acuity and resource needs.

Observation was one of the tools used in the operational planning to understand the role of the physical space and the culture of the facility. Culture is what defines the hospital or facility. A process or processes performed in one facility may not work the same way in another facility. It depends more on the culture.

In touring the existing workspace to learn about current workflow and patient flow, several opportunities were identified. Understanding how work happens at the front-line is a major concern in operational planning.

Creating an overall understanding of the connections between an organisation’s strategic objectives and its assets of people, process, and facilities can help reduce fears and obstructions in the operational planning process.

Studying the Emergency Department through process mapping allowed a visual way for staff to understand their existing processes for handling lower acuity patients and creating a future state process map for reducing wait times, improving turn-around times and improving staff efficiency. Within each acuity, process mapping for the patient flow was done.

Multidisciplinary user group meetings held enables the users to see how each person’s responsibilities and actions interrelate with others.

Improvements in process were developed by researching the team

OR Process Time By Service SERVICE

% OF PATIENTS TO RECOVERY

% OF PATIENTS TO PACU

% OF PATIENTS TO ICU

Transplant

1%

24%

75%

Urology

26%

62%

12%

Vascular

35%

53%

12%

Neuro

15%

35%

50%

Opth

95%

5%

0%

Ortho

9%

79%

12%

Ortho Trauma

9%

0%

91%

Plastics

62%

26%

12%

Podiatry

12%

88%

0%

GYN

44%

44%

12%

Dental/OMS

2%

86%

12%

CT

6%

19%

75%

ENT

9%

79%

12%

Gen Surg

9%

79%

12%

Oncology

9%

79%

12%

Trauma

0%

88%

12%

Surg Peds

9%

79%

12%

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triage/rapid medical evaluation processes. The architectural team, which included the operational planner and the client worked to develop a new rapid assessment unit located near the ambulatory entrance to facilitate rapid treatment. Metrics such as average patient wait time for a room by acuity and utilisation percentage by room type was evaluated. By treating as many patients as possible of a lower acuity before they entered the main ED, the time taken to move from door to physician was significantly reduced, reserving the main ED for more acutely ill patients.

A modular approach creating a Triage/RME/Fast-track was designed.

The module will enhance the patient

experience and optimise efficiency of the process, staffing, and resources needed. ESI acuity 3 patients can prove to be at risk in the Emergency Department lobby and the new module quickly identifies such patients and sort out either to discharge after being examined or to send to the main ED treatment area. This unique team triage/ rapid medical evaluation system makes the patient’s safety and experience a top priority.

Operational Planning Case Study #3: Event Planning for the Design of a Trauma Center:

Operational planning helped conceptualize a design to accommodate the required flexibility and adaptability

team tRIAGE/rAPID mEDICAL eVALUATION/fAST-track Module

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needed for a major Trauma Center, in an attempt to respond to the incredible change in census and acuities on a daily and even hourly basis. Event planning was used to evaluate each clinical event or process in the Emergency Department in order to design a more efficient ED. The planning and design approach was a highly interactive process with the healthcare facility. Each event was evaluated to identify strengths and weaknesses of the facility and explore best practices.

Current workflow evaluation showed only primary rooms with no secondary ED areas identified for the patients.

With the future workflow, the team identified key departmental events that they wanted to restructure, including

FACILITIES & OPERATIONS MANAGEMENT

Operational Planning & Programming Event Planning

Clinical decision unit relationship to other ED components Psych Adult Fast Track

Surgery ICU

RAU

Adult ED

ily m Fa

ECA/ Chest Pain

Imaging

th Pa

Adult ED

Patient Path

Rapid Assessment and treatment

Lab

Creates idealized Processes for key operational "Events" that drive the facility design.

Trauma/ Resusc

High Priority Medium Priority

Peds ED

Low Priority

repetitive design assists patient safety and helps staff to easily find supplies.

Rooms can be tested as mock-ups and enhance the quality of the design. The second strategy was implementing universal modules which enhanced patient visibility and the ease of closing down modules completely or in part and connecting other modules. The modules were designed to interlock. The pattern helps staff movement during peak shifts. The third strategy was structuring secondary treatment areas to decrease turn-around time of primary ED beds.

Operational planning studies identified ways to reduce turn-around times Author BIO

the addition of secondary ED areas. The secondary areas were created to reduce the turnaround time of the ED areas by releasing the primary ED exam beds when the main exam was complete and a disposition is made. These secondary areas include a Rapid Admission Unit, a Clinical Decision Unit and a Behavioral Health Unit within or adjacent to the ED. Unit relationship diagrams to other ED components were developed.

Data analysis was done by evaluating historic workload patterns considering alterations in these patterns that accounted for projected operational and market factors. Treatment room needs were developed with this data plus turnaround time goals using a 99 per cent Poisson distribution ratio. Three main organisational strategies were developed which included the provisioning of universal acuity adaptable rooms, except for trauma and behavioural health.

Standardisation of rooms and the

and improve efficiency. Operational planning and design optimised efficiency of physicians and staff and created optimal patient-staff experiences. The standardisation of rooms promoted patient safety and induced flexibility in patient management during a surge in admissions.

Conclusion

Operational and space inefficiencies are the most common reasons that impel facilities to renovate or expand.

Operational planning allows a deep understanding of the operations of a department, the assessment of the challenges, while analysing options and recommending potential solutions.

Operational planning, using many tools including lean methodology enables the ability to conduct studies that allow the client to make informed decisions and improve efficiency and quality.

Marvina Williams is a Registered Nurse and Lean Black Belt, specialising in healthcare design and planning. Marvina has 34 years of experience in management within the hospital environment.

She performs operational studies including workflow, workload calculations, patient care procedures, support services, simulation modeling, design validation, and process improvement initiatives.

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FACILITIES & OPERATIONS MANAGE MENT

Designing Navigation Friendly Hospitals While navigating complex healthcare facilities has been acknowledged as a critical issue by healthcare administrators for decades, the main focus has been on sign and map systems. This article discusses the findings of a study that examined physical design attributes manipulated by architects and interior designers, and their role in aiding navigation for facility users.

Debajyoti Pati, Rockwell Professor, Department of Design, Texas Tech University,US Sipra Pati, Research Coordinator, HKS, Inc., US

S

hould the availability of easy way-finding (simply put, finding one’s way to a destination) options in hospitals be of concern to health facility designers and executives? From a broader perspective of patient wellbeing, it makes sense that patients, visitors and family members are minimally taxed in finding their way inside a hospital. The issue assumes further importance in the context of competing healthcare facilities and certain reimbursement structures.

The crux of the problem is that the state of being lost has several negative impacts on patients. It has been shown in studies to have increased acute stress,

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blood pressure, physical aggression and fatigue in patients. With large community and specialty healthcare facilities the problem is chronic and severe, worldwide. Such facilities are typically large scale environments, with complex transit systems and complicated navigation. Providing directions to patients and visitors is a challenge in healthcare facilities as it has been shown to cost valuable staff time which would have otherwise been diverted to more productive tasks.

While the quality of treatment constitutes one of the fundamental factors affecting customers’ decision in

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choosing a hospital, when physicians are not employed by hospitals other factors compete in the customer’s decision-making process. In certain population type, such as women expecting childbirth, the quality of the physical environment possibly triumphs over other factors. Among the many physical design factors, easy way-finding (or easy navigation) has the potential to influence several outcomes, including patient satisfaction. It also influences the probability that they will recommend the hospital to their relatives and friends, and their decision regarding a subsequent visit. All of

FACILITIES & OPERATIONS MANAGEMENT

these have implications for a hospital’s bottom line, especially in competitive markets.

Irrespective of the competitive environment, when reimbursements from public or private insurance systems are capped per episode of illness or injury, acute stress generated from navigational issues should be considered serious. Scores of medical literature point to the debilitating influence of stress on wellness, the immune system, and pace of recovery. Stress can increase the recovery time, thereby bearing a direct impact on the organisation’s bottom line.

In some contexts, way-finding problems can affect safety and efficiency of care delivery. Many hospitals resort to hiring a floating clinical staff (staff that is hired on a short-term basis) to tide over occasional peaks and in situations with unusual demand. While a regular staff is not expected to face navigational issues (barring the first few days or weeks in a hospital), for the floating staff most healthcare environments would be new.

In such situations, navigation problems may affect response time in getting specific medications or equipment to a patient, thereby affecting efficiency or safety of care delivery.

It is, thus, of little surprise that way finding has remained a topic for discussion and debate among healthcare facility designers and hospital executives for decades. Not that decision makers have remained idle but the key focus has been on developing improved signage.

In fact, the focus on signage has been so exclusive and exhaustive that it is now a free-standing profession, with science of its own. Scores of studies have been conducted on developing appropriate maps and different types of signs (informational, directional, labelling, etc.) to aid in navigation of all types of complex facilities, from large hospitals

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to airports, transit stations, and other types of buildings. In the meantime, managers of facilities that attract large volume of customers or patients have designed and experimented with improved navigational help through dedicated staff, volunteers, and electronic solutions such as information kiosks. The issue of concern, however, is that way-finding remains a critical problem despite numerous advances in signage systems, staff support, and technology.

So, where could the problem lie?

It was this question that prompted a fundamental study on how people navigate in hospitals, under a large contract with the US Military Health System. The investigating team comprising of researchers from Texas Tech University, HKS Architects, and a large community hospital under the Texas Health Resources System, zeroed in on the most basic question that needed examination: “What kinds of information do people seek from the ambient physical environment when navigating in complex buildings?�

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We did not enter the study with any preconceived notions. If the findings demonstrate the use of signs and maps by people, that would provide valuable information. First, it would highlight the necessity of further research on sign and map systems. Second, it would mean allocating resources to find other ways to aid navigation. Third, it would mean that a lot of strategies contemporary designers incorporate to facilitate way-finding are of no use.

In contemporary hospitals, designers incorporate a large number of strategies to render way-finding easier. The strategies include using colour, artwork, landmarks, vistas, etc. All of these additional environmental cues entail capital expenditure, which typically undergoes serious rethinking when estimations are surpassed (which is more of a rule rather than an exception). If the study data can provide some form of comparison between different strategies designers employ, it would substantially benefit all stakeholders.

But, do people derive value and meaningful information from the

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ambient physical environment to aid in way-finding? Scientific literatures on way-finding in building interiors are not many. However, substantial body of knowledge exists on navigating at an urban scale. Some seminal studies

by Kevin Lynch (1960) and Siegel and White (1975), suggest the central role of cognitive maps in human brains, and that the mental map is constructed of a series of mini-representations of a large and complex environments.

Armed with these theories of cognitive representations as potential organising framework for data generated, we proceeded with a study that captured cognitive processing of information through verbal protocol. The site of the study was a large tertiary care hospital under the Texas Health Resources System. With numerous additions over decades of its existence, and with highly complex transit patterns, the facility represented an ideal site to examine the issue. Furthermore, in its most recent addition, designers from HKS Architects strategised easy navigation by including unique landmarks, unique floor and

FACILITIES & OPERATIONS MANAGEMENT

room numbering systems, outside vistas, and unique framed artwork, among others. Owing to variations in age, different parts of the building complex, provided different types of information.

Subjects for the study were recruited in five age groups – 20s, 30s, 40s, 50s, and 60 and above. Both sexes were represented within each age group. The resultant sample included diverse ethnic origins, including Caucasian, Asian and Hispanic.

None of the subjects had previously visited the study site, and did not belong to a design or allied profession, such as architecture, interior design, or building related engineering. Starting from a point about a mile away from the study site, the subjects were instructed to navigate to eleven destinations in the hospital. The destinations were spread across three connected buildings and four vertical levels. Subjects were instructed to navigate without asking for assistance from hospital employees or volunteers. Verbal protocol data captured with digital audio recorders were supplemented with digital photography of elements highlighted by

the subjects. A survey was administered to each subject at the end of navigation, to provide triangulation data. Data were analysed using established procedures for content analysis. Data analyses included frequency counts of different types of environmental information sought and descriptive analyses of the quantitative data generated. Owing to page limitations, only a synopsis of the methodology and some of the findings are presented here.

So do signs and maps constitute the sole navigation aid inside buildings?

Data demonstrate there are at least eight types of environmental information that subjects sought/ made use of while navigating. Only four of these are discussed here. In line with expectations, signs were the most frequently used source of information. However, the second most sought information source was not maps. The second most frequently used environmental attribute is what we termed ‘architectural features’.

We used the term ‘architectural’ since these are decisions made by architects, and it included all types of designs that enabled broadening of the visual field.

Among the many physical design factors, easy way-finding (or easy navigation) has the potential to influence several outcomes, including patient satisfaction.

By nature, building interiors restrict the visual field of human beings.

Owing to walls, our field of vision is typically restricted, whereas the overall environment we navigate is significantly larger. Architectural features such as atriums and windows/ openings create visual connections between indoor spaces or indoor and outdoor spaces enlarge our field of vision, and thereby the type and amount of information regarding the environment we navigate.

Maps follow architectural features in frequency of use. The next frequently used information sources include another cluster of features that we termed ‘other design elements’. Other design elements include artwork (paintings, sculptures, and strategically placed musical instruments), display boards and information panels (not providing any directional information), and fixed furniture and millwork, among others.

In relation to the portion of findings presented here, two issues are of interest.

First, traditionally way-finding has been discussed purely within the purview of the interior design discipline. The decisions made by architects can have a marked influence on way-finding behavior which is of interest to both healthcare architects and clients.

Designing optimal navigation needs to be considered alongside architectural

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support in healthcare environments.

The key objective of this study was to understand whether and to what extent physical design attributes and elements provide useful information for navigational support, and to what extent people use such information. In combination with volunteer and staff assistance and advanced technology, strategic use of physical design elements

Author BIO

responses in healthcare facility operations, including safety, efficiency, and quality of care. Second, the instrumental role of artwork in aiding way-finding is noteworthy. While for a long time interior designers have claimed such a benefit, empirical data supporting such assertions were not widely available. Furthermore, comparative data were also not available. As a result artworks were the frequent targets of the chopping block of value engineering. The positive and contributing role of artwork in the healing environment (patient rooms, waiting areas, treatment rooms, etc.) has already been established in scientific literature. This study provides evidence supporting the contributing role of artworks in another important process – way-finding.

Finally, the authors do not posit the elimination of other navigational

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and attributes can significantly improve way-finding, and in turn the organisational bottom line.

ACKNOWLEDGMENT

The study, partial findings of which are discussed in this article, was conducted within a larger contract with HKS Architects and the US Department of Defense, Military Health System.

Debajyoti Pati has published extensively on healthcare design research, internationally. He was twice voted among the 25 most influential people in healthcare design and a three-time recipient of the Best International Research Award by the International Academy for Design & Health.

Sipra Pati’s expertise is in examining gender issues in physical space, which she currently investigates in healthcare settings. She was one of the co-investigators in the study reported in this article.

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in healthcare industry across the globe.

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T

he introduction of the Diagnosis Related Groups (DRGs) in 1983 ushered in serious disruptions in healthcare industry and had been attributed by different authors to cause closure of many hospitals, and many consolidations and mergers (Garner C.B. 2011; Jacobsen-Wells J. 1989). The healthcare industry today is impacted probably on a more seriousscale by many different disruptive forces such as upward pressures in healthcare costs, shrinking healthcare resources (financial and professional), increasing regulatory and professional compliance requirements, consumer demands for choices, better quality and a bigger role in decision making, and on top of all, eHealth technology induced changes.

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The Choices: Transform or Peril

Many healthcare organisations are caught in the intersect of these disruptive forces and realise that their existing business model and core services are becoming ineffective, inefficient and financially not viable. - Consequently, the healthcare industry is being forced to undergo significant structural and functional transformations that may help health organisations recognise gaps in their core businesses, and create new and innovative services. Those that fail successful transformations may find themselves following the path of DRG casualties in 1990s.

Quality Reform Since the publishing of the Institute of Medicine (IOM) Crossing the Quality

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Chasm report in 2001, the healthcare industry is still working to realise the elusive goal of improving quality of care.

A more recent analysis by a US researcher on studies published between 2008 and 2011revealed that preventable medical errors are still occurring at the rate of 210,000 to 400,000 per year (James JT, 2013).

For quality improvement to be effective, it needs to be addressed through multiple dimensions: Improvement of care coordination Prevalence of chronic diseases, especially in developed nations, is reaching epidemic level. Epidemiologic studies revealed that 85 per cent of patients 65 years and older have more than

eHealth Revolution

The transformation and strategies Since the automation of administration and financial functions in the 1950s, the healthcare industry is experiencing a new wave of digitalisation (Biesdorf S Niedermann F 2014) which may be considered by many as eHealth revolution. The winners are those who effectively conquer the disruption of the emerging technologies, recognise the gaps, embrace relevant technologies to create new and differentiated opportunities, innovative services, and reach new markets.

Stephen Chu, Adjunct Professor, Multi-Media University, Malaysia

one chronic condition; 14 per cent of patient 65 years and older have 6+ chronic conditions; and these 14 per cent consume 45 per cent of annual healthcare costs (Anderson G, Horvath J, 2004). Fuelled by lifestyle problems, the upward trend and cost pressure show no signs of receding.

These patients are managed by multiple healthcare providers. Each of these conditions has serious risk impacts on many others (e.g. diabetes has serious adverse impacts on cardiovascular conditions, arthritis, and mental health), hence requiring careful and well-coordinated planning and delivery of effective management strategies.

Healthcare is tribal in nature, especially in the private sector. Most

providers operate in silos, resulting in very poor information sharing and care coordination. Financial factors tend to accentuate such practice.

Some countries (e.g. UK and New Zealand) implement policy requiring patients to register with nominated primary care providers. However, care coordination failure is not uncommon under such a model, and compounded by lack of access to relevant patient information during out-of-hours care, serious patient harm including death can only be the natural outcome (Pallister D, 2007).

Shared care plan is considered an effective facilitating tool for disease management planning and care coordination (ONC, LCC).

Strategic use of health IT to facilitate authorised sharing of electronic patient information such as health summaries, test results and care plans may help improve quality of care decision.

Clinical process-based continuous improvement Quality assurance / improvement programmes have produced some promising results (Brown GE, 1998; Canovas JJ, Hermandez PJ, Botella JJ 2009). However, such programmes are retrospective in nature, focusing on collection and analysis of variances or sentinel event data (ECRI Institute, 2009). They may help prevent future adverse events, but bring no comfort to those identified to have already suffered damages.

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A far superior mechanism is incorporation of Deming’s continuous quality improvement model-“plan-docheck-act” (PDCA) into continuous clinical processes improvements (Chu S, Thom J, 1994). With the PDCA steps built into clinical information systems or organisation electronic health record systems, data reflecting patient clinical status or outcomes are continuously monitored and compared to benchmark/outcome measures in real time as the care processes occur. It is designed to pre-emptively identify risks and prevent damages. Any real time patient data indicating deviations from the benchmark, after patient specific thresh-hold adjustments, may trigger alerts and prompt clinicians to start micro-management of the patient before he/she falls off the critical path. The outcome will always be far superiorto treating the patient when damages/complications start to emerge Performance/outcome-based payment Healthcare payment models fall into several categories (Miller HD, 2009; Silversmith J, 2011). The most common include: pay for service (amount of payment is predetermined for each discrete service), episode of care payment (single payments for a group of services related to a treatment or condition that may involve multiple providers in multiple settings for a single care episode), comprehensive care payment (total cost of care payment model involves providing a single riskadjusted payment for the full range of healthcare services needed by a specified group of people for a fixed period of time).

It is widely recognised that healthcare systems in most countries perform poorly despite the rapidly escalating costs (Scheffler RM, 2010).

‘Payment for performance’ has been promoted as a better model to fund health services and is gaining traction in a number of developed economies such as USA, Australia, UK, Canada,

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eHealth is a double-sword edged: it is intended to facilitate the work of clinicians, but also imposes unfamiliar constraints to their work, and facilitates scrutiny of their works from outsiders.

New Zealand, Germany (Eijkenaar F, et al, 2013; Perrin B, 2013).

Payment for performance (P4P) is attractive to the funder (Government included) due to its high potential to lift provider performance and care quality.

International evidences so far either showed marginal or little benefits in quality improvement (Appleby J, et al, 2012;Jha AK, et al, 2012;MehrotraA, et al, 2009; Petersen LA, et al, 2006).

One of the causes of the relative inconclusive evidence on P4P benefits is attributed to the notorious difficulties in determining a set of robust, evidencebased performance measures that can be used effectively in real time outcome measurements.

Strategic use of health IT can support collection, aggregation and analysis of large scale clinical outcome data (at organisation, regional and national levels) to help determinewhich data can best predict outcomes, and which type of healthcare interventions and the timing of their application may produce the best/optimal clinical outcomes for specific types of patient and conditions.

Providers should be able to analyse the pool of ‘big data’ to determine which intervention worked best for certain disease in patients with similar health profiles and to predict outcomes for those with different profiles. For example, it is possible to evaluate the clinical outcomes of their interventions on breast-cancer against those of other

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specialists nationally or internationally and refine their management strategies quickly. The analysis can also produce reliable, evidence-based outcome parameters for incorporation into clinical software to support real-time PDCA care quality improvement.

Analytics on population-based intervention-outcome relationship may also help settle the debates on whether generic drugs are no less effective than brand-named drugs.

When equipped with accurate organisation analytic data, healthcare institutes can effectively refine their clinical processes, perfect health intervention and investment strategies and significantly improve quality and performances.

Such analytic results will have far reaching health economic implications.

The quality and economic benefits can be enormous.

Increase Consumer Choices and Participation In nations that embrace market economy, the principle of choices is to stimulate competitions and hence cheaper and better quality products and services to consumers. This principle is gaining greater traction among astute and informed healthcare consumers.

In healthcare where tribal and silo practices are common, greater choices often bring about unintended consequences. Choices mean that as the consumer can switch between providers, their health data are likely to be spread further among providers.

Poor information sharing and care coordination are likely to increase risk of compromised quality of decision and care (Bellard K, 2011).

Choice and participation in health decision predicates on high level of consumer health literacy. Even among those with high level of health / medical knowledge, making the optimal choice for health problems can be extremely challenging (Rosenbaum L, 2003).

For the less informed, the Internet may provide a wealth of health related

Information Technology

information, but the volume and quality of information (or the lack of quality) can cause havoc - one common and well known problem is cyberchondria (White R, Horvitz E, 2009; WebMD 2002).

Effective consumer participation also requires consumers taking responsibility of their own health (Coulter A, et al, 2008). This means that (a) relevant patient specific health information in plain language needs to be available to consumer, (b) resources are readily available to assist consumer understanding of such information (and to avoid unintended consequences such as cyberchondria), (c) appropriate alerts and reminders to engage in healthy lifestyle behaviours and self-care (e.g. correct medication management and compliant regime) are provided to consumers when and where they are needed.

Home-based health status monitoring supported by Internetbased clinician guided electronic health information delivery that has the smartness of responding to realtime patient health specific data are likely to give visionary organisations a competitive edge.

Specialisation The explosive advances in medical sciences spawn rapidly increasing medical specialisation. Healthcare institutions respond by offering more and more services around the increasing number of clinical specialty and subspecialty.

Systemic reviews appear to indicate that organisations that focus on highly specialised services delivered on high patient volumes produce far better patient outcomes and lower costs (Jovnt KE, et al, 2003; Ley O, 2014).

The findings are in sharp contrast to conventional beliefs of tertiary and quaternary referral institutions - that collection of all clinical specialties under the same entity produces highest efficiency, care quality and revenue.

Around the world, specialist institutions such as Cardiac/

New Services, New Market Worldwide, medical tourism is estimated to grow at a rate of 15-25 per cent per annum (Medical Tourism Statistics 2014) and revenue is estimated to be US $55 billion.

Many Asian-Pacific nations (e.g. Singapore, Taiwan, South Korea, Thailand) are tapping into the rapidly growing medical tourism business.

The industry competes for the business on price and/or quality bases.

Some nations/institutions choose to compete on price alone. Other countries or institutions may not be price competitive, but their differentiating factors will be specialisation, quality and strategic deployment of enabling information technologies.

One of the critical quality measures (and success factor) is the preand post- treatment support to patients back in their home nations. Early adoption of new and emerging technologies, especially those enabling non-invasive clinical status monitoring can provide the much needed services differentiations, quality care enhancement, and hence competitive edge.

‘Smart lens’ glucose monitoring technology for use in diabetes patient is one such example (Smart Lens Technology, 2014).

The Strategic use of telehealth technologies to provide excellent expert support to local healthcare services in the patient’s home base is considered paramount.

cardiothoracic, Eye, Head & Neck, and Orthopaedic hospitals are some examples of hospitals electing to adopt the highly specialised pathway. This strategy will, however, reduce their scope of services and capability to provide the care for patients with multiple health conditions.

The strategic decision to take the core specialisation path creates a set of challenges including how to determine the best location and the most suitable/niche clinical specialty (i.e. picking the winner), and how to develop the required clinical expertise, how to cater for the needs of patient with comorbidities that fall outside the organisation’s core expertise.

Super specialisation limits hospitals ability to provide care to those with multiple complex healthcare needs, especially the 14 per cent with 6+ chronic conditions.

The use of health IT in linking external experts into hospital to provide specialist care to patient problems outside the organisation’s core competency will

be a key strategic decision to ensure the capability to deliver appropriate quality care while keeping focus on the path of differentiation.

The adoption of appropriate telemedicine model and adequate investment in supporting technologies (e.g. home-based patient monitoring) are important strategic decision examples.

IT Adoption: The challenges and strategies

The history of IT implementation is littered with project failures. In 2005, it was reported that about 5 to 15 per cent IT projects were abandoned before or shortly after delivery (Charette RN, 2005).

As IT systems become more ubiquitous and complex, the failure rate increases. According to a Standish Report of 3,555 projects analysed from 2003 to 2012, only 6.4 per cent were successful; 41.4 per cent failed – either abandoned or restarted anew from scratch (Thibodeau P, 2013).

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Health IT projects are very complex, the failure rate is estimated to be much higher.

Key challenges to health IT adoption and strategies are explored in this section.

Vision and Clear Realisation Pathway The initiation of the British NHS national program for IT (NPfIT) in 2003 (eHealth Insider, 2003) typified a national eHealth program with grand and ambitious vision. Nations include Australia, Canada, the Netherlands and other EU nations, Singapore and USA have all embarked on their national eHealth programmes.

Grand visions need to be supported by clear realisation pathways with realistic objectives and milestones. The pathways need to acknowledge and

address difficult eHealth challenges that are borne out of the mismatches between clinical and technical worlds, the unique socio-economic and cultural characteristics and the high complexity of healthcare ecosystems. eHealth programs without clear, well managed realisation pathway, and/ or with poor insights into associated challenges are more likely to produce casualties than to deliver benefits.

The pathways should also be aligned with and capitalise on advancements in new and emerging technologies.

Clinical and Engineering Impedance Mismatch Healthcare organisations are complex.

Clinical processes are complex.

The fundamental characteristics of complexity are imprecision and

unpredictability. The human body exemplifies complex machinery that modern medicine is still struggling with.

The difficulties in modelling knowledge and information on how best to manage multiple comorbidities are akin to modelling weather predictions for the next month. The socio-economic and cultural dynamics between the professional groups, and the imprecise, often convoluted healthcare languages used add more layers of complexities to the ecosystem.

The practice of clinical documentation is characterised by expressiveness with embedded negations, double negations in clinical statements.

The use of propositional contents that carry different illocutionary forces and context/user specific perlocutionary

Health IT Standards It is commonly accepted that standards are critical for interoperability between the thousands of IT systems that must exchange health data. There are three significant challenges in eHealth standards: There are too many standards. Internationally, there are many eHealth standards development organisations on the playground.

A few examples include Health Level 7 (HL7) standards, the International Standards Organisation Technical Committee (ISO/ TC215), the Integrating Healthcare Enterprise (IHE), the European Committee for Standardisation - ComitéEuropéen de Normalisation, Technical Committee 251 (CEN/TC251). Each develops a set of often similar and competing standards.

Standards are like toothbrushes. Everyone needs and wants one (or a few), but none is willing to use others. This is the consequence of (a) my requirements are unique and sufficiently different from others; (b) the ‘not invented here’ syndrome at play Standards are designed to accommodate requirements of a large number of stakeholders; as such they are necessarily broad in nature, and are subject to implementation specific variations. This infamous statement is often repeated in standards meetings: ‘when you see one implementation of a particular HL7 v2.x standard, you have seen only one implementation’ (i.e. another implementation of this same HL7 v2.x standard is almost by guarantee different; the only question is how much different) What should be the optimal strategy on standards?

Standards are required to ensure organisation capability to interoperably share and reuse health data to support collaborative

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care, coordinate care amongst different specialist providers, and especially for cross border exchanges of interoperable information to support medical tourism requirements.

There are three strategies to effectively navigate the jungles of competing and often incompatible standards: (1) Adopt and adapt standards that have the wisest international acceptance and implementation footprints. The Health Level 7 (HL7) Clinical Document Architecture (CDA) is one such example. These standards are likely to be implemented in software by international health IT vendors, thus reducing the costs of implementation; (2) adopt and adapt the standards that best fit the organisational business and clinical requirements; (3) influence the development of international standards to optimise the incorporation of national or organisational requirements into standards design.

Creating one’s own standards is a non-option and should be strongly resisted (Figure 1).

Investment in engagement and active contributions to influence international standards development is the most desirable strategy.

There are three components in standards: (a) what are allowed / supported, (b) what are disallowed, (c) the grey area.

Negotiating what are supported, what are not, and the technical implementation is difficult. It often involves ‘horse-trading’ of competing interests and agenda at social and political levels. The

Information Technology

intents further increases the difficulty of machine processing of the clinical statements.

Engineering approach to software design requires precision and predictability. Even the more advanced fuzzy logic (Novák V, 1999) is inadequate in dealing with the imprecise, unpredictable and context laden languages of modern medicine.

To optimise power and benefits big data analytics and clinical data reusability, precision is required.

Processing fuzzy clinical statements ridden with negations and double negations, multiple illocutionary forces,

perlocutionary intents, and changing contexts has presented seemingly unsurmountable challenges for current technologies.

Most health IT systems designers lack reasonable understanding of the clinical information management problems at hand, let alone theinherent complexity of clinical medicine. They view the clinical problems within the boundaries of current technological capabilities. Given the significant clinical and engineering impedance mismatch, there is little surprise that these systems are often declared unfitfor-purpose when they first meet the clinical users.

Clinical user engagement has been acknowledged to be an important strategy and success factor for health IT projects. However, it is often reduced to an ‘empty slogan’ and given lip-service treatment.

Technical experts often adopt a highly arrogant approach such as ‘show me your forms and I will design a system for you in less than a week’, or ‘train your clinicians to limit medication orders to within 50 characters’. Such arrogance has underpinned countless eHealth project disasters.

Compounding the Health IT application design problem is the fact that clinicians are not trained to

Figure 1: The Proliferation of Standards

persons who champion the organisational or national interests need to be credible, respected, trusted and possess very high level of people skills.

The negotiations will also be on the standard mechanisms required to constrain/profile the international standards such that the organisational/national requirements are met without having to repurpose the international standards.

The organisation will need to establish a set of rules on how to deal with requirements that fall under the ‘grey areas’ (which are often placed in ‘too hard’ bucket and excluded from the standards. Typically, ‘grey area’ contents should be requirements that can be safely ignored by information exchange partners without compromise patient clinical safety. Otherwise, bilateral or multi-lateral agreements with the exchange partners will be required.

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clearly articular information and system requirements. Clinical speak and technology language are diametrically different. Engagement exercises often end up in escalating frustrations, mistrust, and at times outright hostility between the clinicians and the system analysts.

So what is the solution?

Engagement should be considered as dynamic discovery processes. The discovery should include scope and boundaries setting for the target system, communicating limitations of technologies, how to address the limitations, complexity, fuzzy requirements, and out-of-scope requirements. Roadmaps for realisation of the out-of-scope requirements, and incremental realisation of complex requirements in step with technological advances and in alignment of organisation strategic directions are also critically important, especially to avoid alienating passionate stakeholders.

Unintended consequences of different design approaches should be explored and clearly communicated to stakeholders.

Selected clinical domain experts who may also act as champions should receive adequate training in writing high quality clinical storyboards. These storyboards are effective communication tools between clinical users and system analysts developing information and system requirements.

Clinical informaticians should be brought as key conduits between clinical users and technical experts. Their ability to translate the languages used by clinical and technical experts will help minimise/eliminate confusions, misunderstandings and mistrust between these two key groups.

Political and Challenges

Cultural

/

Social

eHealth technologies are disruptive in nature. They impact on multiple stakeholders whose responses are very possibly unpredictable. The challenge in

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Strategic use of health IT to facilitate authorised sharing of electronic patient information such as health summaries, test results and care plans may help improve quality of care decision.

winning clinical support is highlighted

by Massaro’s description of clinician adjustment to eHeath system as ‘KublerRoss phases of mourning’ (Massaro TA 1993; Berg M, 2001).

Technology-induced changes inevitably trigger varying degree of changes in the balance of power among different user groups. For example, the introduction of case manager enabled

by IT adoption may change the coordination authority of some senior clinicians. eHealth is a double-sword edged: it is intended to facilitate the work of clinicians, but also imposes unfamiliar constraints to their work, and facilitates scrutiny of their works from outsiders (Berg M, et al., 2000). Many clinicians react forcefully when required to change their workflow, or when required to be more structured and precise in entering their orders (Massaro TA 1993).

There is no question that disruptive technologies such as eHealth necessitate changes in business and clinical processes.

Business Process Redesign (BPR) requires that stakeholders be willing to radically redesign their work processes so as to optimise business effectiveness and efficiency (Davenport TH, 1993).

However, the healthcare core business processes consist of highly knowledge sensitive activities typified by high complexity that defies predictability and standardisation of simple engineering approach. Forcing top down work

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pattern changes is doomed from the start.

The strategic approach is best to accept the inherent complexity and unpredictability of the healthcare ecosystem; accept that these characteristics need to be nurtured and carefully managed in system development and deployment.

Unforeseen spontaneous uses of the system should be investigated carefully with open-mind and unforeseen benefits of such uses be draw out. eHealth technologies implementation should be viewed in the light of organisational development.

Implementing new technologies involves the mutual transformation of work practices and of the technologies (Berg M, 1997; Bijker WE& Law J, 1992).Management and executives need to understand and accept that the system also has to evolve in the light of knowledge and experiences gain during implementation. The costs of IT systemrefactoring driven byimplementation experiences and the organisational transformation should be budgeted into the costs of IT development and deployment from project inception.

Measuring Project Success IT project success is traditionally measured on two variables: (a) whether it is successful economically, i.e. on time, on budget, (b) the number of users willing to use the system. Both are very poor indicators or measures for eHealth projects. eHealth project success measurement is much more complex. There are at least two perspectives and several dimensions of measurements The organisation perspective Economic measure – The project is delivered on budget, on time, and meeting requirements stated in the functional and technical design specifications Business effectiveness and efficiency measure - The IT system improve the competitive edge of the

Information Technology

interrupted by the IT system will help determine the optimal balance.

Patient satisfaction - It is an indirect measure of IT system success.

Measures include happier patient journey, greater efficiency in care process (e.g. less waiting time for patients), minimisation or elimination of adverse medical events/harms to patients, better clinical outcomes.

Acceptance and sense of ownership of system - The sense of ownership is often enhanced when clinical user requirements and participations are nurtured and acted upon. This may often give users the sense of control and pride (Berg M, 2001).

Determination of project success measures requires willingness of management and project leaders to fully understand and accept professional users’ view of success measures. Project success measures/criteria based on socioclinical-technological synergy balancing the organisational and professional user perspectives will have much better chance in being accepted by the majority, if not all, of the stakeholders.

Conclusion

eHealth is disruptive, but is also strategic and transformational. The benefits can be significant. But the hurdles are also very challenging.

While health information technologies may offer considerable administrative efficiency gains and costsavings, empirical evidences available so far indicate that any clinical costsavings realised from health IT systems adoption are likely to be marginal.

Health IT should be used as strategic and quality improvement tools, not for directed at clinical cost cutting.

Author BIO

organisation’s business (which includes patient/customer satisfaction); supports pan organisation performance analysis and executive strategic decision Professional user perspective Clinical outcomes - The IT system facilitates real time continuous quality improvement: e.g. help detect early warning signs of deteriorating patient clinical status (adjusted to patient’s existing morbidity and comorbidities), supports early micro-management of the patient, and contributes to improvement of patient clinical outcomes; supports cross patient and cross provider comparative analysis of clinical effectiveness Clinical processes / workflow - The IT system reduces clinical documentation burden, enables seamless interoperable exchange and reuse of clinical data across clinical, research, epidemiological and cross organisation secondary use requirements; facilitates easy access to evidence-based knowledge for improved decision making and effective patient management; different system commands are optimised and enable synergy between ordering, documentation and research functions; system navigation should be intuitive and context of use preserved during navigation.

A sensible balance between the need for clinical expressiveness and precision (structured data entry) is important to ensure that burden of data entry does not disrupt clinical workflow unnecessary. Within the boundary of technical constraints, fully structured data entry is best limited to data components that produce maximum return on documentation efforts. Examples of these data components include: clinical findings, diagnosis, allergy/intolerance, adverse reactions, medications, diagnostic test orders and results. Ethnographic methods of analysis to identify clinician documentation preferences, the burden of structured data entry, how and the extent of clinical workflow may be

eHealth programmes design and implementation should be viewed as socio-cultural-technical alignment exercises and not management key-performance indicators or IT-lead deliverable driven projects.

Implementation strategies should be driven by frameworks that coherently incorporate top down visions and also articulating bottom-up views that transcend user needs.

A clear vision of the capabilities and limitations of Health IT and the design of technological solutions that maximise on IT capabilities, embraces user requirements with a clear pathway to incrementally realise overall organisation and user visions in alignment with the pace of technological advances are steps in the right direction.

Quantum computing and multidimensional rendition of complex clinical data when matured out of research laboratory environments will provide some highly promising solutions to clinical computing. The incorporation of these emerging technologies and cutting edge technologies such as fighter cockpit situation awareness into health hardware and software applicationsshould help resolve some of the complex computational problems that have plagued clinical computing in the past decades.

It is important to accept that while technologies transform an organisation, theyalso inevitably transformed by the organisation’s culture and stakeholders.

Achieving socio-cultural-technological synergy is important not only for project success, but also for organisation success.

References are available at www.asianhhm.com

Stephen Chu is a leading international health informatics expert and Adjunct Professor of Multi-Media University Malaysia. He has extensive expertise in many clinical and informatics domains. He is co-chairs of HL7 Patient Care Workgroup, chair of Standards Australia Pharmacy committee and colead of many international informatics standards projects.

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Informati on Technology

The Future of Healthcare New innovative technologies delivering more measurable outcomes With new innovative technologies delivering more measurable outcomes that result in healthier patients, hospitals can renew their resolve to provide the best care for those in the most need.

Arjen Radder, President, Philips Healthcare, Singapore

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T

he global healthcare sector is on the cusp of a tipping point and this is more acutely evident in South-East Asia as the region grapples with key issues such as a rapidly aging population, a chronic Non-Communicable Diseases (NCDs) epidemic and a steady rise in healthcare cost, to name a few.

As the world population expands and ages, total global health spending is expected to accelerate at an average of 5.3 per cent a year over the next four years (from 2014 to 2017), compared to the 2.6 per cent spent in 2013.

Information Technology

This growth will put enormous pressure on governments, healthcare delivery systems, insurers and consumers in both developed and emerging markets as they focus on issues that will continue to place more demands on the healthcare sector, including an aging population, the growth of chronic diseases, ballooning costs and imbalanced access to care due to healthcare workforce shortages and infrastructure limitations.

In Singapore, for example, government spending on healthcare rose from US$3.3 billion (8.5 per cent of the government’s budget) in 2010 to US$5.7 billion in 2014. The total healthcare spending is anticipated to rise by an average of 7.9 per cent annually until 2017, according to the Economist Intelligence Unit.

Average life expectancy is also projected to rise from 72.6 years in 2012 to 73.7 years by 2017, while the number of high-income households earning over US$25,000 a year is anticipated to increase by about 10 per cent to over 500 million, with over half of that growth coming from Asia.

NCDs are responsible for 60 per cent of deaths in South-East Asia, principally cardiovascular diseases, diabetes, cancers and chronic respiratory diseases.

NCDs are also the biggest healthcare threat for the rest of the world, with over 63 per cent of global deaths in 2008 attributed to chronic diseases.

As the population grows older and more affluent, this will boost demand for more healthcare as the number of people afflicted with chronic NCDs rise in tandem.

All these factors will increasingly contribute to the healthcare system’s burden and the industry will be tested to its limits to cope with the ever-expanding volume of patients seeking treatment in hospitals and healthcare institutions.

On the flip side, there is also heightened global awareness on the dangers and causes of NCDs, which include tobacco use, unhealthy diet,

inadequate physical activity and obesity.

Education continues to be a key determinant in reducing the occurrence of NCDs and the proliferation of the Internet and better education have helped in spreading the message on the types of preventive measures people can take to improve their health.

To address the issue of NCDs across the ASEAN region, Philips Healthcare embarked on a mission to support the development of recommendations for governments on managing NCDs in each country since 2013. The support from has seen the formation of the ASEAN NCD Network that comprises of key industry stakeholders from each country in the region. The Network has developed a White Paper, sharing best practices and recommendations on innovative NCD management approaches. The Network aims to address the scourge of NCDs by sharing best practices, fostering collaboration, and thereby co-creating solutions to enact real change on the ground in each country and in the region.

Prevention

Advancement in medical technologies over the past few decades have helped drive down the cost of home-based

Adoption of new digital health information platforms such as electronic medical records, telemedicine, mobile health applications and electronic medical prescriptions heralds a promising future in the way healthcare can be delivered in the coming years.

health monitoring products, which include heart rate, blood pressure, diabetes, and Body Mass Index (BMI) monitors. These products can all be easily found at one’s neighborhood pharmacies.

More dollars are spent on vaccines and other means of preventing or reducing the incidence and severity of chronic diseases like cancers and conditions such as diabetes.

The latest in wearable technologies have sparked a greater interest amongst people when it comes to managing one’s health and activity levels.

The Google Glass, for example, has paved the way for doctors to quickly get the information they need, when they need it most and is proof of how emerging technologies can be applied in the healthcare system to improve patient care. By connecting game-changing technologies, this is the first proof of concept for the seamless transfer of patient vital signs. The Google Glass demonstrates how clinicians can benefit from hands-free, voice-controlled access to critical data while in the operating room or on the go in the hospital.

Wearable technology puts a patient’s real-time personal health data into his own hands, giving sufferers of chronic diseases such as Parkinson’s or diabetes a better peace of mind as they are empowered with the tools to better manage their condition, make better lifestyle decisions and treat symptoms early.

At the same time, the information that is shared with the doctors via the wearable technology can help physicians e-diagnose and advise their patients remotely – cutting out travel time and cost–so caregivers and patients can receive the medical attention they need in a timely and effective manner.

Detection

The increase in awareness of chronic diseases and associated symptoms has also led to more cases of diagnoses, often at earlier stages of the disease.

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Informati on Technology

The Google Glass

Early detection means patients can seek medical attention at the onset of the disease, which can help improve survival rates and prolong life expectancy.

Due to the chronic nature of NCDs, this also means medical institutions will see a surge in cases, further putting pressure on an already strained healthcare system.

In Singapore, for example, acute care hospitals are running at unsustainably high bed-occupancy rates of well over 90 per cent, pushing some hospitals to lease beds from the private sector in order to satisfy demand.

This is an issue that is not unique to Singapore. Medical overuse has become a worldwide epidemic. In the United States alone, unnecessary medical costs US$250 to US$300 billion annually according to conservative estimates.

In addition, there is the danger of hospital-acquired infections, which are avoidable, further adding to a nation's healthcare bills.

Hundreds of millions of patients are affected by hospital-acquired infections globally each year. Of every 100 hospitalised patients, seven in developed and 10 in developing countries will acquire at least one healthcare associated infection. By

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reducing the number of unnecessary hospitalisations, mortality rate from hospital-acquired infections can be greatly reduced.

With the widening strain on hospitals, healthcare systems around the world are recognising the need for innovation and restructuring care delivery models to manage the use of resources.

Adoption of new digital health information platforms such as electronic medical records, telemedicine, mobile health applications and electronic medical prescriptions heralds a promising future in the way healthcare can be delivered in the coming years.

Indonesia still struggles with one of the highest rates of maternal death in the developing world that can be largely attributed to a lack of access to healthcare for mothers and children.

To address this growing concern, Philips partnered with the Indonesian Reproductive Science Institute (IRSI) at PT Bundamedik and the Padang city government to conduct a year-long Mobile Obstetrics Monitoring Solution (MOMS) pilot project in Medan. An Android mobile application software is utilised to collect data such as blood pressure, weight, and fetal movement from pregnant mothers at local clinics

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or even at home. The data is uploaded by the app onto a central server, enabling obstetricians or gynecologists to remotely monitor patients from the hospital or home.

This shift highlights the transition from hospital-centric to patientcentric view to better optimise resources, while patients will be given more opportunities to take charge of their own health and medical symptoms under the watchful eye and support from qualified healthcare professionals.

Treatment

While hospitals and medical institutions remain as providers for treatment of acute symptoms, the volume of chronic disease cases seen at these providers can be alleviated by shifting the focus to more location based clinics and outpatient services.

This presents another challenge that is facing the industry on a global level, as many people living in rural areas still lack access to hospitals and medical facilities. Finding innovation solutions to bring healthcare to them presents an opportunity for disruptive technological advancements.

In the hospital setting, there is a gradual shift from surgical solutions

Information Technology

Management

Wearable technology puts a patient’s realtime personal health data into his own hands, giving sufferers a better peace of mind as they are empowered with the tools to better manage their condition, make better lifestyle decisions and treat symptoms early.

– the research will identify novel drug combinations that will overcome limitations of standard therapy and lead to better outcomes for Asian breast cancer patients.

The Breast Cancer Cell Bank will house tumour cell lines from patients in Singapore, which will be available to research facilities in the Asian region.

Such innovations will collectively help reduce the need for prolonged hospital stay so patients can be discharged early and given tools to help them manage their recovery process at home.

With the help of wearable sensors, mobile health applications and other emerging healthcare innovations, patients can be monitored remotely by qualified healthcare professionals so doctors can be freed up to treat other patients with acute symptoms.

Author BIO

to minimally invasive procedures, which have been applied to many surgical specialties from cardiothoracic, orthopaedic, urological, vascular and neurological procedures.

These procedures are performed using small incisions, where endoscopes are plugged-in to operate from within a body cavity.

Minimally invasive surgery is low-risk and offers a safe, feasible and patient-friendly treatment, leading the way to a swift recovery and shortened hospitalisation period.

In the field of oncology, interventional oncology is adopted to treat difficult-to-reach tumours or tumours in patients who are deemed unsuitable for surgery with tumour embolisation procedures. This minimally invasive treatment starves tumours from its blood supply and is an effective procedure in improving patient outcomes.

Advancements in science and medical research also mean progressively, patients are being treated on a personalised level. Personalised therapies illustrate how patients can be treated more optimally and effectively and at a lower cost with the right combination and dosage of drugs to tackle each case.

Increasingly, there is a steady move away from judgment-based medicine to evidence-based medicine. A report by New York Times magazine highlighted how one hospital used evidence-based medicine to cut its death rate for heart surgery by half and data on outcomes will help improve future treatments.

Riding on this trend, the first-ever Breast Cancer Cell Bank was recently established in Singapore to conduct research on breast cancer tumours from this region so targeted therapies could be developed to revolutionise breast cancer treatment and improve survival rates.

This includes customised treatment for patients who develop resistant tumours over the course of treatment

Elderly and chronically ill patients often experience mobility issues.

With the help of telemedicine and mobile monitoring systems, caregivers and patients can reduce the need to travel to the doctor’s office or the hospital and seek real-time medical advice from healthcare professionals when necessary, from the comfort of their homes.

As the global healthcare system continues to experience a shortfall of qualified doctors, there is a gradual move towards nurse practitioners, physician’s assistants and others in treating and caring for patients.

Telehealth technicians will also come into play as a form of healthcare professional to help patients remotely when it comes to treating mild symptoms.

Collectively, these shifts will improve accessibility, affordability and quality in healthcare delivery in the coming decades as medical care moves from medical institutions to the home.

The Hospital of the Future

As we shift from healthcare to health systems, hospitals will become visionary partners in clinical advancement and technological innovation; leading to improved outcomes, better health, lower costs, and a more sustainable system.

With new innovative technologies delivering more measurable outcomes that result in healthier patients, hospitals can renew their resolve to provide the best care for those in the most need.

References are available at www.asianhhm.com

Arjen Radder is the President for Asia Pacific of Philips Healthcare and a member of the Philips Healthcare Global Executive Team.

He oversees the Healthcare business across Asia Pacific including India, Japan, Korea, Australia New Zealand and ASEAN. Radder joined Philips in 2002 and holds a PhD in Medicine.

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The VACUETTE速 Blood Collection System - One Step Ahead in Asia

56

ln the eighties, Greiner Bio-One was the first company in the world to develop an injection moulding technique for manufacture of unbreakable plastic tubes out of PET material, in which it is possible to keep the vacuum stable over a longer period of time. This innovation has become the industrial standard, and plastic evacuated tubes are now a necessary component of all modern blood collection systems.

High Standard of Quality Across the World

Due to constant development of the VACUETTE速 Blood Collection System, Greiner Bio-One has become the trendsetter on the world market. Further innovations such as the unique PREMIUM Safety Twist Cap, the double-walled coagulation tube, the evacuated sedimentation tube made out of plastic and many more safety products consolidate the image of the modern VACUETTE速 Blood Collection System.

All production locations are certified to ISO standard, guaranteeing comparable high quality of the products. The TOM -Total Quality Management- System is applicable at all Greiner Bio-One production locations across the world, including the production opened in 2008 in Amata Nakorn, Thailand. The factory was designed based on the latest production technology expertise. The efficiency and quality of

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

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Greiner Bio-One products do not just ensure extremely efficient working. They are also the assurance of safety for the user. A wide range of safety products protect the user from accidental injuries from used and contaminated needle tips, which can lead to life-threatening infections.

Greiner Bio-One Production plant, Amata Nakorn, Thailand

production corresponds to European standards. ln addition to Petri dishes for research, VACUETTE® Blood Collection Tubes are also produced in Amata Nakorn. The products conform to the international standards, have CE-labelling and have FDA authorisation for the American market.

New Greiner Bio-One Subsidiaries in Asia In 2011 Greiner Bio-One acquired the majority share in its Chinese trading partner in Beijing. The company operates under the name “Greiner BioOne Suns Co Ltd”.

Greiner Bio-One International GmbH Greiner Bio-One is specialized in the development, production and distribution of high quality laboratory products made from plastic. The company is a technological partner for hospitals, laboratories, universities, research institutes and the diagnostic, pharmaceutical and biotechnology industries.

Greiner Bio-One consists of four business units: Preanalytics, BioScience, Diagnostics and OEM. Today the company generates a turnover of 373 Mio. Euro. Greiner Bio-One is a member of the Greiner Group based in Kremsmünster, Austria.

The next step was taken in July 2012. A joint venture enterprise was founded with Tristar Remedies Pvt., with the aim of being in a better position, dedicated to pursuing the share of the market in India.

Greiner Bio-One founded the new business under the name Greiner Bio-One India Pvt Ltd. The reputation and the degree of recognition of Greiner Bio-One quality products, and above all the VACUETTE® brand, is to be promoted further on both major markets in Asia.

Advertorial

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Information Technology

Emerging Technology Trends in Asian Healthcare Organisations Emerging technologies will come together in unprecedented ways to create efficiency and sustainability in healthcare.

Mobility solutions will be the key technology in Asia with a high adoption rate of smartphones and tablets. Cloud will provide the essential infrastructure required for data access at point-of-care. Analytics will provide real-time views and deep insights required to create that sustainability.

Sash Mukherjee, Asia Pacific Research Manager, IDC Health Insights, Singapore

O

ver the past couple of years, there seems to have been a distinct change in the kind of questions healthcare IT executives have been asking us at IDC Health Insights.

Previously the questions were invariably about which clinical or administration solution provider is preferred by other provider organisations in the region.

Recently, the questions have been around global and regional best practices on newer technology implementations in hospitals, whether public or private.

Emerging technologies like mobility, cloud, analytics/ Big Data and social business are referred to as the 3rd Platform at IDC. Increasingly, healthcare IT executives are getting interested in leveraging these technologies in their organisations, in an attempt to align technology with business goals.

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Asia is seeing several isolated examples of innovation, the emergence of a collaborative healthcare environment as well as a trend towards consumerisation of healthcare IT, where consumers are taking ownership of their own wellness and chronic disease management. This growth in consumer interest in their own health outcomes is forcing provider organisations to focus on patient satisfaction as a key business driver.

New technologies will come together in unprecedented ways to create efficiency and sustainability

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in healthcare. Mobility will be the key technology in the region, with a high adoption rate of smartphones and tablets. By IDC's estimates, AsiaPacific smartphone shipments will reach close to 510 million units by 2017, up from 300 million units in 2012. Cloud technologies will provide the essential infrastructure required for access to on-demand healthcare data at point-of-care. Analytics and Big Data technologies will provide the real-time views as well as deep insights required to create a sustainable system, as it moves from a reactive to a prescriptive phase.

08 Sash Relace Text

Information HEALTHCARE MANAGEMENT Technology

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Informati on Technology

Mobility Trends in Provider Organisations

Mobility has emerged as a key technology as it helps enable a patientcentric approach to cope with rising healthcare costs and resource shortage.

It is the answer to meeting the rising consumption of health services due to ageing populations, chronic diseases, rising patient expectations, and growing costs of treatment. In developing countries, mobility solutions will be the short-cut to achieving universal healthcare over the next few years.

In Asian hospitals, clinical mobility, especially in the case of bedside administration, and remote access to clinical data, has become increasingly common.

In a recently conducted survey by IDC Health Insights where 407 Asia/ Pacific healthcare IT executives were interviewed, implementation of an enterprise mobility strategy emerged as a key concern. When asked about the organisation's mobility adoption, 37 per cent of the respondents indicated that they have already implemented mobility in some form, 44 per cent of the respondents are in the evaluation / planning stage, while only 19 per cent of the respondents indicated that they had no immediate plans to adopt mobility. However, only about 9 per cent of the respondents indicated that they had a mobility solution, while many organisations are focused on the devices and mobile apps.

Over the past few years there has been a buzz around Bring Your Own Device (BYOD) policies in all industries, including healthcare. In Asia-Pacific healthcare, the main driver for BYOD has been the clinician's desire to use a single device for personal and clinical use. Faced with the possibility of unknown breaches, the IT executive works to have registered users, while giving them differential, rolebased, access and network connectivity.

BYOD is essentially a compromise between clinicians and the healthcare organisation. The organisation will

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Asia is seeing several isolated examples of innovation, the emergence of a collaborative healthcare environment as well as a trend towards consumerisation of healthcare IT.

reluctantly allow physicians and staff to use their own devices at work. Due to security concerns, IT is unlikely to fully trust a clinician's personal device and therefore will not fully utilise the capabilities of that device, limiting the clinician's use of the device to deliver better healthcare.

In many healthcare organisations, as in other industries, a new trend is emerging. Eligible users are given a choice of devices that they can use for work, also referred to as the "choose your own device" (CYOD) model. CYOD is a new spin on the traditional corporate-liable mobility model in which the enterprise takes full ownership of the device. Unlike traditional corporate liable model, where the organisation manages only one mobile platform with limited choice of mobile devices, CYOD will have IT manage a few mobile platforms and offers a wider range of popular mobile devices, clinicians actually want to use.

Essentially, CYOD allows IT to take back control of mobility management while giving clinicians choices on the devices.

More than mobilising the individual, mobility strategies need to take into consideration the processes and workflows, which are particularly important in a process-driven industry like healthcare. While iOS and Android

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devices remain popular among end-users, many healthcare organisations looking for enterprise mobility solutions are keen to evaluate and pilot Windowsbased platforms, to ensure continuity in supporting the administrative and clinical workflows that already run on Windows PCs. However, they are evaluating how Windows-based mobility solutions will work with the mixed applications that exist in health organisations.

Cloud Trends in Provider Organisations

IT has become more pervasive in healthcare organisations in Asia.

However, given the traditional siloed structure of the procurement process, , many organisations have been adding applications without evaluating the existent overlapping functionalities and the feasibility of integration with other solutions towards a common procurement process.

One specific area where healthcare IT executive is questioning legacy approaches is clinical data and image management, and the cost and operational impact of maintaining enterprise data and storage. As patient data and medical images are increasingly being shared across departments and affiliated organisations, healthcare providers are looking for ways to provide a level of transparency in giving access to this data, and to centralise enterprise storage; and thus are beginning to explore options that allow this. Providers will increasingly begin to implement Vendor-Neutral Archives (VNAs). There will be a need for these archives to normalise the images, regardless of the PACS and make them easily accessible. There are a number of cloud-based archiving services focussed on medical image data, offered by healthcare IT suppliers and traditional IT infrastructure suppliers alike. The use of centralised solutions for storage of medical data and images will be the first move of healthcare organisations toward a cloud environment.

Informati on Technology

The healthcare IT executives also have as an important mandate the better utilisation of resources and simultaneously have the responsibility of implementing newer technologies within the same budget. 'Do more with less' is a popular mantra in Asian hospitals. Current infrastructures are being rationalised using virtualisation techniques and by aggressively adopting X-as-a-service delivery models. Decisions to implement or maintain each solution in-house are being driven by strong financial and ROI analysis. Given the fast pace at which the industry is changing in the region, infrastructural consolidation ensures better utilisation of resources, cost reduction, security management, and gives the organisations more flexibility and agility.

Consolidation and rationalisation has become a reality in Singapore, where six public health clusters have a shared service like arrangement, when it comes to IT infrastructure. Singapore's central G-Cloud, a private infrastructure for whole-of-government use, with complete security and compliance requirements, including onshore hosting, paves way for similar options in healthcare sector, as the surge in structured and

PRODUCERS

• Personal wellness apps • Home monitoring solutions • Social care agencies

Analytics to evaluate operational efficiency and financial operations have been in play at advanced healthcare organisations in the region for a while now. The key focus has always been

• Storage

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• Data Centers

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• Forecasting

• Remote Care

• Data warehousing Real-Time Events

System integration

• Clinical Research

END USERS

ONDEMAND

• Data Exploration

• Servers

• Cloud

business process

ANALYSTS / SCIENTISTS

360°

• Networking

on giving management and other stakeholders a dashboard view of operations and financials. However, with the growing industrialisation of healthcare, the consumer assumes a new significance, with organisations having to focus on clinical outcomes and patient satisfaction.

When asked the purpose of the intended and current use of analytics in healthcare organisations of the region, nearly 46 per cent of respondents indicated that they were interested in analysing clinical information. Clinical analytics with an eye on patient safety to improve clinical outcomes appears to be the key concern. Increasingly, organisations will establish clinical decision support, standard treatment protocols, and align clinical data to operational efficiency and patient satisfaction. Australian initiatives, such as 'MyHospitals' and 'My Aged Care', aim to make information about healthcare providers transparent. These Web sites provide information about the key parameters of the organisations' performances when benchmarked against the national standards. The Singapore government's initiative for medical bill transparency will find advanced use of clinical analytics.

info processing

ARCHITECTS / ENGINEERS

Volume Velocity Variety Value

• Primary care settings

Analytics Trends in Provider Organisations

data acquisition

DATA CREATION • Acute care settings: HIS/CPOE/Ancillary department systems/EMR/ EHR/RFIDs

unstructured data continues. Other countries in the region, like New Zealand, Taiwan, and Hong Kong, have initiated projects to roll out cloud models for whole-of-government use, with the vision of government agencies using resources on a pay-per-use basis.

With these initiatives, widespread use of cloud technology, especially for office productivity, and back-end solutions will become a reality in the region.

In the recent survey conducted, it became clear that there is an interest around quite a few innovative X-as-a-service models for different functionalities, in Asia-Pacific healthcare. What is interesting in the survey results is the ambition to migrate clinical application systems onto a cloud environment. Fortis Hospitals in India recently announced a similar move which gained the attention of healthcare IT executives in the region.

• Access anywhere analytics • Clinical decision support

Push

• Emergency and ambulatory systems

Objectives

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On Demand

• Business Applications

• Alerts

• Workflow automation Embedded

Delivery Models

Information Technology

The Journey to Efficiency

Ultimately, 3rd Platform technologies will come together to create greater efficiencies for provider organisations.

Healthcare is a data-intensive industry. Data is created by multiple sources, including administration systems, clinical solutions, and increasingly from mobile devices used for clinical mobility. Cloud solutions will become popular as the amount of data created increases exponentially. As the data and image archives continue to grow, and requirements for data retention force healthcare organisations to keep patient data for longer periods of time. And thus managing, protecting, discovering, and retrieving data are becoming challenging for storage administrators.

However, ultimately, the value of all the data lies in converting it into information that the organisations can leverage to fulfil their business objectives. The

information can be used for generating real-time dashboard views on current consumption as well as for deep insights on departmental and organisational financial performance, operational efficiency and clinical outcomes. Various roles in the organisation may need to access this information in different ways. While the management may request the on-demand information, several clinical roles will require the information on push functionality, like clinical decision support solutions. In advanced organisations, this analyticsbased information may be embedded in the systems, for better workflow and automation in areas like inventory management.

Implications for Provider Organisations

Think 'Change Management' not 'Ad hoc’: The drive for adoption of newer technologies often comes from multiple stakeholders in healthcare, including Lines of Business (LOBs) and the C-Suite, while the ultimate task of implementing the projects lies with the IT department and the CIO. Emerging technology implementation projects require careful evaluation of the infrastructure, workflows as well as ROI considerations. Many organisations are too focused on ad-hoc implementations and not on the change management as what is required. The projects need deeper considerations like defining the business requirements, agreeing on the success metrics, finding executive sponsors, workflow and business process changes, risk and compliance considerations, and possible project scope changes.

Empower your IT: The IT skills required for running a successful Author BIO

The idea of accountability will become a part of Asian healthcare.

The healthcare industry has always lagged behind other industries when it comes to IT adoption beyond what is considered bare-minimum.

However, as the consumer takes on a new significance in the industry, and while stakeholders like the payer and the life science industry become active participants, the healthcare IT executives will widen their nets and learn from best practices in other industries. As in the United States and in Western Europe, approaches like lean and six sigma will be increasingly used in hospital operations, such as medicine supply chain management, asset management, revenue management, patient throughput and ancillary department management.

Ultimately, clinical analytics in a much broader sense, including population management and predictive analytics, will find a way into the region, as governments collaborate to combat infectious disease outbreaks.

organisation are no longer limited to network operations, technical support for applications and hardware, and help desk management. Many of these functions will be increasingly outsourced as IT becomes aligned with business.

More and more organisations will need business intelligence and analytics, security, IT management, enterprise architecture and mobile development skills.

Focus on the consumers: Improving patient satisfaction has evolved as the key business driver for healthcare organisations. As technology develops and Internet access spreads, so does the role of the patients. Providers are no longer sole decision-makers in healthcare provision. Patients today are more informed than ever and actively participate in their health decisionmaking processes, influencing demand for healthcare services more than ever before, as they actively determine the quality of care they receive. This new generation of IT-empowered patients has high expectations for care, including expectations for advanced technologyenabled services.

The healthcare industry is at a disruptive stage globally. All countries around the world are facing new challenges around sustainability and accountability of their healthcare systems, which are more or less the same. While legacy systems and prior IT investments may prove to be large obstacles for mature economies, the slower development in emerging markets and the availability of newer technologies may well open up a shortcut for those countries to eventually achieve their own goals on sustainability and accountability.

Sash Mukherjee provides regional, fact-based research and analysis on best practices and the use of IT that assists healthcare providers in improving their capabilities. Sash also provides counsel and customised research services to ICT vendors, and represents IDC at industry events, speaking about ICT trends in healthcare.

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Products&Services

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MANY MARKETS, ONE PARTNER With the world’s largest integrated delivery network, UPS offers the speed and flexibility to help you tackle new markets

or serve existing ones cost-effectively. We can help you scale up or down with market demand and manage package and freight shipments to reach more than 220 countries and territories worldwide.

ABIDING BY THE LAW OF THE LAND Staying compliant globally takes experience, technology, people and processes. UPS’s team of regulatory experts maintains hundreds of geographically specific licenses and registrations to enable your products to meet local requirements, keeping your supply chain compliant while staying ahead of tomorrow’s changes.

To learn how UPS can help your company succeed on a global scale, visit ups.com/healthcarelogistics.

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