SPECIAL ISSUE ON HEALTHCARE TECHNOLOGY
I s s u e 31
2015
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The Future of Healthcare It’s connected, personal and team-based
Make in India for the World The way forward for Indian IVD industry
Healthcare Technology What’s in Store?
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Foreword Healthcare Technology The altering landscape Digitisation of processes has opened up a vista of opportunities for healthcare providers to deliver high quality services efficiently. Innovations such as optical scanner, needle-free diabetes care and remote stroke diagnosis help practitioners better diagnose the diseases and perform relevant surgical procedures. Healthcare technology is a broad area encompassing medical technology, information technology for healthcare, medical devices and equipment, mobile technology for healthcare and more. Apart from meeting the challenges such as cost cutting, efficiencies, documentation etc., increasing use of mobile in healthcare industry is providing positive results. Applications in the field of telemedicine have shown promise by enabling remote access to medical imaging data thus creating quick remote diagnosis of strokes. “Mobile access takes away the pain of the afterhours consult and allows me to participate using my mobile device from wherever I am. Using mobile access to patient images makes my knowledge, skills and experience accessible to my trainees, referring providers and patients much more readily and effectively,� says Jason Helvey, MD a neuro radiologist at Nebraska Medicine. According to GlobalData, the market for Patient monitoring and consultation via mobile devices was worth US$1.2 in 2011 and is expected to increase to US$11.8 billion by 2018, representing a CAGR of 39 per cent. Healthcare apps downloads for smart devices is growing rapidly. Some apps help healthcare professionals improve and facilitate patient care by guiding them on diagnosing and treating patients, while others allow patients access to health information right in their pockets. Apps can also be used as monitoring blood pressure, blood sugar controller, glucose tracker, and tracking carb intake. The US Food and Drug
Administration (USFDA) also encourages development of mobile (medical) apps that provide valuable insights to both healthcare professionals and patients. Not surprisingly, medical apps market is expected to grow by 23 per cent annually over the next five years. By end of 2015, more than a third of the 1.4 billion smartphone users will have at least one mobile healthcare app. Rising consumerism, growing information dependence and the need for better outcomes are the key drivers for this technology growth. However, the healthcare industry is bound to face challenges such as rising operational costs, technology burdens, issues related to privacy and security of health information, legal issues etc. Applying technology to the field is as important as introducing it. By using right technology at the right time for the right purpose, there is a chance of overcoming these challenges. In this special issue on Healthcare technology, our esteemed authors have contributed their thoughts on how healthcare industry is moving forward in embracing the technological developments and enhancements for better outcomes and quality care. I would like to specially thank Rana Mehta, Executive Director Healthcare Leader PwC, India; Laurent Metz, Director, Health Economics & Market Access, MD&D Asia, Pacific, Johnson & Johnson Medical Asia Pacific, Singapore; H Stephen Lieber, President and CEO, HIMSS,USA; Ken Ong, Medical Informatics Officer, New York Hospital Queens, New York.
Prasanthi Potluri
Editor
Contents
Special Issue on Healthcare Technology 18
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Around the Connected Health World
Dave Whitlinger, Execute Director, New York eHealth Collaborative, UK Julien Venne, Strategic Advisor, European Connected Health Alliance (ECHAlliance), UK Brian O'Connor, Chair, European Connected Health Alliance, UK Millard Chiang, Chairman, China Connected Health Alliance, China
05 Person-centred, Consumer, or Patient Engagement? Engage who? Ken Ong, Medical Informatics Officer, New York Hospital Queens, New York
10 New Zealand Keeps Finger on the Pulse of Healthcare IT Solutions Tony Robinson, New Zealand Trade Commissioner, Singapore
18 Dealing with Overcrowding in an Emergency Department Using IT technologies and standardisation Michael Hansen-Nord, Head of Department, Emergency Department, OUH Odense University Hospital, Denmark
56 36 Hospital-based Health Technology Assessment A promising approach to evaluate new technologies for healthcare providers Laurent Metz, Director, Health Economics & Market Access MD&D Asia Pacific, Johnson & Johnson Medical Asia Pacific, Singapore
42 Make in India for the World The way forward for Indian IVD industry Suresh Vazirani, Chairman & Managing Director, Transasia Bio-Medicals Ltd., India
44 How Information Therapy can Heal the Indian Healthcare System Aniruddha Malpani, Medical Director, HELP - Health Education Library for People, India
24 From Drawers to Digital Evolving health ecosystem in India
48 How Hospitals Define Value through Health IT A review of value based on quality improvement
Rana Mehta, Executive Director and Healthcare Leader, PwC, India
H Stephen Lieber, President and CEO, HIMSS, USA
30 The Future of Healthcare It’s connected, personal and team-based
56 Impact of 5G Telematics Christoph Thuemmler, Professor, Klinikum rechts der Isar, Munich, Germany
Fernando Erazo, Senior Director and Head, Philips Hospital to Home, APAC, Asia Pacific
Thomas Jell, Senior Principal Consultant, Siemens, Germany
Jasmine Ong, Clinical Program Manager, Philips Hospital to Home, APAC, Asia Pacific
Swaroop Nunna, Huawei Technologies Duesseldorf GmbH, Germany Ai Keow Lim Jumelle, Educational Psychologist, Edinburgh Napier University, UK
MARINA BAY SANDS, SINGAPORE · 6 -10 SEPTEMBER 2015 6 September: CPHIMS Exam 7-9 September: Conference & Exhibition 10 September: Masterclasses & Hospital Tours Learn More from Global Thought Leaders at the HIMSS AsiaPac15 Conference!
Featured Speakers: Dr. Chong Yoke Sin
ART Healthcare
Chief Executive Officer, Integrated Health Information System (IHiS), Singapore
transforming how we manage health
Chairperson, HIMSS AsiaPac15
Attend HIMSS AsiaPac15 to learn more about SMART Healthcare from leading visionaries in the global healthcare technology sector. Plus! Do not miss these special events taking place at this year’s conference:
Dr. Shinsuke Muto, PhD, EMBA
ŹCPHIMS Examination ŹHIMSS EMRAM Award Ceremony ŹHIMSS-Elsevier Digital Healthcare Award and Reception Dinner (by invite only) ŹIHiS SMARTCare Singapore track and Exclusive IHiS Showcase ŹHospital Tours NEW! ŹMasterclasses by INCP and HL7 Singapore NEW! ŹHIMSS Innovation Awards NEW!
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President, Tetsuyu-Kai Institute Medical Corporation Executive Advisor for Information Policy, Ministry of Health, Labour and
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Special Issue on Healthcare Technology
Person-centred, Consumer, or Patient Engagement? Engage who?
Person-centred, Consumer, or Patient Engagement are essential for the prevention of and care for chronic health problems. This article offers an overview of the various definitions of engagement; the challenges facing their success; and how people and healthcare providers are enabling engagement with health information technology.
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eople who are engaged in managing their health and healthcare can have better outcomes and lower healthcare costs. In a study of more than 30,000 patients at a healthcare system in Minnesota, Judith Hibbard et al. found that patients with low activation scores had costs that are eight to 21 per cent higher than patients with the highest activation levels. If you Google ‘Patient Engagement’ you will get more than 7.8 million results. Among the results are related terms
Ken Ong, Medical Informatics Officer New York Hospital Queens, New York
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like ‘Patient-Centered Care’, ‘PersonCentered Engagement’, and ‘Consumer Engagement’. While the variety of these terms can be bewildering, more than a decade ago the Institute of Medicine Report ‘Crossing the Quality Chasm’ recognised that they all embrace ‘qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient.’ A review of some of the current definitions reveals their commonality. Despite their similarities, there are nuanced differences. For example, the American Association of Retired Persons advocates the adoption of ‘person’ rather than ‘patient’ since it includes the ‘whole person’ beyond the individual’s interaction with healthcare. Population health mirrors this perspective. The World Health Organization estimates that removing the risk factors for chronic disease would prevent at least 80 per cent of heart disease, stroke, and type-2 diabetes; and 40 per cent of cancer cases. This means engaging people before they become ill, which in public health is known as primary prevention. As Benjamin Franklin said, ‘An ounce of prevention is worth a pound of cure’. Challenges
As promising as the terms person-, consumer-, and patient-centered engagement are, they face several challenges. The Center for Advancing Health polled a sample of health leaders who cited both systemic and personal barriers: Systemic barriers include: • The health 'system' is fragmented, complex, and opaque. • People live their lives outside of clinical settings. • Stress is high, in part due to many demands on personal, professional, and institutional resources. • Trust and communications between various stakeholders can be suboptimal.
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Selected Definitions of Person-Consumerand Patient Engagement • Institute of Medicine—Patient-Centered: ‘Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.’ Health Foundation of London—PersonCentered care: ‘Person-centered care sees patients as equal partners in planning, developing, and assessing care to make sure it is most appropriate for their needs. It involves putting patients and their families at the heart of all decisions.’ • Institute for Healthcare Improvement - Person- and Family-Centered Care: ‘Putting the patient and the family at the heart of every decision and empowering them to be genuine partners in their care.’ • American Healthcare Information Management Association: 1.
Consumer engagement—‘engaging healthcare consumers while maintaining their own health as well as while they are caring for others’
2.
Patient engagement—‘focusing on patients when they are dealing with illness or health challenges’
• Center for Advancing Health - Patient Engagement — ‘Actions people take to support their health and benefit from their health care’ • Alzheimer Society of Canada - Person and Family Engagement: ‘Families and friends are involved, supported and engaged in the life of the person with dementia. Families, people with dementia and staff are integral members of the team, each one bringing valued and unique expertise to bear.’ • World Health Organisation—People-Centered Health Care: ‘The term ‘peoplecentered health care’ is not to be confused with patient-centered health care. Peoplecentered health care is an umbrella term which better encapsulates the foremost consideration of the patient across all levels of health systems. Therefore, this term would cover patient-centred health care.’ Table 1
Consumer engagement—‘engaging healthcare consumers while maintaining their own health as well as while they are caring for others’ Patient engagement—‘focusing on patients when they are dealing with illness or health challenges’
• The 'old school' culture—that providers are the experts, and patients should be submissive—persists. • Habit (or inertia for institutions) is a mighty force to overcome. Personal barriers include: • Insufficient prerequisites, i.e., mindset not ready for personal activation; knowledge of insurance benefits, variances in quality and cost, and health literacy; and, skills like being
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able to comparison shop healthcare providers • Health problems, including depression, pain, poor health, and disabilities, to name a few • Non-health complications in life from financial instability to abusive relationships to unemployment, and other difficulties associated with what Amber Haley, Virginia • Commonwealth University Center
Special Issue on Healthcare Technology
on Human Needs, called 'low-resource, high-stress environments' • Language and cultural differences. The overarching solution to these barriers expressed by many interviewed in the report was described by Steven E Weinberger, American College of Physicians: “To get better engagement, a push needs to come from both the clinician and the patient side—each interacting with the other.” LET’S DO IT: Healthcare providers
Patient and family engagement are fundamental to healthcare models such as the Patient-Centered Medical Home and Meaningful Use of EHR. Two of the nine standard categories of the National Committee for Quality Assurance Patient-Centered Medical Home Recognition facilitate patient engagement: Access and Communication and Patient SelfManagement and Support.
Meaningful Use includes objectives that enable patients to view, download, and transmit their health information and for providers to provide EHRgenerated patient-specific education resources. The Healthcare Information Management & Systems Society promotes the Patient Engagement Framework, a model crafted to guide healthcare organisations advancing patient engagement through the use of health information technology. The framework is aligned with Meaningful Use. LET’S DO IT: People, consumers, & patients
According to Google’s Mobile Planet, smartphone penetration is growing across the planet. In their 2013 report of forty-seven countries, the average penetration was 44.6 per cent (range 12.8 to 73.8 per cent).
Figure 1 HIMSS Patient Engagement Framework
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Smartphone adoption is growing across many sectors of the population. It may not be surprising that a 2014 Nielsen survey in the United States found that 85 per cent of millennials own smartphones. However, they are not alone. Some 171.5 million people (71%) in the United States own such a smartphone. The proportion of men and women in the US with smartphones is similar (70 per cent and 72 per cent, respectively). Multicultural consumers are adopting smartphones at a higher rate than average in the US Seventyeight per cent of Asian Americans, 77 per cent of Latino-Americans, and 73 per cent of African-Americans have smartphones. From the person’s perspective, Jan Oldenburg offers six categories for personal activation: Communications, Convenient self-service, Personal health information, Personal health
Special Issue on Healthcare Technology
Personal Activation Communications
• Communicate securely with provider or care team • Complete virtual visit (telehealth) • Receive and schedule alerts and reminders electronically
Convenient self-service
• • • •
Find physician or facility Make/change/cancel appointment Check-in and register for a visit Manage Rx refills
Personal health information
• • • • •
Review outpatient and inpatient clinical data Download or transmit health data Enter or track personal data Upload data from devices Review medication information
Financial
• • • • •
View and pay clinical bills Estimate cost of services Manage health financial accounts Reconcile bills and claims, file appeals to claim denials Order replacement health plan cards
Education and support
• Educate oneself on health issues to make decisions about care and treatment • Manage chronic condition(s) • Receive peer and community support
Conclusion
General capabilities
• • • •
Administrative support (e.g., pre-registration) Manage insurance and coverage Analyze health and health data Manage profile and preferences
Table 2
Electronics Show grew 40 per cent. Award winning personal technology included a thermometer refashioned as
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information, Financial, Education and Support, and, General Capabilities Mobile technology and smartphone applications can promote personal activation by personalising health information technology. The quantified self can track observations of daily living (ODLs) like mood, weight, food intake, and physical activity. The digital health exhibits of the Digital Health Summit part of the 2015 International Consumer
a patch (STEMPTM); a portable device that can capture and report blood pressure, pulse oxygenation, weight, glucose, and temperature to health care providers (@HomeVitals™); the first and only FDA-approved, noninvasive, stool-based DNA (sDNA) colorectal cancer screening test (Cologuard®); and, a mobile health platform that connects patients to the vendor’s doctors by phone, text, and video chat (HealthTap). The most popular health and fitness iPhone apps include 7 Minute Workout; Body Mass Index Calculator; Calorie Counter & Diet Tracker; Cardio-Heart Rate Monitor; WebMD; and Fitbit. Apple’s new iOS8 Health is an application that can coordinate other health and fitness apps that can track heart rate, calories burned, blood sugar, and cholesterol. The application also enables creating an emergency card on the smartphone’s lock screen that can display selected health information like blood type and allergies. The health data can be configured to be shared automatically with a health care provider. Personal activation improves population health, individual health, and reduces healthcare costs. While barriers exist to personal activation, Personal Health Information Technology (PHIT) and healthcare models like Population Health, PatientCentered Medical Home, Accountable Care, and Meaningful Use of the EHR support address those barriers. Engage! References are available at www.asianhhm.com
Ken Ong is the Chief Medical Informatics Officer of New York Hospital Queens, an urban teaching hospital serving the most diverse county in the USA and an affiliate of the New York-Presbyterian Health System. He is a member of the Board of Directors of HIMSS.
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New Zealand Keeps Finger on the Pulse of Healthcare IT Solutions Healthcare demands are set to grow significantly in Asia-Pacific as the region experiences both a flourishing economy and ageing population. Tony Robinson, New Zealand Trade Commissioner, Singapore
A
sia-Pacific is home to more than 335 million people over the age of 60 and the size of 60+ group in the region is projected to double from 9.4 per cent in 2000 to 23.5 per cent of
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the total population by 2050, according to the 2005 UN estimates. This will inevitably result in a greater number of medical conditions related to senior citizens and a much greater
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demand for specialised and improved medical attention. As part of the strategy for establishing improved healthcare systems, governments across South East Asia are
Special Issue on Healthcare Technology
investing in health ICT solutions that will help them manage diverse medical demands on tight budgets. New Zealand suffers the same challenges of an ageing population—with the age group over 65 expected to account for 87 per cent of the growth in total population during 2005 2051. Thankfully, it has recorded one of the highest levels in making use of healthcare IT in the world—with hospitals, doctors and pharmacies known to have employed electronic medical systems for over 20 years. On top of this, the New Zealand business community is known for continuing to deliver innovative and technology-driven solutions, which are increasingly making their way into Asia’s healthcare system. By 2050, according to the UN, almost 30 per cent of Singaporeans will be senior citizens. By that time, some of Asia’s most populous nations–India and Indonesiawill have 12.7 and 15.8 per cent of their populations classed as senior citizens. Another of Asia’s larger populations, Japan, will have 36.5 per cent classified as senior citizens. As a result, Japan’s healthcare spend is expected to grow more than double, from 6.1 per cent of GDP in 2006-2010, to 12.5 per cent in 2060, and Indonesia’s will rise from 1.2 per cent to 7.3 per cent.
Meanwhile urbanisation continues across Asia, and city populations are expected to expand at an unprecedented rate – more than half of the population (55 per cent) in Asia will live in urban areas by 2030, according to statistics from Asian Development Bank. McKinsey predicts that 900 million people are expected to transition from poverty into middle class in developing Asian countries by 2020. Better education and employment opportunities will continue to drive the growth of cities, leading to an increased awareness of and access to quality healthcare. There is already a surge in medical tourism in Asian countries like
• Increased need for quality healthcare in APAC—more than 335 million people over 60 years old • More people can afford healthcare including medical tourism with Asia’s rapid urbanisation • NZ’s healthcare IT expertise and research-driven solutions can boost Asia’s healthcare developments.
Singapore, Thailand and Malaysia, which provide quality healthcare at reasonable costs, attracting increased numbers of Europeans, Australasians and Americans looking for qualitative and cost-effective medical care (Not sure what an asset means here.) Medical tourism is tipped to grow to US$1 trillion in AsiaPacific by 2016, with annual growth rate projected at 13 per cent, according to a UBS CIO research. Patients from America and Europe have realised that they can save a lot of money by travelling abroad for surgery. Those needing heart bypass surgery will spend on average US$113,000 in the US, whereas the same procedure costs just US$20,000 in Singapore, and half this price in India. But most medical tourists in Asia come from within the region, as many patients are drawn to neighbouring countries with better facilities. For example, medical tourists from Indonesia and Malaysia spent US$765 in Singapore in 2011. With such options available, the number of people seeking out treatment in Asia could double during the period 2011 to 2015—the number of medical tourist arrivals is expected to top 10 million by next year. Asia’s two largest medical tourism hot spots are Singapore and Thailand, with India fast becoming another country of
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Medical tourism is tipped to grow to US$1 trillion in AsiaPacific by 2016, with annual growth rate projected at 13 per cent, according to a UBS CIO research.
the United Kingdom, Thailand, Taiwan, Malaysia, Brunei and the United States, and the medical solutions are in use at 50 hospitals worldwide. Precept’s first solid order helped establish the company, and was from Temerloh hospital in Malaysia, following an introduction at a New Zealand Trade & Enterprise trade show. Healthcare Digitisation
choice because of its low cost. Singapore is a standout because it has one of the most advanced healthcare infrastructures in the world—the World Health Organisation (WHO) has placed it at sixth out of 191 countries in its global ranking of healthcare systems. Thailand attracts medical tourists both due to its affordability and quality of services, as well as its natural attractions, which lets patients combine medical treatment with a holiday. To meet the growing demands of medical attention for an ageing population and the surge in medical tourism, Asia will need to invest heavily in healthcare advances and technology. New Zealand, a global leader in healthcare IT, has already been partnering with several Asian institutions to help them manage
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demands through top-notch IT solutions that enable more efficient and affordable treatment. The country has set a strong track record, with its healthcare IT adoption being among one of the highest globally. Every day, 90 per cent of primary care physicians and 100 per cent of laboratories in New Zealand communicate via secure health data networks. 99 per cent of New Zealand’s pharmacies are computerised and electronic medical systems have been in place for over 20 years . New Zealand’s focus on innovation and technology is helping Asia overcome its healthcare challenges by streamlining data systems. One interesting case study is that of Precept Health, which has been selling its technological innovations to the world since 2006. The company integrates patient physiology data from a number of different devices to make it accessible in real-time, through simple yet costeffective means. Precept’s technology is now being used in operating theatres and intensive care units in hospitals around the world, reducing the work-load for clinicians, improving accuracy and creating better outcomes for patients. Ninety per cent of the company’s sales are from exports to Switzerland,
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Digitising health records is an important application of healthcare IT, particularly with the global trend shifting towards cloud adoption, which provides better access to patient history while contributing to overall treatment. Singapore, for instance, has established National Electronic Health Records (NEHR) system with which all public healthcare institutions are now signed up. The platform allows individual electronic health records to be collected and viewed in Singapore over a large distributed network. New Zealand e-Health software company Orion Health was involved in developing the program with Singapore’s Ministry of Health, combining its experience of developing a similar programme for New Zealand and its partnership with over 300,000 clinicians and millions of patients in 30 countries. Confirming its commitment to the region, Orion Health recently signed a major investment agreement for a new 1000sqm2 facility and plans to double their staff in Bangkok. This allows the company to hire and train more staff to take advantage of the rapidly rising demand for high-quality e-Health solutions. Orion’s Thailand team will be rolling out the company’s award-winning Hospital Information Systems, collaborating with their partner hospital, Bumrungrad International, the largest in Southeast Asia and listed on the Thai stock exchange. Of the millions of patients Bumrungrad sees every year, more than 500,000 are international. They include thousands of expatriates who live in
Special Issue on Healthcare Technology
The company currently supports Bangkok Hospital in planning, budgeting, costing, reporting and patient intelligence solutions. This, not only keeps the hospital humming, but also allows people to access highquality medical care, through accurate diagnosis. Cortell’s solutions can be easily integrated into remote and rural areas with limited resources and little access to medical expertise Cortell Health has recently signed a memorandum of understanding with Meridian Health that will see the use of their systems implemented across Malaysia. Not only does this help hospitals to efficiently treat patients attracting more medical tourists, but it also provides data that assesses a hospital’s profitability and performance, which is essential to growth. Cortell’s technology will essentially help Malaysian medical providers compete with their Singapore and Thai counterparts in understanding what needs to be done to deliver high quality service to patients, whilst remaining as cost-effective as possible. Innovation
In developing Asian countries, the improvement of healthcare lies in providing solutions that are affordable, simple to use and easily available. Two New Zealand doctors recognised this need and created a diagnostic platform that can be used in developing and poor nations. Scientists Dr. Sarita and Anand Kumble are the duo behind another New Zealand success story Pictor,
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Bangkok and nearby countries, plus visitors from 200 countries around the world who travel there for safe, costeffective treatment. International patients appreciate that English is widely spoken in the hospitals and there are plenty of interpreters on hand. Orion Health’s Hospital Information Systems help to streamline processes, changing the way that patients are managed and the care is delivered. Reduced patient wait times, speedy processing at laboratories and communication of real-time medical records between the hospital and home-care professionals makes Bumrungrad a world leader in healthcare delivery. Healthcare institutions and providers deal with a large number of patients with different medical conditions daily. The effective management of activities ranging from financial to clinical, helps increase their profitability and performance. New Zealand company HSA Global’s vision for integrated care focuses on patients who are the most frequent, intensive and costly users of healthcare. The company focuses on patient-centric shared care management tools supported by redesign services to enable seamless care delivery that improves quality and removes duplication. HSA Global’s software platform has been localised to fit the Singaporean health ecosystem and supports projects optimising the 'continuum of care' and 'virtual ward' concepts. This enables collaboration between the hospital, SOC, polyclinic, CHC, FMC, nursing home, home care service and the patient’s home and family support. Cortell Health, another New Zealand company, has been working with medical providers in Malaysia and Thailand to provide business intelligence solutions that assess hospital performance and identify areas of improvement helping to lower costs and better service.
which provides an immunodiagnostic solution that can be rolled out in underdeveloped areas with higher rates of disease. Their simple and affordable diagnostic tool, PictArrays can test for five of the major killers of infants— Toxoplasma, Rubella, Cytomegalovirus and Herpes Simplex Virus 1–from just one drop of blood. The product is going to be rolled out in Thailand and Malaysia. Asia and New Zealand partnerships
New Zealand has also been partnering with scientists in Asia to develop innovative solutions for the healthcare industry. In Singapore, scientists from the National University of Singapore and the Singapore Institute of Clinical Sciences are working together with New Zealand’s AgResearch and the University of Auckland to research methods that optimise nutrition for mothers and children, and understand developmental pathways to non-communicable diseases. New Zealand is also researching preventive measures for chronic diseases that plague many Asians, such as diabetes, which has escalating rates in Singapore, Malaysia and Thailand. From record keeping to prescribing medication and providing access to online health records, New Zealand has a long history of implementing healthcare IT. With experience in innovating healthcare IT systems and solutions for leading healthcare providers and its association with governmental bodies, New Zealand is well placed to partner with developing Asia to meet growing healthcare needs.
Tony Robinson is New Zealand's Trade Commissioner to Singapore, appointed in July 2013. Before joining NZTE, Tony established, grew and eventually sold a healthcare company. He has lived and worked in New Zealand, Singapore, Taiwan and Saudi Arabia in Fast Moving Consumer Goods (FMCG) marketing roles with the New Zealand Dairy Board and Heinz Watties. He holds a Bachelor of Commerce and Administration (BCA) from Victoria University of Wellington.
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Around the Connected Health World
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Today's health technology world is fast moving and exciting - but still full of wasteful ‘reinventing the wheel’ and ‘not invented here' attitudes. Collaborations, alliances and above all effective communications are the weapons needed to overcome the obstacles. Dave Whitlinger, Execute Director New York eHealth Collaborative, UK Julien Venne, Strategic Advisor European Connected Health Alliance (ECHAlliance), UK Brian O'Connor, Chair European Connected Health Alliance, UK Millard Chiang, Chairman China Connected Health Alliance, China
e all know the statistics and trends, with ageing populations, the chronic disease epidemic of obesity, diabetes etc. and add the economic cost of treatment,reduction in productivity and the financial problems of many countries—it would certainly be easy to feel depressed and helpless! Add to that, the legions of organisations and ‘Experts’ who state and restate the problems and issue stark warnings of the consequences but, with some notable exceptions, rarely offer practical solutions. There are many well meaning announcements made that repeat the latest warnings and exhortations for all of us to exercise more and manage our health better; and for governments, payers to do more. But does anyone pay any attention? So, before we all get depressed here are some thoughts which might cheer you up a little. There is always a Chinese proverb for every situation and of course there is one for this too. Wei-Jie is a term which means both crisis and opportunity and it is certainly a succinct summary of where the world finds itself now. We often hear of the 'Crisis in Healthcare' usually prefaced with phrases such as 'Out of Control' or Global. Again, it is always easy to state and restate the problems, but there is a shortage of practical solutions. The good news is there is also an opportunity and there are solutions. There are success stories, there are powerful forces which if aligned can deploy solutions which will help solve the problems but the bad news is there are obstacles to effective international collaboration.
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Special Issue on Healthcare Technology
The three organisations, European Connected Health Alliance, China Connected Health Alliance and the New York eHealth Collaborative contributing to this article have experiences in three continents,with a combined population of approximately 2.4 billion citizens. All three run multi-stakeholder organisations in their respective continents and have a helicopter view of the problems and solutions. There are of course many differences on how healthcare is delivered in Europe, China and the USA, driven by differing reimbursement systems, payers, government policies etc. but the three organisations see many more similarities than differences. So lets hear from all three organisations and look for hope and real solutions. Connecting with European healthcare systems
Julien Venne, Strategic Advisor & European Project Team Leader for ECHAlliance notes that the 28 Member States of the European Union have a population of almost 600million,much larger than that of the USA. Currently, about 20 per cent of Europe's population is aged 60 or over; that will rise to 30 per cent by 2030 and will include a large per centage of people over age 80. Venne acknowledged that each country in the EU has 'different healthcare systems, different rules and different politics,' although all follow a common principle: universal healthcare coverage with general practitioners as the main gateway to care. Because the EU cannot decide strategy for its members-it can only foster research and innovation and encourage change-each member state has its own healthcare business model; generally, the model is a mix of public and private sector organisations that together make up the public health and social care systems. Contributing to the market fragmentation is the lack of interoperability among computerised systems and laws
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that differ from place to place. Even so, Europe presents opportunities for companies and organisations from the US and other countries working in the e-health space, Venne emphasised. 'You need to create your own ecosystem to innovate, he said the ECHAlliance is doing its partby helping to connect innovators and their products with funders and purchasers, patients and families and health and social care providers. It has created an International Network of Permanent Connected Health Ecosystems in 25 locations across Europe, each with multi-stakeholders meeting regularly and doing business with one another. These institutions attract, government, academia, industry start ups, small and medium enterprises, patient groups, physician and other healthcare professionals to meet regularly, listen to priorities and collaborate on solutions. More recently venture capital and private equity players are participating as they seek opportunities to invest in this fast growing market. Successes and failures are communicated throughout the network leading to faster, more effective collaboration. The emphasis is on solving real needs rather than talking about the problems. The European Commission provides significant funding for Research and Innovation, €80 billion in the latest plan to encourage job growth and export opportunities. Connecting with China's healthcare system
Millard Chiang, Chair of the recently formed China Connected Health Alliance (CCHAlliance) provides a snapshot of China's patient population and highlights key areas of concern. He noted that while chronic diseases such as cancer, diabetes, heart failure and hepatitis C accounted for 19 per cent (260 million) of patients in 2013, the per centage will grow in coming years along with the ageing population. People aged 60 and over currently
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make up close to 20 per cent of China’s 1.4 billion population. Together, they eclipse those under age 15 (16 per cent). The dwindling younger population is due primarily to the one-child policy instituted in the 1970s, but environmental factors– notably, air and water contamination from industrial products–are largely responsible for the more than a billion cases of non-chronic diseases among all age groups. 'China needs first-rate healthcare technology, operating systems and research-and we need one million additional nurses over the next five years,' he said. Those needs, among others, drove Chiang and his colleague Peter Chau together with Brian O’Connor (ECHAlliance) to cofound the CCHAlliance, forming 'a bridge' to Europe through collaborations with the ECHAlliance. The result is a variety of opportunities for companies involved in 'ehealth, mhealth, telecare, phealth, digital health and related technologies'. Chiang credits networking with countries outside of China, as well as internal networking with China's ministries of health, social welfare and security, with the rapid success of the CCHAlliance's outreach efforts. ‘In eight short months, we've opened our first office in Shanghai ,recruited Members from Government,Industry and Academia and identified specific needs which provide real opportunities for European and U S players,� he adds. The determination of the authorities at central, provincial and municipal levels to dramatically improve medical and social care services to their citizens provides significant opportunities for Chinese local companies and in particular for Western companies. That determination is being matched by additional investment at every level with amounts of additional funding that other countries can only envy.
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David Whitlinger, Executive Director of the New York eHealth Collaborative, says that the US shares the concerns of China and the EU regarding an ageing population and the costs of chronic diseases. According to the latest figures, chronic disease is responsible for 80 per cent of US healthcare spending, or US$2.3 trillion. Implementation of the Affordable Care Act could ameliorate the problem, he said, by 'putting us on track to provide healthcare to all of our citizens, thereby bringing us in line with Europe and China.' Also similar to Europe and China, the US Centers for Medicare and Medicaid Services continue to 'shift from a hospital-centric system to healthcare delivery in ambulatory and home care settings, and from a curative approach to preventive care, 'Whitlinger said.' There's a move to pay for quality, outcomes, wellness-all opportunities for innovation if we can get healthcare ecosystems to align to a set of universal services throughout New York state and across the globe.' Whitlinger concluded by observing that the ECHAlliance is a sister organisation of the CCHAlliance, and that the New York eHealth Collaborative is a member of the ECHAlliance. Together, he said, the organisations 'offer a window into the health status and needs of some 2.4 billion people on three continents, in markets that are spending up to four trillion US dollars. 'He stressed that the global market is ripe for 'killer apps' that can scale across countries and be delivered via a 'coordinated care/ team-based approach'-for example, a 'medication-adherence app' to support care plans or an app that could make a significant impact on obesity, exercise and other lifestyle changes. Right now, Alcoholics Anonymous and Weight Watchers are the only programs proven to work worldwide. We need killer apps that help eduacate citizens to encourage them to take
responsibility for their health and lifestyle choices, thus giving them a better quality of life and reducing health insurance premiums for them and their families and other big health problems in New York, Europe, China and beyond.' When you read the above and think about the sheer scale of US$4 trillion being spent, on providing healthcare and over US$1 trillion of that being spent on managing chronic diseases in over 400 million peoplethis really is both a crisis and an opportunity . When you look at the amounts being spent currently in these three continents on health social care and public health and appreciate that even greater sums will need to be spent, the question which is often asked, but rarely answered is: What can be done?
The answer is: We can do a lot, because the knowledge and experience of solving at least some of the budgetry pressures on Governments everywhere have been tried and are working somewhere already.' This Three Continent Coalition of the ECHAlliance, CCHAlliance and the NYEC is already sharing successes, experiences & opportunities. All three intend to intensify their collaboration by presenting their respective memberships with business deals, engagement with their opposite numbers, jointventure, licensing and distribution possibilities. The combined efforts of these organisations will help turn the crisis into an opportunity for many.
As Executive Director, Dave has overall responsibility for the New York eHealth Collaborative. Previously, Dave served as the Director of Healthcare Device Standards and Interoperability for the Intel Corporation in its Digital Health Group. He led a cross-industry consortium, the Continua Health Alliance. He also served on the Bluetooth SIG Board of Directors for several years. Dave is the author of five research journal articles, four of which focused on breast cancer DNA analysis.
A u t ho r B I O
Streamlining healthcare in the US and beyond
Julien Venne is the Strategic Advisor of the European Connected Health Alliance (ECHAlliance). His role is to support companies in their business development in Europe, and policy-makers and public authorities in several European Countries. His expertise covers innovation development, business models design and ecosystem creation within the Connected Health sector.He has a multi-disciplinary academic background, with economics, sociology, political sciences and complex systemic. Brian O’Connor has worked in the UK, the US and lived in Hong Kong for eleven years. He has gained vast experience as a company director in a variety of industries and professions, and has raised significant sums for companies through both private equity structures and stock exchange listings. Through his long established consultancy company, Corporate Direction Ltd, he is currently providing strategic advice to Governments, International organisations and companies on the challenges facing healthcare in general and specifically on the Connected Health opportunity. For the past 20 years Millard Chiang has specialised in connecting multinational corporations in the fields of accreditation and authentication, elderly care, healthcare, sports, and culture to the appropriate Chinese Ministry. He has established multiple networks with the Ministry of Public Security for programs in ID Cards within multiple areas of China and for product authentication, a prelude to an ePedigree system; with the Ministry of Human Resources Social Security for the only Central Government approved Elderly Care Centers and more.
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Dealing with Overcrowding in an Emergency Department Using IT technologies and standardisation
Dealing with overcrowding, a high per centage of sickness, and a high level of stress among staff are universal problems in Emergency Departments (ED). In creating a new ED, we chose to deal with overcrowding as our major challenge. By using new IT technologies in planning standardised patient tracks as well as focusing on control of logistics, we managed to deal with major overcrowding situations. We brought down the per centage of sickness from 11 per cent to an average of 6 per cent in 2014. In addition, all patients are seen by a consultant 41 minutes after arrival and a final diagnosis and further plan for the patients is completed within 3 hours and 52 minutes. Michael Hansen-Nord, Head of Department, Emergency Department, OUH Odense University Hospital, Denmark
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n January 2012 a new Emergency Department (ED) opened at Odense University Hospital in Denmark —the largest ED in the country. The department should handle small casualties and traumas on level 1 and include facilities for evaluation of patients before admittance and a community service provided by general practitioners. The estimates were 350 patients per day with a day-to-day fluctuation of +/- 30 per cent.
The creation of a new set-up for emergency service was a unique chance to rethink organisation in a building that was made for that exact purpose. We decided that the most important issue to deal with the design of the set-up should be overcrowding and we identified several areas which we found important to work with. This article describes some of the initiatives we took, massively and still supported by our Board of Directors, and how we dealt with them. Nonetheless,
it is very important to emphasize the urgent need to work with attitudes and culture among the staff. We engaged a lot of energy in dealing with these issues and even displaced members in our staff to place the right people in the right positions. We have gone a long way and there is still room for improvements. Background for the Danish emergency services
The majority of patients in a Danish ED will have been seen by a skilled physician
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before arriving. During the day and at ordinary times, patients who contact General Physician (GP), if required are redirected to the ED asking for acute evaluation. Outside opening hours the patients in our region have to call a unique phone number where 80 per cent mainly get in contact with a GP. The GP can ask the patients to consult their own GP in daytime, can ask the patients to come to a consultation by a GP situated in our ED, or can call the ED for an acute evaluation. Apart from this, patients are arriving after calling our general emergency number 112. However, the number of patients arriving at the ED this way accounts for less than 20 patients per day, out of an average of 370 patients. The described system gives our ED a unique case mix where only patients in actual need of ED-services are getting evaluated in the department. In numbers, it means that around 50 per cent of all patients having a consultation outside opening hours are seen by GPs instead of in the ED. The new ED
The new building includes a total of 10.000 m2, including 4.000 m2 at the ground floor and 4.000 m2 at the top floor. The ground floor is the diagnostic area with 4 trauma rooms, radiology, a small casualty-area, 15 consultation rooms, and an area for community
• High level of expertise in the initial phase of contact with the patient • Standardisation • Patient tracks • Logistics • Diagnostic procedures • Waiting time for diagnostic procedure to be performed – don’t postpone • Four hours to diagnose Figure 1 Topics to work with in dealing with overcrowding
service. The top floor houses up to 48 admitted patients who are expected to stay for less than 48 hours (on average, 18 hours). The organisation of the ED in Odense In Denmark (DK) emergency medicine is not yet recognised as a specialty. Odense University Hospital is the largest hospital in DK and our emergency department is the largest ED in DK. The hospital is represented by all recognised specialties in the country and all specialties are on duty–either by attendance at the hospital or on house call. The department is staffed by nurses, secretaries, and a minute number of doctors (12 consultants and 8 junior doctors). The rest of the staff in our
Figure 2 The new Emergency Department at Odense University Hospital, Denmark
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ED come from other departments to solve dedicated work (e.g. radiologist, lab physician, and cleaning) or to take care of the patients belonging to their specialty (e.g. surgeons, neurologist, and orthopaedics). Every patient is allocated to a certain specialty upon arrival and the appointed specialist is in charge of the patient throughout the patient’s stay in the ED. The department has a large scientific unit headed by the first professor in emergency medicine in DK. The agenda of the scientific work is to create scientific results that can be applied to our emergency set-up without too much delay. High level of expertise in the initial phase of the contact with the patient
In the former ED set-up, the youngest doctors were in front. The consultants and other doctors with major knowledge only saw those patients that the junior doctor could not handle. We changed that scenario and made the consultants the front doctors to all new arrivals in the department. The process was not without discussions on whether we were using the right competences at the right level in patient treatment. Nevertheless, our Board of Directors decided, upon our recommendation, that we should have the highest level of competencies
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Figure 3 Screen print of our simulation-model1
in front to spot patients who need specialist services. Our experience is that placing a specialist in front was right. A case mix of older patients with chronic diseases and complications calls for higher expertise from the beginning as the symptoms of a severe illness is often disguised and overlooked (e.g. sepsis). One of the results of having specialists in front is that, the number of patients finishing treatment in the diagnostic area is increased from 60 to 73 per cent, decreasing the number of patients being admitted by almost 5.000 over the last three years. Standardisation–Patient tracks and simulation In preparing the patient flow through the diagnostic area, we described three different patient tracks: A fast track for small casualties (20 minutes), a track for the community service (6 minutes), and a track for patients to be evaluated for admittance (up to 240 minutes). Each of the three tracks consists of a varied number of processes the patient has to pass through until diagnosis can be confirmed and further plans about treatment and observation of the next 8 – 12 hours can be made. Each process is defined by what, who, 1 By acknowledgment to Flexim®
and the number of minutes available. An example could be blood sample, lab technician, and 5 minutes. Combining the patient tracks with the number of patients arriving in an hour through a whole year, we had a mathematical model that could be simulated. From the simulation, it was possible to staff the unit during 24 hours and simulate variations during the week, incorporate incidents with extraordinary incoming patients and so forth. Standardisation–Logistics
One of the biggest challenges in organising the patient flow was to standardise the patient’s way through the diagnostic area without losing track and always knowing if the patient was kept in flow to meet the time criteria. For that purpose we use a special logistic board where all patients in the
department are presented with logistic data. In the diagnostic area the focus is on getting the patient through to a diagnosis within four hours. The continuous surveillance is managed by a “flow master” (a senior consultant) who is the logistic manager and the leader of the doctors in the area. Every 2 – 3 hours (Figure 5) during duty he/ she has a 5 minute briefing with the rest of the staff to ensure that requirements to keep the patients in flow are met. Every 4 hours the flow master meets with the nursing-coordinators trying to look 4 hours ahead of time – the purpose is to prevent overcrowding and stress. Every time the logistic boards are used, the user leaves a time-sample to be used in our follow-up on the organisational set-up. As managers of the department, this information gives us a unique opportunity to adjust to our standardised time-schedules, locate
Figure 4: Example of a patient´s presentation on the logistic board2
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counting the number of primary diagnoses upon dismissal, we found a total of 2.147 different diagnoses. To us, it proved the value of the packages, and the method saved a lot of time 'from door to primary diagnoses'. Waiting time on a diagnostic procedure – Don’t postpone
Figure 5 Planning in front of the logistic boards
bottlenecks, and make valid plans for changes to overcome overcrowding. Standardisation – diagnostic procedures The visitation into emergency departments is traditionally based on a suspected diagnose. We are trying to change that into visitation based on a symptom combined with a triage colour and basic vital parameters. For example: pain in the upper abdomen, triage colour yellow, and with normal basic BP, pulse and temperature. Over a period of three years the Region of Southern Denmark developed 34 somatic and 5 psychiatric packages, each by considering a major symptom combined with defined
blood samples, ECG and suggestions of radiology. Upon arrival the new patient is admitted as per the purview of the packages and the investigations can begin without delay. In addition, a package describes which specialty has the definite responsibility of the patient. The 34 somatic packages will include 97 per cent of all patients coming to the ED. In the spring of 2013 we tested more than 17.000 patients to see if the packages they had assigned led to the final diagnosis without additional investigations. In 78 per cent of the cases, the emergency diagnosis was set from the initial investigations. When
The location of our radiology facilities between the trauma-rooms and the small casualty-area very quickly showed impressive improvement in the time taken to decide on the need of a service from a radiologist to receiving the result. Within weeks of opening the department, we saw a reduction in time for treatment of patients suspected of cerebral thrombosis. The door-to-needle-time was reduced from 75 minutes on an average, to 18 minutes in our new ED–almost 1 hour of cerebral ischemia saved for those patients who had an effect from thrombolysis. The general efficiency of the Radiology Department was increased considerably. The time from referral to CTC was received until the investigation was performed decreased from 43.33 to 24.73 minutes. For chest X-ray the decrease was from 39.60 to 15.8 minutes. Four hours to diagnose
Obtaining an initial plan for treatment and observation within 4 hours after arrival is based on two sets of facts. First of all, we were inspired by clinical studies showing that the patient’s mortality increase with 3 per cent for every hour they spend in an ED beyond 4 hours without a diagnosis. Secondly, the simulations we performed (see above) showed that we increased the numbers of patients in the diagnostic area to a critical level if they have stayed more than 4 hours. 2 By acknowledgement to Insight® by Marques 3 Figure 6 and 7 by acknowledgement to the Department of Radiology, OUH Odense University Hospital Figure 6 Time from receiving the referral to CTC (upper curve) and chest X-ray (lover curve) to completion of the investigation. All in minutes3 22
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Figure 7: Time from referral to completion during 24 hours. The blue columns represent data from 2011 and the green columns represent data from 2013
Conclusions
In planning a new emergency department, we decided to try to cope with overcrowding as our main challenge. The large numbers of patients (350 per day) with a day-to-day fluctuation of +/- 30 per cent was our challenge. We recognised a number of options and through standardisation, simulation, and optimised logistics we succeeded in getting along the way. Having the specialist in front, reducing the time
for radiology services by more than 70 per cent, creating diagnostic packages that lead to a diagnosis eliminating the need for further investigations for 78 per cent of the patients, and reaching the goal of 4 hours counted from arrival until an initial diagnosis to planning for the next hour(s) is settled and are standards now. In our belief these results have contributed to reducing the days of A u t ho r B I O
By the continuous registrations on our logistic boards, we can verify that the 4-hours-criterion is met with an average of 3 hours and 52 minutes.
sick leave among our staff by approximately 50 per cent and have helped us cope with the major challenge of overcrowding. Nevertheless, it is important to remember to deal with the cultural changes needed among the staff in the preparations for so many changes and be ready to answer the question:'What good does it do to the patient and me?'
Michael Hansen-Nord specialist in Internal Medicine and
Endocrinology. For 15 years Head of different 3 departments. Since 2012 head of the new Emergency Department at Odense University Hospital, Denmark. Since the department opened in January 2012 there have been 45 delegations visiting from all over the world including the USA and Asia.
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From Drawers to Digital Evolving health ecosystem in India This article will include the evolution, the current state, the issues and challenges, and foresight into where Indian healthcare segment can be at the current pace and where it ideally should be 10 years down the line. It will also include how Health IT which includes HIS, SMAC, and virtual health (telemedicine) have been playing a role as an enabler and why the investment in these technologies by the provider segment is important in India. Rana Mehta, Executive Director and Healthcare Leader, PwC, India
D
igitising healthcare is a vision aimed at making the world an even smaller place and bringing the patient closer to the provider, if not physically,virtually. Digital healthcare essentially circles around two main areas in healthcare: accessibility and affordability. This visionencompasses digitising all patient health records through an EMR or EHR, integrating the EMR with e-Prescription (prescription for medications reaching the pharmacy directly where the patient can go and collect it), PACS (archiving of radiology images electronically), etc., performing real-time data analytics based on the data captured and using the analysed data for clinical decision support or for predictive diagnosis and treatment of patients. All of this is what providers do within the boundaries of the
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healthcare organisation. Outside the boundaries, use of mobile solutions and enabling of remote consulting and home care through virtual health or telemedicine is another segment that is allowing faster, more efficient, and more accurate care of patients. But even when most of us acknowledge these benefits and are moving in the direction of digitisation, then why is the transformation taking so long? Why are Indian providers’ mindsets still not acclimatising completely to this change? Why does the gap remain?
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On 15th August, 2014, the new Prime Minister of India made a clarion call to move towards a digital India by revolutionising healthcare delivery using telemedicine. The models of telemedicine and m-health, which initially began as proof-of-concept, have been proven to be scalable and replicable in other resource poor settings, highly effective in enhancing healthcare accessibility. However, the foundation of remote healthcare delivery lies in the increased adoption of the health IT (EHR/EMR) across Indian hospitals. The healthcare IT ecosystem still remains in the nascent phase, wherein integration of labs and pharmacies via the internet ensuring seamless communication with the clinicians still remains a recent development. ICTsolutions for developing countries often require a different approach than that used in developed countries and organisational and user needs can be different due to cultural factors, such as overcoming paperbased systems, data-entry hassles, and resistance from doctors and hospitals towards a more transparent care scenarioor a lack of computing skills among staff all of which may complicate adoption. Large corporate hospitals in India still spend under 1 per cent of their operating budget on IT, as compared to 3 per cent in the west and only 6 hospitals in India have reached the stage 6 Level on the EMR adoption model of the HIMSS.
The main expectations of hospitals in future are linked to complete integration of systems, more shareable information platforms, and standardisation that could lead to user-friendliness, and access to mobile devices such as tablets, as well as advanced tools uptake like telemedicine and virtual meeting systems for knowledge sharing.
Overall, the scope of HIT services is restricted to metro and Tier I cities, and success is expected to depend on factors such as cost versus benefit comparison, along with clear and quicker ROI according to a recent report on Health IT in India. Successful Case Studies
Despite these restrictions, there is much reason to cheer as some Indian hospitals have undertaken crucial initiatives in the digital health space, which serve as benchmarks for the Indian healthcare industry in the years to come. Max Healthcare has been one of the first movers in the adoption of EHR, and was the first hospital in India and only sixth in Asia to achieve 'Stage 6' on the EMR adoption model from Healthcare Information and Management Systems Society (HIMSS) in 2012. This was engendered bythe implementation of an open source EHR solution (World VistA) with CPOE (Central Physician
Order Entry), CDSS (Clinical Decision Support System) and BCMA (Barcode Medicine Administration) which ensured the documentation of the entire course of the patient’s stay in the hospitalby the integration of all transcripts, prescriptions and billing information into the system in order to provide analytical insights for improving health outcomes. The hospitals’ transition to the increased usage of data analytics to improve treatment regimens for many disease conditions was a first step towards moving from a traditional measurement of success of a healthcare facility by mere financial performance to clinical performance indices, which would be a representation of the overall health of their patients. With such socio-technical approach towards overcoming technological and non-technological barriers, Max Healthcare was able to provide real time access to patient records using the EHR by maintaining the continuity of the patients’ medical records and thereby reducing delays in clinical decisions. The enhanced clinical decision support systems enabled them to optimize manpower utilisation, particularly in tracking patient outcomes for better disease management such being the case with the prevention of hospital acquired Venous Thromboembolism and in analysis of health outcomes for various treatment modalities for breast carcinoma.
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Apollo Hospitals, which has been the forerunner of integrated healthcare, has also contributed highly towards India’s digital health journey. During 2013-14, four Hospitals within the Apollo group achieved Stage 6 on the Electronic Medical Record Adoption Model (EMRAM). Apart from adopting international clinical standards, Apollo Hospital Group also creates population-specific clinical rules from population studies. In addition, unit drug dispensing dosage and excellent clinical decision support are present. As early as 1999, the Apollo Hospital Group (Apollo Telemedicine Networking Foundation) decided to extend its outreach and initiated the process of providing healthcare to suburban and rural India by adopting Information and Communication Technology for the telemedicine platform. Today, they run the oldest and largest multi-specialty telemedicine network in South Asia, which specialises in remote consultation and second opinion to both patients and doctors, improving access to quality healthcare due to distance and high costs. ATNF’s flagship web-enabled Telemedicine application 'MedintegraWEB’ enables
doctors, nursing homes and hospitals to reach out to patients in inaccessible areas and provide interactive healthcare using modern telecommunication technology by collecting and converting the patient’s data into a secure and confidential Electronic Medical Record (EMR). Based on the investigation, the specialist offers his/her opinion which is transmitted back to the grass root (peripheral) where the doctor is able to treat the patient accurately and without any further delay. ATNF has also been instrumental in demonstrating that 3G technology can be used in transferring health information, thereby, leading the m-health initiatives in India. Text, audio, and video data have been transmitted on a real-time basis and have facilitated interaction between the consultants at the Apollo Hospitals, Chennai and patients in the villages at the remote end. Using 3G, doctors at the tertiary hospital have been able to clinically 'examine' the patients through a high-quality web cam. Health IT trends in India
Growth in data, digitisation trends in health information and EMRs,
Table 1
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improvements in collaborative data exchange, workflows and mobility, and need for better financial management have been recognised as the changing needs of the hospital enterprise. Additionally, patient demographic changes and chronic disease growth, cost control considerations, and importance of patient safety, have all come together to heighten the demand for Health Information Technology (HIT) in India, generating a potential US$1.45 billion health IT market by 2018. The main expectations of hospitals in future are linked to complete integration of systems, more shareable information platforms, and standardisation that could lead to user-friendliness, and access to mobile devices such as tablets, as well as advanced tools uptake like telemedicine and virtual meeting systems for knowledge sharing. A contributing factor is that healthcare organisations are complex and include a variety of work practices. This includes strong interdependency of roles, and a hierarchy of distributed responsibilities. This interdependence can make imposing changes difficult because a small change in one person’s
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workflow may affect the performance of someone else’s workflow. Medical Informatics Systems (MIS) for such hospitals can thus be challenging to design and implement, and nearly half of them fail due to user and staff resistance. The increase in adoption of electronic health records, mHealth, telemedicine, and web-based services has made electronic patient data expand, necessitating the implementation of robust IT systems in Indian healthcare institutions. Challenges
Hospitals have noted that ease of integration with existing solutions is the main criterion they seek from Electronic Medical Record (EMR) vendors which brings us to our next discussion on this topic - the major challenges associated with implementation and successful adoption of health informatics solutions in India: Culture of Indian healthcare providers: The transformational journey of 'Putting patient at the centre of care' has begun but providers in India today still haven't been able to realise this dream in its true sense yet. It seems providers generally do not look at investing in health informatics as a long-term gain to improve operational efficiency and patient health outcomes; to them, it seems to come across as an expense from their budget to make themselves appear more competitive. One of the reasons is that users /clinicians at these hospitals have had a difficult time adapting to the technology and some of them still prefer pen and paper which again ends up getting filed in a drawer as opposed to a digital clinical note that gets saved on a secure server and is immediately available for review the next time the same patient shows up. Now, why would the user have difficulty adapting to a process that essentially is being imitated electronically? There have been cases where processes and workflows in hospitals are not followed
Figure 1 The Value Impact Analysis provides a visual representation of the solutions using a two dimensional matrix. The dimensions are Benefits Realised and Investment.
to the 'T' and thus, when entering the entire mandatory information becomes a requirement, the users tend to resist because of the volume of data entry that may now be required which brings us to our next challenge. Lack of awareness on optimal use of health informatics: One of the reasons for the technology not being able to provide its expected ROI to Indian hospitals is the lack of awareness among users/clinicians on how to 'optimally' use the technology to see maximum benefits from its use. This idea also ties back to the point made above on adoption. Users will adopt the technology better if they are well aware of how it will help serve the provider's goals and objectives with optimal use. Think about it–a software product may be capable of doing the right analysis and generating the right reports but the results may be skewed or not accurate because the data entry (the first step in the process) itself may not be accurate or complete to allow generating valid results.
Understanding the difference between quick wins and milestones: When providers in India implement a health informatics solution, the general expectation is to start reaping immediate benefits from the use. The thought process that ideally needs to be adopted by providers in India is to create an IT Strategy for the health informatics solutions to be deployed and outline the quick wins (initiatives that provide high medical value and require relatively lower fund requirement and time for implementation) and longterm milestones clearly and build KPIs to measure the achievement as time progresses to ensure the expected benefits are being realised at the expected point in time on the strategy roadmap. Having discussed these challenges, it would also help to understand the optimal use of the health informatics solutions considered by most healthcare organisations. In order to ensure providers pick the right solution to address their operational issues, the following is a breakdown of the
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Optimal use of health informatics solutions Scoring Legend 4 = Highest
2 = Medium
1 = Medium -
0= Lowest
Health Informatics Solution
Investment on the solution
Benefits realised
1
mHealth (Mobility Solutions)
3
4
The underlying infrastructure and architecture costs require major investment for enabling mobility solutions. How and where the solution proves specifically fruitful: instantaneous connect of the patients with the health advisors without having to come into the hospital/clinic and 24X7 availability of the service, thus reducing patient footfall and allowing doctors to focus more on more serious cases.
2
Telemedicine
3
3
Again, the infrastructure and the architecture costs require a big investment. How and where the solution proves specificallyfruitful: in terms of accessibility specially in Tier II, Tier III, and rural areas, where there is shortage of medical staff, this is currently the best available solution.
3
Hospital information systems (HIS)/ Electronic Health Records (EHR)
3
4
Depending on the maturity of the infrastructure and architecture, this investment could range between medium to high. If it’s a first time install, the investment will be high but if it's an upgrade, the investment will be relatively less. How and where the solution proves specificallyfruitful: instant secure access to patient information including history and previous test results, thus reducing physical storage space and manpower required in the healthcare organization. EMRs and HIS also support further enhancements in terms of PACS, CDSS, evidence based medicine, etc. making systems more integrated for easier flow of patient data and efficient and accurate patient care.
4
Health Information Exchange (HIX)
4
4
A Health Information Exchange will require maximum effort from all healthcare organizations to allow secure and efficient exchange of info among them. This initiative will involve having a common standard/protocol/language (such as CCDA, HL7, etc.) for exchanging the information. How and where the solution proves specificallyfruitful: Secure exchange of PII across multiple organizations within the same territory allowing efficient patient care.
5
Social Media
1
2
From an investment perspective, this is easiest on the budget since the idea is to use existing social forums to spread awareness and educate. Even an independent website/ portal would not be a big dip in the pocket. How and where the solution proves specificallyfruitful: this solution is the easiest way to reach out to the patient community and build a connect with them. Social media also helps promote awareness and health education among patients, thus, instilling the idea of self-care.
6
Data Analytics
2
3
This solution is a build-up on the existing EMR/HIS and mhealthsolutions and thus, doesn't require overhauling of the infrastructure and architecture. This is not a heavy investment solution. How and where the solution proves specificallyfruitful: this solution benefits hospitals in a wide range of reporting needs including real-time analysis and geospatial analysis of disease spread using GIS.
7
Cloud Computing
2
3
For this solution, due to service providers being available for cloud storage, the initial investment is not very high. How and where the solution proves specificallyfruitful: this solution is very beneficial in eliminating physical space required to store physical servers, thus, preventing any maintenance costs as well as eliminating any damages to servers in calamity prone areas.
#
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Rationale
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8
Med Tech
4
3
The med tech devices require a big investment both in terms of installation and maintenance. The interoperability and integration of various medical devices for treatment modality must be taken into consideration. Data transmission and protection standards and are integral to streamlined clinical workflows.
9
ERP
2
2
The ERP module installation is a relatively less demanding as an investment because again, the idea is that the foundation infrastructure and architecture are already in place with the EMR/HIS install. How and where the solution proves specificallyfruitful: automation and integration of all the back-end processes in supply chain/inventory, finances and HR occurs due to the use of this solution, thus, allowing more transparency in operations. The data is also available instantaneously.
10
CRM
2
2
The CRM module installation is a relatively less demanding as an investment because again, the idea is that the foundation infrastructure and architecture are already in place with the EMR/HIS install. How and where the solution proves specificallyfruitful: this solution allows hospitals with target direct marketing as opposed to mass marketing, allows predictive modelling for consumer expectations, and allows easy real-time tracking of profitability and revenues.
Table 2
solutions in terms of the investment made versus the benefits realised. Rana Mehta is PwC India’s Healthcare Leader. With more than 18 years of experience, Mehta has worked with a host of Indian and international healthcare organisations, including over 50 hospitals in South Asia, to deliver services across the entire healthcare value chain and develop customised healthcare solutions to suit their needs within political, socio-economic, geographic and demographic imperatives.
A u t ho r
1. Max Healthcare’s EHR Journey: From Implementation to Data Analytics; Dr Sandeep Budhiraja; DrVibha Jain; Hardeep Singh; Official Journal of Indian Association for Medical Informatics (IAMI) 2. A case study of an EMR system at a large hospital in India: Challenges and strategies for successful adoption; Jeremiah Scholl, Shabbir Syed-Abdul, LuaiAwad Ahmed 3. Health IT in Indian Healthcare System: A New Initiative Sharma Kalpa; Research Journal of Recent Sciences 4. Healthcare Information Technology Market Outlook in India, Frost & Sullivan 5. Apollo Telemedicine Networking Foundation (ATNF) Case Study: ACCESS Health International and Results for Development Institute / Rockefeller Foundation
BIO
Bibliography
Shib Pramanik focuses on Health Information Technology across the Payer and Provider industry segments. Shib has over 10 years of consulting experience in working with healthcare technology including ehealth program management, HealthIT solution selection, requirements elicitation, planning and roadmap development and fit-gap assessment of technology solutions to healthcare organisation requirements.
Vikram Juneja has one and a half years of experience in market entry and strategy projects in the field of healthcare, medical technology and telemedicine.
Anukriti Puri has 3 years of experience in healthcare technology which includes program management, requirements elicitation, planning and roadmap development and fit-gap assessment to integrate clinical and revenue cycle workflows of healthcare organisations.
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The Future of Healthcare
It’s Connected, Personal and Team-based Health systems in Asia are overly reliant on acute and specialist care while rapidly ageing and complex chronic patients require greater care beyond the hospital. Integrated and predictive care models will help engage patients earlier and more consistently through their healthcare journeys – technology plays a key role. Asia can leapfrog health-system challenges by decisively integrating care, including patients in their care from hospital to home. Fernando Erazo, Senior Director, Head of Philips Hospital to Home in Asia Pacific
I
n Asia, the share of population above 65 years old is rapidly increasing and the region will be home to half of the world’s elderly1 and bear half the global burden of chronic conditions by 2030. Compounding this demandside challenge, growth in working-age population is not keeping pace. In China alone, by 2050, the working-age population will drop by 170 million while the elderly will increase by 190 million2. Today’s already stretched healthcare systems will face increasing constraints in labour supply. Also, patients’ demands as consumers of medicine will change drastically. To expand current care models, Asian nations will need to double or even triple healthcare spend as per 1 The World Bank, Population Estimates and Projections accessed 01 August2014 http://data.worldbank.org/datacatalog/population-projection-tables 2 The World Bank, Population Estimates and Projections accessed 01 August2014http://data.worldbank.org/datacatalog/population-projection-tables
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centage of GDP just to match OECD spend levels. The scale of such change (in many countries already underway) is massive. Against this forecast, Philips foresees smarter and more efficient care models to avert Asian challenges to sustainable healthcare delivery. Tomorrow’s healthcare should be population-based (weighing cost and outcomes) but individually tailored, thoroughly coordinated around patients.It must also leverage the world’s largest workforce of healthcare workers (today largely untapped): patients and their families. Technology is the fundamental enabler that makes this vision of healthcare possible. Slow-motion Crisis: Demand and Supply Challenges in Asia
Economic growth in Asia is changing lifestyles. Affluence allows greater standards of living, while improving healthcare systems help extend average life spans. In the 1950s, Asia’s life
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expectancy was less than 45 years whilst today it surpasses 74 years3. With an ever larger percentage of elderly (8 per cent of total population today, 19 per cent by 20504) and growing middle class living sedentary and indulgent lifestyles, increase in chronic diseases is unavoidable. In South East Asia, cardiovascular diseases alone cause over 25 per cent of all deaths. Additionally, there is a shortage of healthcare professionals. One key challenge is that many of the locally trained clinicians are leaving local systems to pursue opportunities abroad and those remaining are usually overworked. Under such pressure, it is neither sufficient nor sustainable to keep building healthcare infrastructure and adding more hospital beds. Rather, health systems must innovate to escape the predictable path of development. Transformative integrated-care models will help maximise impact of existing and future resources. Today’s Fragmented Care is Unsustainable
Complex, multi-morbid patients will see more and more specialists. Moreover, general practitioners (family medicine), allied health professionals, such as 3 United Nations (2012), Population Facts 2012, Department of Economic and Social Affairs, Population Division http://www.un.org/esa/population/publications/popfacts/ popfacts__2012-2.pdf 4 The World Bank, Population Estimates and Projections http://data.worldbank.org/data-catalog/populationprojection-tables
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In an Intensive Care Unit
TeleHealth-enabled care coordination in ICU uses • • • •
Bi-directional audio/video monitoring Population management tools Proprietary clinical decision support Real-time and retrospective reporting tools and targeted process redesign
Leverages best ICU clinical practices Provides after hours critical care support Provides proactive clinical care Clinically shown to improve patient outcomes
In the Comforts of Home
An Intensive Ambulatory Care (eIAC) programme is an integrated, at-home programme that • Uses telehealth technologies that connect, monitor and educate patients at home • Manages many patients via a population management software and collaboration platform • Leverages data connectivity to deliver proactive healthcare to patients • Allows patients to stay in the comforts of their own home
Figure 1
rehabilitation or physical therapists, plus hospital nursing teams and homevisitation teams, will be involved. Today, each one of these providers operates in their respective care setting, typically independently from each other. Poor coordination leads to repeated doctor visits, prolonged hospital stays, and spiraling healthcare costs. The current payment system does not help either, as it rewards providers for volume of services rendered instead of better patient outcomes. Financial incentives today are not aligned with patient's best interests. The role of patients (and their families) in their own healthcare is usually limited to that of passive recipients of care. Coordinating efforts across the healthcare continuum (with information sharing and efficient care transitions) is
not new – it’s been piloted before and is applied today. However, the challenge is to scale-up such efforts aggressively to reach all patients who stand to benefit from tailored cost-effective care integration programs. With technology, workflow planning solutions and patient engagement tools, Philips is building the platform to scale-up care coordination efforts from site level (few hundred patients) to national-level (thousands of patients). Ultimately, such collaboration and teaming will not be optional. Asia can avoid the pitfalls along the foreseeable path of developed-country systems where improvement in quality and outcomes no longer keeps pace with costs that spiral out of control (leading example is the USA, where annual healthcare spend approximates one-fifth
of GDP already5). Asia can leapfrog the typical evolution seen in the West by decisively adopting care integration, deploying scalable care coordination models that marry technology and team-based, integrative patient care. The Future of Healthcare: Greater Role for Patients, Connected and Team-Based
Healthcare lags other industries in adoption of digital technology. But it is precisely digital technology that will help us achieve care coordination at national scale. Specifically, connected technologies will enable care models that efficiently coordinate individualised, tailored care for entire population 5 OECD Health Statistics, World Population Prospects 2012
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cohorts – while shifting focus from institutional to home-based care settings. Health systems of the future will excel at four core components of scalable integrated care: • In-depth understanding of target population’s needs • Integral workflows that include patients in the care team • Technology foundation for scalable deployment • Seamless care bound by data, analytics and decision support Target Population
Asia can leapfrog the typical evolution seen in the West by decisively adopting care integration, deploying scalable care coordination models that marry technology and team-based, integrative patient care.
Deep understanding and identification of target population cohorts are the first step towards integrated care delivery. There is no one-size-fits-all program. Health systems must understand
Figure 2 32
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in detail the population they serve to create tailored clinical programs with differentiated service levels. By leveraging clinical and psychosocial insights, providers can design interventions that fit specific needs. With clearly identified population cohorts health systems can focus on patient recruitment for targeted programs, iterate improvements to scale-up and achieve organizational learning and network effects. Integral Care Modelling
Health systems must transform current clinical workflows to include effective multi-disciplinary care teaming. This leverages expertise across health specialties and allows all clinicians involved to practice at the top of
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Figure 3
their licenses. Health systems must also welcome greater involvement of patients through education and selfmanagement. Putting patients and their families in the cockpit will give them more control of their health status and reduce the need for repeated visits to specialists and eventual re-hospitalisations. With better understanding of their disease and how to best manage it, patients identify signs of imbalance and alert care providers earlier with the right information to allow for timely adjustments. Leveraging Technology
Until recently, using the patient’s home as a prescribed care environment seemed unfeasible. However, technology today can already allow health systems to
extend care into patients’ homes with better on-site monitoring and engagement capabilities, making care at home the next frontier of healthcare. Instead of unplanned visits to the doctor, followed by frequent hospital admissions as health worsens, technology is enabling physicians and patients to monitor chronic conditions, including daily symptoms, vital signs and medications, to address care needs proactively. Using connected, intelligent devices, patients will share measurements and feedback on their symptoms directly with their caregivers. Video conferencing between patients and providers will be commonplace, too. With this in mind, Philips is finding innovative ways to capture objective and subjective data to create a patient’s
complete picture of health. Leveraging this information, connected care teams spot complications early and adjust care plans accordingly, effectively preventing hospital readmissions or emergency room visits. Patient portals provide recorded discharge instructions, keep patients engaged with health surveys and educational content, enable video communication with doctors, and remind patients of upcoming appointments to help keep them on track. Analytics Foundation
Connected and integrated care requires healthcare data to flow through the system. Providers will have additional
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Figure 4
decisionmaking support (right decisions at the right time), by combining healthcare data from multiple, decentralized sources with help of advanced analytics - algorithms capable of synthesizing complex data sets. Influx of data will otherwise overwhelm care providers: data needs to be translated into clinical utilities and decisionmaking tools that enable accurate, timely interventions for all members of the care team.
decisions. Pitfalls with this system are: • Bedside care teams may be reticent to call the intensivist in-charge during off-hours if they do not think the issue is drastic • Discussing subtle changes to a patient’s condition via the phone is not as accurate and precise • Intensivists immediate availability
Leading Examples of Future Practices in Connected Care
Inside the hospital The connected care model is most dramatically demonstrated in the most acute of care settings: the Intensive Care Unit (ICU) and high-dependency units (HDUs). ICU patients need continuous monitoring to manage their delicate conditions as changes happen rapidly and unexpectedly. Clinicians are on alert. Yet, intensivists, who oversee care, are often on-call and during off-hours are not readily available at bedside. If something goes awry with a patient, bedside team members will attempt to reach intensivists by phone to request directions on imminent care
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Figure 5
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determines how clinical knowledge is applied to interpret subtle – but significant – changes to a patient’scondition. Philips developed TeleHealthenabled connected care models to prevent adverse events instead of responding to them. By establishing a real-time, connected hub for virtual care, health systems can leverage experienced intensivists to oversee patient care anytime, anywhere. Using bedside video monitoring and clinically relevant information fed into the eICUhub, one intensivist and a small team of nurses oversee intensive care for up to 100 patients regardless of their physical location. Such coordinated care team uses analytics to monitor changes in overall conditions that impact care decisions. Recently, Craig M Lilly, MD, Professor of Medicine, Anaesthesiology and Surgery at the University of Massachusetts Medical School, published a study in CHEST6, which examined the impact of such 6 Lilly CM, etal.A Multi-Center Study of ICU Telemedicine Reengineering of Adult Critical Care. CHEST. 2013; doi: 10.1378/chest.13-1973
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have multiple chronic conditions that are difficult and expensive to manage – not to mention damaging to patients’ quality of life. The healthcare system put together a dedicated and coordinated multi-disciplinary care team of primary care physicians, nurses, social workers, pharmacists and health coaches to coordinate various aspects of care for this group of patients within their own homes. Patients in this programme receive various devices with patient engagement apps and video call capability to engage them into participating in their own healthcare, within the comfort of their home.Through this new model, the care team identifies early stages of deterioration through a mix of real-time monitoring data, and when necessary, intervene and adjust care plans to prevent adverse events and hospital visits.
Figure 6
of-stay by 17 per cent, and reduction in death or discharge to hospice care by 26 per cent. Outsidethe Hospital, into the Home
Effective chronic care management must engage patients at home, beyond the controlled confines of traditional, institutional care settings. Philips partnered with a large healthcare system in the US to develop an integrated, at-home telemedicine eIAC (Intensive Ambulatory Care) programme that identifies hundreds of patients most at risk of future highfrequency readmissions. Unlike traditional disease-specific telemonitoring programmes, many of these patients
A u t ho r B I O
TeleHealth-enabled care coordination in ICU. Studying 32 hospitals in the USA, Dr. Lilly found unadjusted and severity-adjusted reductions in both ICU and hospital mortality and length-of-stay. His study examined 118,990 critical care patients over fiveyears which is the largest such study in the world. Patients who received the coordinated Philips TeleHealthenabled ICU care were: • 26 per cent more likely to survive the ICU • Discharged from the ICU 20 per cent faster • 16 per cent more likely to survive hospitalisation and be discharged • Discharged from the hospital 15 per cent faster These results point to a significant opportunity in Asia to improve patient outcomes and reduce costs, especially as health systems in the region rely heavily on acute care. Beyond ICU, a comparable study of an acute care (HDUs) TeleHealth programme showed reduction in patient’s length
LookingAhead: Scalable, Integrated Care for Entire Populations
Throughout Asia, healthcare providers should accelerate coupling of technology and coordinated, proactive patient care in anticipation of inevitable shifts in care needs from populations with long-term chronic diseases, clinician shortage and the rising cost of care. These challenges require a new approach to delivering patient care. With technology-enabled care coordination programs providers can maximise impact of clinical resources and engage patients to proactively manage their care. Doing so at scale will improve quality and cost across the continuum, from institutional care all the way to the home.
Fernando is head of Philips Hospital to Home business for Asia Pacific. He believes deeply in moving care to the Home, helping people play bigger roles in managing their own health. His career includes strategy, marketing, commercial leadership roles across Philips Corporate, Consumer Lifestyle and Healthcare in Middle East & Africa, Asia. Before Philips, he was a management consultant with A.T. Kearney in Europe.
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Special Issue on Healthcare Technology
Hospital-based Health Technology Assessment
A promising approach to evaluate new technologies for healthcare providers Providers across the world are under tremendous pressure to manage their budget and deliver better services. The cost containment measures in place do not guarantee a superior treatment outcome to patients. Approaches assessing both costs and outcomes at providers’ levels start emerging as a new method to assess medical technologies. Laurent Metz, Director, Health Economics & Market Access MD&D Asia Pacific, Johnson & Johnson Medical Asia Pacific, Singapore
I
n today’s healthcare environment providers face significant challenges to address both payers’ requirements and demographic changes. Pressure from both payers and healthcare authorities increases to improve hospital efficiency and value delivered to patients. At the same time, ageing populations and increasing burden of non-communicable diseases
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are changing the nature of healthcare services delivered. The World Health Organization (WHO) anticipates that the global population aged 60 and above will rise from 600 million in 2000 to 2 billion in 2050. In Asia, the number of people aged 65 and above will increase from 207 million in 2000 to 857 million in 2050, according to the United Nations.
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Non-communicable diseases (NCDs) kill more than 36 million people worldwide each year. Nearly 80 per cent of NCD deaths, or 29 million, occur in low-and middle-income countries. Simultaneously, new and innovative healthcare technologies have brought significant improvements in treatment safety and efficacy. Patients’ quality
Special Issue on Healthcare Technology
of life and life expectancies have increased. Ageing populations, increasing prevalence of non-communicable disease and rapid introduction of new healthcare technologies have put significant pressure on healthcare budgets. Delivering the best possible outcome for patients and managing increasing costs have become global
challenges for healthcare decision makers both at national and local levels. Health Technologies Assessment (HTA): Allocate resources more efficiently to maximise patients’ outcome
Over the last 20 years health technology assessment methods have been used
to assess increasing demands from patients for new technologies and their impact on healthcare systems with scarce resources. Health Technology Assessment (HTA) helps decision makers to identify which interventions provide the best value for money and prioritise their investments accordingly. Three main international HTA organisations have
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respectively proposed a more formal definition of the process: The International Network of Agencies for Health Technology Assessment (INAHTA) HTA is a multi-disciplinary field of policy analysis that studies the medical, social, ethical, and economic implications of development, diffusion, and use of health technology. Health Technology Assessment International (HTAi) The systematic evaluation of the properties and effects of health technology, addressing the direct and intended effects of this technology, as well as its indirect and unintended consequences, and aimed mainly at informing decisionmakers regarding health technologies. The European network for Health Technology Assessment (EUnetHTA) A multidisciplinary process that summarises information about the medical, social, economic and ethical issues related to the use of a health technology in a systematic, transparent, unbiased, robust manner. Its aim is to inform the formulation of safe, effective, health policies that are patient focused and seek to achieve best value. Despite its policy goals, HTA must always be firmly rooted in research and the scientific method. A brief history of health technology assessment The beginning of evidence-based medicine can be traced back to several thousand years. In India, archeological findings suggest that medical interventions were performed as early as 7000 B.C. in the sub-continent. About 3000 years ago a more formal scientific approach emerged with the Ayurveda system. China’sHuang-Di Nei-Jing might be the oldest medical text book in the world and was written probably in the third century B.C. In the code of Hammurabi published around 1780 B.C., physicians were punished for bad surgical outcomes: “If a physician
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Health Technology Assessment (HTA) Agencies in Asia-Pacific
Hospital-based HTA can help hospital managers and clinicians to identify which interventions provide the best ‘value for money’ for the patients and prioritise their investments accordingly.
makes a large incision with the operating knife, and kill him, or open a tumour with the operating knife, and cut out the eye, his hands shall be cut off.”(Code of Hammurabi 218). In western medicine the first clinical trials and evidence-based medicine are considered to have appeared in the 17th and 18th centuries. In 1662 a Belgian pharmacist suggested to divide patients into two groups; one receiving a new treatment and the other a traditional treatment. In 1747 James Lind, a Scottish physician, conducted a prospective controlled experiment to compare the efficacy of six treatments for scurvy in 12 patients. A French physician PierreCharles-Alexandre Louis (1787-1872) introduced the ‘method enumerique’. He demonstrated that bloodletting was a valid use only in the late stages of pneumonia. More recently, in a famous 1972 publication Archie Cochrane recommended the development and use of randomised controlled trials to improve the medical decision-making process. Starting in the mid-seventies, health technology assessment has had a rapid development first in the academic field and then amongst policy makers to improve allocation of health resources.
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HTA is relatively new. The Health Intervention and Technology Assessment Program (HITAP) was established in Thailand in 2006. In 2008, Taiwan started Health Technology Evaluation for drugs with the Center for Drug Evaluation (CDE) and thus the National Evidence-based Healthcare Collaborating Agency (NECA) was founded in Korea. Other Health Technology Assessment Activities in Asia-Pacific
China: The China National Health Development Research Center (CNHDRC) is a HTA body, part of the ministry of health. Japan: Reimbursement of new drugs and devices is decided by the Ministry of Health Labour and Welfare after consultation with the Central Social Insurance Medical Council (Chuikyo). Singapore: The Ministry of Health has created a HTA unit in 1995. This health technology assessment branch is a part of the Performance and Technology Assessment Division. It performs health technology assessment to inform policy-makers within the ministry of health. It also publishes clinical practice guidelines for medical practitioners in Singapore. Malaysia: The addition of a new drug to the Ministry of Health drug list is based on clinical advantages over best and current treatment options and the treatment costs. The Philippines: In 1999 a HTA Committee was established by the Philippine Health Insurance Corporation (PhilHealth). It reviews the drugs for their inclusion in the PhilHealth positive list. The committee evaluates the safety and effectiveness of medical devices and surgical procedures as well.
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A need for a more relevant approach for hospital decision makers
HTA was mainly in use to keep policy makers informed during ‘decisionmaking at a macroeconomic level. A need to develop more specific approaches for hospitals and other healthcare organisations have emerged over the past 10 years for several reasons, including: • A HTA Agency may not exist in the country. Even if an agency does exist, it may not evaluate the medical technologies such as medical devices • Decision-making tends to be more decentralised in healthcare systems nowadays. Purchase and acquisition of new technologies are performed more at the regional or local level and less at the central level. Therefore, hospitals are under increasing pressures to control budgets and increase their efficiency
• Importance of the context. The benefit and risk related to the use of any of the health technologies depends on the specific context of the healthcare organisation where the technologies have been implemented. • In the hospital context it is extremely challenging to perform a comprehensive HTA evaluation every time a decision has to be made on the acquisition of a new technology. A hospital’s economic decisionmakers and clinicians need tools to better manage the allocation of resources to improve the clinical governance. Hospital-based HTA has been developed to address the specific challenges of technology evaluation in hospital settings. The Hospital-based HTA consortium has developed a specific definition of a hospital based HTA: It ‘consists in
The four HTA models are:
Models of local / hospital HTA
Organizational Complexity
High (group-team unit)
Low (individual)
the implementation of processes and methods of HTA at hospital level. The contextualisation of HTA to a specific hospital brings into the assessment process the consideration of its unique characteristics, such as the choice of an available comparator and the specific organisational patterns of the hospital. Hospital-based HTA can be performed by a team of professionals working at the hospital, or by an external team of professionals’ At the hospital level, health technology assessment may be applied in different formats. The Health Technology Assessment International (HTAi) Interest sub-group hospitalbased health technology assessment has adopted a conceptual model to describe how HTA is performed within hospitals. The model identifies four different groups depending on (i) the focus of the action and on (ii) the level of complexity of the organisation solution implemented to perform HTA.
Focus of action Clinical practice
Managerial decision-making
‘Internal Committee’ Model
‘HTA Unit’ Model
‘Ambassador’ Model
‘Mini-HTA’ Model
Reproduced from: Hospital Based Health Technology Assessment(HTA) Sub-Interest Group. World-Wide Survey: Health Technology Assessment International; 2008
• Ambassador model (Q1): Clinicians recognised as ‘opinion leaders’ play the role of ambassadors of the HTA ‘message’ inside the healthcare organisation. They may not take part in the assessment but play a key role in the diffusion of results within hospitals. • Mini HTA (Q2): Individual professionals participate in the assessment by collecting data at an organisational level to inform decision makers at higher levels. • Internal Committee (Q3): Evidence is produced by multidisciplinary groups (called internal committees) representing different perspectives and taking the responsibility of reviewing evidence to issue recommendations that are useful hospital-wide. • HTA Unit (Q4): The formal organisational structure is based on specialised HTA personnel working
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In order to foster the development of hospital based health technology assessment, the European Commission has provided a three-year (01/09/2012 – 31/08/2015) research grant to a collaboration of 10 institutions in Europe for their project AdHopHTA, or Adopting hospital-based health technology assessment. The key objective of the project is ‘to perform a critical analysis of existing hospital-based HTA Initiatives and to evolve methods, instruments and processes to evaluate technology in hospital settings’. The AdHopHTA project will facilitate the start of new hospitalbased HTA programmes and improve the quality and efficiency of existing ones. Practical approach to start evaluating new technologies in hospital settings
As mentioned previously, starting formal health technology assessment in hospital settings may be challenging. To facilitate the process the Danish Center for Evaluation and HTA has developed a practical tool that can be used in hospital settings when considering the evaluation of a new technology1. 1 You can find the full version of the document on the Danish National Board of Health Web site at http:// sundhedsstyrelsen.dk/publ/publ2005/cemtv/mini_mtv/ introduction_mini_hta.pdf
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BIO
The AdHopHTA initiative: Creating hospital-based health technology assessment
The guide identifies key questions to be asked to perform the technology evaluation. These include: Introduction: Who is the proposer (hospital, department, person)? What is the name and designation of the new technology? Which parties are involved in the proposal? The technology: Based on which indications is the technology going to be used? In which way is the proposal new compared to the usual practice? Has an assessment of the literature been carried out and what is the level of evidence available? What is the effect of the proposal on patients in term of diagnosis, treatment, care, rehabilitation and prevention? Does the proposal imply any risks or adverse events? Are there any on-going studies on the proposal in your country or abroad of the effect of the proposal? Has the proposal been recommended by any scientific societies or other evaluation agencies? Has the department previously apply for the introduction of the new technology? The patient: Does the proposal entail any specific ethical or psychological considerations? Is the proposal expected to influence the patients’ quality of life, social or employment situation? The organisation: What are the effects of the proposal on the staff in terms of information, training or working environment? Can the proposal be accommodated within the present physical setting? Will the proposal affect other department or
A u t ho r
on a full time basis within the unit. This is the highest degree of structure for the hospital HTA. To implement a health technology assessment process in a hospital setting may be challenging. Potential hurdles limiting the implementation of hospital based health technology assessment include the lack of dedicated resources and limited skills to conduct literature research and evidence evaluations.
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service functions in the hospital? How does the proposal affect the cooperation with other hospitals, region or the primary care sector? When can the proposal be implemented? Was the proposal being implemented in other hospitals in your country or abroad? The economic aspects: Are there any start-up costs of equipment, rebuilding, training? What are the consequences in terms of activities in the next coming years? What is the additional or saved cost for the hospital in the next couple of years? What uncertainties apply to these calculations? Maximising value for patients-A new strategic focus for providers
There is a clear global trend that providers should focus on strategies to deliver superior outcome for patients. As significant competition exists among healthcare providers, competing on outcome is seen as a way to differentiate themselves. When providers deliver superior outcome more efficiently, patients, payers and physicians, all win. As providers are one of the first entry levels for the introduction of new innovative technologies, there is a need to identify which health technologies will provide significant added value for the patient. Hospital-based HTA can help hospital managers and clinicians to identify which interventions provide the best ‘value for money’ for the patients and prioritise their investments accordingly.
Laurent Metz is the Senior Director of Health Economics, Market Access and Clinical Research for Johnson & Johnson Medical Asia- Pacific. He has been working in Health Economics, Outcome Research and Reimbursement with Johnson & Johnson for the past 17 years in Asia Pacific, Europe and in the United States. He has led the development and implementation of health economics and evidence generation strategies in most of the markets around the world and has been involved in multiple submissions to Health Technologies Assessment Bodies.
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Make in India
for the world The way forward for Indian IVD industry India’s leading in-vitro diagnostic company has been manufacturing and supplying diagnostic solutions for over 35 years now. Transasia Bio-Medicals Ltd., has fortified its presence, being recognised as India’s top manufacturer and exporter of diagnostic instruments and reagents in over 100 countries. Infact, Transasia is the first Indian company to manufacture and export sophisticated, state of the art blood analysers and reagents. Suresh Vazirani, Chairman & Managing Director, Transasia Bio-Medicals Ltd., India
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he Indian healthcare sector, one of its fastest growing industries, is expected to grow at a CAGR of 17 per cent to touch US$ 280 billion by 2020. Diagnostics forms an integral part of the healthcare sector as 70 per cent of the treatment decisions are based on lab results. Over the past few years, In-Vitro Diagnostics market has been projecting substantial double digit growth. India, with its rich pool of resources, is being
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recognised as the next destination for establishing manufacturing set-ups. Indian diagnostic industry –where we stand
The last decade has been very progressive for the Indian healthcare industry. Rural areas have seen an increase in the number of primary healthcare setups. Health drives are regularly conducted; as a result the awareness amongst the people has gone up considerably.
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Emphasis is laid on early detection and precise treatment. In the urban areas, there has been a boom in the number of centres offering quality healthcare. The Government has encouraged the setting up of secondary and tertiary healthcare centres. Continuous technological advancements in diagnostics and an increased healthcare awareness have made in-vitro diagnostic testing an indispensable tool in current medical practices. The increase in the diagnosis of chronic lifestyle and genetic diseases, ageing population, and rising acceptance of personalised medicine drive the in-vitro diagnostic market growth. Preventive healthcare is gaining popularity, due to growing health consciousness, improved spending power and increased life expectancy. The emerging industry structure is heading towards providing healthcare services as an integrated comprehensive package rather than the traditional concept of
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Need for ‘Make in India’
There has been a paradigm shift resulting in adoption of technology and automation. The need for accurate and quick results has led to the introduction of high end products for in-depth analysis. A host of Indian companies today, have shifted base from importing to manufacturing. Transasia Bio–Medicals Ltd. has pioneered ‘Make in India’ as it began ‘Making in India’ in 1991. Today, Transasia is the No. IVD company in India with subsidiaries in 11 countries and sales network in over 100 countries across the globe. The Government is supporting Public-Private Partnerships (PPP) and other new initiatives for promoting the growth of the Indian IVD. The Government has encouraged Foreign Direct Investment (FDI) as well as indigenous research thereby promoting the sector. There has been a rise in the number of players entering the segment and offering quality products and after sales services. Pool of skilled manpower has always been India’s forte. And there is no dearth in the Indian IVD Industry either. Our fast-paced and stable economy is encouraging foreign and domestic players to increase the investment in healthcare infrastructure. Today, the diagnostic business is mainly based on technology. The drive or thrust for smaller, faster and easily accessible devices is increasing. Emerging markets have different needs with respect to test menus, technologies and operating procedures. Thus customised solutions
need to be developed depending on the need. Indian companies with their R&D facilities have developed a range of good quality products for the local market amidst fierce competition. Deterrents to Indigenous Technology
Today, the market is flooded with analysers from China, offering their services at cheap rates. The brain drain to the West acts as the biggest deterrent to promoting indigenous research and development. It is also difficult to change the mindset of clinicians to accept the ‘Made in India’ tag. Moreover, certain government policies need to be revisited to promote indigenous production. Boost to innovation
Despite the Government introducing a host of policies for in-house production, there is still scope for more. The government and private players need to join hands to promote innovation at reasonable prices. The Government needs to initiate policies to encourage indigenous manufacturing. This can be done through availability of funds, land demarked for setting up manufacturing units, tax relaxation, encouraging research & development, etc. Encouraging foreign players to set up manufacturing units in India can help further. Indigenous manufacturing of medical equipments –Where we stand today
Indigenous manufacturing is picking up pace. At one point in time, the ratio of indigenous manufacturing to imports was just 5 per cent. However, tables have turned today. A lot many companies A u t ho r B I O
providing healthcare infrastructure and reactive medical care. Moreover, even patients today are well read and are key decision makers in their treatment process. As a result, now there is greater onus on the diagnostic setups to provide precise and quick results. This in turn has made the diagnostic product manufacturing companies to offer their products at competitive rates.
are now involved with in-house manufacturing. Indian companies have been manufacturing kits for blood grouping, serology, clinical chemistry, pregnancy detection, HIV detection and other rapid tests that are accepted globally. Today, imports of such products are negligible in finished form. Transasia Bio-Medicals Ltd. - Local for global
India’s leading in-vitro diagnostic company has been manufacturing and supplying diagnostic solutions for over 35 years now. Transasia Bio–Medicals Ltd., has fortified its presence, being recognised as India’s top manufacturer and exporter of diagnostic instruments and reagents in over 100 countries. Infact, Transasia is the first Indian company to manufacture and export sophisticated, state of the art blood analyzers and reagents. Transasia started off, with marketing and after-sales service of a Japanese blood cell counter. It was during 1980s-90s, the machines were relatively expensive and affordable by only top hospitals. That is when Transasia started manufacturing them indigenously. The biggest challenge at that time was to counter the competition pouring in from the West. European and American manufactured products were widely accepted, because of their accuracy. So, it did take some time to prove the credibility of the indigenous instruments. And today, Transasia is recognised as India’s Leading In-vitro Diagnostic Company. It has an installation base of over 45,000 instruments across India with a vast network of more than 150 service engineers, 350+ sales and marketing team, 14 zonal offices, and 350+ distributors.
The year was 1979 when Suresh Vazirani founded Transasia Bio-Medicals Ltd. Numerous awards and recognitions from private, public and Government institutions have made the journey, from 1979 to 2014, a sweet success. Just recently Mr.Vazirani received the Global Growth Award 2014 by the World Economic Forum.
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How Information Therapy can Heal the Indian Healthcare System The Indian healthcare system is sick - what can we do to heal it? In fact, even the term healthcare system itself is a misnomer. In reality, what we have in India is a medley of doctors who are used to providing episodic care to people when they fall ill. Healthcare is fragmented and disorganised and there are too many specialists, most of whom have tunnel vision. Aniruddha Malpani, Medical Director, HELP - Health Education Library for People, India
I
n most instances, a cardiologist has no idea what the patient’s gastroenterologist is doing – and they are so focused on treating the heart or the liver that they sometimes forget that these belong to a human being! The only way to reform the healthcare ecosystem,
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would be to make it patient-centric. Patients (or their relatives & friends) are intelligent and capable. What’s even more important considering the patient’s health is at stake is that they have the motivation to get good healthcare. If provided with the right tools, they are
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also willing to invest time and energy to ensure a good outcome. An untapped resource
We believe that patients are the largest untapped healthcare resource. They only need to have direct access to the right
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tools. One of the major influences that is rapidly changing the dynamics between doctor and patient is easy availability of medical information on the internet. The only problem is that it’s not easy to find reliable information, and patients end up getting lost and frustrated. They go to the doctor with reams of internet printouts. No doubt, this upsets the doctors as they have to then wade through heaps of rubbish. Benefits of Information Therapy
Dr Google can truly cause a lot of heartburn for patients as well as doctors. This is exactly why doctors should be proactive in keeping their patients wellinformed. Information Therapy means providing the right information; to the right patient; at the right time. There are a number of benefits of Information Therapy: • Promoting Self Care-It helps patients do as much for themselves as possible. It helps them with evidence-based guidelines and they are able to seek the exact treatment they need — nothing more, nothing less. • Veto Power- It empowers patients to say ‘no’ when they do not require it; prevents over-testing and unnecessary surgery. If we all agree that information therapy needs to be prescribed, how do we ensure that it is efficiently dispensed?
The solution
We can begin by ensuring that every point of clinical care i.e. the doctor's clinic, the pathology laboratory, the scan centre, the pharmacy and the hospital should have a patient education resource centre. When someone falls sick, these are their contact points with the healthcare system. Each of these represents an opportunity to educate the patient. This could be as simple as a tablet/information kiosk that the patient can browse through while he/ she is waiting. We all are aware that in order for information prescribed to be effective, the information must be available to the patient at the point when it is required. All of these are ‘moment-of-truth’ encounters when the patient wants to know more about his problem and available treatment options. Unfortunately most of these opportunities for educating patients are routinely lost. Patients are being forced to look for this information by themselves. Using technology to create goodwill
The ubiquity of the Internet allows the clever use of technology to empower patients with Information Therapy, so that they can become experts and engaged patients. India has in excess of 700 million phone subscribers and the number billows with each day passing. Today, every mobile handset has the
basic functionality of sending and receiving SMS in different languages. Emerging 3G and 4G spectrums also offer uninterrupted data services & high-speed seamless video chats via mobile phones. With all this in view, visiting clinics for common ailments and check-ups will soon become a defunct practice. The doctor will be able to effectively prescribe information to the patient who is calling from his home. Patient education shouldn’t be looked upon as an expense. It is an integral part of patient service; it offers the doctor, laboratory and the diagnostic centre an ideal way of marketing their services. Anyone who takes the time and energy to educate the patient is likely to create a lot of goodwill and get referral patients. A positive impact
Since reliable health information is highly valued by patients and family members, it also creates increased brand awareness in the community. We all know that medicines play a very important role in helping patients get better, which is why they are routinely prescribed by doctors. Information has an equally important role to play in medical treatment, and needs to be actively prescribed and dispensed. This is an extremely cost-effective way of improving patient satisfaction and patient compliance. How doctors can prescribe information therapy digitally
One of our goals is that all doctors should have their own websites! This will compel them to be open and transparent; and patients will trust the local information that their personal doctor provides them, in their regional language. This information will be available 24/7, and will be free. Health insurers
It makes business sense for all players in the healthcare ecosystem to empower patients with Information Therapy. For
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example, one of the major issues that health insurers need to tackle today is their high claims- loss ratios. This is caused by: • Medical inflation • Hospitals inflating medical bills, when they are aware that their patients have insurance coverage • Over-testing and overtreatment by doctors because the insurance company is footing the bill • Information Therapy can reduce policy holder bleed by creating loyalty and stickiness • It can help an insurance company differentiate itself in a competitive market • Helps insurance companies attract new customers • Builds brand value and trust • Helps insurance companies position themselves as organisations that seek to promote health, and not just as claims processors. The Government
From the government’s perspective, it’s a humungous challenge to provide high-quality healthcare to India’s teeming millions. Ours is a developing country and there just aren't enough doctors to go around. In fact, this challenge is an opportunity in disguise; one way to fix it is to do some ‘out of the box’ thinking. It’s obvious that if we do not venture onto the untrodden path, we will continue to fail. This is a great opportunity to create new solutions that can provide value for money. We need to remember that constraints can act as catalysts for creativity and innovation. Indians are intrinsically frugal and we can make even a small amount go a long way, as we are great at wringing-out the last ounce of value. The trick is to flip the problem on its head. Instead of looking at this massive number of patients as being a burden, we need to look at the situation as a potential problem solver.
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India has in excess of 700 million phone subscribers and the number billows with each day passing.
A hidden opportunity
If patients are the largest untapped healthcare resource, the fact that we have more than 1 billion of them is an opportunity in massive proportions. So how can we tap into their creativity, to help them get the best care possible? For example, in India, hospitalised patients generally have family members helping them with nursing care. Instead of treating them as unwelcome obstacles, how can we make better use of their skills, to reduce the nurse’s workload? It’s sad that we continue to undermine the ability of patients to healthemselves. It’s possible for us to use technology to create a win-win situation and turn India into a trailblazer in the healthcare space. We have a treasure-house of doctors and medical expertise and are recognised as the worlds’ IT powerhouse. The one sure-shot path to success is to see these two marry; the combined intelligence and creativity will help us to improve the health of a billion Indians. It will help us create a virtuous cycle where better health allows citizens to become even more productive! The role of pharma companies
In the past, pharma companies were held in high regard as the drugs they discovered helped fight diseases and saved lives. Today, the situation has turned turtle and they get a lot of bad press. They are looked upon as greedmongers as they overcharge for their patented drugs. They spend inordinate amounts of money on promoting their products and develop drugs that ‘treat’ unimportant lifestyle issues.
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Moreover, they are thought to be unethical because they indulge in underhand practices to encourage doctors to prescribe their medications. Now, these companies too can benefit by promoting Information Therapy and they can use it to polish the tarnish off their reputations. Companies that do this proactively and enthusiastically have the potential to become market leaders. Tactics that pharma companies used
The conventional methods that companies use to influence doctors forpromoting their brands were through the use of Medical Representatives (MRs). Their sole job was to establish a personal relationship with the doctor; then leverage this relationship to cajole the doctor into prescribing their brand. However, with increased competition, this started becoming very difficult, and many companies began resorting to underhand practices (such as bribing doctors / sponsoring them for overseas medical trips) in lieu of promoting their brand. It is also a fact that MRs are no longer very effective. Doctors have now wised up to their tricks; since they are so busy, many do not even entertain them any longer. MRs are a very expensive resource, and most pharma companies find that they hold very less value for them (in terms of the marketing / promotions they do). Since companies can’t give doctors expensive gifts (providing costly freebies to doctors is now illegal under the new Medical Council of India rules), they do not enjoy the clout they previously did. Direct-to- consumer marketing
Traditionally, doctors used to be pharma companies’ primary customers. But now, it has become very important for companies to market to the end-user. Though it’s the doctor’s job to prescribe medications, patients are the ones who actually take them. Now pharma companies are looking to reach-out directly to consumers and spend
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The ‘Trust Marketing’ factor
Disease management is ‘trust marketing’—patients go to websites because they want to learn how to manage their illnesses – and a pharmaceutical company that provides them with reliable information will be looked upon as being trustworthy. Any time a patient takes a drug, he has a number of questions about it. What are the side effects? Risks? Complications? A study showing that patient compliance with treatment for high blood pressure was less than 50 per cent, revealed the following interesting facts: • Many patients are afraid of medications and their side effects • They resent the lacklustre attitude of their doctors. If we are seeking to improve patient compliance, we will have to analyse the patient's perspective. The only way to do this would be to put patients in charge of their own game plan; this will help them become active partners in their healthcare. A patient who understands why he needs to take medication for high blood pressure all his life will not need to be cajoled or bullied. Some more solutions
Patients need answers to their questions about the medicines they take, but doctors and pharmacists are often too busy to answer ‘routine’ questions. This is why pharma companies provide patient information leaflets with their
drugs. Unfortunately, these leave a lot to be desired. They are difficult to read and even more difficult to understand. • Clever companies can use these patient information leaflets as a valuable tool to establish a direct digital relationship with the patient. The leaflet could provide the website address where the company provides more information about that drug and the disease it helps to treat • Since the information is online, it can be very detailed and extensive, and this can inspire confidence in the patient • Patients could register on the site and get their questions answered by medical experts, thus getting their doubts resolved • They could sign up for an e-zine which would allow the company to provide them with more information about an illness and its treatment • This kind of permission marketing can help companies build a database that is worth its weight in gold • The site could act as a nucleus for the formation of online patient support groups • Expert patients could provide valuable feedback to the company about their wants and needs. This opportunity is waiting to be tapped; it will allow clever companies to build a direct relationship with patientssomething that is especially important for patients with chronic illnesses. The lifetime value of these patients can be enormous. To date, no Indian company has taken the initiative of reaching out to these patients, who are now spending a lot of their time online.
A u t ho r B I O
significant amounts of money on Direct-to- Consumer (DTC) marketing. Though this concept is still in its nascent phases in our country, it’s only a matter of time before Indian companies start focusing on DTC in a concerted manner. This form of marketing has made a huge impact in the US but many pharma companies there have suffered by releasing dishonest DTC campaigns. The need of the hour is to create diseasespecific websites that focus on providing Information Therapy to the patients.
In closing
Information Therapy gives pharma companies an opportunity to connect with patients, because it allows them to create a partnership with the latter. There are a number of other positive outcomes: • Patient education programmes can increase patient adherence and retention and provide an excellent return on investment. For example, patient counselling tools can increase calls from physicians requesting MRs to come back to the clinics and replenish these tools. • Digital, customised patient progress, self-monitoring tools can motivate them to stay in therapy; this helps doctors and patients • Progressive global pharma companies are using Facebook and other forms of social media to reach out to their patients. The affluent Indian is already online, but Indian pharma companies are still lagging behind. If they use Information Therapy to empower patients, they will be able to reach out to a larger number of Indians. The general public will once again see the pharmaceutical industry in a positive light; and as an important player in improving human health. E-healthcare is the future of medical care with the promise of online medical records, online appointments, m-health, digital-health and telemedicine. The opportunity to help our patients is now in our hands. We owe it to ourselves and our patients to meet the challenge that lies before us all.
Aniruddha Malpani is an IVF specialist and his clinic at www. drmalpani.com attracts patients from all over the world. He has founded the world’s largest free patient education library, HELP, at www.healthlibrary.com. He has authored 5 book and his passion is patient empowerment; he believes that using Information Technology to deliver Information Therapy to patients can heal a sick healthcare system ( www.puttingpatientsfirst.in). He has pioneered the use of innovative technology to educate infertile couples, using cartoon films, comic books and e-learning on his website, www. ivfindia.com. He is an angel investor is many startups in India.
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How Hospitals Define Value through Health IT A review of value based on quality improvement
How do hospitals define value related to quality improvement? The Electronic Medical Record Adoption ModelSM (EMRAM) is an eight-step process hospitals can use to analyse their organisation’s level of EMR adoption, chart accomplishments, and benchmark against other healthcare organisations across the country. This article will describe the model and include examples of Stage 6 and Stage 7 hospitals in Asia and other parts of the world that have demonstrated quality improvement (not profitability), improved patient outcomes, reduction of errors, and patient safety through the use of information technology. H Stephen Lieber, President and CEO HIMSS, USA
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he vision of improving health with information technology has been the focus of Healthcare Information and Management Systems Society (HIMSS) since its establishment in 1961. Now, as a mission-driven, not-for-profit and global enterprise, HIMSS continues to focus on leveraging
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healthcare information technology (IT) to improve patient outcomes, reduce costs and expand access to healthcare with offices in the United States, Europe and Asia. HIMSS leads efforts to improve health with IT solutions through thought leadership, education, events,
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market research and media services around the world. The organisation includes more than 60,000 individuals, of which more than two-thirds work with healthcare providers, governmental and not-for-profit organisations across the globe, plus over 650 corporations and 350 non-profit partner organisations,
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that share this cause. Headquartered in Chicago, Illinois, USA, HIMSS has offices and activities in Europe, Asia, Middle East, and Latin America. Recognised as a global partner and advisor for governments and organisations, HIMSS employs 350 staff members worldwide and hosts more than 100 events across the globe and another 100+ online educational events and webinars. The largest events, from attendance perspective, are the United States (38,000+), Europe (3,000+) and the Middle East (2,000+). The HIMSS analytics measurement model – EMRAM
As the market research business unit within the HIMSS organisation,
HIMSS Analytics collects data about information systems deployed in healthcare systems in the US and Canada on a census basis, and on a sample basis in Asia, Europe, Latin America and the Middle East. In 2005, HIMSS Analytics decided to use the collected data to ‘score’ each hospital based on the hospital’s sophistication in using EMR technologies. This data populates the Electronic Medical Record Adoption ModelSM (EMRAM). The EMRAM is an 8-step process reflecting the typical manner by which hospitals rollout enterprise clinical systems from a largely paper-based environment (Stage 0) through to a highly advanced EMR environment
(Stage 7). Using the EMRAM, hospitals and health systems are able to track their health IT implementation progress against healthcare organisations across Asia and other parts of the world and view all scores in the HIMSS Analytics® Database. Reaching stage 7 on the EMR adoption model
Hospitals must follow several steps to earn the Stage 7 designation. Participation in the HIMSS Analytics Asia-Pacific Annual Study allows hospitals to receive their EMRAM score through the collection of specific health IT data. This data tracks implementation and adoption of EMR applications through each stage of the
Asia Pacific EMR Adoption ModelSM Stage
Short Description
2014 Q1
2014 Q2
2014 Q3
2014 Q4
Stage 7
Complete EMR, Data Analytics to Improve Care
0.1%
0.3%
0.3%
0.4%
Stage 6
Physician documentation (templates), Full CDSS, Closed Loop Medication Administration
2.8%
2.8%
2.9%
3.2%
Stage 5
Full R-PACS
5.7%
5.4%
7.5%
7.3%
Stage 4
CPOE, Clinical Decision Support (clinical protocols)
2.2%
2.1%
1.9%
1.8%
Stage 3
Nursing/Clinical Documentation, CDSS (error checking), PACS Available Outside Radiology
0.4%
0.4%
0.5%
0.5%
Stage 2
CDR, Controlled Medical Vocabulary, CDS, HIE capable
29.1%
29.2%
33.4%
33.8%
Stage 1
Ancillaries - Lab, Rad, Pharmacy - All Installed
5.4%
5.1%
4.5%
4.6%
Stage 0
All Three Ancillaries Not Installed
54.3%
54.7%
49.0%
48.3%
N= 687
N= 720
N= 733
N= 757
Data from HIMSS Analytics® Database © 2014 HIMSS Analytics Figure 1 Asia Pacific EMR adoption modelSM
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EMRAM. Hospitals receive validation of Stage 6 with phone interview followed by an on-site review by a HIMSS executive or regional designate. The Stage 7 review includes an on-site visit by a HIMSS-lead team, including a physician, to confirm this highest level of health IT adoption.
Electronic Medical Record Adoption ModelSM (EMRAM)is an 8-step process reflecting the typical manner by which hospitals rollout enterprise clinical systems from a largely paperbased environment (Stage 0) through to a highly advanced EMR environment (Stage 7).
Stage 7 hospitals can:
• Share patient data, using electronic health IT systems, with all groups within the health information exchange network • Advance widespread use and sharing of health and wellness information by consumers and providers • Capture and analyse patient care data – with large scale data analytics which show operational, financial, quality and safety improvements throughout the organisation.
EMR ADOPTION ACROSS THE GLOBE
In addition, Stage 7 hospitals have a competitive and quality advantage because with sophisticated health IT systems in place, they can access and share patient health data electronically to improve the overall delivery, quality and safety in patient care. The database includes information on the EMRAM requirements, demographics, finance, vendors and use of IT. Data is collected from: • 5,450 hospitals in the United States; • 700 hospitals in Canada; • 2,000 hospitals in Europe, and • Additional data collection from hospitals in Asia-Pacific, Middle East, New Zealand, Australia, India and others. In the last decade, The EMR Adoption Model has become a preferred evaluation tool used by many health systems in Asia-Pacific, Europe, Canada
based on HIMSS Analytics’ Electronic Medical Records Adoption Model (EMRAM) 7
Hospital EMRAM Score (Mean)
6
5.3
5 4 3 2 1
1.4
1.6
2.0
2.0
2.2
2.4
2.6
2.9
2.9
3.1
3.4
3.7
4.3
5.3
4.4
0.5
0
Source: HIMSS Analytics Database, derived 10/2014 (European and Asia-Pacific data from 2012 – 2014, US data from Q3/2013 – Q3/214); Average is based on mean EMRAM scores from countries displayed; no weighting applied; samples from Australia, Denmark, Norway, Singapore, Turkey reflect public hospitals only. Chart 1 EMR adoption across the globe – HIMSS analytics EMRAM
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Figure 2 HIMSS health IT value suite
and the United States, as evidenced by the EMRAM models developed for and used by these respective areas . Several factors account for the acceptance and use of the EMRAM by healthcare and government organisations, since this evaluation tool provides: • Only recognised evidence-based model of its kind • Guidance on how a hospital should progress towards a paperless EMR environment • A roadmap for hospitals, governments and regions • Information for governments, regions and hospitals of current status quo from a neutral partner; and • A global benchmarking tool. The HIMSS health IT value suite
The HIMSS Health IT Value Suite is a robust library of value-focused, evidencebased examples of value classified using a common vocabulary namely, the
HIMSS Health IT Value STEPS™. The Value Steps identify five types of value, health IT creates for patients, healthcare providers and communities. S – Satisfaction T – Treatment/Clinical E – Electronic information/data P – Prevention and Patient Education S – Satisfaction From these categories, users can further filter the examples based on other selections from location to type of organisation. In this article, examples may reference the ‘HIMSS Value Suite’ as the source. Improved patient outcomes - the quality connection to advanced EMR adoption
Lower Mortality Rates and Higher EMRAM Scores: HIMSS Analytics conducted two studies in 2014 on lower mortality rates and higher EMRAM scores, one in the United States and the other focused on hospitals in the
United Kingdom. In this category of quality, four examples follow: 1. HIMSS Analytics and United Kingdom Trusts 2. HIMSS Analytics/Health grades United States Hospitals 3. Chang'an Hospital (2013) – China 4. The Joint Commission Top Performing Hospitals and Higher EMRAM Scores The 2014 HIMSS evidence of the effects of healthcare IT on healthcare outcomes report (UK) This report uses data from the HIMSS Analytics’ EMR Adoption Model and mortality rate measures from 91 National Health System (NHS) trusts in the United Kingdom. The mortality rates are from the Healthcare & Social Care Information Centre (HSCIC), a UK governmental agency that publishes the Summary HospitalLevel Mortality Indicator (SHMI) for all UK hospitals.
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The Sample for this anlysis consists of a cohort of 91 English National Health System ("NHS") trusts evaluated between 2013 and 2014. The demographic distribution was as follows(HSCIC, 2014): Hospital Size by Numberof Beds
Community Hospital
General Acute Hospital
Multi-Service Hospital
Specialist Hospital
Grand Total
Large
0
24
0
0
24
Medium
0
15
4
2
21
Small
4
13
5
8
30
Grand Total
4
52
9
10
75
The cohort's distribution across the 8 EMRAM Stages was as follows: 0
1
2
3
4
5
6
7
8%
15%
16%
9%
4%
48%
0%
0%
Evidence of the Effects of Healthcare IT on Healthcare Outcomes Chart 2 91 english national health system trusts and EMRAM status
Analysis: Providers tending to score higher on the EMRAM have ‘stronger clinical systems in place to support interventions designed to diminish deaths associated with hospitalisation than those with a lower EMRAM
score.’ In addition, the EMRAM tracks only IT-related subjects, leading to the conclusion that ‘it is fair to infer that IT progress leads to lower mortality.’ In addition, comments from hospital CEOs or CIOs interviewed by the
30.00%
16.00% 26.70%
25.00% 20.00%
14.90%
14.00%
19.40%
12.00%
10.90%
10.00%
16.80% 15.00% 10.00%
researchers emphasise their belief that a ‘conditional’ relationship between IT and healthcare quality exists: It’s visible in detail in ways statistics can’t show; get a good useful piece of IT to work, and staff become more effective, less stressed,
Actual Mortality Low EMRAM
8.00%
10.30%
Actual Mortality High EMRAM
6.00% 4.00%
5.00%
2.00%
0.00% Heart Attack
Respiratory Therapy
0.00% Identifying Sepsis Risk
Actual Mortality Low EMRAM
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Actual Mortality High EMRAM
Chart 3 Actual Mortality Low & High EMRAMS
Chart 4 Identifying Sepsis Risk
• Heart attack actual mortality rate 16.8 per cent (low EMRAM) to 10.3 per cent (high EMRAM) • Respiratory failure actual mortality rate 26.7 per cent (low EMRAM) to 19.4 per cent (high EMRAM)
• Respiratory Failure Predicted Mortality rate 15.9 per cent (low EMRAM) to 17.9 per cent (high EMRAM) • Sepsis Predicted Mortality rate 10.9 per cent (low EMRAM) to 14.9 per cent (high EMRAM)
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Location
Stage 7 Hospital Name / Website
China -2 hospitals
Peking University People's Hospital (1,954 beds) No. 11 Xizhimen South Street, Xicheng District, Beijing www.pkuph.cn
China
Shengjing Hospital of China Medical University (4,750 beds) No. 36 Sanhao Street, Heping District Shenyang, Liaoning www.sj-hospital.org
Korea - 1 hospital
Seoul National University Bundang Hospital(1,409 beds) Gyeonggi-do, 463-707, South Korea http://en.snubh.org:8001/global/en/main/Index.aspx
3
Stage 7 Hospitals in Asia Pacific
more attentive, and consequently perform better at their jobs. In a place where it takes everyone to make difference, making anyone’s job easier means making the outcome better.’
Location
Australia 1 hospital
St Stephen's Hospital Hervey Bay (96 beds) http://ststephenshospital.com.au/
India 6 hospitals
Apollo Health City, Jubilee Hills (530 beds) http://apollohealthcity.com/ Apollo Hospitals Aynambakkam (96 beds) http://chennai.apollohospitals.com/apollo-hospitalsayanambakkam Apollo Hospitals Chennai (554 beds) http://www.apollohospitals.com/hospitals/hospital-inchennai.php Apollo Specialty Hospital, Nandanam (268 beds) http://chennai.apollohospitals.com/ Max Super Specialty Hospital, East Wing, Saket (379 beds)Delhi http://www.maxhealthcare.in/index.php/hospitalnetwork/max-super-speciality-hospital-saket Max Super Speciality Hospital, West Wing, Saket (282 beds) Dehli http://www.maxhealthcare.in/index.php/hospitalnetwork/max-super-speciality-hospital-saket
P.R. China 5 hospitals
Affiliated Zhongshan Hospital of Dalian University (2,200 beds) - www.dlhospital.com/ Chimerica Chang An Hospital (1,000 beds) Shanxi - www.cacah.com/ Ninghe County Hospital (550 beds) http://www.nhxyy.com/
EMR effectiveness - the positive benefit electronic medical record adoption has on mortality rates (US)
HIMSS Analytics and Health grades, an online resource for comprehensive information on US physicians and hospitals, reviewed a total of 4,583 facility records selected from the HIMSS Analytics Database, representing the total number of facilities with complete data from 2010 through 2012. In analysing the hospital mortality metrics amongst 19 different disease cohorts, the report found most cohorts experienced improvement in predicted mortality rates when compared to hospitals with lower EMRAM scores on specific high mortality cardiac and respiratory conditions. The predicted mortality rate is an indicator of the level of documentation and capture of patient risk factors that are correlated to increased risk of mortality. Analysis: • An increased predicted mortality rate suggests hospitals are more accurately able to identify the per centage of patients at risk of a negative outcome because: • Low EMRAM hospitals are able to accurately estimate that 10.9 per cent of their patients are at risk of experiencing a negative sepsis outcome, while • high EMRAM hospitals are able to accurately estimate that 14.9 per cent of their patients are at risk of experiencing a negative outcome. In addition, as noted in the report, ‘with the prevalent mortality rates, the analysis found: the more advanced the hospital’s EMR capabilities… the more likely the hospital is to
Stage 6 Hospital Name / Website
Yantai Yuhuangding Hospital (1,613 beds) Shandong - http://www.ytyhdyy.com/ Zhongshan Hospital, Fudan University (1,700 beds) www.zs-hospital.sh.cn/
Taiwan 4 hospitals
Kaohsiung Medical University Chung-Ho Memorial Hospital (1600 beds) - http://www.kmuh.org.tw/ Taipei Medical University Hospital (719 beds) http://tmuh.tmu.edu.tw/ Taipei Medical University Shuang Ho Hospital (923 beds) - http://shh.tmu.edu.tw/ Taipei Medical University Wan Fang Hospital (726 beds) - http://www.wanfang.gov.tw/
Singapore 7 hospitals
Changi General Hospital (790 beds) http://www.cgh.com.sg/Pages/Home.aspx KK Women's & Children's Hospital (832 beds) www.kkh.com.sg/ KhooTeckPuat Hospital (550 beds) http://www.ktph.com.sg National Heart Centre Singapore (185 beds) http://www.nhcs.com.sg National University Hospital (991 beds) www.nuh.com.sg/ Singapore General Hospital (1,590 beds) www.sgh.com.sg/ Tan Tock Seng Hospital (1,200 beds) www.ttsh.com.sg/
Malaysia 1 hospital
Prince Court Medical Centre (277 beds) www.princecourt.com/
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Stage 6 hospitals in Asia Pacific
Source: HIMSS Analytics Asia Pacific website: http://www.himssanalyticsasia.org/ emram/stage7hospitals.asp
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3 or Less
50.0%
4 or More
45.0%
All hospitals within each EMRAM Stage
39.8% 40.0% 35.0% 30.0% 25.0% 20.0%
16.3%
15.0%
6.2%
10.0% 5.0% 0.0%
2.3%
20.7%
18.1%
10.1%
10.6%
12.9%
30.1%
12.8%
6.4%
6.5%
6.4%
1.7%
0.4% 1.9%
4.8%
10.1%
8.1%
4.2%
6.5%
7.9%
9.7%
0
1
2
3
4
5
6
7
EMRAM Stage Source: HIMSS Analytics Chart 5 Representation of TJC Top Performing HospitalsBy Number of Quality Metrics Excelling In, within each EMRAMStage
have better risk-adjusted mortality rates when treating conditions, such as heart attack, heart failure, stroke, several types of GI surgeries, pneumonia, sepsis and respiratory failure.’ Chang'an Hospital (2013) – China (Stage 7 hospital): This hospital, as noted in the HIMSS Health IT Value Suite, reduced antibiotic consumption from 727 DDSs (defined daily doses) to 480 DDSs per 1,000 patient days in 7 months. As a result, rational antibiotic use resulted in a 64 per cent decrease in mortality rates. Quality Measures at US’ Top Performing Hospitals with Higher EMRAM Scores: This example reviews the association between EMRAM and The Joint Commission (TJC) Top Performing US hospitals. The Joint Commission accredits and certifies more than 20,500 healthcare organisations and
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programs in the United States. In 2013, hospitals could be recognised as a Top Performing Hospital, if they excelled in at least one of the following measures: • Heart Attack • Heart Failure • Pneumonia • Surgical Care • Children’s Asthma • VTE • Stroke • Hospital-Based Inpatient Psych • Immunisation. Advanced EMRAM stages have a higher proportion of The Joint Commission’s Top Performing Hospitals excelling in multiple quality measures than EMRAM stages with lower EMR capabilities, In other words, the proportion of hospitals excelling in multiple quality measures (4 or more) increases with advancing EMR capabilities.
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Reduction of errors - the quality connection to advanced EMR adoption
According to research on medication errors from The Joint Commission in the United States : • 58 per cent of errors occur in administration • 36 per cent of errors occur in transcribing from handwriting • 6 per cent of errors in ordering, transportation, and documenting Barcode medication administration (BCMA) has improved patient outcomes and reduced medical errors, as noted in this study on timing errors without & with bar codes. • 6,723 without bar codes: 11.5 per cent timing errors/3.1 per cent were judged serious ADE • 7,318 with bar codes: 6.8 per cent timing errors (-40.9 per cent)/1.6
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Improvement in patient safety:
The Quality Connection to Advanced EMR Adoption Patient safety efforts address many intersections of patient care – from medication management to accurate medical history and access
to that data. With proper IT patient safety systems in place, clinicians and other caregivers can begin improving patient outcomes and reducing medical errors early in the continuum of care. This component of advanced EMRAM score include: US Agency for Research, Health and Quality (AHRQ)- Hospital Survey on Patient Safety Culture Seoul National University Bundang Hospital (2012) – Korea (First Stage 7 hospital in Asia and outside the United States) Chelsea & Westminster Hospital Trust – UK Royal Free London NHA Foundation Trust – UK AHRQ: In general, the more advanced the hospital’s EMR capabilities, the more positive the staff members are about their hospital’s “patient safety culture.” This statement captures a comparison of 2011 EMRAM scores against the most currently available data set (2011) from the US Agency for Research, Health and Quality’s (AHRQ) Hospital Survey on Patient Safety Culture. This review considered two AHRQ variables by EMRAM stage: • System and procedure effectiveness in ensuring patient safety • Overall patient safety culture grade Both variables showed a strong association with the EMRAM score. The staff’s perception of the effectiveness of their hospital’s systems and processes in ensuring patient safety increased with advanced EMR capabilities. The staff’s self-reported grade of the hospital’s patient safety culture (where A = the best grade;
A u t ho r B I O
per cent were judged serious ADE (-50.8 per cent) • Wrong Medications – 57.4 per cent • Wrong dose – 41.9 per cent • Improper documentation – 80.3 per cent • Transcription errors: - 100 per cent The five examples included here focus on hospitals that reported these improvements in medication errors using BCMA; these Stage 6 and Stage 7 hospitals must use closed loop medication, as noted on the Asian EMRAM at Stage 6 and on the US EMRAM at Stage 5. Sentara Health System – Stage 7: 96 per cent compliance on scanning and 12,459 medication errors avoided per month. SSM Health System – Stage 7: Journal of Health Care Quality sites 59 per cent reduction in medication The next three examples -from the HIMSS Health IT Value Suite - cite reduction in medical errors with both qualitative and quantitative data and references to outcome improvements. In this category of health IT value, it is important to recognise this overlap and connection between fewer medical errors and improved patient outcomes. Prince Court Medical Centre (2014) - Kuala Lampur (Stage 6 hospital): Ensures proper documentation of patient care. Singapore National Skin Centre (2014) – Singapore (Stage 6 hospital): Reduced probability of medical errors. Marina Salud (2012) – Spain (First Stage 7 hospital in Europe): 42 per cent reduction over 2 years in the time from suspected breast cancer to initiation of treatment; improved coordination between primary and specialized providers.
B = second best grade; etc…) improved with advanced EMR capabilities. Seoul National University Bundang Hospital (2012) – Korea (Stage 7 hospital):
With over 140 clinical pathways built into the system, (up from 32 five years earlier), the hospital has reduced inappropriate administration rate of pre-operative antibiotics to less than 2 per cent of the cases from 10 per cent, while still generating a 15 per cent reduction in length of stay. Chelsea & Westminster Hospital Trust – UK: 77 per cent decrease in medicines being prescribed despite known allergy. Royal Free London NHA Foundation Trust – UK: 67 per cent decrease in inappropriate use of proton pump inhibitors. Summary: The adoption of electronic medical records across the globe offers a universal opportunity that benefits patients in any location: to improve health with information technology. The vision means that hospitals and health systems must evaluate their progress along this path to IT implementation, a task demanding a standardized tools usage with effective and measureable metric milestones. The HIMSS Analytics Electronic Medical Record Adoption Model identifies and reports on hospitals at Stage 6 and Stage 7. With advanced EMR capabilities, these hospitals demonstrate improved quality measurements for improved patient outcomes, reduction of medical errors and improved patient safety. References are available at www.asianhhm.com
Steve Lieber is President and CEO of HIMSS, a global, causebased, not-for-profit organisation focused on better health through information technology. A recognized healthcare management executive, Lieber brings to the HIMSS over 30 years of experience in healthcare, primarily in healthcare association management. He joined HIMSS in 2000 as CEO/President of the organisation.
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Impact of
Telematics New technologies such as wearable wireless medical devices are transforming the way healthcare is delivered. As these devices become more powerful and numerous, the daunting challenge is whether the existing communications infrastructure can meet the requirements of the changing landscape. 5G technology offers huge potential for future personalised healthcare delivery. Christoph Thuemmler, Professor, Klinikum rechts der Isar, Munich, Germany Thomas Jell, Senior Principal Consultant, Siemens, Germany Swaroop Nunna, Huawei Technologies Duesseldorf GmbH, Germany Ai Keow Lim Jumelle, Educational Psychologist, Edinburgh Napier University, UK
A
ll around the globe, e-Health has been a buzzword over the past 10 years or so. Although according to European studies the pick up rate of e-health in Europe is moderate, demographic data in
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most countries are speaking a clear language and it is unlikely that well established care models with hospitals as their centrepieces will be economically viable and sustainable in the future.
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According to OECD figures healthcare costs all around the world will drastically increase. In comparison to 2006, healthcare costs in Germany and the US are expected to double by 2020, while the healthcare spending in China is predicted to grow more than seven fold until then. The fact that in most industrialised nations healthcare costs in general have been growing faster than the national gross domestic product (GDP) for a good number of years is alarming but there is no indication that this trend might reverse. So all in all, demographic and socio-economic factors suggest that new care models have to emerge primarily not so much in order to increase the quality of care but to release badly needed efficiency reserves not only in hospitals but across entire healthcare systems. In Europe there is clear statistical evidence showing that the number of hospital beds has been continuously dropping since the 1990s while the number of day surgery interventions like in the case of Cataract and Tonsillitis have picked up year on year. Also, the number of outpatient episodes has been steadily growing with more people being seen on an outpatient basis than ever. Policy makers and legislators throughout Europe have recently proposed to utilise m-health approaches to increase the self management capabilities of patients and their formal and informal care providers. The underlying ideas of applying (digital) technology to enable lesser skilled people to move ‘up-market’ and cover routine tasks of higher skilled individuals takes us to the ideas of Clayton Christensen, well known for his theory of ‘Disruptive Technologies’. From a systemic perspective this concept is looking at the emergence of dynamic distributed patient-centric care ‘cells’ which are flexible with regard to their members and proprieties and may connect to each other (peer-to-peer) for instance, to form self help groups. Individuals or groups might also integrate or establish contact with experts in
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central locations, whereby this does not imply expert centricity. Through means of virtualisation the point-of-care will clearly be shifted towards the patients or their individual peer-to-peer networks. Hospital care in the future is likely to be more the exception than the rule and will be reserved for cases such as major surgery, major illness or similar scenarios which would not be manageable outside hospitals. Distributed patient-centred care has been accepted as a viable and most likely strategy to maintain the quality of care in the future, empower patients and increase the efficiency in healthcare systems. Recently the European Commission (EC) published infographics to highlight key parameters demonstrating the pickup of m-health. According to this, there have been 6 billion mobile subscriptions in 2014. According to Cisco figures, 2014 has been a very special year in so far that for the first time ever mobile subscriptions broke even with the number of people on this planet. Furthermore, the EC predicts the value of the global m-health application business at 17 billion Euro by 2017. More people than ever will use their mobile devices to monitor and manage their health, connecting with peers, specialists and with machines via the World Wide Web. Exponential growth rates are expected. This is clearly good news for many industrial domains and the world economy. However, some questions remain unaddressed. Cisco figures suggest that the global mobile data traffic has grown between end of 2013 and end of 2014 by 70
per cent. Until the end of 2020 the data traffic is predicted to grow by a factor ten. Currently, the network does not grow at the same rate but according to Forbes the Internet of Things will be booming over the years to come, which will put additional stress on the mobile infrastructure. How will we be able to secure a highly reliable infrastructure that will meet the requirements of patients, healthcare experts, policy makers and legislators with regards to bandwidth, latency, reliability, safety and security for years to come? How can we enable the future of healthcare? How can we ensure accessibility and prevent digital exclusion, especially in rural areas? How can we cut costs and keep control of our carbon footprint? Distributed patient-centred care = distributed patient-centred computing
When telecom operators started to offer 3G networks this was widely hailed as the silver bullet to cut latency and download times and enable a growing Internet with even quicker growing traffic. Now in many urban areas 4G technology is available and it has become clear that progress in the sense of ‘more of the same but faster’ will not be sufficient to really make m-health a ‘Disruptive Technology’. According to Christensen the decisive, distinguishing feature of a Disruptive Technology is the fact that it replaces an existing technology or strategy, thereby forcing existing providers out of their market dominating positions. The case of M-Health as a ‘Disruptive Technology’ with regards to
how ‘health market participants’ access the ‘market place’ and how healthcare providers deliver healthcare clearly needs to be rejected as long as mobile networks are relatively slow and expensive and bandwidth consumption is capped as part of the telecom provider’s business model. However, recent scientific progress with regards to network technology suggests, that we are likely to witness a technological revolution, which could also fundamentally change the way healthcare is consumed and delivered. 5G to shape the future of healthcare
Huge multi-national companies such as Ericsson, Nokia-Siemens, Huawei and others have been developing technologies to overcome current limitations in the network technology. Huawei and their strategic research partner, the University of Surrey (UK) have recently transported data at a rate of 1 TBit/s in their press release. At the heart of 5G Technology are different wave formats and protocols, which allow for less latency and more efficient data transmission through specific network environments. However, 5G technology offers more than just significantly higher transmission rates, lower latencies and faster backhaul systems. The overall network package will also allow on a high level allocation of ‘isolated’ virtualised networks to individual healthcare providing organisations excluding interference from third parties. This will be achieved by the use of Software Defined Networks (SDN). This will enhance safety, security and privacy for all parties and should lower litigation concerns in particular
Figure 1 Health spending (in billion USD)
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Figure 2 mHealth, what is it? (Source: European Commission,https://ec.europa.eu/ digital-agenda/en/news/mhealth-what-it-infographic)
from the perspective of the healthcare providers. 5G will also enable patients to create their own individual care networks, which they will be able to administer easily on their smartphones. In these networks not only individuals will be interlinked but there will also be
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interaction with sensors and monitoring devices in order to enable formal and informal care providers to monitor patients. Patients will also be able to control access to their data although this data will typically be distributed in a variety of different databases across different organisations and networks. The technology will be able to manage files, such as MRT or CT files, which currently can only be shared via expert systems (Hospital Information Systems). Other potential future 5G enabled healthcare applications include the real time remote interventions with artificial
IS S Ue - 31 2015
organs, such as pacemakers, defibrillators, insulin pumps and brain pacemakers but also remote robotic surgery and remote surgical assistance. A very important future field of interest will be human machine interfaces, in particular with neurological structures, for example the support for visually impaired people. A real world test bed has been announced during the opening of the Huawei 5G Vertical Industry Accelerator programme in Munich by the State of Bavaria, the City of Munich, Huawei and Technical University of Munich. Unsurprisingly one of the main foci was healthcare. During the course of 2015 and the years to follow, Klinikumrechts der Isar, the main teaching hospital for Technical University Munich, will be initially 4G LTE and successively 5G enabled. It is interesting enough to note that the German government has recently published a draft for e-health telematics legislation due to be rectified by parliament not later than 2016. The legislation is concerned with highlevel regulation of reimbursement for telematic care, matters of governance and technical requirements such as interoperability. Legislative action has been proven a vital step towards the spread of tele-health adoption in the US and it has become widely accepted that legislative clarifications have to precede the role out of any technology to make it appeal to healthcare providers. The technological approach in Munich will not only cover new protocols and wave forms but will also consider new architectural designs, such as Mobile Edge Computing (MEC). MEC or also known as Mobile Edge Clouds has been known and discussed as a concept for some time. However, it has never left the lab for wider testing. Mobile Edge Computing for e-Health and m-Health
With the motto ‘solve local problems locally’, MEC is the emerging paradigm wherein application and service deployment can be performed within
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Figure 3 Schematic view of MEC
vicinity. Furthermore, MEC is local to a given geographical location. This means that with MEC, privacy of the medical data can be emphasised by limiting its storage and processing to the hospital region. This in turn avoids the risk of
exposure which might be caused due to transmission and processing of the data beyond the hospital boundaries and in the core network as it often happens with the current systems. References are available at www.asianhhm.com
Christoph Th端mmler is Professor for e-Health at Edinburgh Napier University and also collaborative researcher at Technical University Munich, Germany.Christoph completed a PhD on cerebral haemodynamics with distinction before training to become a General Physician. His current interests include the utilisation of superfast networks in healthcare and the virtualisation of care.
A u t ho r B I O
a cloud like environment provided to the mobile network edge. Typically such a cloud is installed in the proximity of a mobile base station and will have the scope of its services bounded by a given geographical area. This approach provides significant reduction in data transmission latencies and is in stark contrast to the traditional applications and services that are deployed over a cloud connected to the core network. shows a schematic view of MEC in a mobile communication system. The concept of providing computing resources at the network edge to reduce latencies is nothing new and was developed around 2004 to provide lower response times for enterprise web applications. In the area of mobile communications, the idea however has only been recently introduced. An MEC Industry Specifications Group (ISG) was recently established within European Telecommunications Standards Institute (ETSI) to standardise and develop interoperable MEC architectures. Compared to the traditional edge computing, MEC goes beyond reducing latencies. In MEC, the network is expected to provide context-awareness to the services deployed over the edge cloud in a safe and secure manner. This contextual information would include the location and features of the individual connected devices among many other things. It is envisioned that MEC when combined with other evolving concepts in 5G would provide effective real-time context-awareness collaborations between devices and/ or users. In the context of healthcare, such a system would be a holy grail that could enable a plethora of future e-Health and m-Health scenarios. For example, surgeons located in different are as of a hospital could collaborate over the MEC to perform remote robotic tele-surgeries. And, in the scenario of elderly care, if some patients need immediate assistance, the MEC could immediately locate and inform the certified caretakers available in the
Tom Jell is Program Manager for the department Technology and Innovation and Senior Principal Expert at Siemens Mobility Division (Munich and Beijing). His research focus is on secure eHealth solutions introducing hybrid clouds based on a software to data approaches as well on resilient fault tolerant industry systems and Reliable Systems. Swaroop Nunna is a research engineer in the future wireless network technologies group at the Huawei European Research Center, Munich. Swaroop received his Masters in Communication Engineering from Technische Universitaet Muenchen, Germany. His current research interests aim at establishing an integrated connectivity framework for Internet of Vehicles and Internet of Things environments. Ai Keow Lim is a Research Fellow working with the EU FI-STAR project team at Edinburgh Napier University.She obtained her MSc and PhD in Education from the University of Edinburgh. Her research interests include social and psychological aspects of human-machine interaction, Internet research ethics and educational aspects of Internet-based learning.
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Greiner Bio-One Suns - a reliable premium service provider for hospital laboratories China, with a population of almost 1.4 billion people, has surely been one of the world's most rapidly growing economies in recent years.
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In order to secure access to this vibrant yet challenging growth market, Greiner Bio-One (GBO) decided to purchase a majority share in what was then its only Chinese sales partner in Beijing in 2011. The company operates under the new name of "Greiner Bio-One Suns Co. Ltd"; in addition to its core product VACUETTE®, it also distributes other diagnostic products by well-known manufacturers such as Siemens, Johnson&Johnson and Biomerieux. Thus GBO-Suns can cover all the major components of a modern hospital laboratory. The successful "bundling strategy" of VACUETTE® products with diagnostic equipment provided by major international manufacturers has made GBO-Suns in Beijing one of the prominent providers of medical laboratory items. With its 100 employees, the company was able to achieve a turnover of approximately 44 million euros in 2014. The constantly rising number of VACUETTE® bloodcollection tubessold in China in the last 10 years confirms the continuous growth of a thriving economy such as China and the increasing demand for high-quality medical consumables. Although competitive pressure has increased due to a rising number of local bloodcollectiontubemanufacturers, who are also attempting to extend their business internationally, GBO-Suns remains unequalled when it comes to quality and its image as a premium service provider. Targeted expansions in some densely populated Chinese provinces and regional sales offices in various urban centres such as Shanghai, Guangzhou and Chongqing are aimed at reinforcing the image of VACUETTE® as a premium brand and its market penetration.
As the Chinese health authorities are planning to reform the sales channels to hospitals to make them more efficient, leaner and more cost-effective, so-called "3rd-party logistics licences" have been granted in some major cities on a trial basis. GBO-Suns was one of the few companies in Beijing to be granted a logistics licence from the Beijing FDA for the Greater Beijing region during 2014. Apart from selling its core product VACUETTE®, the company distributes a variety of diagnostic products manufactured by wellknown companies, thus gaining a further support pillar to secure additional development options for GBO-Suns as one of the key players in the market. In addition to the Chinese market, Greiner Bio-One serves almost all other markets in Asia via an extensive network of distributors. In 2011 it was decided to enter into a joint venture with the company's Indian sales partner, Tristar Remedies. Since then, this equally growing market has also been directly supplied by Greiner Bio-One India Pvt 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, pharma-ceutical 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).
Advertorial
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RHAPSODY INTEGRATION ENGINE – FIRST WITH FHIR Dr. David Hay, Product Strategist at Orion Health
Large amounts of patient information are generated each and every day – such as medications, allergies, blood tests, radiology and clinical history information. Access to such pieces of information can help save patients’ lives. But how useful is this valuable information if there aren’t systems in place to consolidate, organise and present it? With modern healthcare systems, data must move freely among various systems to match the complex workflows. Interoperability - the extent to which systems can exchange and correctly interpret shared data – has become a must-have feature of any product offering. The latest Health Level Seven® (HL7) standard – Fast Healthcare Interoperability Resources, also
known as FHIR® – is a new standard that promises to revolutionise the way healthcare information is shared and utilised across multiple platforms. Using existing standards commonly adopted by tech developers outside of healthcare (including giants like Facebook, Twitter and Google), FHIR is designed to offer unprecedented ease of use in a complex domain. Moreover, it is easily understandable even by non-healthcare professionals.
Executing on user feedback Hospitals and care teams are a primary target for FHIR. An active community that conducts practical testing throughout the standard’s development has been critical in producing an easy-to-use standard, and freely-available test servers and
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software libraries for development have been a crucial part of this. ‘Connectathons’ are held to bring developers together to test the standard’s suitability, and have proven invaluable in making FHIR work across all aspects of healthcare IT. FHIR is being implemented around the world even as it is still being developed and improved. Early adopters are using FHIR and providing feedback to inform further development as the standard matures.
Room for customisation FHIR allows for customisation and country - specific items can be added and removed from a core menu. The pick-and-choose concept of extensions embedded in FHIR keeps resources as small as possible while providing room for customisation. Profiles also provide customisation for specific purposes. FHIR can meet different institutional and market needs while still enabling seamless sharing between hospitals and countries.
FHIRing up worldwide Despite its relative youth, FHIR has garnered enormous interest worldwide. To date, trial implementations are taking place in more than 15 countries. Expressing keen interest in FHIR, large organisations ranging from hospitals to healthcare systems have recognised FHIR’s advantages over other standards and have since supplied their own resources and funding to help further its development. In particular, Orion Health’s™ Rhapsody® Integration Engine rapidly and reliably connects, integrates, and shares information between disparate
health software systems and organisations, laying the foundation for delivering consistent, efficient, and high quality patient care. To continually extend the advantages of developing fast and powerful interfaces, Orion Health is committed to supporting emerging standards that will empower Rhapsody interface developers to solve problems using FHIR. Early adopters of FHIR are already touting its simplicity, and Rhapsody has a big part to play in assisting implementers to incorporate FHIR exchanges. If you are in the healthcare industry, chances are you will be using FHIR or working with a partner who incorporates the standards. Now is the best time to learn how FHIR is built, how it can be customised and how FHIR implementation can benefit your organisation. Don’t wait - get FHIR-ed up! orionhealth.com/us/intelligent-integration
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Company....................................................................Page No. HEALTHCARE MANAGEMENT BPL Medical Technologies Private Limited.............................. IBC Global Data..............................................................................07 Greiner Bio-One GmbH.................................................... 60 & 61 Medical Fair Thailand 2015.................................................... OBC Orion Health............................................................. IFC, 62 & 63 MEDICAL SCIENCES BPL Medical Technologies Private Limited.............................. IBC Greiner Bio-One GmbH.................................................... 60 & 61 Medical Fair Thailand 2015.................................................... OBC Orion Health............................................................. IFC, 62 & 63 TECHNOLOGY, EQUIPMENT & DEVICES BPL Medical Technologies Private Limited.............................. IBC HIMSS Asia Pacific..................................................................03 Hocoma AG.............................................................................23 INFORMATION TECHNOLOGY HIMSS Asia Pacific..................................................................03 Medical Fair Thailand 2015.................................................... OBC
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Company................................................................... Page No. BPL Medical Technologies Private Limited.............................. IBC www.bplmedicaltechnologies.com Global Data..............................................................................07 www.store.globaldata.com Greiner Bio-One GmbH.................................................... 60 & 61 www.gbo.com HIMSS Asia Pacific..................................................................03 www.himssasiapac.org Hocoma AG.............................................................................23 www.hocoma.com Medical Fair Thailand 2015.................................................... OBC www.medicalfair-thailand.com Orion Health............................................................. IFC, 62 & 63 www.orionhealth.com
To receive more information on products & services advertised in this issue, please fill up the "Info Request Form" provided with the magazine and fax it, or fill it online at www.asianhhm.com by clicking "Request Client Info" link. 1.IFC: Inside Front Cover 2.IBC: Inside Back Cover 3.OBC: Outside Back Cover
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