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2015
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Smart Health for Smart Communities
Creating a System for Safety
FINDING NEW MODELS OF CARE IS A FOCUS FOR THOSE WHO SOLVE
Today’s healthcare environment is changing rapidly. To respond, healthcare providers need to shift to transformational new models of care. Learn how CSC helps providers embrace new models of care that maximize the potential of data and analytics to enable better patient outcomes. To know more about CSC Next-Gen Healthcare Solutions that will transform your business, visit csc.com/solvehealth
Foreword Healthcare in Southeast Asia Poised for growth Rapid economic growth and growing population have combined to create a critical situation for Southeast Asian governments. Even as the spending on healthcare systems in the region has increased with the increase in incidences of adverse health conditions it looks like demand is outstripping the supply of healthcare in the region. According to Deloitte’s 2015 Healthcare Outlook, Thailand’s spending on healthcare is estimated at 3.3 per cent of GDP in 2013, which is proportionately less than the Philippines, Malaysia or Singapore, but more than Indonesia (at 2.8 per cent in 2013). Following Thailand’s introduction of a universal healthcare system in 2001, its healthcare spending has been increasing and is projected to grow eight per cent a year from 2014 to 2018 to reach US$18.7 billion. However, the Thai government is still working on reducing its budget deficit and healthcare’s share of GDP is expected to stay flat, despite the growth in demand. Indonesia, comparatively, has a very poor public healthcare system with only two doctors per 10,000 people. The country is suffering from severe infrastructural limitations with only 0.6 hospitals bed per 1,000 population. Myanmar spends the least on healthcare at 1.8 per cent of GDP in 2013, according to World Health Organisation (WHO). Meanwhile, the private healthcare market is strengthening its position. Private investment is increasing rapidly in order to meet the increasing demand. Developed areas in the region such as Singapore and Malaysia are
providing world-class services to both local and international patients. The region also enjoys the benefits of having a strong medical tourism industry. The region’s healthcare market is projected to be worth US$134.2 billion by 2020. The private sector is likely to continue to be dominant, accounting for a 53 per cent share and is forecasted to reach US$71 billion in 2020, nearly double the size in 2010, according to the research by Al Masah Capital Management Limited. Regulations and measures like the restructuring or corporatisation of public hospitals in Singapore in 1985 and the Swadana (selffinancing) hospitals in Indonesia, the WHO Regional Strategy for Universal Health Care (UHC), strengthening the community-based health workforce in the context of revitalisation of primary healthcare and more have positively affected the region. Both the public and the private players have to work together to meet the increasing demands on region’s healthcare system. In the cover story, Amit Varma of Quadria Capital discusses the opportunities in Southeast Asian Healthcare market and explains how to plan for the healthcare demand.
Prasanthi Potluri
Editor
Contents COVER STORY
12 Planning for Healthcare
Demand and Growth in Southeast Asia Amit Varma, Managing Partner, Quadria Capital, India
Healthcare Management
Information Technology
05 ACO Movement in the United States
55 Smart Health for Smart Communities
Peter Gross, Chair, Board of Managers, HackensackAlliance ACO, USA
20 Evidence-based Medicine and Outcomes Analysis An evaluation Suman Bhusan Bhattacharyya, Member National EHR Standardisation Committee, MoH&FW, GoI, India Member, Health Informatics Sectional Committee, MHD 17, BIS
K Ganapathy, President, Apollo Telemedicine Networking Foundation, India
special features 35 Books 58 Reserch Insights
Medical Sciences 32 Chemical Allergy in Healthcare Patty Taylor, Vice President, Professional Education and Clinical Affairs, Ansell, US
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Facilities & operations Management 36 Environmental Impacts for Healthcare Sustainability Jeffrey E Thompson, Pediatric Intensivist and Neonatologist, Gundersen Health System, US
44 Creating a System for Safety Frank A Federico, Executive Director, Strategic Partners, Institute for Healthcare Improvement (IHI), USA
50 Toileting Aids in Hospitals Reuse or Dispose? Emma Sheldon, Marketing Director, Vernacare, UK
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Advisory Board
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HEALTHCARE MANAGEMENT
ACO Movement in the United States The movement to grow Accountable Care Organisations (ACOs) in the United States is now more than 600-member strong. As we move from an economic system based on fee-for-service and volume to one based on paying for quality and value, many changes will take place. The changes are expanded culture of quality and accountability, creation of new business models, identifying the importance of health information technology, and the centrality of clinical integration. Peter Gross, Chair, Board of Managers, HackensackAlliance ACO, USA
T
he movement to grow Accountable Care Organisations (ACOs) in the United States is now more than 600-member strong. The movement of late has been spearheaded by the U.S. Centers for Medicare and Medicaid Services (CMS) under its Medicare Shared Savings Program (MSSP). What exactly is an ACO? An ACO, as defined by CMS, refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the patients they serve under original Medicare (that is, those who are not in a Medicare Advantage private plan). The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries, while improving quality and lowering costs. The ACO would be a patient-centred organisation where the patient and providers are true partners in care decisions. Patient and provider participation in an ACO is purely voluntary. The MSSP will reward ACOs by allowing the ACO share in accrued savings. These savings come from lowering growth in Medicare
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healthcare costs while meeting performance standards on quality of care and putting patients first. To share in savings, the quality standards that ACOs must meet fall under five key areas: • Patient / caregiver care experiences • Care coordination • Patient safety • Preventive health • At-risk population / frail elderly health. The MSSP programme was set up to provide either upside potential to earn savings (Track 1) or upside potential for savings or downside risk should losses occur (Track 2). As we move from an economic system based on fee-for-service and volume to one based on paying-for quality and value, many financial and cultural changes will have to occur. These changes will have to expand: 1) the culture of improving quality and increasing accountability 2) result in the creation of new business models 3) make health information technology an important tool for every practice, and 4) necessitate the centrality of clinical integration of all practices in a region. If you want to create an ACO, the first item on your to-do list is to set up your organisation and appoint staff in the initial areas of need. We started out with a President and CEO and a Vice-President and Chief Medical Officer—both practising. A Board of Managers was created to officially conduct the business of the ACO. The Board should have practising physicians, hospital representatives, and patient representatives. It should have a separate Chair. An Executive Committee should be created to help run the ACO. Several committees will need to be formed to monitor credentials, compliance, information technology, performance improvement, finance, research and others.
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Physician selection is next and is critical. We chose physicians whose practices were already certified as Patient-Centered Medical Homes (PCMHs) approved by the National Committee for Quality Assurance (NCQA). These physicians, by being approved PCMHs, already understand the future of health care and will work to comply with the Triple Aim (improve patient experience of care, improve the health of a population, and reduce the cost of care). Two of your most important appointments are Director of Care Coordination and a Data Coordinator and IT liaison. They are critical to implementing the Triple Aim. Billions of dollars are lost annually because of inadequate coordination of care. Select your leader for this area who will then in turn pick nurse coordinators to place them in the large practices where they will focus on improving the care of high-risk patients. They will set up a special relationship with high risk patients to help them avoid unnecessary admissions and ER visits. Nursing level candidates should suffice. Their leader may be an advanced practice nurse. Some of the nurse coordinators can be medical assistants depending on the level of responsibility. Another key
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position is the Data Coordinator and IT liaison that will help process CMS quarterly data and work with nurse coordinators to monitor the quality measures. Alternatively, you may have your own computer systems to do that or you may contract with a commercial company such as Health Endeavors. We hired a few coordinators at a time, trained them in Duke’s Population Care Coordination Program, and then placed them in the offices of large, private practices. We also put nurse navigators in the hospital to help manage the patients when they were admitted to the hospital. We used a six-step care transition bundle that consisted of: 1. Transition planning: coordinate with family, identify provider for outpatient setting, give discharge information to patient, do medication reconciliation to avoid confusing hospital medications with home medications 2. Patient and family engagement/ education: consider health literacy, use teach-back methods 3. Information transfer: use personal health record and integrate into EMR 4. Follow-up care: assure timely office access to key providers within a few days of discharge
HEALTHCARE MANAGEMENT
If you want to create an ACO, the first item on your to-do list is to set up your organisation and appoint staff in the initial areas of need.
You will also require a special focus on post-acute care, which means meeting with those employed for skilled-nursing facilities and home health agencies. They need to be on board with the same approach to efficient use of resources as you do. They need to monitor the quality of their services and correct any deficiencies in quality and service. Newer technologies may also be useful. For example, we are using an iPad given to a patient with heart failure for them to record essential parameters of their condition. It will provide us with early warning signals of imminent deterioration. You will find that there are many opportunities to reduce costs. You can: 1. Reduce admissions, re-admissions, and emergency room visits 2. Open your private offices after hours to avoid patients going to the ER 3. Switch to generic drugs from trade name drugs Author BIO
5. Healthcare provider engagement: identify primary care provider, coach patient on self-care 6. Share accountability across providers and organisations: assure one healthcare provider is responsible at all times; sender and receiver assume responsibility for care transition. You then need to create a system to monitor at least 33 performance measures where this information is taken from the chart by hand or by computer. Collecting this information is very time consuming but important as the savings achieved can be eliminated if compliance with the quality indicators is not met. Medicare monitors 11 quality measures and we are responsible for the other 22. Each ACO needs to set up a system to keep track of these 22 measures for each patient. What will be your method of recording, storing and extracting the measures for each ACO patient? Prior to setting up the system, typically through electronic medical record, you need to be sure that each ACO provider is aware of the quality measures and is part of the solution when the practice sets up systems to measure compliance with these measures. As you are setting up your organisation, don’t forget to line up C-Suite for support. That includes the CEO, CFO, CMO, CMIO and CNO as soon as you can. Their support is critical, as you need to hire personnel, supplies, and equipment as well as set up contracts with other payers. They should be genuine partners, not distant sources of funding for your episodic financial needs. Patient engagement can be a challenge. Define your organisation’s vision for patient engagement. Then create a culture of engagement. Employ the right technologies and services. Empower the patients to become collaborators in their care. Chart their progress and be flexible to change and adapt as needed. (AthenaHealth white paper, Feb. 2014)
4. Set up outpatient special care units to manage chronic illness education and consider providing an ambulatory intensive care unit 5. Reduce inappropriate testing 6. Contract with a data analytics firm to point out other opportunities for improvement 7. Consider the new Chronic Care Management fee program to manage high-risk patients 8. Be assured that you are following all your assigned patients. You are likely to encounter some problems. For example, you may not have lined up your financial resources ahead of time. Consequently, it will take longer to hire people and finalise necessary information technology projects needed to decide how you will include the sub-specialists. Make sure that financial reporting provides you with necessary information. For example, what are the expenses for inpatients, skilled nursing facilities, outpatient services, physician fees, home health, durable medical equipment, and hospice expenses? Benchmark years have to be established to compare with current year expenses in order to determine savings. If savings have been generated, that is excellent. You then need to decide how to divide them. We generated over $5 million in our first year and divided it by the number of beneficiaries or patients in each practice group and the duration of care for the patients. Quality compliance will play a larger role in the next year if we continue to save. We wish you good luck. It is not an easy undertaking but it is the direction that health care is moving and you need to be on board.
Peter Gross, MD is Chair, Board of Managers, Hackensack Alliance ACO and the co-chair, National Association of ACOs (NAACOS). He has chaired FDA's Drug Safety and Risk Management Advisory Committee, IDSA's Practice Guideline Committee, JCAHO's National Patient Safety Goals Committee, and was President, Society of Healthcare Epidemiology of America.
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Southeast Asia Set for Resurgence " With increased healthcare challenges of delivering affordable quality care to the masses, the Southeast Asian region is planning to manage healthcare with new innovation. Innovation would entail a collaboration of differentiated ideas applied to business models for delivering healthcare services, to regulation, to financing, to leveraging technology and to the nature of partnerships between different types of healthcare organisations, be they private companies or government organisations."
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Planning for Healthcare Demand and Growth in Southeast Asia Asian healthcare is the new centre of gravity with the global healthcare growth. Growth is primarily driven by robust fundamentals such as large, rapidly growing ageing population, increasing affluence, rising middle-class and increasing incidence of chronic diseases. However, a large demand-supply gap and low public spending on healthcare has created challenging operating healthcare landscape. Many of the economies in Southeast Asia are struggling with a relatively underdeveloped healthcare system. As we look beyond the current into the future, we find that the impending systemic changes in the system, supported by investor friendly policies and collaborations, would be needed to create a stronger healthcare ecosystem. Amit Varma, Managing Partner, Quadria Capital, India
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of global healthcare expenditure. As the region ages (Chart 1) and becomes more urbanised and more affluent leading to life style changes, the incidence of chronic diseases (Chart 2) will increase. The incidence of chronic diseases is expected to double from 2001 to 2025. This in turn will create increasing demand for good quality healthcare delivery facilities and infrastructure. The region, especially Indonesia and the Philippines, is expected to exhibit strong growth in the period 2014-18 (Chart 3) on account of strong domestic demand, high infrastructure spending and execution of structural economic reforms. This in turn would result in an increase in disposable income and hence create further need for healthcare services at all levels. Supply Overview
T
% of Population
he healthcare delivery market in Southeast Asia, valued at US$71 billion, remains significantly under-penetrated and underprepared. This is reflected in the high growth rate of 15 per cent, clocked year-on-year. The region accounts for 10 per cent of the world’s population and 20 per cent of the world’s disease burden, yet commands only 3 per cent
While on one side, the demand is expected to grow multi-fold, the supply side situation does not look encouraging. Healthcare infrastructure in the region, to say the least, remains severely undersupplied and underdeveloped, with the gap expected to widen. Average healthcare expenditure as a per cent of GDP in the region, for instance 2.3 per cent in Indonesia and 3.7 per cent in the Philippines, significantly trails that of developed nations (Chart 4). In absolute terms, Indonesia and the Philippines spend only
US$91 (PPP) and US$129 (PPP) per capita on healthcare respectively versus the global and US average of US$899 (PPP) and US$7,164 respectively. Low healthcare spend by governments in the region has further resulted in healthcare systems that are often ageing, under-developed and overstretched. For instance, there are only nine hospital beds per 10,000 population in Indonesia and 10 hospital beds per 10,000 population in Philippines as compared to the global average of 30 beds per 10,000 population and OECD average of 50 beds per 10,000 population. Governments are now trying to meet this demand. Indonesia, for example, has decided to implement universal healthcare at national level; where previously more than 125 million (more than half the population) lacked access to state health coverage, state or private health insurance. However, the efforts still fall short of narrowing the demand-supply gap and as a result, the healthcare market in the region varies in structure and maturity (Chart 5). The human resources aspect of supply looks equally discouraging. The overall healthcare talent canvas has massive gaps, with several critical talent pools virtually non-existent. The health education system in the region is ill prepared to produce adequate talent of reasonable quality. There is significant challenge in building the core pool
Chart 1: Proportion of Population Aged 60 and Over
Sources: Frost & Sullivan
Chart 2: Increasing Incidence of Chronic Diseases
Sources: Frost & Sullivan
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of doctors, which is a cause for alarm. Indonesia, for example, has only 4 doctors per 10,000 people, lower than the global average of 14 doctors per 10,000 people (Chart 6 and 7). Consequently, governments in Southeast Asia seek to attract private capital into healthcare systems to increase the access and affordability of healthcare services in the region, develop efficient healthcare systems and meet the increasing capital requirements for new and upgraded systems. In most Southeast Asian countries, the share of private healthcare expenditure is higher than that of public expenditure. Furthermore, due to growing healthcare costs and significant portion (more than 60 per cent) of the expenditure financed out of pocket, the calling is for the government to rise up and address the supply side of healthcare eco-system. Planning for the Healthcare Demand
Whilst most industries develop products and services keeping customer at the centre of everything, healthcare, traditionally, has been paternalistic in nature. However, with changing nature of medicine, growing patient awareness and increasing spread of the internet, the scenario is changing. Patients are becoming more informed about their health profile and are devoting time, money, energy to stay healthy. Patients today are demanding uniform access to preventive and curative care at a
The region, especially fast emerging economies such as Indonesia and the Philippines, is expected to exhibit strong growth in the period 2014-18 on account of strong domestic demand, high infrastructure spending and execution of structural economic reforms.
given level of cost. Many countries are struggling to address increasing costs, poor or inconsistent quality and inaccessibility to timely care. Attempting to resolve these issues is daunting. And many believe the only cure is a fundamental transformation of healthcare. To be able to cater for tomorrow’s healthcare demand, proper planning needs to be done. I believe that there are four areas, where both governments and private organisations would need to focus on to be able to cope up with the demand. i. Infrastructure planning: Infrastructure forms a critical part of healthcare delivery in any country. Availability, accessibility, affordability, equity, efficiency and
GDP CAGR (2013)
8.0%
14.0%
5.0% 4.0% 3.0% 5.3%
5.3%
6.9%
6.1%
Healthcare Spend as % GDP
GDP CAGR
6.0%
12.0% 10.0% 8.0% 6.0% 15.2%
4.0% 2.0%
1.0%
0.0%
0.0% Malaysia
Vietnam
Indonesia
Chart 3: High Economic Growth
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Significant Underspend on Healthcare
16.0%
7.0%
2.0%
quality services highly depend on the distribution, functionality and quality of infrastructure. In most part of the region, the healthcare infrastructure has large gaps and inadequacies, both quantitatively and qualitatively. Since, over the last few years, the growth in healthcare infrastructure has been driven by private organisations, the focus has been on generating returns rather than increasing accessibility and affordability. Consequently, most of the health systems are focused on advanced secondary care/tertiary care services in metro and tier 1 cities. Furthermore, due to lack of focus by the government, the existing public facilities have deteriorated over time creating a huge undersupply of quality public health systems in the region. To be able to narrow the infrastructure gap, a holistic approach needs to be taken. The focus needs to shift from construction alone to ensuring that infrastructure is well integrated in health systems, managed efficiently, and operated at high quality. In addition to increasing the traditional health models, such as primary health clinics, secondary and tertiary care hospitals, organisations would need to develop other delivery care structures, such as ambulatory care centres, single specialities clinics and home-based care. These emerging delivery care structures can help free up capacity from income-generating assets in
A si a n H o s p i t a l & H ea lt hcar e M an age me n t
Philippines
Source: IMF and WHO
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2.3%
3.7%
Indonesia
Philippines
8.5%
8.7%
Global
UK
Chart 4: Potential to Increase the Healthcare Spending
USA
Source: IMF and WHO
HEALT HCARE MANAGEMENT
Target Countries
Key Characteristics
1
Engineering Stage
• Provision for basic healthcare • Government contributes 35-50% of healthcare funding
• Indonesia • Philippines • Vietnam
2
Developing Stage
• Good to high healthcare facilities • A well developed healthcare infrastructure majority supported by public financing • Direct healthcare subsidies and social security schemes available
• Malaysia • Thailand
3
Advanced Stage
• Advanced healthcare infrastructure • Private sector participation is high • Increased demand for more sophisticated healthcare services
• Singapore
Chart 5: Potential to Increase the Healthcare Spending
rural areas / small town / tier 2 cities. The last component of healthcare infrastructure, where governments and private organisations would need to work together is to strengthen the medical education system in the region. There is a need to be a focus on increasing the number of quality medical institutes to tackle the issue of supply constraint of clinical staff. ii. Collaboration across the value chain: Currently the entire healthcare value chain is going through different stages of evolution across the regions. For
hospital and as a result make the entire ecosystem more effective and efficient. Furthermore, the ability to differentiate their services and focus on a few select specialities helps these models to be operationally efficient, economical and capable of generating higher return compared to traditional health systems. A ‘factory-approach’ mind-set allows them to focus on creating operating protocols that help deliver affordable quality care. Also, as these centres are asset-light models, it enables them to scale up faster and reach out to a larger population across
instance, the gloves manufacturing industry in Malaysia is one of the largest in the world, while the healthcare delivery market in Thailand has some of the largest healthcare chains in the region. However, in most countries, some part of the value chain (Chart 8) is either underdeveloped or constrained segregation in silos. To help strengthen the healthcare delivery segment, governments in the region would need to take a holistic approach and focus on collaboration of all the components of the value chain. Pharmaceutical manufacturers
Hospital Metrics
(In ‘000s) Singapore
Hospital Beds (per 1,000) 4.0
Doctors (per 1,000) 3.0
2.8 2.4
2.0 1.3
2.0
1.0
1.2 2.2 2.1
1.8
Chart 6: Underserved Region with Growing Needs
Malaysia
Vietnam
Singapore
US
0.0
Thailand
0.3 UK
45
1.5
Phillipines
152
Thailand
152
1.0
1.2 0.2 0.6
0.5 0.5 Philippines
2.7
Indonesia
3.0
Malaysia
2.5
1.9
3.0
3.0
4
0.0
605
Indonesia
958
Southeast Asia 0
200
400
Chart 7: Shortage of Physicians (By 2020)
600
800
1000
1200
Sources: IMF and WHO
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Manufacturers
Distributors
Pharmacies
Payers
Life Sciences
Providers
Healthcare
Chart 8: Healthcare Value Chain
and medical device companies will play a greater role, as they did in other geographies, by increasing healthcare access, better experience for patients, improving clinical outcomes, and reducing the total cost of care. For instance, the pharmaceutical industry in India is highly sophisticated and developed. Most of the Indian companies supply medicines across the world and have tie ups with large MNCs. Additionally, the cost of developing medicines in India is minimal when compared to many countries. This has resulted in increased access to affordable critical medicines for the masses. Similar focus of developing the indigenous pharmaceutical markets, in Southeast Asia is necessitated. On the other hand, development of the medical devices industry would help in early detection and better outcomes at a lower cost. Increase in local manufacturing of these devices could lead to opportunities to introduce low
cost solutions and devices. Currently, the access to medical devices is highly variable in the region (Chart 9) iii. Use of IT: IT offers a huge potential to revolutionise healthcare by making it more responsive to consumers’ needs, and being convenient for patients to access, and efficient and satisfying for providers to deliver. As different countries are trying to re-structure delivery model and promote efficient use of resources, a clear trend is pointing towards technology-enabled healthcare as means to revolutionise the way people receive and manage care. Healthcare systems would need to leverage technology to cater to the demand and need of healthcare services Until now, IT was applied more to support the non-clinical functions such as accounting, procurement, human resources, admission, discharges, etc. However, the providers are now increasing the application of IT across various functions, including clinical 1.0%
100.0
0.8%
80.0
7.0
3.0
0.2% 2.0 0.05% 0.0% Indonesia
Malaysia
Singapore
0.10% 16.0
45.0
0.0
0.4%
0.40%
Phillipines
0.18%
0.27%
Vietnam
20.0
94.0
Thailand
40.0
0.6%
0.45%
60.0
Chart 9: Medical Devices Spend Per Capital and as per cent of GDP
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Spend As A % of GDP
Spend Per Capita (US$
120.0
Sources: Medtronic and IMF
functions, due to its ability to save costs as well as improve the quality of clinical care. IT-enabled healthcare services will see growing use in areas such as Electronic Health Records (EHRs) and Computerised Physician Order Entry (CPOE) that help reduce medical errors by mapping patient history with current prescriptions. These technologies also assist the physician in reviewing the patient’s medical history and accurately diagnose the condition. As a result, application in ancillary activities such as scheduling for doctors, staff, equipment and assets will transition to an online system which will allow administrators to analyse various trends and as a result minimise wastage of resources and optimise labour. Most of these technologies don’t require significant changes to workflow for the hospitals, apart from building a comprehensive patient management system. e-ICU, a concept that is growing particularly in India and could be exported to this region, is one of the many examples of leveraging clinical expertise, processes and highend technology for the benefit of the hospital as well as patients. In a country like India, that has more than 5 million ICU admissions every year, there are only approximately 5000 critical care physicians. An e-ICU is aimed at taking adequate critical care to patients at peripheral systems and minimising patient dislocation and disruption. The e-ICU can also train staff at peripheral care centres to treat critical patients
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in real-time and thereby improve critical care delivery. With most of the technology and manpower requirements standardised, an e-ICU spoke centre can be set up in less than three weeks; hence, minimises the disruption of hospital operations. IT will also play a significant role in transforming the mind-set to view health more from proactive measures rather than reactive measures. Growing usage of smartphones and increased access to internet is allowing patients to stay informed, monitor and manage various conditions on a regular basis from home at their convenience and view health as a general wellness. As a result, an increase in the number of remote monitoring services as well as bio-sensing devices will take place, which will help in optimising the care coordination and patient engagement channels. iv. Robust payer model: Out-of-pocket expenditures have increased significantly in the region, reaching as high as 85 per cent1 of total health expenditures in Vietnam and 80 per cent1 of total health expenditures in Malaysia. This compares very differently to the developed markets, where the out-of-pocket expenditures account for less than 35 per cent2 of total health expenditures. Healthcare insurance in the region has remained highly underdeveloped and less significant segment, reflecting the overall stage of development of healthcare systems. However, with increase in affluence, increase in chronic diseases, improvements in healthcare systems and increase in medical costs, the demand for healthcare insurance is expected to rise significantly. Overall, the private health insurance market remains highly fragmented in Southeast Asia, with over 30 licensed insurers among the life and general insurance companies in Malaysia, 40 1&2. Source World Bank (Developed markets
include US and UK)
As different countries are trying to re-structure delivery model and promote efficient use of resources, a clear trend is pointing towards technologyenabled healthcare as means to revolutionise the way people receive and manage care.
in Singapore and over 75 in Thailand. In comparison, the mature markets are more consolidated, with the ten biggest players accounting for close to 80 per cent of the total premium. In order to capture a higher market share, insurance companies should be flexible in designing products as per the need of the customers and making the reimbursement mechanism more convenient. Also, based on changing needs and awareness of the consumers, product offerings should evolve from basic standalone policies to integrated packaged polices covering hospitalisation cost coverage, as well as products for maintaining general wellness for various types of family construct. As a result, the healthcare insurance model will have to evolve to create strong synergies between private and public players, complementing each other’s service offerings. A focused approach encompassing public and private sectors and leveraging emerging technology will play a disruptive role in the healthcare transformation ahead. I believe that the transformation will be built on increased spread of government-driven universal healthcare delivery and financing model, augmented by private healthcare insurance ensuring
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access, cost and quality with patient centric focus. The private insurers will need to develop processes for identifying and on-boarding patients, to correctly estimate the risk profile and subsequently develop a strong and underwriting process to the exact needs of different population segments. Role of Governments and Private Organisations in Healthcare Management:
As we can see, different stakeholders to get together to create a robust healthcare ecosystem, and it includes the government, private sector, multilateral organisations, charities, and social enterprises. As the region continues on its path to development, each of these stakeholders would play a key role and function to create a sustainable healthcare environment in the region. To strengthen the ecosystem, there should be a clear demarcation of roles between providers of healthcare system and financiers for healthcare systems. This need emerges from the fact that no one type of operator can manage things alone, and both public and private organisations would need to collaborate. Collaboration between public and private organisations could be on infrastructure development in form of PPP or could be in the form of providing a specific service within public health system. However, in general, the government is best placed to act as regulator and financier of health services, with providers coming from the private sector. First, the government should be responsible for providing healthcare systems to the vulnerable sections of the society. This would include both providing for infrastructure, in terms of establishing primary and secondary care clinics, as well as financing the cost of treatment. Secondly, the government should also work towards ensuring that the ecosystem has adequate
HEALTHCARE MANAGEMENT
Healthcare PE Deal Volume 236
250
213
209 195
195
200
179
No. of Deals
168
163 142
150
125
100
88 70 54
50
0
2001
2002
2003
2004
North America
2005
Europe
2006
2007
Asia-Pacific
2008
2009
Alongside large demand characteristics, the external factors such as improving economy and stable government in most parts of the region are helping attract private investors and resulting in an increase in the deal activity (Chart 10). Governments across the regions are trying to deregulate most of the services
2012
2013
Sources: Bain Private Equity Report
and also offer tax incentives for players to develop healthcare infrastructure (including pharmaceuticals and medical devices). Due to the cost advantage offered in the region, it is also witnessing a large influx of medical tourism patients. Additionally, the need for growth capital among healthcare start-ups is expected to push the number of transactions in the healthcare space. Conclusion
Southeast Asian countries are facing double burden characteristics of a developed country, i.e. of increasing ageing population and incidence of chronic diseases. However, the economies haven’t developed to a level comparable to the developed countries.
Author BIO
Attractiveness for Investment
2011
Rest of World
Chart 10: Increasing Deal Activity in Asia
number of skilled clinical staff. This would require them to establish more medical institutes and ensure that the quality of clinical staff is maintained. Lastly, the government should create an ecosystem to attract and enable the growth of private organisations. On the other hand, private organisations should focus on providing advanced healthcare services for middle income and high income groups, and the manufacture and distribution of medical equipment, supplies and pharmaceuticals. A business-like approach would be critical. Private organisations would need to re-design their approach with an aim to keep patient attention and build value.
2010
This is leading to increased healthcare challenges of delivering affordable quality care to the masses. Solving these issues demands innovation: to manage healthcare in different ways, more efficiently, with better quality and affordable cost. It would be naĂŻve to think of innovation to being limited only about new drugs and better machines. However, innovation would entail a collaboration of differentiated ideas applied to business models for delivering healthcare services, to regulation, to financing, to leveraging technology and to the nature of partnerships between different types of healthcare organisations, be they private companies or government organisations.
Amit Varma is the Managing Partner of Quadria Capital, a US$304 mn healthcare focused private equity fund that invests in healthcare sector across Southeast Asia. He also spearheaded India Build out Fund, US$100 mn Healthcare and Education focused domestic Private Equity Fund. Dr. Varma has Over 20 years of Private Equity, strategic & operational leadership and board level experience in healthcare organisations across USA, Asia and Australia.
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Evidence-based Medicine and Outcomes Analysis An evaluation
Evidence-based medicine is fast overtaking experiencebased medicine in the field of healthcare delivery. Outcomes analysis allows the assessment of the quality of care delivered and matches them against the resource costs. It is becoming increasingly imperative for the various stakeholders involved in the entire healthcare delivery process, that is, the care deliverers and clinical managers, are not only knowledgeable but also practice it on a regular and rigorous basis. This paper attempts to put both the knowledge and the practice methodologies in a simplified manner so that all the care deliverers can easily implement them in their workplaces. Suman Bhusan Bhattacharyya Member, National EHR Standardisation Committee, MoH&FW, GoI, India Member, Health Informatics Sectional Committee, MHD 17, BIS
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A
new paradigm for determining diagnosis and prognosis is evolving that is set to revolutionise the way patients are managed, thereby increasing effectiveness without compromising productivity or quality of care provided. It is called ‘practising evidence-based medicine’. Clinical practice is changing due to rapid advances in technology and the clinicians need to change their practice methodology in order to continue to deliver high levels of specialised care. An average clinician today is faced with a multitude of problems. Ever increasing medical knowledge in the form of 27kg of guidelines, more
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make the necessary corrections, it has become necessary to perform outcomes analysis. Evidence-based Medicine
than 3000 new papers per day, 1000 new Medline articles, 46 randomised clinical trials, and the number of biomedical journals alone doubling since 1970. Couple it with the average workload for a clinician of anything between 100 to 200 consultations a week resulting in 5000 to 10000 per year (UK figures). Add to it the difficulty in being sure that one is doing the right things for all these cases, relying solely on experience while using 2 million pieces of information all stored in one’s memory, ever increasing pressures to provide value-for-money services, raised patient demands and expectations, pressures due to a myriad of obtrusive and mostly
confusing regulatory compliances, and rapidly altering business demands. It does not paint a happy picture by any stretch of the imagination. Every encounter with a patient identifies appear more often than not to reveal some gaps in the understanding of the aetiology, diagnosis, prognosis, or therapy of their illness on the part of most clinicians. Recent research reveals that even as seasoned clinicians generate about five knowledge ‘needs’ for every in-patient encounter, and two ‘needs’ for every three outpatient’s encounters. To bridge these gaps and fulfill the ‘needs’, it has become imperative to practice evidence-based medicine. To evaluate the best evidence and
The most commonly accepted definition of ‘Evidence-based Medicine’ is that it is the conscientious, explicit and judicious use of current best evidence in making clinical decisions about the care of individual patients. Dr.DavidEddy of Kaiser Permanente is widely credited for having coined the term ‘Evidence-based Medicine’. He explains that when there is evidence that something works and is good and benefits the patient, one should do it. When one has evidence that there is no benefit and that it is ineffective, where it is going to harm the patient either directly or indirectly by stealing resources, one should not do it. When there is insufficient evidence to determine either way, one must be conservative, relying on individual clinician discretion. This means the integration of individual clinical experience with the best available external clinical evidence from systematic research. Individual clinical expertise means the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care. Best available external clinical evidence means clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. Such evidence validates previously
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accepted diagnostic tests and treatments, and where necessary, replaces them with new ones that are more powerful, more accurate, more efficacious, and safer. Any practice that uses best evidence, while delivering healthcare, is called ‘evidence-based practice’. Such practice generally is the application of up-todate information from relevant, valid research about the effects of different diagnostic tests and the predictive power of prognostic factors across the broad field of healthcare, including education, practice management and health economics. A new approach for practising evidence-based medicine is to build evidence-based balance sheets to integrate the best evidence with the possible outcomes to help in deciding the ‘right’ method of treatment for a patient. The purpose is to display this information as quantitative estimates of the effects of alternative treatments on all the important outcomes in a compact form so that all the stakeholders can make an informed choice when deciding on a treatment plan. These are especially useful for informed shared decision-making between clinicians and patients. The main strength of these balance sheets is that they summarize in one place the critical information needed to make decisions. Evidence-based healthcare is a newer term broadening the evidence-based medicine techniques to other aspects of healthcare delivery. This is defined as the conscientious use of current best evidence in making decisions about the delivery of healthcare services. This is as defined at First Annual Nordic Workshop on how to critically appraise and use evidence in decisions about healthcare, National Institute of Public Health, Oslo, Norway, 1996.
To evaluate the best evidence and make the necessary corrections, it has become necessary to perform outcomes analysis.
The Process
the hospital administrators and the health economists to perform costbenefit analysis, and care providers to justify their clinical decisions regarding treatment plans as well as to validate the clinical protocols when followed. Not only are the outcomes of an event, but also the variances between different treatment methodologies are measured. In a clinical setting, it also allows one to find out how well a particular treatment method is faring. The aim of outcomes analysis is not to find ways to reduce, but to put a cost on a given treatment regimen. It is entirely possible that the measure ends up recommending a treatment
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Evidence-based medicine converts reading and appraising the information into using it to benefit individual patients while concurrently adding to the clinician’s knowledge base. Instead of reading all the articles in a journal, it is better to focus on the ones that are related to specific problems. It is critical that one follows a constructive method of framing the pertinent question related to the problems on hand, and then searching for evidence related to that question. The aim is to keep one’s knowledge at a more usefully productive level. Evidence-based medicine requires some knowledge regarding the calculations and interpretations of relative
The seven ‘A’ methodology for practising evidence-based medicine Assess the patient
a clinical conundrum or question that arises out of the clinical examination
Ask the patient
the care provider needs to construct a well-built clinical question from the findings in step 1
Access the information
the appropriate resources needs to be selected and searched for the answer to the question framed in step 2
Appraise the evidence
the information gathered in step 3 needs to be critically appraised using the various indices for its validity and applicability to the patient’s problems
Apply the findings
the validated evidence needs to be integrated with clinical expertise and patient preferences and then applied as required
Assess the outcomes
the performance of the evidence with the patient needs to be evaluated
Add the knowledge
the information so gathered added to the clinician’s knowledge base for future reference to best evidence in similar problems
Outcomes Analysis
Outcomes analysis is a non-prejudiced analysis of the outcome of an event, episode or encounter. It is used by the nurses as a measure for patient acuity,
regimen that is costlier because it is more beneficial. It can also be used as a costing method to perform cost-benefit analysis and effort estimations. The various parameters that are evaluated are as follows: • Quality Adjusted Life Year (QALY) • Patient preferences • Resource use including time, money, equipment, hospital stay, etc. • Nursing Acuity • Cost effectiveness.
Table 1
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HEALTHCARE MANAGEMENT
Common sources of best-evidence
Areas of application of evidencebased medicine
Past clinical experience
Primary care
Reasoning and intuition
Academic institution
Colleagues and peers
Routine practice
Notes (like those kept in shelves, bottom drawers, etc.)
Difficult cases
Published evidence Online information
Clinical decision support Formulation and continuous evaluation of clinical protocols
Table 2
risks, absolute and relative risk reductions, odds ratio, numbers needed to treat/harm, sensitivity, specificity, likelihood ratio, pre-test probabilities, etc. Outcomes analysis is an inherent requirement for the total adoption of evidence-based medicine. Without the results arrived at from analysis of outcomes being added to the knowledge repository for future reference, the internal expertise is not enriched, i.e. there is no value-add of the process for future patient with similar clinical picture demanding the answers to similar questions. Calculations in Evidence-based Medicine
There two broad types of calculations that go into effective practice of evidence-based medicine. These are evaluating the following: 1. Evidence regarding the efficacy of a certain treatment as opposed to another, including no treatment. Mostly results from randomised clinical trials are used. It is a type of prognostic assessment 2. Evidence regarding a particular diagnostic test or patient finding. It is a type of diagnostic assessment. For Assessment of Treatment Protocols
Absolute Risk Reduction (ARR): This is the difference in the risk of the outcome between patients who have undergone a
particular method of treatment (called experimental) and those who have not undergone that method (called control). This measure tells us the percentage of patients who were spared the adverse outcome as a result of having received the experimental rather than the control therapy. It is calculated as |EER – CER| Relative Risk (RR): This is the ratio of the risks in the experimental to the control groups and is represented as a percentage of the original risk. It is calculated as |EER – CER| / CER Relative Risk Reduction (RRR): This is the extent to which an experimental treatment reduces a risk, in comparison with the control, and assesses the effectiveness of a treatment. This is calculated by subtracting the RR from 1. If the RRR is 0, then the experimental treatment is no different from the control. The relative risk reduction is fundamentally an estimate of the percentage of baseline risk that is removed as a result of the experimental therapy. It is calculated as |CER-EER| / CER. A risk is considered to be baseline if the risk of an adverse event among patient either in the control group or who are receiving the standard or inferior therapy. Numbers Needed to Treat (NNT): This is the most recently introduced measure of treatment efficacy, and is defined as the number of patients who need to be treated to achieve
1 additional good outcome. It the reciprocal of the ARR, and is measured if the outcome of the experimental treatment is positive. When the outcome is negative, numbers needed to treat (NNH) is measured. This is the number of patients who need to be treated with the experimental method to cause 1 additional patient being harmed as compared to those who are treated with the control method. The thumb rule is that if EER > CER, then calculate NNT else calculate NNH. The numbers needed changes inversely in relation to the baseline risk. If the risk of an event doubles, one needs to treat only half as many patients to achieve the same results, and if the risk decreases by a factor of four, one needs to treat four times as many. It is calculated as 1 / ARR Odds Ratio (OR): These are the odds of an event (usually adverse) occurring and are usually the measure of choice in the analysis of case-control studies. Generally, the odds ratio has certain optimal statistical properties that make it the fundamental measure of association in many types of studies. The statistical advantages become particularly important when data from several studies are combined, as in meta-analysis. Among such advantages, the comparison of risk represented by the odds ratio does not depend on whether the investigator chose to determine the risk of an event occurring (e.g. fatal) or not occurring (e.g. improvement). This is not true for relative risk where the definitions of experiment and control can alter the figures. In some situations the odds ratio and the relative risk will be close like in case control studies of a rare disease. The odds ratio is calculated by dividing the odds in the experimental group by the odds in the control group. It follows that efficacious treatments generate odds ratios that are less than 1, which is analogous to the relative risk for the adverse event (EER/ CER) being less than 1.
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Meta-analysis: It is a statistical procedure that integrates the results of several independent studies considered to be ‘combinable’ and should be viewed as an observational study of the evidence. Well-conducted meta-analyses allow a more objective appraisal of the evidence than traditional narrative reviews, provide a more precise estimate of a treatment effect, and may explain heterogeneity between the results of individual studies. Ill conducted metaanalyses, on the other hand, may be biased owing to exclusion of relevant studies or inclusion of inadequate studies. Methods used for meta-analysis use a weighted average of the results, in which the larger trials have more influence than the smaller ones. Results from each trial are graphically displayed, together with their confidence intervals. A black square and a horizontal line represent each study, which correspond to the point estimate and the 95 per cent confidence intervals of the odds ratio. The 95 per cent confidence intervals would contain the true underlying effect in 95 per cent of the occasions if the study were repeated again and again. A solid vertical line is drawn that corresponds to no effect of treatment (odds ratio 1.0). When the confidence interval of any study includes 1 the difference in the effect of experimental and control treatment is not significant at conventional levels (p>0.05). An area made of black squares reflects the weight of the study in the meta-analysis. A diamond shape represents the combined odds ratio, calculated using a fixed effects model, with its 95 per cent confidence interval. It should be noted here that a result that is meta-analytical in origin should be viewed with a higher degree of confidence than one that is not. For Assessment of Findings / Diagnostic Tests
Sensitivity: Representing the accuracy of a positive test result, this is the proportion of patients who have the
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target disorder and also test positive for the diagnostic test. Specificity: Representing the accuracy of negative test result, this is the proportion of patients who do not have the target disorder and also test negative for the diagnostic test. Likelihood Ratio (LR): This measures how likely the presence (or absence) of a finding (or diagnostic test) would result in ruling in (or out) a diagnosis. The ratio is used to assess how good a diagnostic test (or finding) is, to help in selecting an appropriate diagnostic test or a sequence thereof. It is better than sensitivity and specificity numbers because it is less likely to change with the prevalence of the disorder, can be calculated for several levels of signs and symptoms, can be used to combine the results of multiple diagnostic tests, and can be used to calculate the post-test probability for a target disorder. A likelihood ratio greater than 1 produces a post-test probability that is higher than the pre-test probability, while an LR lesser than 1 accomplishes the reverse, thereby altering the chances of finding the target disorder. A diagnostic test result with a very high LR (e.g. >10) would virtually rule in a disease when found positive, while one with a very low LR (e.g. <0.1) that would virtually
A new approach for practising evidencebased medicine is to build evidence-based balance sheets to integrate the best evidence with the possible outcomes to help in deciding the ‘right’ method of treatment for a patient.
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rule out the chance that the patient has the disease. Pre-test Probability (Priori of Bayes Rule): It is defined as the probability of the target disorder before a diagnostic test result is known. It is especially useful for (1) interpreting the results of a diagnostic test, (2) selecting one or more diagnostic tests, (3) choosing whether to start therapy without further testing (treatment threshold) or while awaiting further testing, (4) deciding whether it’s worth testing at all (test threshold). The probability of the target disorder can be calculated as the proportion of patients with the target disorder, out of all the patients with the symptoms, both those with and without the disorder. Post-test Probability (Posteriori of Bayes Rule): It is defined, as the probability of the target disorder being present after the diagnostic test result is known.
Bayes Rule – This is based on the theorem proposed in mid-nineteenth century by Rev. Thomas Bayes and is on probability inference. It is a means of calculating the probability that it will occur in future trials from the number of times an event has occurred. Examples Explaining the Above
Evaluation of treatment confusion matrix for comparison of treatment methods Randomised trial comparing treatment of condition X with method A and with method B (all numbers are fictitious). These results indicate that the risk of fatality in method A is 31per cent and in method B is 46 per cent, the relative risk of fatality after receiving treatment method A as compared to the treatment method B is 67 per cent. That is, the risk of fatality after method A is only
HEALTHCARE MANAGEMENT
OUTCOME TOTALS FATAL
IMPROVEMENT
METHOD A
20
45
65
(experimental)
a
b
a+b
METHOD B
30
35
65
(control)
c
d
c+d
50 a+c
80 b+d
130 a+b+c+d
INTERVENTION
TOTALS
two-thirds as that of after method B, thereby indicating that method A is better than method B. The absolute reduction of risk is 15 per cent. The relative reduction of risk is 33 per cent. The odds of fatality after method A as compared to method B is 0.52 and as it is less than 1, the treatment is considered to be effective. The numbers needed to treat is 6.5, which means that 7 more patients need to be treated to decrease the adverse outcome by 1 when method A is used instead of B. Evaluation of a Diagnostic Test
Table 3
Calculations Experimental Event Rate (EER) = a/(a + b) =
20/65 = 0.31
Control Event Rate (CER) = c/(c + d) =
30/65 = 0.46
Relative Risk (RR) = (a/(a + b))/(c/(c + d)) =
(20/65)/(30/65) = 0.67
Absolute Risk Reduction (ARR) = |(a/(a + b) - c/ (c + d))| =
|(20/65) - (30/65)| = 0.15
Relative Risk Reduction (RRR) = |((c/(c + d)) - (a/ (a + b)))|/((c/(c + d))) =
|(30/65) – (20/65)|/(30/65) = 0.33
Odds Ratio (OR) = (a/b)/(c/d) =
(20/45)/(30/35) = 0.52
Numbers Needed to Treat (NNT) = 1/ARR =
(1/0.15) = 6.5
Table 4
TARGET DISORDER TOTAL
POSITIVE
DIAGNOSTIC TEST RESULT NEGATIVE
TOTAL
PRESENT
ABSENT
870
330
1200
a
b
a+b
C
d
c+d
144
1056
1200
1014 a+c
1386 b+d
2400 a+b+c+d
Presence of a target disorder when the diagnostic test value is positive Suppose there is a patient with target disorder and a positive diagnostic test result. A systematic review provides the results that are summarised in the confusion matrix below (all numbers are fictitious). These results indicate that 86 per cent of the patients with the target disorder have a positive test result, while 76 per cent of patients who do not have the disorder test negative. The likelihood ratio of finding a positive test result is 3.6, while the likelihood ratio of finding a negative test result is 0.19. The prevalence of the disease in the study is 42 per cent. The post-test probability of finding a target disorder when the diagnostic test result is positive is 73 per cent, while that of finding it when the result is negative is 12 per cent. Since the likelihood ratio for positive test is more than 1, the post-test probability of finding the target disorder when the test is positive is more than the pre-test probability. Important Note
Mark VanRaden opines that the p-value is able to provide good ‘hints’ regarding a hypothesis, but fails to provide any confirmation of it. It represents merely the probability of an observation being purely due to chance. Thus, a p-value 0.001 means that there is only 1/1000th possibility that the conclusion was due
Table 5
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Chi Squared ( χ2) Test
Calculations Sensitivity =
a/(a + c) = 870/1014 = 0.86
Specificity =
d/(b + d) = 1056/1386 = 0.76
Likelihood Ratio for a positive test result (LR+) = sensitivity/(1-specificity) =
0.86/(1 – 0.76) = 3.6
Likelihood Ratio for a negative test result (LR-) = (1-sensitivity)/specificity =
(1 - 0.86)/0.76 = 0.19
Pre-test Probability (priori) =
(a + c)/(a + b + c + d) = 1014/2400 = 0.42
Post-test Probability for a positive test result (posteriori LR+) = (priori*sensitivity)/ ((priori*sensitivity)+((1-priori)*(1-specificity))) =
(0.42*0.86)/((0.42*0.86)+((10.42)*(1-0.76))) = 0.73
Post-test Probability for a negative test result (posteriori LR-) = (priori*(1-sensitivity)/((priori*(1sensitivity)+((1-priori)* specificity)) =
(0.42*(1-0.86))/((0.42*(10.86))+((1-0.42)*0.76)) = 0.12
Expected (Finding if they are by chance) – Computed from Observed Values above Outcome 1
Absent
Outcome 2
W = ((A+B)*(A+C))/ (A+B+C+D)
Y = ((C+D)*(A+C))/ (A+B+C+D)
X = ((A+B)*(B+D))/ (A+B+C+D)
Z = ((C+D)*(B+D))/ (A+B+C+D)
Table 7
Figure 1
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Outcome 1
Outcome 2
Present
A
B
Absent
C
D
Table 8
to chance or else, the conclusion is not by chance. On the other hand, Chi squared tests are better, while likelihood ratio are the best indicators about a conclusion. Test of Significance:
Table 6
Present
Confusion Matrix Observed (actual finding)
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For most clinical data/observation purposes the degree of freedom (df ) is always1 and 〈(probability) is always 0.05 (5 per cent), the 〈being the predetermined (assumed) level of significance. The corresponding critical value of Chi squared (|2) is 3.841 (from Chi squared critical values distribution tables). Any χ2 value above this is significant. Interpretation:
If the calculated χ2 value is more than 3.841, the observation is a significant and NOT by a chance finding. Conversely, when the calculated |2 value is less than or equal to3.841, the observation is an insignificant and by a chance finding. This still is not very robust, which likelihood ratio is able to provide. The Likelihood Ratio (LR) is a ratio of likelihoods (or probabilities) for a condition. The first is the probability that a given condition occurs (or not) in the first observation paradigm. The second is the probability that the same condition occurs (or not) in the second observation paradigm. The ratio of these 2 probabilities (or likelihoods) is the Likelihood Ratio.
HEALTHCARE MANAGEMENT
How much does Likelihood Ratios change the likelihood one way or the other?
Likelihood Ratio
Confusion Matrix
Present Absent
LR Value
Outcome 1
Outcome 2
A
B
C
D
Table 9
Likelihood ratio+ = sensitivity / (1 - specificity) or (A/(A + C)) / (B/ (B + D)) Likelihood ratio- = (1 - sensitivity) / specificity or (C/(A + C)) / (D/(B + D)) Thus, LR is a way to incorporate the sensitivity and specificity of a test into a single measure. Since sensitivity and specificity are fixed characteristics of the test itself within the clinical sciences paradigm, the likelihood ratio is independent of the prevalence in the population. The LR basically measures the power of a test to change the pre-test into the post-test probability of a particular outcome happening. Thus, using likelihood ratio, it is easy to figure out whether an item like an observation (investigation) or intervention (treatment) is going to make a difference of any sort by considering the interpretation above. Outcomes Analysis
There are two broad types of calculations that go into outcomes analysis. These are evaluating the following: • Cost effectiveness of a particular treatment that results in a particular outcome—time, money, clinical effectiveness, patient preference. It is a type of cost-benefit analysis • Resource utilisation in the course of a particular treatment that results in a particular outcome—time, money, clinical effectiveness, patient preference —also known as nursing acuity. It is a type of effort estimation.
Interpretation
LRs greater than 10 or less than 0.1 (LR > 10 or LR < 0.1)
causes large changes
LRs 5 - 10 or 0.1 - 0.2 (LR > 5 &< 10 or LR > 0.1 &< 0.2)
causes moderate changes
LRs 2 - 5 or 0.2 - 0.5 (LR > 2 &< 5 or LR > 0.2 &< 0.5)
causes small changes
LRs less than 2 or greater than 0.5 (LR < 2 or LR > 0.5)
causes tiny changes
LRs equal to 1 (LR = 1)
causes no change at all
Table 10
There are no formal equations for this and are usually performed on a caseby-case or departmental / institutional basis. Discussion
Seeking an evidence base for medicine is as old as medicine itself. However, in the past decade the concept of evidence-based medicine has done a sound job in focusing explicit attention on the application of evidence from valid clinical research to actual clinical practice. Although current clinical practice is often evidence-based to an extent with new treatment methods being applied more often than not, there is still much to be gained. Important new evidence from research often takes a long time to be implemented in daily care, while established practices persist even if they have been proved to be ineffective or harmful. In the meantime, many clinicians struggle to apply the results of studies that do not seem to be that relevant to their daily practice. Good clinicians should use both individual clinical expertise and the best available evidence from external sources. Neither alone is enough. Without clinical expertise, clinical practice risks becoming hostage to evidence and without current best evidence clinical practice risks
becoming rapidly outmoded and outdated to the detriment of overall patient care. The evidence on its own is usually not conclusive but can help in supporting the process of patient care. Adopting all of these into clinical decisions enhances the chances of maximising clinical outcomes and quality of life. The practice of evidence-based medicine is usually triggered by patient encounters, which generate questions about the effects of therapy, utility (or futility) of diagnostic tests, prognosis of diseases, or aetiology of the underlying disorders. It requires new skill-sets of the care provider and includes efficient literature searching and application of formal rules of evidence in evaluating clinical literature, apart from the basic clinical skills of sharp observation, intelligent and logical inference from these. Careful application of intelligent and logical inference made from these is vital in justifying the practice of evidence-based medicine. Normally a clinician uses observational studies, logical intuition, personal experience and expert opinions. Most clinical care relies on a combination of informed guesswork, unsystematic observation, common sense, the consensus views of clinical experts, and the treatment and procedures used by most
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Pros and Cons Advantages of Evidence-based Medicine • Makes medical education more problem-centered, lifelong learning and less about memorising a static body of knowledge that is growing daily. Relying solely on memory is fast becoming an inherently inefficient method • Functions as a tool in CME to keep up-to-date with research and to understand research techniques • Encourages more focused and productive reading habits and data handling thereby avoiding information / cognitive over-load. One must continuously strive to avoid analysis paralysis at all costs. Much of the published material is irrelevant or of poor quality • Improves confidence in decision-making making it easier to justify decisions to the various stakeholders in the delivery of optimised patient care • Provides rules and rationale for group-based problem solving and teaching • Allows quicker application of good research findings to clinical practice • Helps in interpreting inconclusive or incomplete clinical tests results • Emphasizes outcome (end result for patient) as well as the process (what is done by the healthcare professional) • Allows increased patient involvement in decision-making by offering them the various odds for each of the various treatment options.
Barriers to Evidence-based Medicine • Unrealistic patient expectations – patients demand treatment despite lack of supportive evidence for the same. (Curiously, this problem is peculiar to the GPs and not to the specialists whose words are taken more on face value) • Constraints of time – with irritated patients crowding the waiting room on a gloomy day, the clinician’s focus needs to be the patient in front and not the journals, archives, or
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computers, consequently making the practice of evidencebased medicine a killjoy • Constraints of money – access to online databases is costly. Cochrane library can be accessed by individuals from their clinics at around US$235.00 per annum fee (2003 figures). Although Medline is free, one requires a high performance PC with an ISDN or more preferably a broadband connection. The ever-dependable medical journals are quire costly • Necessary expertise to handle the PC, if not the process. Framing the right question is the key and more often than not is missed on an otherwise busy day. Even at the best of times is not a routine walk in the park • Requires significant investments in educating and changing the behavior patterns and habits of clinicians, many of whom view it as a threat to their autonomy – although this perception is fast changing in the areas where they are being practiced • Poor indexing leads to frustration due to unproductive literature searches • It is a rigorous but rigid system that seeks to restrict the functional independence of providers of patient care • Uses the results of studies applying to populations, whereas clinicians have to deal with single patients on an individual basis. Also, the entry criteria for the studies may be so strict as to rule out most ‘real’ patients with some studies accepting only 10 per cent of the apparently eligible patients • It demands a certain degree of knowledge of statistics that few have mastered, thereby necessitating the use of specialised solutions • It is most effectively implemented through a comprehensive clinical information system and electronic medical record, which require substantial investments • There is insufficient scientific evidence regarding the outcomes of many clinical interventions. • Using Evidence-based Medicine tools, such as evidence tables, for shared decision-making with patients requires special communication tools and skills, and extra consultation time • Few of the current health delivery systems are sufficiently integrated to facilitate the effective practice of evidencebased medicine • It is often viewed as a form of rationing that could be used to stop clinicians using treatments of unproved efficacy even where their clinical acumen suggests it may benefit the patient.
HEALT HCARE MANAGEMENT
put in place, one can definitely look to providing improved care with lesser pain. Concluding Remarks
It is interesting to note here that with the advent of significant computing power coupled with increasing use of EMR/ EHR systems, wearable / homecare devices and mobility apps, all backed up by clinical analytics including big clinical data analytics, it is now very much feasible to process and present evidence-based figures and conclusions on-the-fly to the care providers to help them make optimal decisions regarding care delivery. Performing evidence-based analytics using the formulae discussed above on just the data collected within an organisation can prove to be a real game-changer for many a care setting. Although the analytics are performed on a smaller data set than in a typical clinical research setting, the findings are nevertheless very relevant for that data set. With regional variations and local Author BIO
other clinicians in a local community â&#x20AC;&#x201C; the standard and accepted practice. An assumption is made that a traditional knowledge of physiology, pathology, and common sense is sufficient to guide clinical practice and evaluate new treatments and diagnoses. However late Archie Cochrane has stated that only 15-20 per cent of medical practice is backed up by scientifically and statistically sound research. Evidence-based practice aims to move beyond such anecdotal clinical experiences by bridging the gap between research and the practice of medicine. The aim is to use diagnostic tests and therapeutic interventions that are as accurate, as safe and as efficacious as possible. The clinical assessments are validated against the best evidence before they are applied to clinical care. A subsequent rigorous examination of the outcomes of different clinical actions through outcomes analysis an overall effort assessment is made to ensure the maintenance of high standards of clinical care. The need for evidence-based healthcare arises as a direct consequence of too many patients presenting with too many problems, while the information regarding the current treatment guideline exist in too many journals. Dr David Eddy opines that the complexity of modern medicine exceeds the inherent limitations of the unaided human mind. A rich source of new evidence for clinical care has been generated as a consequence of application of modern research methods and statistical tools, and this very abundance of evidence has made the task of practising evidence-based medicine more difficult than ever for the individual clinician. Evidence-based medicine is here to stay and is being actively promoted by such institutions as NHS, etc. As increasing number of care providers begin to adopt and gain from this technology and better solutions that specially cater to its effective use are
environmental conditions having varying degrees of impact on the disease processes, health and wellness of individuals, such information can prove to be most helpful for care provider and care receivers alike as personalised medicine can now be practiced more easily, even in the absence of genetic / genomic data. Without doubt it can be said that changing clinical practices to evidencebased practices is no more just a dream but a very real possibility. The promise of transforming even single-doctor practices into centers of excellence cannot fail to excite even the most skeptic. Disclaimer: Most of the material for this article has been extensively harvested from the references detailed at the end. Individual references as footnotes have deliberately been avoided to ensure ease of read and maintain continuity. The copyrights lie with their respective authors. Some web site addresses point to free online evidence-based medicine resources. References are available at www.asianhhm.com
SB Bhattacharyya, MBBS, MBA, FCGP is a practising family physician and health informatics professional working as business solution architect for IT in the healthcare and life-sciences domains. He is Honorary State Secretary (2015), IMA Haryana State, Member, National EMR Standards Committee, MoH&FW, Member, Health Informatics Sectional Committee, BIS and Ex-President, IAMI. His main interests include EHR, predictive analysis in medicine and application of machine learning techniques for treatment protocol planning.
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MEDICAL FAIR ASIA 2016 Date: 31 Aug – 2 Sep, 2016 Venue: Marina Bay Sands, Singapore
• Region’s hallmark event for Asia’s medical and healthcare sector returns to Singapore for 11th edition • Exhibition well-positioned to meet the next wave of healthcare modernisation
Following on its successful growth path since its inception in 1997, the region’s most established platform for the medical and healthcare sectors— MEDICAL FAIR ASIA—will see its most impressive line-up ever of prominent medical and healthcare players from around the world from 31 Aug to 2 Sep 2016. Reinforcing the global appeal and market relevance of the trade fair, MEDICAL FAIR ASIA 2016 is expected to attract strong participation from some 1,000 exhibitors from 45 countries including 20 national pavilions and country groups. This is a marked increase from 2014, which saw MEDICAL FAIR ASIA welcome a stellar list of 700 exhibitors from 38 countries. Visitor attendance is also expected to increase by 50 per cent from the last edition in 2014, with 15,000 trade visitors coming from across ASEAN and the Asia Pacific region.
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Co-located with MEDICAL MANUFACTURING ASIA 2016, a trade fair focusing on the medical technology and medical manufacturing sector and jointly organised by Messe Düsseldorf Asia and the Singapore Precision Engineering & Technology Association (SPETA), the synergistic qualities of both trade fairs will present a comprehensive one-stop event for trade professionals sourcing for solutions across the value chain. Focused on equipment and supplies for the hospital, diagnostic, pharmaceutical, medical and rehabilitation sectors, MEDICAL FAIR ASIA 2016 is well positioned to be the No.1 procurement stage for industry professionals to experience new and innovative technologies, solutions, products and services – many of which will be launched in Asia for the first time – but will also align its theme with current and future demographic trends, challenges and notably, the next wave of healthcare modernisation.
Spotlighting on digital healthcare at the 2016 event
In the spotlight at MEDICAL FAIR ASIA 2016 will be a platform dedicated to Digital Healthcare. Global key leaders from the industry will showcase new disruptive digital healthcare solutions such as remote and wireless healthcare, IT platforms, wearable devices and smarter medicine, and healthcare analytics. Industry experts will also be sharing their wealth of insights and expertise in this fast-growing area. By creating a platform for the exchange of the latest innovations and technologies, MEDICAL FAIR ASIA continues to raise the overall capabilities and spur the growth of the region’s medical and healthcare sectors to meet the changing demands in both the public and private sectors. Driven by rapid urbanisation, increased population and increased longevity, the focus of medical and healthcare services within the region is turning to disease management and healthcare provision for the elderly, as well as preventive healthcare for the general population. Coupled with the launch of the ASEAN Economic Community (AEC) and the rise in affluence, the demand for quality medical services by both local and international patients within the region is rapidly increasing, opening up a wealth of opportunities. As the region’s medical and healthcare sector continues on the robust growth, MEDICAL FAIR ASIA will continue to be the preferred strategic business platform for region’s medical and healthcare industries. With exhibition spaces filling fast, interested exhibitors are encouraged to submit their space booking forms for MEDICAL FAIR ASIA 2016 at the earliest opportunity. For more information on the trade fair, please visit www.medicalfair-asia.com
Press contact: Maria Wesson Tel: +65 6332 9651, Email: maria@mda.com.sg Exhibitor contact: Daphne Yeo Tel: +65 6332 9682, Email: daphne@mda.com.sg Organised by: Supported by:
Messe Düsseldorf Asia / Organiser of:
Held in:
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Medical Sciences
Chemical Allergy in Healthcare This article will present a review of the problem of chemical allergies associated with glove use and key considerations in the selection and use of alternative medical glove products to minimise and / or prevent chemical allergies. Patty Taylor, Vice President, Professional Education and Clinical Affairs, Ansell, US
N
ext to healthy intact skin, medical gloves are the first line of defence against infectious pathogens, providing a protective barrier for both the healthcare provider and the patient. The World Health Organization (WHO), the U.S. Occupational Health and Safety Administrationâ&#x20AC;&#x2122;s (OSHA) Blood-borne Pathogen Standard, the European Agency for Safety and Health at Work (EU-OSHA), the National Institute for Healthcare and Care Excellence (NICE - UK) and the Australian National Occupational Health and Safety Commission (NOHSC) all define PPE as the specialised clothing or other equipment worn by employees to protect themselves against a hazard; the use of PPE such as medical gloves is required whenever there is a risk of occupational exposure to blood or other potentially infectious material. However, in some users, medical gloves have been associated with skin irritation. Adverse skin reactions to medical gloves include latex protein allergy (Type I, immediate hypersensitivity to natural rubber latex proteins), chemical allergy (Type IV, allergic contact dermatitis (ACD)), and general skin irritations.
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Incidence of Latex and Chemical Allergy
Most hospital allergy management programs concentrate on the understanding and treatment of latex protein allergy. Latex allergyis mediated by the allergic antibody IgE, which is directed against retained proteins in latex products; it is triggered by direct skin contact, mucosal surface contact, or inhalation. The prevalence of latex allergy in the healthcare population has been reported to be as high as 17 per cent. Latex allergy symptoms may include hives, angioedema, rhinitis, conjunctivitis, asthma, and anaphylaxis with or without death. This allergy may be life threatening and therefore, is the problem that has captured the attention of healthcare personnel. However, chemical allergy remains an even more important cause of disability and loss of work hours to the healthcare provider. Identified in the 1930s, this chemical allergy is still not well understood. Chemical allergy is an expansive allergic condition which represents approximately 30 per cent of occupationally-induced skin diseases thereby making it a significant occupational hazard. Chemical
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allergy is the second largest occupational disability reported to OSHA. Occupational skin disease (OSD) is the second most common work-related problem presenting to general practitioners in Australia (Hendrie & Driscoll 2003). A survey of UK National Health Service (NHS) staff showed that 43 per cent had signs or symptoms of irritant contact dermatitis or allergic contact dermatitis, while 10 per cent showed latex hypersensitivity. (Johnson G.,Time to take the gloves off? Occupational Health (London), 1997; 49: 25-28). Of particular concern to healthcare providers is that this allergy may predispose some individuals to even greater risk of blood-borne pathogen infection as it compromises the body's most efficacious barrier, skin. The breakdown of the dermis may also
Medical Sciences
permit the passage of latex proteins into the body thereby facilitating latex protein hypersensitivity in some individuals. Cause of Chemical Allergy
Chemical allergy is due to an immunological reaction to a residual chemical leached from the finished glove products. The chemical involved penetrates the skin, resulting in vesiculation, erythema, swelling, cracking and itching of the skin at the site of contact. This dermatitis frequently extends beyond the area of contact (e.g., the forearm in a healthcare provider wearing a glove). The response is delayed rather than immediate, usually occurring in 6-48 hours after initial contact, although symptoms can last up to 4 days. Continued exposure may lead to chronic dermatitis manifested
as dry, irritated, cracked, pruritic skin with erythema. Chemical allergy is more common than latex protein allergy and it may precede latex protein allergy in up to 40 per cent of individuals with latex protein allergy (Thompson R. 2000). A common factor contributing to the development of chemical allergy is a pre-existing skin condition, such as irritant contact dermatitis, which represents about 70 per cent of all the reported dermatitis cases and is caused by a number of factors such as frequent hand washing, aggressive scrubbing techniques and inadequate hand drying. Chemical residuals in gloves are frequently responsible for the development of chemical allergy. These chemicals used in the manufacture of gloves fall into broad classifications of accel-
erators, accelerator activators, stabilisers, antidegradants, retarders, fillers and extenders. It is the accelerator group chemicals (especially thiurams and carbamates) that induce the majority of the skin dermatitis reactions and to a lesser degree the thiazoles, aldehydamines and guanidines. The residues from these accelerators have become a major concern because of their ability to sensitise users and elicit chemical allergic reactions. Over 80 per cent of reported glove-associated allergic contact dermatitis is attributable to chemical accelerators (Heese, A 1991). Use of Chemical Accelerators in Manufacturing
The use of chemical accelerators in gloves is not limited to the manufacture of natural rubber latex gloves. They
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Medical Sciences
Strategies to Manage Chemical Allergy
The key to managing allergies and adverse glove reactions in healthcare professionals lies in education and awareness programs, correct recognition and appropriate action. Healthcare providers should be encouraged to report any symptoms. Individuals experiencing recurrent or persistent dermatitis should consult with their doctor in order to establish a specific diagnosis. A diagnosis is made by a medical history, physical exam, and patch testing with the offending glove chemicals. Chemical allergy is completely curable. If specific allergens are identified and appropriate strategies are implemented for allergen avoidance, such as selecting accelerator-free gloves or gloves manufactured without the causative agent or accelerator many individuals will not require treatment. Further, healthy, intact skin plays a very important role in prevention of chemical allergies. Instituting a regular skin care regimen to keep hands healthy is highly recommended. New Technology
Today, in response to the growing chemical allergy concern, new research
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Today, the growing impact of chemical allergies as an occupational hazard among healthcare workers is clear, considering that 30 per cent of glove-related reactions are chemical allergies, whereas 17 per cent are latex allergies.
and technologies have led to the development of accelerator-free synthetic gloves; these surgical and examination gloves are the latest innovation in the ongoing effort by glove manufacturers to provide strong effective barrier protection without causing allergic reactions. As noted above, since the majority (over 80 per cent) of reported glove-associated chemical allergy is attributable to chemical accelerators, the removal of accelerators from gloves does offer the potential for helping to decrease the prevalence of chemical allergy. SUMMARY
Protecting healthcare providers and patients from transmission of potentially infectious agents is a primary goal for all healthcare facilities; the appropriate selection and use of PPE are key practices in achieving this goal. Medical gloves are the most common type of PPE used as a means of protection by healthcare workers in complying with the WHO & OSHA Blood-borne Pathogen Standards. The frequent use
Author BIO
are also used to manufacture synthetic gloves such as nitrile, neoprene or polyisoprene gloves. Historically, without the use of chemical accelerators, many of the qualities that healthcare workers seek in NRL and most synthetic gloves (e.g., barrier performance as demonstrated by tensile strength; elasticity) would not exist. Chemical accelerators used in the manufacture of both NRL and synthetic medical gloves transform the original raw liquid state to a very thin, strong, elastic glove film; they also accelerate the bonding process of the gloving material during the manufacturing process. Accelerator chemicals help to tighten the glove matrix, improve and enhance barrier performance, and stabilise the raw gloving material.
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of gloves has resulted in an increase in reports related to several glove-related issuesâ&#x20AC;&#x201C;particularly allergies and other sensitivitiesâ&#x20AC;&#x201C;which continue to be a concern among healthcare staff. Today, the growing impact of chemical allergies as an occupational hazard among healthcare workers is clear, considering that 30 per cent of glove-related reactions are chemical allergies, whereas 17 per cent are latex allergies. Chemical allergies may compromise intact skin and therefore, predispose some individuals to an even greater risk of blood-borne pathogen infection. Skin breakdown can also permit the passage of latex proteins into the body, thereby facilitating latex protein hypersensitivity in some individuals. Chemical allergies to glove products are generally associated with the accelerators that are used in the manufacturing process to give gloves many of the qualities that health care workers desire. Chemical exposure and the resultant skin disorders can be inconvenient as well as costly; fortunately, they are also unnecessary and can be preventable. Today, in response to the growing interest in chemical allergy, new technologies have led to the development of accelerator-free gloves. These gloves are the latest innovation in the ongoing effort by glove manufacturers to provide effective barrier protection without causing allergic reactions. By understanding the clinical implications of chemical allergies related to glove use, healthcare providers can select and use glove products that promote the highest degree of safety and efficacy for their patients and themselves.
Patty Taylor received her bachelorâ&#x20AC;&#x2122;s degree from the University of Western Ontario with major emphasis in psychology and sociology. She is a registered nurse with international experience focusing on peri-operative safety, quality and education. Being an active member of professional associations and networking groups for more than 30 years is a key factor in her professional growth and success.
Books
The Cancer Prevention Manual: Simple rules to reduce the risks Editor: Ian Olver, Fred Stephens No of Pages: 96 Year of Publishing: 2015 Description: Stories in the media about the cancercausing risks present in everyday life can cause alarm and confusion, and make it difficult to know how to alter one's lifestyle. &lt;i&gt;The Cancer Prevention Manual&lt;/i&gt;, Second Edition, is a handy guide to all key issues in cancer prevention, presenting medical and scientific information in a plain, accessible style. Written by authors with distinguished careers studying the illness, and based on a solid scientific grounding, this book provides the facts about how our lifestyles pose cancer risks, and what we can do to change them.
The Green Solution to Breast Cancer: A Promise for Prevention Editor: Kristen McHenry No of Pages: 186 Year of Publishing: 2015 Description: This unique, research-based investigation of the U.S. breast cancer movement compares the "pink" and "green" efforts within the movement and documents their use of similar citizen-science alliances, despite the contention over the use of consumerbased activism and pink products. • Examines research findings that suggest that the pink and green aspects of the breast cancer movement are no longer separate but in fact are converging towards a focus on environmental prevention • Provides an in-depth examination of advocacy organisations and the ways in which an organisation's structure and ideology shape its agenda and strategies • Presents valuable information for upper level undergraduate and graduate students in political science within American politics or health politics courses as well as those studying women's and gender studies, sociology, nursing, and non-profit enterprises.
The Heart Healers: The Misfits, Mavericks, and Rebels Who Created the Greatest Medical Breakthrough of Our Lives Editor: James, Forrester No of Pages: 400 Year of Publishing: 2015 Description: At one time, heart disease was a death sentence. In The Heart Healers, world renowned cardiac surgeon Dr. James Forrester tells the story of the mavericks and rebels who defied the accumulated medical wisdom of the day to begin conquering heart disease. By the middle of the 20th century, heart disease was killing millions and, as with the Black Death centuries before, physicians stood helpless. Visionaries, though, had begun to make strides earlier. On Sept. 7, 1895, Ludwig Rehn successfully sutured the heart of a living man with a knife wound to the chest for the first time. Once it was deemed possible to perform surgery on the heart, others followed. In 1929, Dr. Werner Forssman inserted a cardiac catheter in his own arm and forced the x-ray technician on duty to take a photo as he successfully threaded it down the vein into his own heart...and lived.
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t Gundersen Health System, we define health of the populations we serve to include physical and mental health, social well-being, and the fiscal health of our communities. We are so convinced that this should be a part of responsible healthcare, and thus been embedded in our strategic plan and is a measured, integral part of how we accomplish our goals. That is, we pursue a broader purpose than just taking care of sick people who show up at the door. The purpose of the organisation expects us—indeed demands of us—that we see beyond our walls and look at our effect on the general health and well-being of our communities.
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Furthermore, healthcare facilities, as a rule, are some of the most energyintensive buildings in the commercial sector in the United States. According to the United States Department of Energy, hospitals are 2.5 times more energy-intensive than other commercial buildings. The fact that we are more energy intensive and that the energy costs will continue to escalate, increases the urgency—if we are to hold down our costs—to address these issues. Just as a reference, our organisation is a healthcare delivery system made up of five hospitals, 61 clinics, 7000 employees, 500 doctors, and 300 nurse practitioners and PAs. We teach, we
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conduct research, and we work with many partners to improve the health of the communities. We serve across 19 counties in three states. Gundersen Health System didn’t set out to be the greenest health system in the country when we embarked on our plans to reduce our energy spending and improve our impact on the communities through, both, better health and improving the local economy. However, in October last year, when we reached energy independence, we became the first in the country to reach that goal. To achieve success, we started by measuring our impact on regional environment. We found in 2008 that we were putting
Facilities & O perations MA NA GEMENT
Environmental Impacts for Healthcare Sustainability Gundersen Health System is the first US healthcare organisation to achieve energy independence, producing more energy than it consumes. Gundersen’s Envision® programme saves the organisation millions of dollars each year, boosts the local economy and teaches organisations on how to become better environmental and fiscal stewards. Jeffrey E Thompson, Pediatric Intensivist and Neonatologist, Gundersen Health System, US
48 million kilograms of carbon dioxide into the atmosphere, 1 kilogram of mercury and 197,000 kilograms of particulate matter. For a healthcare organisation, we felt we could not continue on the same path. We had to be better for our patients and the communities we serve. So how did we do it? We took a two-sided green approach to our efforts—green as in good for the environment and green as in financially sustainable—not programmes that would detract the financial performance of the organisation. We did not want to take any more money out of the community to pay for this activity. And we had to be conscious about not
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Fa cilities & Operations MA NAGE M ENT
passing any unnecessary waste off on our patients through higher healthcare costs. Our goal, therefore, was to decrease our costs, decrease our negative impact on the environment and work to find ways to reduce our reliance on energy from outside our region. More specifically, since all of our energy comes from outside our region (coal from Wyoming for electricity and natural gas from Texas for heat), we felt developing local resources would improve that profile. Our approach was multi-pronged and looked to decrease waste in every part of the organisation with the same principles of decreasing pollution, improving the organisation’s finances, and improving the regional economy. One of our earliest gains was to focus on recycling. We rapidly pushed our recycling rate above 35 per cent and held it there for five years. This gave us a financial start as we received payment for recycling plastics, cardboard and paper, bringing in tens of thousands of dollars. We also focused on food waste. In fact,
over a five-year period, we reduced our food waste by 80 per cent. It kept 18 tons of food from going to the landfill each year and resulted in donations of thousands of meals through the Salvation Army. This saved money and served a community good at the same instance. Other activities that resulted in substantial savings include remanufacturing of single-use devices—supplies from surgery, oxygen sensors from the intensive care units, and toner cartridges from printers across the organisation. All could be remanufactured and purchased back at remarkably low costs. This recycling of equipment saved US$400,000 – US$500,000 every year. The combined savings of recycling and reusing and remanufacturing of waste and equipment consistently, year over year, averaged savings in the US$500,000 per year range and easily paid for a coordinator and many of the projects we started. Other areas of significant waste occurred around bio-hazardous (blood-stained or body-fluid contaminated waste)
Chart 1
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and pharmaceutical waste. Disposal of contaminated and pharmaceutical waste has been historically expensive. A focused approach to carefully examine what exactly was in this waste and how to mitigate it had substantial savings. This was not easy work. It meant taking red bags of waste, carefully putting them out on large tables, sorting through them, and asking ourselves what is regarded as waste and what can be recycled. Then it meant going back and revising systems and using the LEAN methodology of careful examination, developing a plan, and re-working the flow. Bio-hazardous waste per patient visit has dropped by over 25 per cent and pharmaceutical waste has dropped by over 60 per cent and is saving us hundreds of thousands of dollars. Not only did the pharmaceutical waste reduction save all this money, it markedly increased the efficiency of our staff by now having to deal with only one barrel a month of pharmaceutical waste, rather than 17. We not only saved
Facilities & O perations MA NA GEMENT
hundreds of thousands, we saved a great deal more in staff time. A great advantage in focusing on waste has been addressing the issue of medication waste in the public. In the United States, the most common pathway to heroin addiction is the abuse of prescription opioids. Once that is no longer available or is too expensive, patients then turn to heroin. As a public service, in the first six months of 2015, Gundersen Health System placed public drop boxes in several clinics. We collected 3,000 pounds of medication that otherwise would have gone into the sewer system or into landfills. By collecting these medications and disposing of them in an appropriate fashion, we kept all those chemicals out of the landfill. A little known effect is that many medications, antibiotics, and hormones, when put through the sewer system, are not altered and end up in our water and food supply unchanged. Of the 1500 kilograms of medication that we collected in the public drop boxes, we believed that 10-20 per cent was narcotics. We kept them off the street and out of the hands of persons who may become addicted. In addition to managing waste, at Gundersen Health System we made a huge effort to address our energy needs. In 2008, we set a goal to become the first healthcare system heated, powered and cooled, by local renewable energy. As you can see from the chart our goal was to start out with a very heavy dose of conservation, add in wind, landfill bio-gas activity, a bio-mass boiler using local hardwood chips, a geo-thermal system, bio-gas from dairy farms, and more conservation. This aggressive plan could not have happened without a dedicated Board willing to take on this plan. You might ask – why would a strong Board allow this plan? The Board felt that it was the best use of a small portion of its savings, that the overall program had a good return on investments (7.7 years), the investment was safer than the stock or bond market, and
The combined savings of recycling and reusing and remanufacturing of waste and equipment consistently, year over year, averaged savings in the US$500,000 per year range.
that it was a great local investment that raised our status in the community as a business partner. At that time, there were certain grants and interested partners available that helped us accomplish our goal. And as important, we had early successes with very hard measures that showed we could improve our environmental footprint and save money for the organisation. To be a disciplined organisation, we had to carefully measure all these activities. Where were our biggest payoffs? The biggest financial successes were in conservation. Our initial US$2 million spent on conservation saved us US$1.2 million every year thereafter. That is a tremendous return on investment. Our wind farms vary depending on the rate that the utilities are willing to pay us–and for the most part are a strong financial success. The land fill bio-gas and the dairy bio-mass boiler are also very strong. Solar hot water is a little less of success but still has a reasonable return on investment that helps pre-heat the water for our dialysis unit. However, in full disclosure, not every item we worked on was a success: • Early on we put up some solar panels that were a bit expensive and so the payback on them was a little longer than we anticipated • We tried a bio-gas project with a local brewery, but with high sulphur content it became unattainable and hard on our engines
• The solar hot water project for the Gundersen daycare is wildly popular with the kids at the school who point out every day that they are washing their hands heated by the sun, however, financially; it is not a big win. As you look through the options, where do you start? Energy should be your first fuel. As I mentioned, our US$2 million dollar investment in conservation had a significant savings the first year and every year thereafter. We lowered our fixed operating costs, which was essential for the long-term financial health of the organisation. Our landfill gas project was a partnership with our county government who had a solid waste landfill site where the methane was just being burned off into the atmosphere. We collected that methane, it was piped to our campus, and our campus is now heated, cooled and powered all with this previously wasted methane. The county receives US$250,000 every year that they never had before. The system saved several hundred thousand dollars over the cost of previous fossil fuels, and the staff was very proud that they were in the first campus in the country that was completely heated, powered, cooled, and saved a lot of money from renewables. That outpatient campus, in Onalaska, Wisconsin, has 1,200 staff members. The inpatient and large speciality campus, in La Crosse, Wisconsin, has several thousand staff, and a large tertiary hospital, which has its heat and electricity augmented by a large bio-mass boiler. This boiler, powered by locally sourced hardwood chips, produces a majority of the steam to heat that campus, as well as a high pressure steam turbine providing electricity. This saves the organisation US$600,000 a year, produces almost no greenhouse gasses, and when coupled with a large geo-thermal field, is able to produce remarkably clean, safe, and cost-effective energy for that campus.
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Facilities & Opera tions MA NAGE MENT
Another piece of our energy portfolio was to examine all facilities and see if they could be replaced. An inpatient Behavioral Health hospital (psychiatric hospital) was replaced with a newer facility. Not only was the newer facility one-third as expensive per square foot to heat and cool, the patients had a remarkably faster healing time, required less medications, and less restraint because of the better design of the facility. In addition, a brand new 250-bed hospital had cut down the energy use from 253 in the United States, to 120kgb per square foot. These facility designs work great on the large scale, but also work equally well on smaller clinics or smaller hospitals. Our energy experts have worked not only in our central campus, but also in regional clinics that are 3,700-5,000 square yards, whose energy costs range from US$70,000-90,000 per year. With careful identification, a good energy audit, and implementation of recommendations, energy savings of 35-50 per cent is common, and the payback of investments are averaging one to two years. Small 10-20-bed hospitals also can see similar savings with energy costs decreasing by 15-20 per cent with short one to two-year payback periods. This may seem daunting to start out on such a journey, but there are many
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opportunities to help you along the way. The Global Green and Healthy Hospital Initiative is an international program with many great ideas that are available on the web. At Gundersen we are talking what we have learned and now teaching and consulting. We are always looking to help others1. Equally important, beyond all these issues, is the impact on your staff. The rise in staff pride around an organisation who said “we will lead on being environmentally sound and take care of the health of our community, and we will do it in a way that saves money and improves the health of the economy” has raised the interest and engagement of the staff across our organisation. Another thing that is absolutely critical that I mentioned earlier, is the tying together of the mission of the organisation. When you look at sustainability in this light, it affects the patient’s care experience, it lowers the per-capita costs and it will improve the health of the population. Sustainability is a central core to the Triple-Aim that the Institute for Healthcare Improvement has been pressing and mentioning for some time. A disciplined organisa1. More information can be found on our website: http://www.gundersenenvision.org/.
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tion should be able to spread the culture of discipline across the whole organisation. Because of that, Gundersen has felt it is inappropriate to continue investing in fossil fuels. So, from our savings as of January 1, 2015, the managrs of many of our investments will not purchase any bonds issued by companies listed on the Carbon Underground 200. We do not feel it is appropriate for healthcare to invest in fossil fuel generation when those fossil fuels are clearly linked to making people ill. So what’s the total impact of this programme? For the organisation, the total costs savings will be US$3-4 million per year. For our contribution to greenhouse gasses, our carbon dioxide production is on track to be 83 per cent less than it was in 2008. Our particulate matter is over 75 per cent less than in 2008. Our local energy production includes wind, wood, geo-thermal, dairy bio-gas, landfill gas, as well as solar hot water. Our overall cost savings to the organisation will be US$3-4 million dollars a year at a minimum. Our food waste, as mentioned before, is down 80 per cent, and to help decrease the overall impact of our food energy footprint, we have developed a regional food co-operative that will help us increase the percentage of local bulk buying of regionally grown foods. Although our educational impact has been from grade schools, technical schools, universities, and world-wide visitors, inspiration beyond our staff has extended to patients, our patient families, community partners, job applicants and our competitors. If you want to set out to be recognised as one of the most environmentally sound organisations to truly approach the Triple Aim of improving the health of the population, the experience of care, and lowering per-capita costs, there are many important factors. First, you must commit to significant goals that may seem difficult, but are certainly possible to achieve. Develop a programme that connects a broad group of your staff
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CleanMed Conference held every year in the United States, are great sources of information and inspiration. As set out by the National Health Service, we need to move from more than just a consideration of pollution, to broader awareness of the health and well-being of our communities. We have to move from thinking just about carbon reduction to the reduction of oil, greenhouse gasses and our overall impact on air and water. We need to move from just doing a few things better to doing better things consistently. We need to
Author BIO
that includes recycling, conversation, and food-waste reduction. Front-line staff can become actively involved in all of these areas. Along with your highgoal setting, measure clearly what your baseline is and what your impact is; it will help you build momentum. Report these initial small gains to your staff, help them understand that you truly are improving the well-being of the patients, the organisationâ&#x20AC;&#x2122;s economy, and the economy of your region. Prove the outcomes to communities so that the schools, businesses and government become partners and help you not only in improving your environmental impact, but that of your whole region. There are also great resources available. Look to other regional, national and international examples to glean the best practices. The World Health Organisation, Global Green and Healthy Hospital Initiative, the
not only start new projects; we have to stop many of the old things that we have been doing. We need to, of course, measure some process and activity, but we need to move to measure outcomes. We need to look at sustainability, not as a problem to be solved, but as a solution and an opportunity to improve the health and well-being of our communities and distinguish ourselves as organisations. We need to move from sustainability being done in isolation to seeing it as the responsibility and a great opportunity for an integrated system of care.
Jeffrey E Thompson, MD is a pediatric intensivist and neonatologist at Gundersen Health System in La Crosse, Wis, US. During Dr. Thompsonâ&#x20AC;&#x2122;s 14 years as chief executive officer, Gundersen received international recognition for its high-quality patient care and innovative clinical, population health and business initiatives.
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VACUETTE® Sample Collection System–More Safety in Routine Care
In the mid-80s, Greiner Bio-One (GBO) became the first manufacturer in the world to develop the first shatter-proof blood collection system made out of plastic with safety cap. This was a milestone in terms of both safety and hygiene. Now, 30 years later, these shatter-proof tubes belong as standard in hospital and laboratory routine work in many parts of the world.
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The strongly growing Asian markets are following this trend, which is why Greiner Bio-One decided some years back to start manufacturing locally and distribute the VACUETTE® products directly via an Asian sales subsidiary or to work closely with distribution partners in each country. The clear commitment of Greiner Bio-One to the Asian market is an essential component of the company’s strategy.
In pursuance of this target, the company has continually expanded its presence in the core markets. In 2008 Greiner Bio-One opened a state of the art production facility in Amata Nakorn, Thailand. The VACUETTE® products have the CE mark in accordance with European standards as well as the FDA-Thailand certificate. In 2011 GBO took over the majority share of a joint venture with the former Chinese distribution partner Suns Real. Since then, the company has operated under the new name Greiner Bio-One Suns Co. Ltd. In addition to VACUETTE® specimen collection products, diagnostic products as well as instruments are sold successfully from the headquarters in Peking. In the following year, 2012, another joint venture was founded in India. Greiner Bio-One India Pvt Ltd. in Noida close to the capital city of New Delhi is a cooperation between GBO and the long-term distribution Tristar Remedies Pvt. There is a second location in Ahmedabad in the west of the Indian subcontinent. Both companies have developed extremely well over the past few years. In 2015 Greiner Bio-One Preanalytics began distribution of the VACUETTE® specimen collection system in Japan. The company has in fact been active on the Japanese market with a GBO subsidiary for many years now, but previously only
BioScience products for the research sector were sold. With a population of 127 million people and an estimated market potential of 800 million blood collection tubes, Japan is one of the biggest markets in the Far East. The official product launch was at this year’s JACLaS trade fair in October in Yokohama. In addition to products for blood collection, such as holders and blood collection tubes, GBO is offering caps for re-capping tubes as well as tourniquets and disposal containers on the Japanese market. The practical ID snap rings can be used to identify tubes for special analysis purposes. These just need to be clicked onto the tube cap, then enabling fast optical recognition of specific specimen material.
Greiner Bio-One International GmbH Greiner Bio-One specialises in the development, production and distribution of high-quality plastic laboratory products. The company is a technology partner for hospitals, laboratories, universities, research institutes, and the diagnostic, pharmaceutical and biotechnology industries. Greiner Bio-One is split into four divisions – Preanalytics, BioScience, Diagnostics and OEM. In 2014, Greiner Bio-One International GmbH generated a turnover of 388 million euros and had over 1,800 employees, 23 subsidiaries and numerous distribution partners in over 100 countries. Greiner Bio-One is part of Greiner Holding, which is based in Kremsmünster (Austria). Advertorial www.asianhhm.com
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Creating a System for Safety
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It needs to be ensured that each and every patient receives evidence-based care, unless contraindicated, as part of everyday work. This means that safe care is provided. If safe care is delivered, the events that contribute to patient morbidity and mortality can be reduced. The opportunity for infections will also be reduced. Frank A Federico, Executive Director, Strategic Partners, Institute for Healthcare Improvement (IHI), USA
Is the existing environment sufficiently suitable for practising a better healthcare system? What measures have to be taken for better outcomes?
In order to build a system of safety, we must first all agree as to what we mean by patient safety. As with any work, unless we agree to a common definition and understand ‘why’ we need to improve a situation, we will not be able to build the system to support our goals. The National Patient Safety Foundation defines patient safety as “The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare”. At the Institute for Healthcare Improvement (IHI) we have adopted the term ‘harm’ which includes any harm resulting from the delivery of healthcare, preventable and non-preventable. With this definition we have broadened the discussion. As a result, it has also been more difficult to determine if we have made improvements in reducing that harm. We started with working on events such as wrong site surgeries, medication errors and falls. We expanded the work to include infections and pressure ulcers. Many
continue to build on this work. And, as we become more sensitised to the patient experience, we are adding many more events that were in the past considered unavoidable, as in, ‘this is just what happens in healthcare.’ Attitudes toward patient safety continue to change. And, along with those attitudes the environment is also changing, although probably not as quickly as we would like to see. Remember that the healthcare system has a history of layering processes after processes on a system which must be rebuilt and redesigned to meet the challenges of today’s complexity. We have developed new technologies, procedures, and medications that promise better outcomes. Yet, we have not worked enough to better understand the challenges these developments present to those who work in healthcare who must deliver this level of care. I believe that we have a foundation upon which we can build. Leaders and providers have a better understanding of their role in developing improved healthcare systems. We must continue to explore and address how humans interact with the system, each other, equipment, and the environment.
What will be the role of hospital leaders in creating a system for patient safety?
Hospital leaders at every level of the organisation including the board, senior leaders, middle managers, and leaders at the point of care, play a significant role in developing a system of safety. At IHI, we have developed a framework that has leadership as foundational to any patient safety effort. Leaders must engage key stakeholders such as the board of trustees, physicians, staff, and patients and families. We believe that leaders must make safety a number one priority for the organisation. That is not to say that finances and efficiencies are not important. However, as healthcare providers, we are entrusted to ensure that our patients are not harmed by the care we deliver. That is paramount. As in any industry, the customer should be first and foremost in leaders’ minds. An airline can have the best ticketing system, best luggage handling, cleanest planes, and the best food but, if the planes are not safe to fly, then what is the purpose of the airline? It is the same in healthcare. We must have efficient and effective systems. We must provide care that is timely and equitable; we must provide care that is safe. From the highest level, governments must expect that the healthcare providers in their jurisdictions provide safe and effective care for the population they serve. And, leaders at all levels of the organisation and outside the organisation must be involved. The highest level of leadership within an organisation, such as the board of trustees, must set a vision and goals for the provision of safe and effective care. That vision must penetrate flow down to all departments and services in the organisation. Middle managers and clinical leaders must operate their areas of responsibility in a manner that supports the vision. The people who directly provide care are also leaders and must understand their roles in identifying
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defects and poorly functioning processes which need improvement. Reasons that many are not involved in quality improvement include not having the encouragement to identify defects and to fix them, not having the skills to improve, and the fear that improvement means ‘change’ is quite a disruption for the workers themselves. This suggests another level of responsibility for leaders: in order to achieve safe care it is necessary to ensure that the appropriate infrastructure and culture are in place. Leaders have responsibility to facilitate and mentor teamwork, improvement, respect for patients and all workers, and psychological safety. Psychological safety is defined as feeling safe to speak up, safety in taking risks in a team setting, and trusting that your voice will be heard. Communication and building awareness about patient safety are also vital. Leaders can carry the banner for patient safety through Walk Rounds, an opportunity to visit with care providers where they do their work. Safety briefings at the ward and department levels offer another
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opportunity to discuss and deal with safety issues. Communication breakdowns have been identified as a contributor to patient harm. Implementing a communication tool such as SBAR, a structured communication tool, is helpful in providing clear, concise, and actionable information. Leaders must also set the stage for the development of teamwork training. Maureen Bisognano, CEO of IHI, asks leaders to consider the following: “Do we know our outcomes or how good we are?” “How do we compare with the best?” “Do we know where the variation lies in our care?” “Are we improving fast enough?” To answer these questions it is necessary to have a system to measure and track performance over time. A common complaint is that we have so many projects and so much work to do. Where do we start? Leaders must organise and manage the portfolio of projects and activities that must also be aligned with the aims of the organisation. Patients and families and staff are impacted by the outcomes of medical
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errors. It is the responsibility of the organisation to support each person who has been impacted by harm related to the delivery of healthcare. We cannot continue to do the same activities and expect different results. To provide safe and reliable care we must redesign and improve the systems of care we have today. Leaders must demand that improvement is more than new policies, more training and education, and merely asking people to be more vigilant. We must change how we do our work. Our experience is that many middle managers, the group of people responsible for translating the vision of the organisation to those who provide care, are often not trained in quality improvement. Many are so overwhelmed with meetings, messages, and reports that they have little time to focus on those who report to them. In order to be successful, middle managers must know improvement science and how to coach teams who are working on improvement efforts. At the same time, middle managers must relinquish control and allow those who do the work to test different methods for improving the completion of their task. I realise that this is a difficult change for many managers. However, we have learned that successful changes are those that originate with those who are closest to the work. Once various methods are tested, the best one can be standardised. This will then ensure that the process will deliver the care we want our patients to receive, support training and competency testing, and help us continually learn and improve. What are the beneficial effects of the patient safety practice? What system do you think will suit patients for their safety? Please explain.
We tend to think of patient safety as a special project that we must undertake. I suggest that we look at patient safety as something we should be doing every day. That is, we should not make following
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What are the most significant patient safety challenges related to process improvement? What measures have to be taken to overcome these challenges?
At IHI we believe that in order to make changes, there must be the will or a desire to change. Many still deny that they have a patient safety problem. Even if an organisation has not had a serious event, leaders must ask “Can it happen here? Are our processes capable and reliable to ensure that every patient receives safe care? How do we know?” One must also have ideas about what changes should be tested. And, the ability to get results. That is, does
the organisation use an improvement methodology? We find that in many organisations there is a desire to improve, and there are many ideas. The point at which many are having difficulty is executing or getting results. Each organisation must examine where its own challenges are along this continuum. It is the responsibility of all leaders and providers to challenge the status quo. All must gather new ideas from each other, other organisations, the literature, and places like IHI. Then the organisation must use an improvement method that engages the workforce in the redesign of care. Written policies, asking people to work harder and to pay attention, training, and education may be necessary to varying degrees, but they are insufficient. What are the new innovative approaches towards patient safety?
The recommended approach of using standardisation and simplification will always apply. We are learning more about applying human factors research and using methods that develop resilience. High reliability organisations are implementing huddles as a way of raising situational awareness. We are beginning to study prediction, the skills to predict where we might have issues, better identifying those patients who might be more likely to deteriorate. As we focus on improvement, we are learning to move away from the project by project approach to one that makes patient safety and quality improvement the way work is done every day. We are also examining patient safety from the perspective of the continuum Author BIO
evidence-based practice a special project. What we should be doing is ensuring that each and every patient receives evidencebased care, unless contraindicated, as part of our every day work. If we do that, we will provide safe care. Systems designed to deliver safe care must also be designed to be efficient and easy to use. As a result, staff will have the time needed to provide care. Processes that are not well designed complicate daily work and result in rework. If we deliver safe care, we will also reduce the events that contribute to patient morbidity and mortality. We will reduce the opportunity for infections and all of the associated work that goes along with treating the infection. All of the above contributes to safer, more efficient, more effective and timely delivery of care. There will also be cost benefits realised. A benefit that is not often discussed is the joy in work that results when systems are designed to make it easy to do what is correct for the patient. Teamwork and proper communication help all who are delivering care by fostering a community of care. Elimination of rework helps with efficiencies. Ensuring the safety of the workforce is a key element of safety. A safe and respected workforce is one that works to ensure that patients are safe and respected.
of care. Until now, most of the work has been conducted in silos of care. That is, we have focused on harm in the hospital, in the ambulatory setting, and in long-term care. We must now look at harm across all these areas as part of the patient’s journey. We may be able to prevent harm in the hospital if we work to keep the patient safe at home or in the doctor’s office. Anecdote
Recently a colleague shared his experience with the healthcare system. He was not feeling well and walked into a hospital so someone could check on symptoms. From the outset, his concerns were not addressed; the doctor dismissed them even though the patient, a doctor himself, attempted to draw attention to things that were being ignored several times. The doctor spoke disrespectfully to the patient and his wife. Those of us in healthcare entered the profession to help patients. We become so caught up in the day-today activities that we often forget the patient to be a person. I believe that it is only when we experience the healthcare system as any person does that we begin to understand that being taken seriously, being seen and heard, is as important to healing as is the science of medicine. Let us not forget that each patient is an individual who is in need of respect and empathy. I am pleased to note that Beth Israel Deaconess Medical Center in Boston, in the United States, now recognises psychological harm of the sort I’ve just described as real harm which too many patients endure. And, this respect should not stop with patients. It must extend to everyone who works in healthcare, too.
Frank A Federico works in the areas of patient safety, application of reliability principles in healthcare, preventing surgical complications, and improving perinatal care. A registered pharmacist, Mr. Federico serves as faculty for IHI's Patient Safety Executive Development Program and has co-chaired a number of Patient Safety Collaboratives.
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REDEFINING HEALTHCARE VISIBILITY
The Challenge Healthcare staff and administration need real-time visibility to make the best decisions in all areas of the healthcare facility. One of the biggest challenges facing hospitals is ensuring that their patients are safe by reducing errors as much as possible. As soon as the patient is admitted to the hospital, the various processes and intervention at different levels by medical professionals from administration, nurses and doctors to laboratory staff and pharmacists all increase the risk of mistakes being made. Let’s take a closer look at the various areas where mistakes could happen and explore patient care and operational efficiency solutions that can help alleviate this risk.
Positive Patient ID Upon admissions, the patient’s ID card is scanned using a CS4070-HC barcode scanner and the information is entered into the Electronic Health Record (EHR) system. A barcoded, comfortable, long-lasting wristband using the HC100™ Patient ID Solution is printed for the patient to wear. A
barcoded wristband provides two forms of identification in one easy-to access place by encoding the patient name and identification number. Barcoded patient wristbands provide the necessary foundation for preventing errors by ensuring accurate patient information is always available at the point-of-care.
Mobile Specimen Collection As the phlebotomist arrives to draw blood, she starts by scanning the patient’s wristband followed by her badge with the all-in-one voice and dataenabled MC40-HC handheld mobile computer. It prompts a screen with the type and number of tests to administer, including a submission button after completion. With the mobile QLn220™ healthcare mobile printer a barcode specimen ID label is printed at the point of care and applied reduces the possibility that the specimen will be misidentified. The Zebra devices used to enable mobile specimen collection contain medical grade plastic that is disinfectant-ready for cleaning, thus preventing microbes from spreading throughout the facility.
Why Zebra Solutions?
Zebra's solutions provide the needed visibility to enhance patient safety, improve operational efciency and optimise IT investment. With the goal to streamline supply chain processes and reduce overall healthcare costs, our solutions make it possible to automate management systems, track patient progress, and improve responsiveness of healthcare providers. *Models quoted subject to region availability.
CS4070-HC
HC100
Zebra Technologies Asia Pacic Pte Ltd
71 Robinson Road, #05-01/02/03, Singapore 068895 | T: 65 6858 0722 | F: 65 6885 0838 48
© 2015 ZIH Corp. All rights reserved. Zebra and the stylised Zebra head are trademarks of ZIH Corp., registered in many jurisdictions wordwide. All other trademarks are the property of their respective owners.
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Laboratory Management At the lab, a technician scans the vials of blood using the DS4308-HC and processes the sample. A new label is printed and placed on the slide using the GK420™ healthcare printer that provides a date and time stamp. Detecting and preventing errors that threaten patient safety is a closed-loop process that begins at the point-of-care, extends to laboratories, and then back to the caregiver. Sample identification and results reporting errors can lead to misdiagnosis and inappropriate treatment with deadly consequences.
scan, to verify that the patient should be receiving the medication at the indicated dosage and method at that time. The nurse continues after getting a conrmation or warning on the MC40-HC handheld mobile computer. Finally, the nurse scans her own barcoded ID badge to record who administered the medication. The system essentially automates the Five Rights check, with wristband scan verifying the right patient and the database lookup from the medication scan verifying the other elements: right medication, right dose, right time and right route.
Right Diagnosis
Remote Patient Monitoring
After examining the patient and the lab results, the doctor diagnoses the patient and recommends treatment. The doctor sends the prescription to the pharmacy wirelessly and securely using the Computerised Physician Order Entry (CPOE) on a tablet, specifying the medication and proper dose.
The nurse is able to continuously monitor the patient remotely using an app on the MC40-HC handheld mobile computer. A wireless connection to the vital medical equipment that is keeping a patient stable allows nurses to constantly monitor patient vital signs and equipment status as they move through the hospital unit, tending to other patients. No longer do nurses need to return periodically to the patient room or the nursing station to monitor EKG machines, respirators and medication pumps. Alerts are also sent to the handheld mobile computers about potentially life threatening situations.
Pharmacy Management The pharmacist receives the electronic order and begins by scanning the box of medication with the DS9808 and prepares the prescription. A medication label is printed using the GK420™ healthcare printer, placed on the container and its barcode scanned. This immediately veries and records medication dispensing in the CPOE to ensure the correct medication in the correct dosage will be administered to the correct patient.
Medication Administration The MC40-HC handheld mobile computer then alerts the nurse that the medication is ready to be administered to the patient. The nurse scans the patient’s wristband followed by the barcode on the medication. Application software then compares the medication to information in the patient’s electronic record, which was called up by the wristband
MC40-HC
QLn220
Supply Chain Management Barcode scanning also allows hospitals to costeffectively take rapid and accurate inventories on a daily basis – from the contents of the supply cabinets on each hospital oor to the pharmacy shelves. The result is the visibility required to improve the speed and accuracy of the ordering and replenishment process, ensuring that caregivers always have the right supplies and medications on hand to treat patients. Scanning consumables and equipment as they are utilised also enables the instant and accurate capture of all items used for specific patient.
DS4308-HC
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GK420
DS9808
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11. Emma Sheldon - Edited
HEALT Fa cilities HCARE& MANAGEMENT Operations MA NAGE M ENT
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Toileting aids in Hospitals Reuse or Dispose?
As part of a portfolio of infection control and waste management measures, disposable systems can help save nurse time and improve working conditions. This in turn helps to preserve patient dignity and enhance the patient experience by providing a clean product every time to aid safer healthcare. Emma Sheldon, Marketing Director, Vernacare, UK
H
ealthcare providers are under increasing pressure in today’s society - populations are expanding at an unprecedented rate and many people are living longer. With demand for the services on the rise, hospitals strive to meet their patients’ needs and expectations for highquality treatment, without compromise. However, the risk of Healthcare-acquired Infections (HCAI’s) is a prevalent global issue, and is a real challenge for hospitals to overcome. HCAI’s – A Concern for Patients and Hospitals Worldwide
According to the World Health Organisation (WHO), hundreds of millions of patients are affected by healthcareassociated infections worldwide each year, leading to significant mortality and financial losses for health systems. Of every 100 hospitalised patients at any given time, 7 in developed and 10 in developing countries will acquire at least one healthcareassociated infection. The level of infection contraction amongst patients in hospitals cannot be ignored. In June 2014, the Indian Journal of Critical Care Medicine published an article on the importance on preventing hospital-acquired infections, ‘a constant threat to hospitalised individuals’. Also, in Singapore, doctors questioned regarding the issue have estimated that one in seven patients acquire an infection on the hospital
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ward, leading to prolonged illness, extra incurred costs and even death. Newborn babies are especially at high risk from HCAIs in some countries, for example in Southeast Asia where HCAIs are responsible for 75 per cent of all causes of death in the neonatal period. The management of human waste is recognised as a high risk for transmission of infections in healthcare environments. Pathogens of particular concern in the hospital setting include: Clostridium difficile (C.difficile), Carbapenem-Resistant Enterobacteriaceae (CRE), Vancomycin-Resistant Enterococci (VRE), Multi Drug-resistant Gram-negatives (MDR Gram-negatives), Meticillin-resistant Staphylococcus Aureus (MRSA) and Norovirus. C. difficile infection is usually spread via the hands of staff and those who come into contact with infected patients or with environmental surfaces like floors, bedpans and toilets that have been contaminated with the bacteria or its spores. The bacteria and spores are extremely hardy, and some pathogens can survive on dry surfaces such as clothes and environmental surfaces for months.
Items that become contaminated with human faeces, such as bedpans, are categorised as non-critical devices defined as items that come into contact with intact skin, as opposed to critical items that enter sterile tissue or the vascular system. As a result, surprisingly little attention appears to be paid to the risks of disease transmission and environmental contamination, both of which are particularly likely to occur during diarrhoea episodes. Safe management of human waste therefore has the potential to reduce HCAI through the employment of better hygiene and infection prevention measures. Current Solutions
There are a number of chemical, physical and mechanical toileting aids and human waste disposal solutions in healthcare environments for immobile patients. These include: • Reusable plastic / metal bedpans and implements that are manually cleaned using unvalidated methods and without testing of their efficacy • Reusable plastic / metal bedpans and implements that are
Figure 1
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Figure 2
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cleaned in local washer disinfectors • Single-use bedpans and implements that are processed in disposal units • Other more invasive solutions include urinary catheterisation. However, such a procedure should only be undertaken if there is no other option, as it introduces the risk of Catheter-acquired Urinary Tract Infection (CAUTI). Singleuse urinals are a safe and alternative toileting option for patients who are unable to use conventional toileting methods and do not require catheterisation. Practices with regard to human waste disposal in healthcare environments vary in different parts of the world: • In countries such as India, South Africa and Poland, manually washing reusable bedpans is a commonly accepted practice • In Australia, it is a combination of single-use pulp macerator systems and bedpan washer disinfectors. • In the UK, 94 per cent of hospitals use a single-use pulp disposable system • In the US, the preferred method is a single-use patient plastic bedpan.
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or spraying with disinfectant. This cleaning method fails to fully eliminate bacterial and spore loads and is believed to be a contributing factor for increased C. difficile infections. A Canadian study showed that the infection rate dropped by as much as 50 per cent when a disposable bedpan system and other interventions were introduced. In addition, MRSA rates also dropped by 30 – 50 per cent. 2. Reusable Bedpans and Utensils that are Reprocessed in Washer Disinfectors
But the most common practice worldwide is reusable plastic containers reprocessed in washer disinfectors. Below is an analysis of each practice: 1. Reusable Bedpans and Utensils that are Manually Washed
It has been found that the often commonly accepted practice of manual washing poses extremely high health risks to both patients and healthcare workers. A survey undertaken by the International Federation of Infection Control (IFIC), showed that when bedpans are cleaned manually, 44 per cent of the time it is done in the patient’s bathroom. Manual cleaning typically involves just rinsing or spraying with cold water, often using bedpan sprayers or ‘wands’, which results in
splashing and the aerosolisation of faecal material. This also causes visible splashes and splatters on hands and surrounding items. There is also a lack of standardisation in validation, testing and monitoring of methods, particularly with regard to effectiveness. Disinfection is often carried out without the observation of correct procedures, if it is carried out at all. Survey findings from Belgium, Canada and the US found that even though healthcare workers were aware of the advisory from the WHO Infection Prevention and Control (IPC) that bedpans have to be cleaned and disinfected after each use, nurses often only do it with water because of their workload, only sometimes following up by wiping
The reusable bedpan washer system is used in combination with plastic and stainless steel bedpans and urinals used for patient toileting. Pre and full washes last for an average of 5-8 minutes, with pre-wash and rinses using hot and cold water before being washed between 80-85 degrees for 60 seconds. Thermal disinfection and detergents are required to reduce the load of pathogens to a level thought to be safe given the Spaulding classification of ‘low’ risk. The benefits of this system include the one-off capital and installation costs, with limited consumable costs thereafter, and a standard operating procedure that ensures continuous monitoring when
Figure 3
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Features
Reusable utensils reprocessed in washer disinfectors
Cycle time
Model-dependent, typically 5-10 minutes
2 minutes
Water consumption per cycle
Model-dependent, typically 33-51 litres
24 litres
Energy consumption per cycle
Model-dependent
0.020 Kwh
Capacity
Model-dependent, typically 2 bedpans
Up to 4 items
Running costs
• Minimal on-going consumables • Detergent costs, around 700 pounds per annum • Utilities (water and energy) • Engineering time: Periodic (annual) validation and revalidation required
• On-going pulp consumable costs • Utilities (water and energy)
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3. Single-Use Systems
Single-use systems comprise the use of a disposal unit and single-use paper-based utensils. The singleuse items are broken down into a fine watery slurry using only cold water. Each cycle takes two minutes, reducing instances where there is the potential for a stockpile of soiled bedpans and waste matter is left to dry and solidify, leaving residual soil even after the wash and disinfection cycle. From an engineering standpoint, the time spent on maintaining disposal units is half of that required to maintain washer disinfectors, and when all costs are considered, single-use systems can be up to 39.4 per cent cheaper to maintain than alternative systems.
Author BIO
fitted to the machine. It can be used to clean a range of utensils other than bedpans, and ensures low exposure of chemicals to healthcare workers. However, a recent study found that 7.6 per cent to 33 per cent of reusable items failed an audit due to visible faecal soiling after processing in a bedpan washer disinfector. Even though heat and disinfection might reduce pathogens, another study found that “the current accepted thermal decontamination parameters for all bedpan washer disinfectors (i.e. 80⁰C for one minute) are not adequate to eliminate C. difficile spores from bedpans”. Inadequate disinfection of bedpans was also associated with cross-infection by VRE. and has also been linked with transmission of VRE. There is a possibility of recontamination as soon as the item is removed from the machine if procedures are inadequate. Reusable bedpan washers also require periodic validation as well as revalidation following repair or servicing. Some have a lack of warning systems when the machine is not functioning correctly, giving rise to ineffective functioning if detergent or rinse aid run out.
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Conclusion
There are comparable benefits to both washer disinfector and single-use systems, but due to the high risk of HCAIs to both patients and healthcare workers, the choice for toileting aid and human waste management solutions and systems in healthcare facilities needs to be carefully considered. Both systems require training and can still be subject to the risk of operator error. Even though the use of reusable bedpan and utensils reprocessed in washer disinfectors has been a widely-accepted practice, the fact is that the currently accepted thermal decontamination parameters, such as 80⁰C for one minute, are simply not adequate to eliminate C. difficile spores and VRE from bedpans. Single-use products (such as Vernacare’s) are manufactured using excess and otherwise wasted clean newspaper. No bleach colouring is added, ensuring products are as environmentally-friendly as possible, and the biodegradable slurry is then safely washed down the drain. Single-use disposable systems have been proven to increase patient and healthcare worker safety by contributing to the reduction in C. difficile infections by as much as 56 per cent, thus breaking the chain of infection. As part of a portfolio of infection control and waste management measures, such disposable systems can help save nurse time and improve working conditions. This in turn helps to preserve patient dignity and enhance the patient experience by providing a clean product every time to aid safer healthcare. References are available at www.asianhhm.com
Emma Sheldon is Global Marketing Director for Vernacare, a medical products manufacturer and leading infection control organisation. Emma is responsible for leading sales and marketing activities across 48 countries and has experience working in partnership with patients and healthcare providers to develop and bring to market innovative infection prevention products.
Information Te chnology
Smart Health for Smart Communities That healthcare is essential even for sustenance is well known. Formation of a smart village presupposes healthy individuals in the ‘smart community’. ‘Smart healthcare’ is eminently feasible, cost effective and must be integrated with other ‘smart facilities’. Behavioural modification among all stakeholders in the healthcare ecosystem is critical. K Ganapathy, President, Apollo Telemedicine Networking Foundation, India
T
hat healthcare is absolutely essential even for sustenance is well known. Water management, energy management, building automation, transportation –every single item in the formation of a smart city presupposes healthy individuals in the ‘smart community’. Attention to ‘smart healthcare’ in 2015 is therefore not a luxury but an
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Informati on Technology
absolute necessity. Contrary to public perception providing ‘smart healthcare’ is eminently feasible, cost effective and just needs a little tweaking of software and hardware used to provide other ‘smart facilities’. The major difference between deploying Smart Healthcare (SHC) and other smart functions is the requirement of a radical transformation in the mindset of the healthcare provider and the receiver. SHC presupposes: a) DIY (Do it yourself ) b) POCD (Point of Care Diagnostics) c) Promoting wellness proactively d) Staying Smart the eWay. While behavioural modification at all levels of the healthcare ecosystem is critical in deploying SHC, it is WiiiFM (What is in it For Me) that needs to be primarily addressed. Some examples of SHC are provided below 1. Promoting health literacy the eWay providing authenticated, validated customised health information to a pre-defined population through smart phones etc. If public WiFi is available this could be exploited 2. Telemedicine enabled pre-hospital management in smart ambulances for emergencies, trauma etc 3. Remote health monitoring at home that reduces hospital bed occupancy by converting a home into a hi care ward using technology 4. Today’s glucometers can be supplemented with similar tests for liver function , kidney function, cardiac function etc. This can be done with just a few drops of blood without any requirement of a paramedic. This will eventually be replaced with non-invasive sensors which through the skin will use surrogate biomarkers to study blood biochemistry. Eventually urinalysis using surrogate biomarkers will even be able to examine brain pathology–just a few examples of ‘smart’ diagnostics 5. Large hospital complexes can have in-house SHC for its residents 6. Large offices can have in-house SHC for employees
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7. Family physicians, specialists, super specialists can conduct virtual OPs at offices, malls, or residences 8. Most importantly 24/7 availability of EMR will considerably reduce duplication of investigations. Immediate access to entire past and present medical history to authorised personnel will produce incremental changes in quality of health care delivery 9. Scientific, statistical evaluation of health care outcomes, incidence
prevalence, follow up etc. will for the first time be feasible 10. ‘Health’ is an inherent and major component, which must always be taken into account while planning a smart city. Whether it be pollution, the metro or even water or transportation management, inputs of a clinician who is familiar with technology and its implications and most importantly the behavioural response to use / imposition of technology needs to be considered
Industrial sectors have a significant role in the 'smart cities' agenda The industrial sectors that are expected to play a major role in building smart cities are 1. Telecommunications 2. Electronics 3. IT and ITES 4. ICT manufacturers 5. Infrastructure 6. Energy 7. Environment 8. Materials 9. Others It is to be reiterated that worldwide, the only industry that was recession proof in the 2008 economic slump was the healthcare industry. We can live without entertainment, without furniture. There may be no direct deaths or morbidity in the general population if there is a power failure but without access to healthcare providers the results will be highly visible. It is a matter of grave concern that at the best ‘Health’ is classified as ‘Others’. If planners are not healthy there will be no smart cities–if one ‘smart’ industry is not appropriately represented, it may have shortcomings but it will still be there!! In Healthcare there are at present not many hospitals, clinics or doctors who regularly use products which would come under ‘m2m’. However, the first thing that has to be done is to clearly define what constitutes m2m in healthcare. From telemedicine to telehealth to remote healthcare; from e-home visits to promoting eWellness and e-Health Literacy we are slowly but surely entering the arena of ‘Smart’ healthcare. Sooner than later m2m, IoT and IoE will be the new buzz words replacing digital health and e-Health. Internet of things has already become Internet of Everything. Who would have thought that the World Bank would fund a relatively backward state like Uttarakhand in India to use drones for sending drugs and collect biological samples from remote areas. There are many of us who are afraid of the future and cling desperately to the present not realising that we have already become the past. Mark Twain was absolutely right when he once remarked ‘the future ain’t what it used to be’ and of course the future is always ahead of schedule.
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Information Technology
11. In the past, health has always been an afterthought, retrofitting being the order of the day – we have never ever been future ready – with the imminent construction of smart communities, this is once in a life time opportunity. Challenges in Implementation of Machine-to-Machine (m2m) and Internet of Things (IoT)
Author BIO
The challenges in implementing SHC are more with individuals than with the technology. Considerable behavioural modification is required. Receiving health care is not like buying a pizza online or a commodity on Flipkart. Champions and evangelists should be identified from the Health care community who have a passion and
believe in SHC. The product has to be packaged to suit each customer. Care requirements are variable in different places, at different times and for different people. All this needs to be understood. In most m2m implementations and designing, sufficient emphasis is not given to the specific needs. Technology should not search for an application. It should be the reverse. A HCP (healthcare provider) should be involved at every stage not just a m2m expert. Reliability and accuracy This is even more important in SHC as the user’s health and life are directly involved. Any m2m product must be compared with existing gold standards. Prospective double blinded, randomised, statistically valid clinical
K Ganapathy (Neurosurgery) is a Past President of the Telemedicine Society of India. Former Secretary and Past President of the Neurological Society of India, former Secretary of the Asian Australasian Society of Neurological Surgery, Past President of the Indian Society of Stereotactic & Functional Neurosurgery. Ganapathy is an Adjunct Professor, at the IIT Madras, Tamilnadu Medical University & Anna University, Chennai. Dr. Ganapathy was formerly Honorary Consultant and Advisor in Neurosurgery Armed Forces Medical Services.
trials are necessary; patient feedback is critical. These are expensive and time consuming but absolutely essential. Today most m2m products in healthcare are driven by mega MNCs with an eye on RoI – whether they are useful or necessary is secondary! Interoperability and the need for standards This is as essential as with any other ‘smart’ application but we need not get paranoid about this. Much more difficult to ‘sell’ to the end user is the fear of dehumanisation – of the human touch disappearing altogether. We still require a kind doctor who practises TLC (tender loving care) to be at the back end of the m2m technology. This must be viewed as a means to achieving the end not the end in itself . Estimating the industry's existing capabilities for 'smart health' The stakeholders need to fund a project to establish a base line, to clearly define what constitutes SHC in the Indian context, what is required, what is not required, what is available now, what do we really need, when, where, how, at what cost and so on.
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Research Insights Equity and Noncommunicable Disease Reduction under the Sustainable Development Goals Authors: Harald Schmidt, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America, Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America Anne Barnhill, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America Summary Points • Currently proposed Sustainable Development Goals (SDGs) include a timely call to significantly reduce the burden of noncommunicable diseases (NCDs) • Existing policy guidance highlights cost-effective interventions for NCDs, but focusing just on costeffectiveness risks exacerbating socioeconomic and health inequalities rather than reducing them • In implementing the SDGs, targets and interventions that benefit the worst off should be prioritised • The United Nations should develop practical guidance to assist policy makers at the country level with incorporating equity considerations. Citation: Schmidt H, Barnhill A (2015) Equity and Noncommunicable Disease Reduction under the
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Sustainable Development Goals. PLoS Med 12(9): e1001872. doi:10.1371/journal.pmed.1001872 Published: September 8, 2015 Copyright: © 2015 Schmidt, Barnhill. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited Funding: No funding was received for this work. Competing interests: The authors have declared that no competing interests exist. Abbreviations: FCTC, Framework Convention on Tobacco Control; GA, General Assembly; LDC, least developed country; MDG, Millennium Development Goal; NCD, noncommunicable disease; SDG, Sustainable Development Goal; SIDS, small island developing states; TRIPS, Trade-Related Aspects of Intellectual Property Rights; UHC, universal health coverage; VIA, visual inspection with acetic acid; WHO, World Health Organisation Provenance: Not commissioned; externally peer-reviewed
Open Access to a High-Quality, Impartial, Point-of-Care Medical Summary Would Save Lives: Why Does It Not Exist? Authors: James Heilman, Faculty of Medicine, Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada, Wikipedian at WikipediaCitation: The PLOS Medicine Editors (2015) Point-of-Care Information in Open Access: A Time to Sow? PLoS Med 12(8): e1001870. doi:10.1371/journal.pmed.1001870 Summary Points • Currently no open access point-of-care (POC) medical summary aimed at a professional audience exists • Some nonprofit and multiple professional, for-profit POC medical summaries are frequently accessed by clinicians and policymakers • Efforts to create open access POC summaries have been stymied by the difficulty of attracting highquality contributors • The open access medical publishing community can create this resource with engaged donors, crowd-sourcing, and technology. Citation: Heilman J (2015) Open Access to a High-Quality, Impartial, Point-of-Care Medical Summary Would Save Lives: Why Does It Not Exist? PLoS Med 12(8): e1001868. doi:10.1371/journal.pmed.1001868
distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited Funding: No funding was received for this work. Competing interests: I have read the journal's policy and have the following conflicts. I have no financial competing interests. Non-financial conflicts of interest include the following: I am a long-term editor of Wikipedia; I am president of Wiki Project Med Foundation, an NGO that supports the improvement of Wikipedia's medical content; and I speak on the topic of Wikipedia and medicine at conferences, for which I do not receive honorariums, but I have previously received some travel support from the NIH, UCSF, WMF, and Cochrane Collaboration. In July of 2015 I became a Board Member of the Wikimedia Foundation, the not-for-profit that runs Wikipedia. Abbreviations: BY, by attribution; CC, creative commons; NC, non-commercial; ND, no-derivatives; NGO, non-governmental organisation; OA, open access; POC, point of care; SA, share-alike Provenance: Commissioned; externally peer reviewed
Published: August 25, 2015 Copyright: © 2015 James Heilman. This is an open access article
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Products&Services
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Information Technology Computer Sciences Corp .......................................................IFC GlobalData...............................................................................10 HIMSS Asia Pacific 2016................................................ 08 & 09 Medical Fair Asia 2016............................................. IBC, 30 & 31 Medica Germany 2015.............................................................03 Zebra Technologies.................................................OBC, 48 & 49 Company................................................................... Page No. Computer Sciences Corp.........................................................IFC www.csc.com GlobalData...............................................................................10 www.globaldata.com Greiner Bio-One GmbH.................................................... 42 & 43 www.gbo.com HIMSS Asia Pacific 2016................................................ 08 & 09 www.himssasiapac.org Indian School of Business Management...................................41 www.isbm.org.in Medical Fair Asia 2016............................................. IBC, 30 & 31 www.medicalfair-asia.com Medica Germany 2015 . ..........................................................03 www.medica-tradefair.com Zebra Technologies.................................................OBC, 48 & 49 www.zebraapac.com/healthcare 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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