Asian Hospital & Healthcare Management - Issue 33 by Ochre Media Pvt. Ltd.

I s s u e 33

2016

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2nd Edition

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Foreword Managing Change For successful transitions “It's never easy but is always necessary. Culture change is harder than trying to go in and fix something. But culture change is important because otherwise you don't have sustainability,"—Joseph Fortuna, Chair of the American Society for Quality's Healthcare Division. Change is an essential concept for any organisation. However, managing change is not an easy task. Willingness, ability and leadership play a key role in adapting to changes. Care providers need to actively identify problems and resolve issues. Despite the willingness of healthcare leaders to change an organisation’s environment, they are sometimes let down by the inability to change. Proper co-operation from all the teams and availability of resources also matter, identifying areas of change and initiating change become difficult in such situations. Change management models need to be created according to the requirements of the organisation. Understanding the status quo using detailed research and planning and evaluating communication needs are critical to successful change management. The process of managing change to attain desired change includes developing and deploying plans to address, mitigate and overcome barriers. Where change really begins also matters. Engaging right people in the right place for the right entity is very important. Irrespective of the level—top management, middle level or bottom line—organisations will need to develop proactive strategies to recruit new people, implement new goals, develop leaders to meet consumer demands with an eye on cost efficiencies and quality of the care.

Numerous theories of how people respond to change and the various models used to plan successful change processes have been developed so far. Most change models focus on the organisation finding a reason and need for the change with a vision or desired business result. Some theories also address the concept of changing or creating organisational processes to deliver change. To remain competitive in the current market, healthcare organisations need to undergo changes almost constantly. Aligning with new technology, effective communication, addressing potential resistance and teamwork can drive successful change management. In the cover story of this issue, Professor of Harvard University, University of Monterrey Business School, David A Shore shares his views about the change resister: those saboteurs who are harmful to the health of next innovation. A current or future healthcare leader must understand that success will not be possible unless you leverage resistance management strategies en route to converting that large body of change resisters into change insisters. For feedback on the cover story and other articles in this issue, please reach me at prasanthi@ochre-media.com.

Prasanthi Potluri

Editor

Contents HEALTHCARE MANAGEMENT

Cover Story 20 Managing Change

An essential element of healthcare success David A Shore, Professor, Harvard University, University of Monterrey Business School, Mexico

04 A Guide to Guard Exploring different approaches for engaging physician leaders to deliver cost-effective and high quality care Jimmy Y Chung, Board Certified General Surgeon, US

10 China's Private Hospitals Set for Growth Pete Read, CEO, Global Growth Markets, China

16 Are Healthcare Professionals Prepared to Succeed? Amogh Deshmukh, Member key leadership team, DDI, India

FACILITIES & OPERATIONS MANAGEMENT 26 Lean Operational Planning in the Design of Ambulatory Care Centers For high quality building Marvina Williams, Senior Healthcare Operations Planner, Perkins+Will, US

INFORMATION TECHNOLOGY

32 Designing Hospital Information Systems An overview SB Bhattacharyya, Member, National EHR Standards Committee, MoH&FW, Govt of India

38 Universal Interface for Electronic Medical Records for Developing Countries Abu Md Akteruzzaman Bhuiyan, Health Informatics Expert, Bangladesh University for Health Sciences, Bangladesh, India Pradeep Ray, Director, WHO Collaborating Centre on eHealth, UNSW, Australia

42 The Future of Wearables Amy Cueva, Founder & Chief Experience Officer, Mad*Pow, US Chris Hass, Sr. VP of Experience Design, Mad*Pow, US

48 Research Insights 54 Events 56 Books

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Advisory Board

Editor Prasanthi Potluri Editorial Team Grace Jones Karishma Kumar Sasidhar Pilli Art Director M A Hannan Product Manager Jeff Kenney Product Associate David Nelson John Milton Circulation Team Naveen M Sam Smith John E Adler Professor Neurosurgery and Director Radiosurgery and Stereotactic Surgery Stanford University School of Medicine, USA

Sandy Lutz Director PricewaterhouseCoopers Health Research Institute, USA

Subscriptions In-charge Vijay Kumar Gaddam IT Team Jareena K Ranganayakulu.V Sitaram Y Uday V Head-Operations S V Nageswara Rao

Peter Gross Chair, Board of Managers HackensackAlliance ACO, USA Asian Hospital & Healthcare Management is published by

In Association with

A member of

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

Confederation of Indian Industry

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A Guide to Guard

Exploring different approaches for engaging physician leaders to deliver cost-effective and high quality care The evolution of our healthcare system from a volume-based to a value-based model is driving provider organisations to adopt patient-centric, outcomes-based success metrics for operational processes in both acute and non-acute settings. Within this new paradigm, physician leadership is an essential component of traditionally ‘non-clinical’ healthcare entities, like supply chain. How to define, develop, and integrate these physician leaders into this model is a new challenge that all organisations must now face. Jimmy Y Chung, Board Certified General Surgeon, US

hen the Institute of Medicine published ‘To Err is Human: Building a Safer Health System’ in 1999, the report received a broad range of responses. This was the first time most Americans had even heard of medical errors, let alone that preventable errors were the cause of almost 100,000 deaths and cost US$17-29 billion in unnecessary healthcare expenses. The federal government acted swiftly, by holding Congressional hearings, creating task forces, and appropriating US$50 million to the Agency for Healthcare Research and Quality (AHRQ) to study ways to reduce errors. The goal was to reduce errors by 50 per cent within five

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years by implementing improvement programmes and establish a culture of safety in the US healthcare systems. Physicians, on the other hand, initially retorted with skepticism, arguing essentially that the data is faulty and dependent on how the terms ‘error’ and ‘preventable’ are defined. Despite the initial denial, the fact that preventable medical errors is still the third highest cause of deaths in the United States (behind heart disease and cancer) is indisputable and serves as the cornerstone for a monumental reform in the way we deliver and pay for healthcare. Sixteen years later, however, there has been no significant improvement in healthcare quality despite all the work

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that has been put in by thousands of very dedicated people in the industry. So-called ‘never events,’ healthcareassociated infections, socioeconomic disparity in access to care, and wide variations in practice still occur daily at alarming levels. A study published in 2013 estimated that over 4000 surgical never events still occur annually. Furthermore, the cost of healthcare is still climbing uncontrollably with no correlation to improvement in the quality of care. According to the Centers for Medicare and Medicaid Services, healthcare spending accounted for 17.5 per cent of Gross Domestic Product in 2014 and is expected to increase each year. This is the highest rate amongst

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all developed nations (Netherlands is second at 12.9 per cent). New Medicare payment models, including Value-based Purchasing, are placing greater emphasis on patient safety and outcomes. Hospitals and providers are assuming a larger share of risk for the populations they serve. Hence, the need to integrate physician leaders into financial and operational strategies is greater than ever before. But How?

The role of physicians in controlling the cost of care is not well defined in most healthcare organisations, but can be described through these functions:

1. Improving quality of care 2. Reducing unnecessary variation 3. Creating a culture of high reliability. Improving the quality of care has greater meaning than just becoming a better doctor or safer hospital. To quote former CMS Administrator Donald Berwick, MD, "Most of what you do in your life is better today and less expensive because we have figured out a better way to do it. The same applies in healthcare.â&#x20AC;? This suggests that focusing primarily on quality improvement will result in considerable reduction of

cost; however, the opposite is not necessarily true. For physicians, quality improvement is achieved through a variety of strategies. These may include a more robust process for credentialing and privileging physicians, a structured effort to analyse physician-specific performance and cost data, implementing standardised evidence-based care pathways and participating in quality registries like the National Surgical Quality Improvement Program (NSQIP). A recent study reported that hospitals that participated in NSQIP for at least three years saw an estimated

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annual reduction of 0.8 per cent, 3.1 per cent, and 2.6 per cent for mortality, morbidity, and surgical site infections, respectively. Reducing unnecessary variation can be a challenge in the surgical culture, where the surgical training environment has often encouraged residents to take pride in the unique approaches taught by their institutions. While this practice creates fodder for much name-dropping and social exchanges of folklore at surgical society meetings, there is a potent risk in promoting variation in practice among surgeons. For example, surgeon-specific practice variation in spine surgery has been shown to be a significant factor in patient outcomes, including hospital length of stay and blood transfusions. Also, a recent survey showed significant variation in the reporting of adverse patient events by residents and that remarkable improvements can be achieved by using a multifaceted intervention approach. From a financial standpoint, variation in practice also leads to unnecessary inventory needs that cause waste and squander opportunities to use large scales of economy as leverage when negotiating with vendors. Clearly, the need for standardisation to improve patient safety and reduce costs by addressing unnecessary variation in surgical practice is paramount to the success of healthcare providers, but these efforts are challenged by surgeons’ (mis) education, experience, inertia and misaligned interests that often cause resistance to change, despite the lack of clinical evidence to support these differences. This is where physician leadership is needed. Medical staff leadership, for example, can utilise the Ongoing Professional Practice Evaluation, a mandatory process required by the Joint Commission for physician credentialing, since one of the core

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In the context of supply chain management, value analysis must be primarily a clinical quality improvement strategy, not a cost reduction strategy.

competencies is ‘System-based Practice.’ This process can be used as a tool to incentivise physicians to practice evidence-based, cost-conscious care for their patients. What is Clinical Value Analysis?

As acute care organisations are beginning to transform into population health management organisations or accountable care organisations, a new role for physician leadership is arising in the supply chain. To simplify, ‘value’ can be defined as a simple equation of quality and outcomes divided by cost. Historically, physicians have ignored or have been shielded from cost, focusing mostly on the quality of their care and the products they use to treat patients. Although the medical education culture has traditionally scoffed at the idea of considering cost as a factor in medical decision-making, the transition to value-based care is bringing cost to the forefront of medical practice. Traditionally seen as a cost-cutting tool for supply chain, Value Analysis has focused on finding ways to cut costs by standardising materials and medical products wherever possible, typically within the walls of the

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hospital. Commodities such as gauze, IV supplies and bedpans can easily be reduced to a single vendor, but products that physicians commonly request (the so-called “physician preference items,” or PPIs) are more difficult to standardize because hospitals often lack the skills or leadership to engage physicians in supply chain discussions. Additionally, physicians are generally excluded from supply chain activities. One study showed that while 95 per cent of hospitals have a Value Analysis team, only 20 per cent of these teams are led by physicians, and they tend to have better performance than those without physician leaders. In general, most hospitals offered no significant incentives for physicians to help improve supply chain efficiency. Furthermore, not all value analysis teams addressed PPIs. A 2012 survey of 4,500 hospitals showed that 64 per cent of hospitals were using such teams to evaluate and select PPI’s. The future of physician leadership in value analysis is already written on the walls. In its recent white paper, ‘Value Analysis—A New Model for Healthcare’, Strategic Marketplace Initiative (SMI), a collaboration of healthcare providers and suppliers, stated that, “Value Analysis programmes focused solely on cost reduction may not be optimally positioned to produce sustainable benefits over the long term, as modern supply chain and Value Analysis leaders recognise that a programme must balance its focus on cost, quality and outcomes.” Current State of Involvement

Many healthcare organisations realised that Physician Leadership was necessary to manage PPI standardisation. However, they generally approached the issue in one of three ways: 1. They engaged the chief medical officer in cost-cutting initiatives or in product evaluation committees 2. They asked the service line medical

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director to standardise a particular medical product being used by that speciality 3. They engaged a high-volume surgeon to use his or her influence to persuade other surgeons to use his or her preferred product. Perhaps a major fallacy that sets them up for failure is that hospital administrators generally believe that physicians do not wish to be ‘bothered’ with business issues. However, a survey by Physician Wellness Services (now Vital WorkLife for Physicians) in 2014 showed that most physicians want to be engaged in hospital operations and that they felt a large gap existed in their ability to have a voice in clinical operations and processes. Another survey of 2300 physician leaders conducted by the American Association for Physician Leadership revealed that 90 per cent of respondents felt the business knowledge in understanding finances and access to capital is important or very important. A bigger factor in this gap may be the lack of cost-transparency. A survey of 503 orthopaedic surgeons at seven major medical centres in the United States showed that only about 21 per cent of the surgeons were able to correctly estimate the cost of implants within 20 per cent of the actual cost. Hospital administrators have long understood that cost is a major factor of value, but sometimes have not realised that the quality of a particular category of products varied in ways beyond just workmanship and materials.

Lean, simply stated, is the creation of value through elimination of waste. Everything from reducing inventory to eliminating unnecessary motion leads to improved patient outcomes and savings for the hospital. On one hand, this is an incredibly powerful tool for hospitals that are trying to meet the regulatory requirements for value-based purchasing and other pay-for-performance programs. On the other hand, implementing lean requires a total cultural change and support from physicians, which can be difficult to achieve. Organisations that focus on supply chain, such as the Association for Healthcare Resource & Materials Management, Association of Healthcare Value Analysis Professionals, Strategic Marketplace Initiative and others, are driving healthcare supply chain toward a maturation model that leads to a patientcentred, value-creating network. What this means is that ultimately, as healthcare organisations evolve into population health management companies, the total cost of care will be determined by patient outcomes. Already, metrics such as length of stay, 30-day readmission rates, complications, hospital-acquired conditions and mortality rates are being used to determine reimbursements. Hospitals will need to look beyond just the price of their supplies and labor costs to determine the true cost, and thus the true value of the care they provide.

In 2002, Virginia Mason Medical Center in Seattle was the first healthcare organisation to officially adopt the ‘lean principles’ of the Toyota Production System. Other hospitals soon followed, and ‘lean’ rapidly became the hot topic in patient safety and cost reduction in healthcare.

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Author BIO

The Future of Value

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Physicians must take the lead in this new model, as no one else is better positioned and trained to manage patient outcomes. Indeed, as physicians, it is our duty to take ownership of patient outcomes. Much has been written about the direct relationship between quality improvement and cost reduction. physician leaders can lead quality improvement programmes for the sake of their patients, which in turn will lead to overall cost reduction and vice versa. In the context of supply chain management, value analysis must be primarily a clinical quality improvement strategy, not a cost reduction strategy. It is not entirely clear what this best-practice model of physician leadership should be for supply chain management. physician leadership in supply chain value analysis is itself not a “standard’ role. There are very few physicians actually in supply chain leadership roles, and their titles and reporting structures vary significantly. Some positions are that of part-time advisors whereas others are full-time senior executives. However, supply chain administrators have historically led value analysis programmes. In the new world of patient-centred, valuebased care, it is now up to physicians to step up and take ownership of the process to optimise the value of healthcare for our patients. References are available at www.asianhhm.com

Jimmy Chung is Board Certified Surgery and Health Care Quality Management, and is a fellow of the American College of Surgeons. He is a member of the Technology and Value Assessment Committee of the Society of American Gastrointestinal and Endoscopic Surgeons and recently elected to the Board of Director of the Association for Healthcare Resource & Materials Management (AHRMM). He has spoken at numerous conferences around the country as an expert on development of physician leadership in optimising the cost, quality, and outcomes of healthcare.

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02 Pete - Edited

China's Private Hospitals Set for Growth

Changing demographics and lifestyles in China are the reasons behind emerging opportunities for foreign companies to operate hospitals, clinics and care homes in the country. And the need is now widening to include primary care, rehabilitation and elder care. The range of incentives for foreign investors is increasingly wide. But there remain hurdles to be overcome. Pete Read, CEO, Global Growth Markets, China

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n China over the past 20 years, rapid change has been a constant theme. These changes have now, finally, reached the healthcare services sector. As a result, many new opportunities are emerging for foreign companies interested in operating hospitals, clinics and care homes in China. In the 1990s, we saw a boom in foreign investment in many different sectors, from hotels to cars to beer

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industry. In the decade from 2000 to 2010, China was known to become the factory of the world. Foreign companies like Philips and Sanofi invested in manufacturing and selling pharmaceuticals and medical devices, both locally and for export, eventually coming to dominate the local branded pharma and medical device markets. But other sectors, including healthcare services, remained largely closed to foreign companies. Now, the domestic market is becoming an ever more important driver of growth. Consumer consumption is the key. This means changing lifestyles, less healthy eating habits, less exercise, less Tai Qi and more TV. And as a result, more: Non-Communicable Diseases (NCD). Coupled with an ageing population which will see 47 per cent more people, aged over 40 in 2024, than in 2014, and the lack of a well-structured and appropriately-resourced primary care system, this is placing China’s healthcare sector under great strain. While these trends are not unique to China—we see a similar pattern in India, Southeast Asia, the UK and the US for example—China’s healthcare services sector is struggling to cope with demand. In response, the government is now allowing greater scope for market forces to operate and opening up the private hospital sector to foreign investment to help relieve that pressure.

putting huge pressure on China’s already weak healthcare system. China already has five cities with a population of over 10 million: Beijing, Tianjin, Shanghai, Shenzhen and Guangzhou. By contrast, India has only three, and the US has just two. China also has 14 cities with a population of more than 5 million. But only about 54 per cent of China’s 1.4 billion population lives in cities —compared to 80 per cent in most developed countries—and this figure is set to hit 60 per cent by 2020. This will continue to create huge urban markets for healthcare of all types. Meeting healthcare demands in the urban areas is already a huge challenge, but at the same time the government is aiming to improve healthcare in rural areas and at ‘grassroots’ level, creating opportunities for companies there. While health spending is much higher in urban areas, the share of spend in rural areas is now increasing. This current situation, with such a great need for new medical institutions, is a once in a lifetime window of opportunity for both local and foreign hospital groups and investors, as the scale of healthcare infrastructure that the country needs is huge.

Private hospitals in China tend to be smaller than public hospitals. Almost 90 per cent of them have fewer than 100 beds, and there are very few large private hospitals with more than 500 beds. By contrast, more than half the public hospitals have over 100 beds, and there are 2,000 ‘Level III’ large public tertiary hospitals. China Hospitals by Ownership and Bed Size

Six out of every ten private hospitals are specialised in China. As a result, the private sector is very important when it comes to delivering specialised care such as Traditional Chinese Medicine, maternity services and orthopaedic treatment. There are also hundreds of specialised eye hospitals, dental hospitals, plastic surgery hospitals and rehabilitation hospitals around the country, among others. Foreign Investment

Looking more closely at the investment opportunity in healthcare services, a wave of foreign investments in secondary care has already started, with some organisations already pushing into tertiary care. The opportunities

The Private Hospital Landscape

There are now about 26,000 hospitals in China, more than in any other country; 60 per cent are public and 40 per cent are in the private sector. China has about 10,000 private hospitals which are already in operation, and several hundred are opening or being upgraded from clinics to hospital status every year. The rapid rate of urbanisation is driving growth and demand for healthcare and at the same time is

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are now widening to include primary care, rehabilitation and elder care. Rehabilitation and elder care are currently big growth areas, as the Chinese government is seeking to find ways to reduce the impending stress these areas are expecting, as demographic and disease profile changes take effect in the coming years. Many foreign hospital groups are now investing in China, including Columbia from the US, IHG, Optegra and Sinophi from the UK, IHH from Malaysia with its well-known Parkway brand, Raffles Group from Singapore, and Ramsay from Australia. And many of the facilities in creation are world class. Healthcare Reforms

There are two main themes in China’s healthcare reforms that are currently under way: First, improving the public sector, and second, allowing market forces to come into play. China’s government is hoping that foreign investment will relieve the burden on the public sector, and close the gap in availability of care between East and West China. That is partly

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Most notably, China’s private healthcare sector decision-makers and influencers are getting behind health IT and interoperability, electronic medical records, diagnostic imaging and mobile health technologies.

why we are now seeing a rise in private sector hospitals in West China. For example, more than half of the hospitals in the western provinces of Sichuan, Guizhou and Yunnan are privately owned. In almost all other provinces, healthcare provision is dominated by public sector institutions. Reforms were first announced five years ago and investment momentum

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started to build in 2011, but it was only in 2014 that the government announced it would be “reducing restrictions on foreign ownership in medical Joint Ventures (JVs) and collaborations”. Later in the same year 100 per cent foreign ownership became possible, and the first wholly foreign-owned hospital was established by German company Artemedin in Shanghai Free Trade Zone. Private Hospitals and Digital Health

In a 2015 Global Growth Markets survey about Digital Health among hospital doctors and managers in China, and other countries in Asia, analysts found a very high level of support for digital health in China. In fact, it was the highest in the region, with 48 per cent of respondents saying that they believe various aspects of digital health are likely to improve patient outcomes in the next three to five years. The average for Asia as a whole was only 23 per cent. It appears that China’s clinicians and hospital management have recognised health tech as one possible solution which could contribute to alleviating

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Investment Incentives

The range of incentives for foreign investors is increasingly wide. Relaxing restrictions on foreign ownership is the starting point. In 2015 it was announced that 100 per cent ownership would be allowed in some select locations, namely Beijing, Tianjin, Shanghai, Jiangsu, Fujian, Guangdong and Hainan. Notably these are all major markets for healthcare services with rapidly expanding middle class and affluent populations possessing the means to spend on private healthcare services. Hainan—a tropical island province to the south of the Chinese mainland—is also the location selected for heavy government investment in facilities for inbound medical tourism. There are now financial incentives available, such as allowing capital from private equity and other sources, allowing equipment leasing rather than purchasing—which means lower up-front investment for hospital operators—and reimbursement from public insurance for care services provided by the private sector. It is also becoming easier to employ foreign doctors. And at the political level, healthcare is near the top of the agenda. This was

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evident when President Xi Jinping and Vice Premier Liu Yandong visited the UK in mid/late 2015. Attracting inward investment in healthcare services and bringing the UK’s National Health Service expertise to China were important themes for this visit and resulted in the announcement of billions of dollars of investment commitments. These are currently being led by the UK’s International Hospitals Group (IHG) and China’s Wanda Group – a 10-year exclusive partnership that involves building and managing the new 200 bed IHG Qingdao International Hospital and future projects in Shanghai and Chengdu. Hurdles

There are, of course, also many hurdles to be overcome by aspiring investors. Rules set by Beijing are implemented in practice at the provincial or city level, meaning the eventual reality on the ground may be quite different from the theoretical letter of the law as written by central government mandarins. The practical application of many of the investment incentives mentioned above is often not a simple issue. For example, an investor may gain permission to establish a children’s hospital while at the same time, regulations may prevent the same investor from employing any paediatricians. Restrictions—both written and unwritten—on doctors working in the private sector present a major issue for private hospital employers. The vast majority of doctors are used to the concept of a job for life in the public sector, along with the loyalty that implies, and are reluctant to jeopardise

Author BIO

some of the huge challenges healthcare is facing in the country. In the public sector, telemedicine is the technology which is attracting most attention, as national telemedicine initiatives are developed. But it is in the private sector that a much broader level of support for a variety of different digital health technologies is emerging. Most notably, China’s private healthcare sector decision-makers and influencers are getting behind health IT and interoperability, electronic medical records, diagnostic imaging and mobile health technologies. For example, medical imaging was mentioned by 75 per cent of respondents from private hospitals but only 53 per cent from public hospitals.

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their position by taking work in the private sector. Unrealistic expectations among investment partners—both foreign investors and their Chinese counterparts —and a lack of experience among Chinese hospital managers in private hospital group management are also regular sources of difficulties. A good example of this is Ramsay Health Care’s scrapping of its proposed hospital joint venture in Chengdu in March 2016 due to ‘a number of threshold conditions precedent not being satisfied’. The private hospital operator, along with Malaysian partner Sime Darby Bhd, had signed a deal in May 2015 to invest US$135 million in a joint venture with Chinese healthcare group Chengdu Jinxin Healthcare Investment. Finally, while 95 per cent of the population now has some form of state health insurance, the reimbursement level is often not enough to pay for private care, even though regulations may allow spending public money to pay for private care. People and Patients

Ultimately, healthcare is about people and about patients. China is becoming older, with 166 million more people aged over 40 by 2024 – a huge increase. Lifestyles are changing, more and more people have NCDs such as diabetes and hypertension, and the healthcare system is under huge pressure. It is fortunate, though perhaps ironic, that the increase in wealth which is partly the cause of these lifestyle diseases will also allow millions of people to pay for private healthcare.

Pete Read is CEO of market information company Global Growth Markets (GGM). He specialises in China and other emerging markets and has led many assignments for some of the most successful healthcare companies. GGM delivers market data and insights primarily in healthcare and med tech, helping companies to succeed in their targeted growth markets.

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Are Healthcare Professionals Prepared to Succeed? Innovation within recruitment and talent development should gain greater momentum, widening its remit to drive change, improvement and forward thinking. Amogh Deshmukh, Member key leadership team, DDI, India

nlike a few decades ago, the Indian healthcare industry is attracting more and more companies looking to enhance their operations in the country, thereby creating a huge need for talented employees. There are challenges ahead such as variation in health facilities between urban and rural areas, variation in public and private health services, and issues of regulation. Nevertheless, the industry is embracing infrastructural transformation coupled with highend technological services and vital policy amendments and is targeting sustainable growth by 2030. Healthcare is expected to be one of the fastest growing sectors and in order to be a strong ecosystem it will need systemic changes supported by investor-friendly policies and collaborations. Whilst most industries develop products and services keeping customer at the centre of everything, healthcare has traditionally been paternalistic in nature. However, the approach is shifting due to the changing nature of medicine, growing patient awareness and increasing penetration of the Internet. The industry is now talking about ‘Patient-Centered Care’, ‘PersonCentered Engagement’, and ‘Consumer

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Engagement’. In the move towards a patient-centric model, the healthcare workforce has a critical role in embracing this change and making the shift. As patients become more informed, they are demanding uniform access to care and lower associated costs. Many countries are struggling to make incremental changes to address increasing costs, poor or inconsistent quality and inaccessibility to timely care, while other countries believe the only cure to this is a fundamental transformation of healthcare. Resolving these issues is a daunting task. Development Dimensions International (DDI) is a leading talent management consultancy which specialises in supporting healthcare companies get ready for the future. DDI recently released its global research ‘High-Resolution Leadership’, which draws on assessment data of over 15,000 candidates for five leadership levels: frontline, mid-level, operational, strategic executive, and C-suite executive across 20 industries and 300 organisations. One research finding (see the chart) looks across a mix of industries in relation with the core leadership skills/competencies. This detailed look at the leadership skill variation

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“Health is being ‘embedded’ in the growth story of the country as India charts an impressive growth curve that is being recognized at various global platforms.” JP Nadda Union Health Minister offers a high level perspective on each industry’s readiness to meet their unique business challenges. One key differentiation among industries is with respect to the degree of pressurest hey had experienced and how much technological and demand uncertainty faced. Harvard Business Review labelled these differentiators as the VUCA Index (Volatility, Uncertainty, Complexity, and Ambiguity) and we incorporated it in the cross-industry summary to add one more layer of nuance. What came out very clearly as a driving force for healthcare leaders is that they are strong in building organisational talent, customer focus and driving execution which are all critical for the healthcare industry success.

HEALT HCARE MANAGEMENT

Chart 1

Accelerating the Development of Key Leadership Skills

Building organisational talent involves assessing the key strengths and gaps of current talent pipeline. Leaders who are strong in this area are able to determine the mix of talent required by the organisation to support current and future clinical, business objectives. The starting point is recruitment: leaders should attract and recruit internal and external talent to ensure that the organisation is appropriately staffed. They are required to initiate strategies to develop internal talent while balancing the effort with external hiring. Strong leaders target challenging developmental assignments that build individual confidence and organisational capability. Customer Focus is a driving force behind strategic priorities and organisational processes. Leaders who are strong in this area make sure that the internal and external customerâ&#x20AC;&#x2122;s

perspective is heard. They craft and implement service practices that meet customersâ&#x20AC;&#x2122; needs. They encourage taking personal responsibility for satisfying customers as a value and believe that customer focus should be the organisation's highest priority. Driving Execution is a crucial skill to have in order to translate strategic priorities into operational reality. Leaders who are strong in this area have the capacity to align communication, accountabilities, resource capabilities, internal processes, and ongoing measurement systems to ensure that strategic priorities yield measurable and sustainable results. Healthcare organisations have most current leaders ready for building future talent and should continue to bolster this skill. If you think you are a healthcare professional who does not match the skillset, it is time to take immediate steps to remedy the deficiencies in this area to avoid severe

risks for internal pipeline of future leaders for the organisation. Letâ&#x20AC;&#x2122;s direct our attention now to THE GAP / Weakness of healthcare, comparing compared to other industries. The leaders in the healthcare industry lag other industries in being business savvy, initiating coaching and developing others. If you are a leader in a healthcare organisation this information gives you a competitive advantage as you can immediately start working to narrow that gap. How to Develop Workforce Skills

Business savvy is a key skill needed to drive execution and customer focus. Leaders who lack this ability do not have the horse power to take the organisation from strength to strength when the organisation might demand 2X or 3X growth due to their sheer inability to understand their own business. This weakness will eventually build pressure on the top management as we find this

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HEALTHCARE MANAGEMENT

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Top - and Bottom - Ranked Industries Across Leader Skills

Chart

way of building skills over a period of time. To accomplish these bold goals, healthcare organisations need to make informed hiring decisions based on solid diagnostic assessments and then guide their employee development journey. Incorporating research-based tools into selection and promotion processes will be particularly valuable for industries with weaker skill profiles. The need to craft and implement a robust talent management process is crucial in the healthcare industry especially in the current environment. Dynamic organisations face greater risk of not having the talent they need. The leadership capabilities demanded

Author BIO

layer of leaders lacking strategic depth and ability to execute strategy well. This competency needs to be developed through experiential learning and personal mentoring by top management of the organisation. Leaders need to demonstrate a keen understanding of basic business operations and of the organisational levers including systems, processes, departments and functions that drive profitable growth. Leaders who master this skill will be able to learn from their personal experiences helping them quickly evaluate business plans and processes to identify data or recommendations that need further investigation. Coaching and developing others is a weak area for healthcare in comparison to other sectors like finance and retail. Today with the kind of manpower and scale of education in healthcare, we need leaders who are good at coaching and developing their teams, leaders who know how to provide development feedback and guidance to help others excel in their current or future job responsibilities. Leaders, who are strong in this area, are good at supporting the development of their subordinates. They do not limit their conversations to being transactional but conveying performance expectations and implications on a timely basis, helping subordinates evaluate misalignment, without ignoring the responsibility to support them in their development journey. In conclusion, with no development or poor development focus, we will not have adequate number of leaders required to deal with the growth in the healthcare industry. Leaders will have to broaden their mindset and think beyond functional and operational areas. They might want to look at some macro level data like market drivers and customer trends to make informed decisions. Leaders might be good at leading their functions and departments, but should also look at development of team members by

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by changing businesses are quite different and less common than those needed in more stable environments. Innovation within recruitment and talent development should gain greater momentum, widening its remit to drive change, improvement and forward thinking. As the healthcare industry is evolving in India, managing talent is becoming more crucial to the success and sustainability of all healthcare organisations. DDI works closely with these organisations to help hire and retain exceptional talent, develop leaders, help them make confident decisions and identify potential talent for future.

Amogh heads the sales and marketing division that works with clients in many different industries across India. He represents the needs of our clients within DDI as well as speaking for DDI to our clients. With more than 10 years of experience Amogh Deshmukh worked across sectors like IT, ITES, Human Resource Consulting.

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Cover Story

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HEALT HCARE MANAGEMENT

Managing Change

An essential element of healthcare success No surgeon would ever enter the operating room without a refined understanding of the relevant anatomy and physiology. Yet, one of the most compelling reasons for the chronically high failure rates of change initiatives is a limited appreciation for the fact that the focus and skills necessary to operate an organisation are very different than the focus and skills needed to change an organisation. This article spotlights the change resister: those saboteurs who are harmful to the health of next innovation. David A Shore, Professor, Harvard University, University of Monterrey Business School, Mexico

magine the healthcare leadership that says, “We want to be the best; but we don’t want to change anything.” Sadly, this is a sentiment echoed far too often throughout the healthcare delivery organisations. Of course, sometimes it takes a different

tone, such as the hospital manager that proclaimed, “We all know that things need to change around here… and those guys better get started.” And then there is the health system CFO who began his quarterly financial report to the board of directors by observing that

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the system “is not very good at being agile.” He then proceeded to deliver the worst financials in thirteen quarters. This comes at a time when it has become abundantly clear throughout the world that healthcare is in need of significant change. Healthcare reform legislation and reform initiatives are everywhere, with ‘reform’, simply being the political term for ’change’. What is equally clear is that more often than not, change initiatives fail and with it, the promises of faster, cheaper, better, safer healthcare are not realised benefits are denied. Hundreds of innovative postmortems reveal multiple critical failure factors. However, one factor is prominent in determining why most innovations are more likely to disappoint than delight. At the root of the problem is the glaring reality that for many, all change is bad, even when it is good. For these resisters, they would rather fight than change. Change resisters are the most common thieves of successful change initiatives. Alternatively, a prevailing signature of Higher Performing Healthcare Organisations (HPHOs) is they work very hard to both identify and overcome resistance to change. While working with organisations wishing

The Semmelweis Reflex

To become a high performing healthcare organisation you must understand that you are not solely conformed to healthcare business, you are also in the innovation business – keeping up with and leading innovation.

to transition to HPHOs, I encourage them to constantly ask questions such as: • How do we ignite innovation • How do we move from a Type S – Static organisation to a Type A – Agile organisation • How do we move our workmates from change resisters to change insisters? My final question and perhaps the most important is, “Have you heard of Ignaz Semmelweis?” If the answer is no, (as it almost always is) it is where we begin.

Ignaz Semmelweis was a Hungarian obstetrician who attempted to introduce the new evidence-based practice of hand washing into medical care in the mid-1800s. It is worth noting he practiced teaching and research at Vienna General Hospital. The mortality rate on his ward was one per 10 people. It is estimated that in Vienna alone, during the time 2,000 women died each year from ‘childbed’ or Puerperal fever. More than half the women who contracted the disease died within days. Patients begged to be moved out of Semmelweis’ section and onto a second section of the maternity ward where the mortality rate was one in 50. Why did such a profound variance exist? One obvious difference between the sections was that Semmelweis’ was attended by physicians, while the other section was staffed by midwives. As an academic medical centre, doctors divided their time between research on cadavers in the morning and treating patients in the afternoon. Midwives would not perform autopsies. Semmelweis concluded that ‘particles’ from cadavers and other diseased patients were being transmitted to patients through the hands of the physicians. His innovation – he instituted a policy

Managing Change in Healthcare Using Action Research(1st Edition ) Editor: Paul Parkin No of Pages: 248 Year of Publishing: 2009 Description: The management of change in the context of new policy directives and agendas is a critical issue for healthcare practitioners. All professionals? not just managers - need to develop and implement new services designed to bring patients into the centre of healthcare delivery. This book looks at the leadership, interpersonal, and management skills needed to manage such change effectively within multi-professional healthcare settings.

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HEALT HCARE MANAGEMENT

Managing Disruptive Change in Healthcare Lessons from a Public-Private Partnership to Advance Cancer Care and Research Editors: Arnold D Kaluzny, Donna M O'Brien No of Pages: 352 Year of Publishing: 2015 Description: Healthcare faces unprecedented global challenges. Rapid advances in genomics, computational sciences, and technology â&#x20AC;&#x201D; as well as the new focus on value-based care and an increased trend toward healthcare commercialization â&#x20AC;&#x201D; represent disruptive changes to an already-fragmented delivery system. The healthcare establishment has been slow to adapt, and now faces rising cancer-care costs and lags in outcome improvement and genomically informed interventions.

requiring physicians to wash their hands thoroughly with chlorine lime solution before examining any patient. This innovation yielded a precipitous drop in the death rate in his section from one in 10 to one in 100! And how was the good doctor rewarded? He was dismissed from his post at the clinic and turned down

for a teaching appointment. Despite demonstrating similar results in another hospital and publishing a book documenting the evidence, he and his work were routinely ridiculed and rejected by the medical community. In 1885, he suffered a nervous breakdown and was taken to a mental hospital. There he died after being beaten by

the mental asylum personnel. It took another 14 years for his discovery to be accepted when Louis Pasteur showed the presence of Streptococcus in the blood of women with child fever. Lessons Learned

This vignette reminds us of how perceptive Voltaire was when he said

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“it is dangerous to be right in matters on which the established authorities are wrong”. Along with Dr. Semmelweis, countless women paid the ultimate price for this clinical resistance to change. The Semmelweis Reflex is a reflex-like rejection of innovations which often contradict existing beliefs, norms, or paradigms. Consider this: If nineteenth-century physicians found it so challenging to accept something as linear as the benefits of hand washing, we can begin to understand the challenge of introducing far more complex and impactful innovations. Our very human resistance to change is nothing new. Twenty-five hundred years ago, The Buddha spoke of three types of suffering – including the ‘suffering of change.’ His insights included that everyone suffers, even when a change is perceived as something positive (i.e. birth of a child). It would be a mistake to underestimate the challenge of change, and to think that changing organisational systems and structures alone will change the people with them. Biologically, we are hard-wired to resist change as we strive to maintain a relatively stable state of equilibrium. If homeostasis is successful, life continues; if unsuccessful, disaster or death occurs.

Ironically, in the 21st century little has changed. Hand washing, along with influenza vaccinations for healthcare personnel, medical error risk mitigation strategies, rapid adoption of the EMR, the use of checklists, and many other practices that have both face validity and are evidence-based, continue to suffer from sub-optimal compliance and persistency rates. A century and a half after Semmelweis revealed the ROI (Return on Innovation), including patient lives saved, our protagonist met a level of resistance that would ultimately lead to his demise and the death of an untold number of women. The Semmelweis case reminds us that being right is rarely a catalyst that stimulates innovation and certainly is not worth sustaining. This comes as a little surprise to many of us. After all, people are people; carbon and water. Most experienced healthcare leaders believe that, if one wants to make enemies, all it takes is changing some practices! Organisational Readiness for Change

In my work on launching, leading, and realising value from change initiatives, I consistently observe that leaders have a remarkable capacity to

overestimate their power to change others and underestimate their need to change themselves. Why is change hard? In part because the human mind often treats new ideas the same way the body treats a strange protein — it rejects it and often tries to destroy it. One can think of this as a statusquo-trap, in which maintaining the current situation involves the least psychological risk. Along with individual readiness for change, there is this concern of organisational readiness for change. ‘Readiness’ means we are willing and have the ability to take action. We can think of readiness for organisational change as a shared psychological state in which stakeholders feel committed and confident in their collective abilities to create it. Change readiness is comprised of two key dimensions: 1) Change commitment: stakeholders’ shared resolve to implement change; 2) Change efficiency: shared belief in the collective capacity to actually make change happen. I have consistently found that the drivers of organisational commitment to implement change are based on three discrete motives: 1) because we want to (value the change); 2) because we have to (little choice); 3) because we ought

Managing Change 2015 From Health Policy to Practice Editors: Susanne Boch Waldorff, Anne Reff Pedersen, Louise FitzGerald Ewan Ferlie, Paul G. Lewis No of Pages: 262 Year of Publishing: 2015 Description: Managing Change is about implementing healthcare reforms, policies and programs into everyday practices. The book explores organisational change in healthcare as influenced by contemporary policy and management concepts, and presents and applies theoretical perspectives.

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Understanding and Managing Change in Healthcare A Step-by-Step Guide Editor: Jaqui Hewitt-Taylor No of Pages: 264 Year of Publishing: 2013 Description: Change happens constantly in healthcare contexts and professionals, whether newly qualified or managing staff, need to be ready to understand, adapt to, manage and implement change as necessary whilst continuing to work effectively in busy environments. Unlike most change management texts, this book focuses specifically on change in frontline healthcare practice. It covers the process of change from problem identification, to evaluation of new practice, to continuation of change. Offering practical guidance in an accessible style, all health professionals alike should not be without this book.

disengaged. For they will be saboteurs, and actively resist the change. 2. Regime change – this argument that we have attempted to change things in the past and they have failed – often miserably. It is clear our leadership is unprepared to lead the next change. It is clear that the processes and skills necessary to run an organisation are quite different from those needed to change an organisation. Only with a change in leadership, the organizations will stand a chance of success. Action Plan

Author BIO

to (feel obliged). Change efficiency often comes down to answering the question, “Given our current state, do we have the resources (people and processes) to implement the change effectively?” Inevitably, at some point in the conversation someone will utter those 10 uncomfortable, if not politically incorrect words: “to change the people… you need to change the people.” The implications are that people can’t really change and hence need to be replaced. But what people are we really talking about? It depends on how you read the statement. I have found that an organisational-specific understanding of what is meant by these 10 words is critical to successfully initiating any innovation. After all, with change initiatives people need to be your greatest asset, yet often are your greatest liability. As with a Rorschach test, where people stand on the intent of this statement depends on where they sit; and most bunker down into one of two silos: 1. Staff change – this argument goes that innovation requires discretionary effort and in the absence of an engaged workforce change won’t happen – so we need to replace those that are actively

and sustain. As a current or future healthcare leader, you must understand that success will not be possible unless you leverage resistance management strategies en route to converting that large body of change resisters into change insisters. Regretfully, resistance management training is perhaps the single biggest deficit in the training of healthcare leaders. It should also be understood that any insights gained about healthcare management will equally apply to clinical interaction where a positive health outcome is co-produced by the clinician and the patient, and where the four action verbs necessary for success are – inspire, implement, spread, and sustain. Note: This article is based in part on material covered in a two-day executive education Mater Class led by Professor Shore entitled, ‘Strategies for Leading Successful Change Initiatives.’ The seminar is offered through the Harvard University Extension School.

David A Shore is a leading authority on innovation and managing change to gain competitive advantage. He is the former associate dean of the Harvard T.H. Chan School of Public Health. He is a faculty at Harvard University and adjunct professor of organisational development and change at the University of Monterrey Business School, Mexico. His most recent book is ‘Launching and Leading Successful Change Initiatives in Healthcare Organisations’.

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Facilities & Operations MANAGE MENT

Lean Operational Planning in the Design of Ambulatory Care Centers For high quality building

This article outlines the use of Lean methodology and the impact on design in the Ambulatory Care Center setting. Case studies are presented to demonstrate the use of lean methodology on both operations and design strategies. Lean is centred on what adds value and reduces waste. Each project is unique in their design, but the lean operational planning allowed the ability to seek ideas and solutions that added value and an environment that would continue to form and improve each centre. Marvina Williams, Senior Healthcare Operations Planner, Perkins+Will, US

he subject of ambulatory care setting continues to grow and provides a much needed resource for urgent care, primary care and speciality practices. Ambulatory care centres can provide better access for patients and increase efficiencies in healthcare arena. Design changes to these centres can be impacted with lean operational planning. Lean is centred on what adds value and reduces waste. Each centre has to define ‘value’ to understand their vision. Once defined, it allows the ability to seek ideas and solutions that add value and an environment that will continue to form and improve the system.

Lean Ambulatory Care Methodology

In the ambulatory care setting, the lean process should be a very interactive and participatory process. Meetings should involve senior leadership, physicians, managers and clinical staff representation including ancillary

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services that may be a part of the facility such as registration, laboratory, medical imaging, materials management, environmental services, pharmacy, and other services. Assessing space needs should be derived from sound prediction techniques and tools. Key rooms should be determined using operational variables that are established with the centre’s leadership group. A lean overview with users will identify the customer, what the customer values, and what are considered eight deadly wastes of healthcare. Lean concepts identify value added time and reduce non-value added time. This allows for a visioning of the project and helps find operational and design solutions to create an environment that can continuously adapt to change and constantly improve. Guiding principles or project goals are established with a vision that would allow the team to test every decision they make whenever

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questions about doing or not doing something arise.. The lean operational planning and the development of the vision, guiding principles/goals are intended to maximise the flexibility, effectiveness, and life cycle of the building. They will help shape future decisions regarding new programmes and emerging technologies. Lean current state process mapping depicts current operations and workflow for processing patients through the ambulatory care centre. Value Stream Maps (VSM) can also be created to demonstrate value-added and non-added-value time. Each step can be mapped resulting in opportunities for Kaizen moments or improvement that can be depicted on the map as ‘starburst’. Lean future state process mapping is employed to rethink and visualise the ideal process for every operational task. The future state map will depict the desired methods for operating the

Facilities & Operations MANAGEMENT

centre. Process analysis uses data process steps to evaluate flow of staff and patients. This lean methodology process generates diagrams that document preferred processes for the seven flows of healthcare. Diagrams such as ‘swim lane’ are just an example of what can be done. Identification of process changes that could be implemented in the existing facility as well as the new facility is an added bonus in lean planning. The seven flows of healthcare are patient flow, staff flow, supply flow, equipment/instrument flow, lab flow, medication flow and information flow. Spaghetti diagrams can be extremely helpful in mapping the seven flows. These seven flows can be identified both vertically and horizontally throughout the facility.

A ‘kit of parts’ is another tool in the lean toolbox that can be designed to allow users to actually see the many programmed rooms and spaces for creating adjacencies. The users can break into groups and organise individual pieces and then present back to each other their designs. Clinic modular adjacencies can be created on paper for the users to begin looking at the placement of clinics or support spaces within the actual building and on the floors. Observational studies of existing clinics or ambulatory care centre sallow users to ‘Go to the Gemba’ and understand how work happens in the centres, especially newer facilities. Physical mock-ups can be developed from a module in a clinic setting, an exam room, a procedure room, or

other spaces for the users to visualise and possibly standardise spaces being designed. If the workload in one clinic module increases, there is the capacity to flex over due to the standardised room or module concept accommodating change in clinic programmes. The clinic module can also have support areas within which can be designed to be manipulated for meeting the needs of a specific clinic. This helps users to understand their space and in reviewing for functionality and cost-effectiveness. Several scenarios can be played out in these mock-up spaces. Open houses with designated stations led by the users, will give access to the staff and providers who are not a part of user meetings to see the developments and provide feedback.

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Centralized Registration

Simulation modelling is another lean tool that can be utilised. For example, a simulation model can be built to mimic patient flow and can be useful in testing facility plans. This can aid in the lean design process to understand specific space requirements during the programming stage. At the same time when lean operational planning is taking place, the architectural team is busy listening to and evaluating ways to help address many of the challenges identified and the banking on opportunities to improve the operations through design. Lean operational planning as seen through the following case studies

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Lean principles and concepts assisted in mapping of the future state and given the rate of change in healthcare, allowed flexibility for changes in clinical practice and workload.

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had impacted design approaches innovatively. Not every tool in the lean tool box is used in each of the case studies. Lean tools are selected on what best meets the need for a particular facility. Lean Operational Planning Case Study #1

In the operational planning and design of an ambulatory cancer centre, efficiency for patients, family, providers, and staff is often through lean. The centre needs to be integrated into the community and contribute to the community in a beneficial way. Ease of access through multiple entry points or the navigation to

Facilities & Operations MANAGEMENT

different areas is important. Flexible planning and design allows potential future changes in process and technology without major renovation. Creating spa-like environment versus a sterile healthcare ambience and collocating of services so that the patient does not have to travel to several locations is the key. In this particular case study, the process of workflow was reviewed for multiple oncology practices in a facility and the client made the workflow process one of the main drivers in the design of the large cancer centre. The operational planning played a vital role in the facility planning. It assisted the client in obtaining goals of quality, efficiency, and experience. The ability to optimise operations was a wonderful opportunity for designing the cancer centre which is projected to see 800 patients per day. An understanding of the operational practices from their previous facilities was done by observing studies of their workflow process in their existing

work space. The observational studies involved the scope and functions of their roles, their interaction between roles, visualising their workspace and patient care spaces, identifying schedules and much more. All this would impact patient flow and workload. So the guiding principles were developed from the beginning with the client for the new facility. A Value Stream Map (VSM) was developed to identify the time allocated to a patient’s journey in the clinic setting. Lean methodology allowed the client to develop desired results and the user groups determined the process to meet or obtain these results. This paved way for taking ownership and keeping afloat the drive to continuously improve the process as needed. Impact on Design 1. ADA accessible private registration booths were created for patients to register by face-to-face contact. 2. Kiosk registration space developed as future technology for patients to self-register.

Infusion Area CARTI

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3. Multiple entrances allowing patients to access different areas depending on their needs i.e. Medical Imaging, Laboratory, Pharmacy. 4. Increased work areas that make staffmore visible and designate ‘on-stage’ and ‘off-stage’ work areas for collaboration and privacy. 5. Infusion areas with a 1:4 nurse/ patient ratio that incorporates a handwashing station and separate computer workstation 6. Spectacular views from the infusion bays and private infusion areas with a balcony off the infusion area. Lean Operational Planning Case Study #2

In this ambulatory care clinic, multiple clinic practices were integrated into a single large medical building. Lean operational planning included a numerical analysis in determining the planned number of waiting spaces for each clinic area in the building to meet projected patient volumes over 10

Facilities & Operations MANAGEMENT

Waiting Space Needs Prior to Patient Entry to Exam Board

45% * 0 companions

35% * 1 companion

20% * 2 companions

0.75 seats for companions

After patient entry to exam room 13% of Companions do NOT accompany patient to the exam room. 0.75 seats * 13% of companions remaining in waiting area = 0.1 seats for companions

Source: Perkins + Will

Figure

providers in each clinic was performed to understand the range of waiting spaces during daily work hours. For example, if all providers start at 9AM, the analysis assessed to understand the required number of waiting spaces. However, with a variable schedule of provider 2 starting 30 minutes later than planned and provider 3 starting 1 hour later than planned, the required number of waiting spaces was reduced. A summary of the planned number of waiting spaces in the design, along with the numbers obtained from baseline and variable scheduling scenarios were done for each clinic along with opportunities for improvements based on the observed process flow that included identification of potential bottlenecks in future operations of the centre. Impact on Design 1. Allocation of adequate waiting spaces for each clinic 2. Identification of the need for Author BIO

years. The information required for this analysis included: a. Daily projected patient volume by clinic b. Number of providers expected c. Treatment time average for each step in the provider/staff flow d. Average length of stay by clinic e. Number of companions expected for each clinic patient f. Number of exam rooms planned A draft numerical analysis provided. an estimate of the minimal number of waiting spaces required per clinic and this was used as a guideline for a conservative estimation of the waiting space numbers. The actual numerical analysis involved a detailed provider based schedule for a typical day in the clinic along with certain process assumptions in validating the numbers for the waiting spaces. Process cycle times for patientsâ&#x20AC;&#x2122; visits to each of the clinics were developed. A model workflow for the each clinic was created to calculate the actual number of people waiting during different hours of the day. Baseline process flow mapping illustrated the actual number of people in the lobby for the projected daily patient volume during different work hours. A variable scheduling scenario with different operating hours for the

re-evaluation in the number of allocated clinic rooms in some specialities with respect to the projected patient volume. Some clinics required more rooms, while others required less. 3. Ability to share some waiting spaces with other clinics based on schedules. Conclusion

Several methods of lean operational planning were used in these two ambulatory care settings. Lean principles and concepts assisted in mapping of the future state and given the rate of change in healthcare, allowed flexibility for changes in clinical practice and workload. Integrating lean strategy during planning stage yields efficient design process. Lean impacts the design for the creation of a more efficient, high quality building that can be developed in a shorter period of time.

Marvina Williams is a registered nurse and Lean black belt, specialising in healthcare design and planning. Marvina has 33 years of experience in management within the hospital environment. She performs operational studies including workflow, workload calculations, patient care procedures, support services, simulation modelling, design validation, and process improvement initiatives.

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INFORMATION TECHNOLOGY

Designing Hospital Information Systems An overview

This is an overview of how to design a hospital information system highlighting the fact that implementing an IT system invariably means a dramatic change in the way the various business processes are run. Broad discussions on requirements management and change management are followed by an overview of general requirements and functionalities where a tentative list of all the modules is presented. These are followed by some technical considerations that the stakeholders like system designers, implementation agencies, customers and end-users need to factor in for all such information systems. SB Bhattacharyya, Member, National EHR Standards Committee, MoH&FW, Govt of India

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Hospital Information System (HIS) basically is a synonym for information management system at use in hospitals. Hospitals generate a wealth of data round the clock, 365 days a year, all of which needs to be well managed to ensure efficient functioning. Patients visit such establishments for outpatient care, in an emergency, or get admitted for either a short stay

INFOR MATION TECHNOLOGY

(a few hours) or long in duration (that may sometimes be indefinite). While in the past, the important modules of an HIS tended to be those that dealt with revenue management aspects, the recent trend sees a growing emphasis on improving overall efficiency and clinical management. It must be noted here that while some modules are required by all clinical establishments, requirement for others depend on the size of and specialities covered by a particular establishment.

Important HIS Aspects to Consider

Requirements Management In the requirements gathering phase, one should undertake an as-is study exercise to perform a comprehensive impact analysis of all business processes in order to identify the ones that will be affected by having the new system in place and the way this will occur. The various business processes that exist, the stakeholders involved and the systems / applications currently

being used within the establishment that would be affected, albeit to varying degrees. A draft vision document should then be prepared and a visioning workshop should be conducted to create a blueprint for the future. Once his has been finalised and agreed upon, a requirements analysis followed by documentation needs to be prepared. Several follow-up workshops are usually required — depending on the size of the establishment and complexities of the underlying business processes—coupled with general and focused meetings with various stakeholders to validate the requirements and manage the various expectations. Once finalised, the software requirement specification and functional design documents should be prepared with proper functional architecture in place. These should be signed-off by the competent authorities on both the customer and the vendor sides. The documents should then be turned over to the system design team for further action to ensure that the required system is delivered as per the specifications. Change Management

Introducing a new information system, where one is already in place and is actively used, requires a certain degree of change management as this new system reflects a ‘new way’ of working.

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INFORMATION TECHNOLOGY

Hospital Information System (HIS) Modules Module: PATIENT ADMINISTRATION SYSTEM Description: This functionality, also known by the acronym PAS, consists of RADT (Registration-Admission-DischargeTransfer), pre-admissions and waiting lists, bed management, and bed charges. It needs to interface with nursing information module for managing bed availability. Module: MASTER PATIENT INDEX Description: This functionality is vital for any healthcarerelated system that manages patient-related information and includes patient search (basic and advanced), patient merge and demerge (to manage multiple patient entries), and unique patient identifier management. This ensures that a particular patient is accurately and consistently identified and referred to for any patient-related transaction. Module: APPOINTMENT SCHEDULING Description: This module deals with appointment scheduling of all types like patient scheduling (for any purpose â&#x20AC;&#x201C; visit, admission, investigations, procedures, etc.) and resource (human, equipment, facility, etc.) Scheduling. Pre-booking, booking, over-booking, cancellation, deferred booking, and patient tracking are some of the functionalities covered in this module. Module: PATIENT BILLING Description: Perhaps the most important of all modules from a hospitalâ&#x20AC;&#x2122;s business perspective, this module deals with the aspects of patient billing including cash, and credit management. This includes dealing with chargeable items and waivers for reasons such as service not rendered, repeat services for faulty services (e.g. Investigation sample unusable; test result inconclusive or erroneous, etc.), discounts provided etc. Module: FINANCIAL ACCOUNTING Description: This module explains how to handle accounts payable, accounts receivable, cash management (of the hospital instead of just the patient), purchase order processing, cash book and general ledger, budget control, etc. Module : EQUIPMENT MANAGEMENT SYSTEM Description: A clinical establishment needs a large number of instruments, both clinical and non-clinical, that require regular maintenance and occasional replacement, all of which must be efficiently managed for its optimal functioning. Module: HUMAN RESOURCE MANAGEMENT Description: This module caters to the functionalities related to resource scheduling, payroll management, resource engagement and separation management etc. 34

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Module: NURSING MANAGEMENT SYSTEM Description: This module is for exclusive use by the nursing staff and defines functionalities for general nursing information management, bed management, orders tracking (of successfully posted orders), medication administration, patient assessment and classification. Module: ORDER MANAGEMENT Description: Also known as CPOE (Computerised Physician/ Provider Order Entry), this module is for posting all patient orders / prescriptions related to medication, investigation, procedures, and other orders that the patient needs to follow as part of his / her treatment. Module: MEDICATION THERAPY EVALUATION Description: This module is for management of medications and is generally used in inpatients care settings. All ordered medications are listed according to their recommended doses, route and schedule. Whenever any medication is administered, a record entry is made to the effect. If for any reason it cannot be administered, like patient sleeping, no suitable injectable site found, patient refused, etc., the fact is also noted. This module is the follow-through of the Orders Management module and closes the loop by providing information about what the outcome was of all ordered medications. Module: OT MANAGEMENT Description: A specialised appointment scheduling system for operation theatres, this module deals not only with scheduling but also listing of procedures and personnel involved, documenting of procedures performed and charging for services rendered. Module: LABORATORY INFORMATION SYSTEM Description: Depending on the laboratory size this module can be subdivided into pathology, microbiology, biochemistry, haematology, serology etc. Generally, sample collection lists, specimen registration, work schedule, results management of entry, verification, and reporting. As investigations are increasingly carried out by semi-auto and auto-analysers, machine to system interfacing is required for sample testing and reporting. Charging for services rendered should also be handled within the module with the information being exchanged with the patient billing module. Module: BLOOD BANK Description: This module is only required if the establishment has a full-fledged blood bank. Functionalities such as donor management, blood stock management, departmental inventory management, departmental

INFOR MATION TECHNOLOGY

laboratory information management, charging for services rendered etc. need to be supported.

inventory items of the hospitals including processing of purchase orders.

Module: RADIO-DIAGNOSTIC INFORMATION SYSTEM Description: Although similar in concept to laboratory, radiodiagnostics has its own special requirements like the patient having to be physically present during the investigation, meriting a separate module of its own. Functionalities include procedure scheduling, investigations management, results reporting, charging for services rendered and interfacing with radio-diagnostic machines and such modules like patient billing, order management, EMR, nursing information systems.

Module: SYSTEM ADMINISTRATION SYSTEM Description: This needs to include such functionalities as Single Sign On, user management, roles management, privileges management, password management, and audit trail management, besides management of servers and periodic data backup management, contingency and recovery management; operating procedure management to ensure physical security, countering viruses and other software and hardware threats, data encryption, digital certificates and administrative panels for efficient monitoring and management of these.

Module: PICTURE ARCHIVING & COMMUNICATION SYSTEM (PACS) Description: With storage systems becoming larger and cheaper coupled with almost all radio-diagnostic machines becoming totally digital increasingly PACS are becoming either de facto part of the machines or being available as a special module. The functionalities include management of the actual storage and archival process, image display through workstations, image management and printing on films, apart from interfacing with radio-diagnostics information systems and web integration. Module: PHARMACY MANAGEMENT SYSTEM Description: This is a specialised inventory management for medications and medical devices that have a definitive shelf-life and need control in terms of dispensing and patient education regarding how these need to be used. Interfacing with CPOE/ order management, medication administration and nursing information system is required. Module: CLINICAL INFORMATION SYSTEM Description: This module is for use by the clinicians and consists of patient lists, electronic health records/electronic medical records clinical data entry, eReferral, clinical summary etc. It needs to interface with CPOE/Order Management, Nursing Information, Laboratory Information, Radio-diagnostics Information, PACS etc. Some special requirements in terms of management of medical certificates like fitness certificates, discharge summary, and treatment summary. Module: ANAESTHESIA MANAGEMENT SYSTEM Description: This module is for use by anaesthetists and needs to support functionalities related to pre-anaesthetic check-up, per-operative management and post-operative management. Module: FIXED ASSETS MANAGEMENT Description: This module deals with managing the fixed assets of the hospitals. Module: INVENTORY MANAGEMENT SYSTEM Description: This module deals with management of general

Module: CENTRAL STERILE SUPPLIES DEPARTMENT (CSSD) Description: A hospitalâ&#x20AC;&#x2122;s primary business is patient care, in pursuit of which sterile supplies are required 365x24x7. This module helps in their management and needs to interface with OT Management and Nursing Information Systems for its proper functioning. Module: LAUNDRY DEPARTMENT Description: This module deals with the management of the laundry requirements of the establishment. A hospital houses sick people who may require several change of clothes and linen every day. Efficient management of these items is necessary and interfacing with inventory management and nursing information systems is required. Module: DIET & KITCHEN MANAGEMENT Description: Not only do patients need to be fed with many having specialised dietary requirements, the various personnel who provide round-the-clock service need to be fed too. This module manages meal orders, diet management, kitchen management, and inventory management. Interfacing with inventory management and nursing information systems is required. Module: MANAGEMENT INFORMATION SYSTEM Description: This module is for designing and running reports and displaying them as dashboards, onscreen, etc. as required by the users. Module: TRANSPORT MANAGEMENT Description: Both surface and air transport in the form of ambulances needs to be managed and this module is being asked for by many institutions, particularly those that deal with medical tourism. Having a large fleet of ambulances also requires efficient management to ensure that they are optimally used. Resource management of drivers and assistants and those vehicles that are in maintenance also needs to be taken care of. www.asianhhm.com

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However, it is equally important to view this new system as being only a part of the entire process of creating a new way of working and not its whole sole. The people who will interact with the system would need to get used to it and will require varying degrees of hand holding as the old system, which mostly still is anon-ITpaper-based system, is phased out. Furthermore, many of the business processes will need to be reviewed. This will result in some of them undergoing minor to major changes; others left completely unaltered; and the rest stopped permanently. This inevitably means a total redesigning of the entire business ecosystem of the establishment, which is a massive exercise in itself. It is important to recognise that the change, whether insignificant or significant, needs to be sustainable in order to realise accrued benefits to the fullest extent. This will neither happen by itself nor can be expected to be enough. Implementing the change successfully demands that the solution (not just the system but the outcome of the implementation in its entirety) must fundamentally be designed differently.

The following points need to be given serious attention in order to build and implement a viable solution that will be able to deliver true value-for-money on a long-term basis: 1. Use of a unique patient identifier like UHID (unique health identifier). 2. Quick registration in times of emergency – use of “break-theglass feature”, with due record of who did what, when and why (the reason for this action). 3. D a t a s e c u r i t y , patient confidentiality and privacy. 4. User-based-role-based access control with a sound and practical process using password/biometrics. 5. Eligibility check of all insurance and ability to accept an upfront deposit to cover the estimated cost of care. 6. e-prescription for outpatients, CPOE for others Technical Considerations

Client-Server or Cloud-based?1 Architecture Type

Description

Advantages

Disadvantages

Client-Server

Local server or server groups are accessed by clients through private networking; this can be a standalone system where the same machine functions both as the client and server, the latter being the database storage system.

The architecture helps in providing adequate levels of comfort related to safety and security. System performance and various systems dependencies can be well-managed.

If the server or the networking is down, the entire system is also down. Anytime anywhere access to the system cannot be expected, let alone guaranteed.

Cloud-Based

The server is accessed through the Internet and its location is largely unknown and essentially invisible. The various cloud types are private, public, hybrid, community, virtual private.

Anytime anywhere 365 x 24 x 7 access can be guaranteed, if not expected. Anyone with the correct access credentials can use the system.

Safety and security is always a concern as access through the Internet. (Private and virtual private clouds are safer and more secure than the others).

General Requirements– An Overview

Generally, the system should be safe and secure from a data management point-of-view. Highly sensitive data is handled by such systems and hence the comfort-level related to privacy and safety issues need to be addressed aggressively. The system should ensure efficient flow of information that provides interdepartmental support to the establishment, functional and process integration, be adaptable and flexible from a user perspective, and last, but not the least, be standards-based to ensure interoperability in terms of syntactic, semantic and process.

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7. For investigations, the consultant needs to know the total costs and the individual investigation charges. This would allow them to prioritise the ones that the patients must get done right away irrespective of the costs while leaving the rest later when they can afford them. 8. The EMR needs to be integrated with LIS, RIS and PACS to allow all images to be viewed and compared with any archived images. 9. Secured remote access to view information and add notes. 10. Checking for EOQ and re-order levels and automated listing of near-expiry items at least 90 days prior to expiry. 11. Slow moving materials in the medical stores should be tracked and appropriate alerts should ensure that all stakeholders are aware of the situation.

1 Cloud Computing: Comparison with Previous Technique and Research Challenges; Nimisha Gupta, Bharti Chauhan, TanviAn and, CharulDewan; International Journal of Computer Applications (0975 – 8887); Volume 85 – No 8, January 2014

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12. Bar coding for tracking patients, services, material and medication. 13. MIS reports that serve as de facto registers will need to be maintained as per prevailing rules, regulations and legal requirements.

Hospitals generate a wealth of data round the clock, 365 days a year, all of which needs to be well managed to ensure efficient functioning.

HIS Modules (Tentative List)

System Performance

This is business needs-dependent. While patient administration systems typically require around one to two minutes system response times, governance systems can be run in batch (asynchronous) mode or with around five minutes response times. However, clinical and nursing information systems require sub-second response times irrespective of data size, volume, type and location 24x7x365. Better than 99.9 per cent uptime for non-clinical and 100 per cent uptime for clinical systems is the minimum requirement. Accordingly, fail-safe measures, sufficient redundancies and fail-over support need to be built-in.

Additional Observations

Conclusion

A fact that is frequently overlooked, mostly unappreciated and grossly underestimated is that it is the end-user of any IT system that makes or breaks it. It is vital to take them into confidence and actively engage them right at the planning phase itself and continued through each and every stage of the software development life cycle. Otherwise one is, more often than not, left to sincerely rue the decision. Furthermore as a thumb-rule of sorts, the author would seriously advocate that only those IT implementations where at-least 80 per cent of modules (and their functionalities) of the system are being used by 80 per cent of the users 80 per cent of the time six months

The final success of any such implementation lies in the overall buy-in and whole-hearted support of all stakeholders. Through active cooperation, enthusiasm and support by the departmental heads as well as the end-users, coupled with the belief and desire of the sponsors that the implemented IT system is exactly what they need is vital for the success of any IT system implementation. The key success factors definitely are robust requirements management, successful change management and sensible business process reengineering. Efficient management of these translates into the difference between success and failure of any such project.

Author BIO

A tentative list of modules would be as follows. At the outset it is important to note that many of the modules listed below can be merged into one larger module. Usually this is a vendor and system-specific decision, mostly based on marketing considerations. A master code maintenance functionality needs to be provided for all modules. These codes may be non-standard or standard as required by the locally prevailing laws and regulations. It would be prudent to take a long-term view and incorporate the international best-practices in handling codes even if these are not specifically asked for by the customer. Queries and reports is another functionality that needs to be provided for every module. Without these, the â&#x20AC;&#x2DC;managementâ&#x20AC;&#x2122; portion of management information system is missing from action.

post-implementation after go-live be deemed a success. Else, it should be classified a failure. The importance of training and retraining of all users can neither be over-stated nor over-emphasised and should not be just one-off. Furthermore, this needs to be periodic. One-off intense training followed by periodic re-training is vital. Every major upgrade or functionality change that would impact the business process should be considered equivalent to a new implementation. In all such instances, an appropriate training schedule needs to be prepared and rigorously followed to ensure the projectâ&#x20AC;&#x2122;s success.

Suman Bhusan Bhattacharyya is a practising family physician and a business solution architect for medical devices and healthcare IT applications with nearly twenty nine years of experience. Currently, he is a member of EMR Standards Committee, Ministry of Health and Family Welfare, Government of India and is also member of Healthcare Informatics Standards Committee, Bureau of Indian Standards. His main areas of interest include clinical data analytics particularly treatment protocol planning using predictive analytics, EHR& EMR, mobility applications and application of machine learning techniques in healthcare.

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Universal Interface for Electronic Medical Records for Developing Countries Electronic Medical Records (EMR) have transformed the way information is managed in healthcare. However, developing countries face major challenges in the development of EMRs to suit their specific requirements. Thanks to the proliferation of mobile phones, developing countries can have universal interface to an EMR for access anytime, anywhere as presented in this article. Abu Md Akteruzzaman Bhuiyan, Health Informatics Expert, Bangladesh University for Health Sciences, Bangladesh, India Pradeep Ray, Director, WHO Collaborating Centre on eHealth, UNSW, Australia

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he WHO Collaborating Centre on eHealth at UNSWAustralia is working towards in the development of EMRs allowing the developing countries easy access to universal interface to an EMR anytime, anywhere. In Bangladesh, the work involved Bangladesh University for Health Sciences (BUHS) and its partners. APuHC has been leading research in eHealth (Healthcare using

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Information and Communication Technologies) and mHealth (healthcare using mobile phones) sponsored by global bodies, such WHO, European Union, IEEE and ITU-D in Australia, Europe and Asia-Pacific including developing countries, such as Bangladesh, India, China, Vietnam, Philippines, PNG and Nepal. It has been well documented that coordination among healthcare professionals (i.e Physician, nurses and other clinicians) helps to achieve desirable patient outcomes. Health Information Technology (HIT) such as EMR, when appropriately designed and implemented, can help to achieve this goal by timely, accurate, adequate information exchange among the parties involved. Bringing in the patient to actively engage in managing the health information is of greater value, particularly in the contexts of chronic care diseases and in cases where the patient takes active part in managing their own disease process. However, achieving successful coordination has also been difficult given the challenges in synchronising activities of different parties involved and the varying need of information requirement. Moreover, depending on the availability of time and the patient load, managing EMR during care delivery has been a daunting process for the clinicians, particularly in the developing countries in South Asia where the doctor-patient ratio is much worse than in developed countries. Unlike developed countries, developing countries often suffer from some additional issues in adopting HIT, apart from technical issues. There are also issues with the available infrastructure, resources and technical expertise both from the development and users perspective. For example, there are questions such as how can patients actively engage in their own health information management in view of low literacy levels? There is a need to supplement the traditional use of EMR

Recognising handwritten characters will require the implementation extensive machine learning techniques and might be something interesting and quite feasible in near future.

through desktop or laptop devices (or in recent cases through tablets), where the availability of these systems is a problem. How can the Healthcare Professionals (HCPs) actively engage in such cooperative health information exchange where they are heavily timeconstrained? How can we manage the information in one place where the healthcare delivery system is pluralistic and information exchange at intraand inter-organisational levels do not exist, and where â&#x20AC;&#x2DC;One country, one EMRâ&#x20AC;&#x2122; vision might not be available (or achievable) in near future? Proliferation of mobile devices, especially the low-cost smartphones have bridged the digital divide among the rich and poor and have been ubiquitous in their use, particularly in the developing countries. In comparison to the personal computer, these mobile phones are substantially cheaper (decent Android handsets can be found under $50), small and portable, have good battery backup, and have voice communication, text, multimedia capabilities along with access to the internet. Feature phones are even cheaper. People around the globe are using phones successfully for a variety of purposes. Voice call remains at the top of the functionality with texting and taking pictures of their life events. Smart phones are now a part of the daily life of people of developing countries as a means to receive and make payments

(mobile money), getting consumer and health information (mobile health / mHealth). Among young people the use of social media sites through their mobile phone is quite popular. Healthcare professionals have varying needs or use of EMR. A physician, moving between hospitals, clinics and practices, can have great uses of mobile devices to transfer vital patient information, lab results, and images. Although smartphones offer the potential to support mobility of applications like EMR, the usability of the interface, particularly the screen size, limits the use of its full potential as an EMR interface. From a patientâ&#x20AC;&#x2122;s perspective, getting the list of medication and providing data of home-based monitoring or procedures to clinicians (i.e. Blood pressure, blood glucose readings, weight) are important. From a developed area perspective, these may seem to be very basic and rudimentary. Using EMR interfaces on laptop, desktop, or through a tablet with sufficient screen size ease out the process, but in a resource-poor setting, providing fixed terminal to every workspace is not feasible and to consider everyone is capable of using a large screen tablet is not quite realistic. Porting the EMR interface to a mobile phone has been tried but the limited screen size makes it quite cumbersome and time-consuming for maintaining an effective EMR. Although there are arguments in favour and against the use of an EMR, the use of EMR has positive impacts on patient care. Writing paper scripts is still the most favoured choice for documenting patient encounters among the healthcare professionals; and while transitioning to an EMR almost invariably leads to some sort of combination of paper and electronic chart. In a busy patient care scenario (where doctor-patient ratios are poor), physicians almost invariably have to work in a time-constrained fashion and to ask them to maintain an EMR

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in such a setting may result in mass resistance. We looked into the physician and patientâ&#x20AC;&#x2122;s common practice of carerelated information, storage and uses in such a setup. Physicians write their scripts in SOAP (Subjective, objective, assessment and plan) protocol. However, not everything detailed in the protocol is used, rather physicians use information obviously pertaining to the disease process (and more often only the positive findings). In a country with provision of only paper records and no inter-organisational data sharing culture, visiting a doctor and undergoing procedures results in documents (i.e. medication scripts, investigation reports, log book), to be stored which are the responsibility of the patient. Maintaining all of these,

particularly for a patient suffering from multi-morbid chronic diseases, is tedious and carrying all of them around for subsequent visits may not be possible. There are strong evidences of the use of smartphones as an information retrieval and image capturing device. Taking an image through a mobile phone is quite straight forward and it is basic to have an email account to activate a smartphone feature. By using the intuitive features of a smartphone in an innovative way, it is possible to use the basic functionalities of an EMR (i.e. Storage and Retrieval of information) and thus to maintain (add/modify/delete) health records and access them during a visit or in an emergency.

Figure 1

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Based on the above understanding, a task-oriented template based EMR was interlaced with a mobile phone. The EMR itself is capable of defining templates, based on the work practices and reuse it without further processing. It also enables to define the templates to retrieve records formatted in XML. We built an interface that links smart phones with the EMR in varying roles (i.e. patient, doctor, physician assistant). The information to be provided in the screen was based on use-cases of mobile phones analysed from a small group of potential users internally. The basic strategy incorporated for the solution was to leverage the intuitive applications of the smart phones that we believed will make

INFORMATION TECHNOLOGY

(CCD) based on HL7 standard from the EMR to the physicianâ&#x20AC;&#x2122;s mobile interface. Alternatively, the physician can also view the document through the desktop interface of the EMR. Upon patient examination and preparation of the script, the physician or the patient or any authorised person can scan the code, take the snapshot of the script or any other document and send it to the parser. The document sent is stored within the relevant field for further optimisation or transcription. A simplified view of the overall process is depicted in figure1. The mobile interface can also be made to use the voice recognition feature and speech to text functions of a mobile phone, if available, to enter the script directly to the EMR through the mobile phone. The script can be called via the interface and sent to a network printer to print out the script.

Author BIO

the solution usable for all streams of users. In particular, we wanted to put the patient at the forefront to update the health-record in a setting where physicians or healthcare organisations do not maintain patient health records and where it is the patientâ&#x20AC;&#x2122;s duty to maintain the paper-based care records that have been provided during the care or the end of a care episode (i.e. surgical note, discharge summary). This was done on the basis of the understanding that an effective, accessible and relatively complete set of health records in such situations can only be achieved when the physicians and other care providers, including patients themselves, get better at sharing information. As the solution was optimised for resource poor settings, there was an attempt to eliminate possible recurring costs to the user. Also, developing countries have an abundance of semiskilled or unskilled people who need employment. Hence it was necessary to adapt the workflow of the EMR to involve more semi-skilled people, saving the physiciansâ&#x20AC;&#x2122; workload. They could then focus on patient treatment. The authors are currently working with an Australian EMR developer to develop and trial the system in Bangladesh. A brief description is given below. Upon registering on the system, a bar coded ID card is provided to the patient. This will return an XML encoded continuity of care Document

The EMR will be made to perform OCR (optical character recognition) on the uploaded document and will extract text to populate the relevant field upon review and confirmation of the extracted data by the physician or any other authorised person. However, recognising handwritten characters will require the implementation extensive machine learning techniques and might be something interesting and quite feasible in near future. The solution provided here is being implemented for a small trial in a multisite, multi care setup that treats chronic kidney patients. The solution was implemented in a setup where patient documents are maintained manually and have no inter-organisational relationship for patient data sharing will answer whether simplifying the overall process using mobile devices will enable the healthcare provider to maintain a working health record of a chronic patient in an efficient and usable way. In summary, this is an attempt to adapt the workflow of a proven EMR system (using mHealth innovations) to suit the needs of developing countries with a view to better utilise the scarce time of qualified physicians while employing more number of relatively abundant unskilled and semi-skilled people in the developing countries. References are available at www.asianhhm.com

Abu Akteruzzaman Bhuiyan is a qualified medical doctor from Bangladesh with Masters in Health Informatics from Karolinska Institute, Sweden. He is teaching Health Informatics in Bangladesh University of Health Sciences and he has been working on mHealth in collaboration with the WHO CC on eHealth in UNSW on Mobile EMRs.

Prof Pradeep Ray is the Founder and Director of the WHO Collaborating Centre on eHealth at the University of New South Wales, Australia. He led to completion several global initiatives, such as the WHO Research on the Assessment of e-Health for Health Care Delivery (eHCD) involving a number of countries in the Asia-Pacific region.

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The Future of Wearables Fitness trackers, health, and activity monitoring ‘wearables’ are increasingly prevalent yet focus primarily on data capture. Design and materials approaches that merge precise data capture with clinically relevant reporting and positive user experiences are more likely to succeed. Here are key performance indicators for successful wearable design and adoption. Amy Cueva, Founder & Chief Experience Officer, Mad*Pow, US Chris Hass, Sr. VP of Experience Design, Mad*Pow, US

hink of fitness wearables as New Year’s resolutions. Acquiring one is an act of optimism. “This will be the year I get more active, more physically fit, you think, more in tune with me, more in control”. For many people the act of acquiring a fitness tracker symbolises taking decisive action to improve their future. Yet like many New Year’s resolutions, we quickly discover that fitness and

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behaviour changes rarely respond to enthusiasm and gadgets. As care and health providers know, making active, productive change takes sweat equity (literally) and a willingness not only to take an unflinching approach at one’s own motivations but to seek assistance from others. Depending on the individual, of course, the social component of a fitness programme, receiving the advice and

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encouragement from others, may make the difference between keeping those New Year’s resolutions or seeing them fall by the wayside. Interestingly, however, the most effective fitness wearables available today are encroaching on the traditional role of activity coaches and care providers even when they lack key elements of the equation required to inspire lasting behavior change. Let’s envision the future of fitness wearables, drawing upon their practicalities and promise for supporting a ‘better you’ by examining current trends, technological capabilities and fitness philosophies. Let’s create a roadmap for maximising the future of fitness wearables. Wearable fitness trackers are not particularly new, but they are experiencing growth as popular gadgets, as aids for helping sedentary persons to become more active, and for helping those who are already active to achieve more challenging fitness goals. One of the key factors in the increasing success of these devices, both in terms

INFORMATION TECHNOLOGY

of sales numbers and efficacy, may be attributed to technology integration. Where many wearables provide summary data to users through small, shock-protected interfaces, they also connect with external data repositories and reporting engines which can be accessed via mobile applications, websites, and other devices. This opens a world of reporting possibilities where individuals can track their activities, evaluate their progress, receive automated coaching, and more from the comfort of a chair. Remarkably, as a motivator, a fitness tracker can help quantify an individual’s exertion in relation to their identified goals and by doing so make the individual, in a sense, their own support system. This

digital partner can help individuals see themselves in an unflinching light that rewards progress, however small, and by illuminating daily goals can encourage even the most sedentary to become more active step by step. While this works for some, two problems emerge: data alone may not be a sufficient motivator for sustained change (fitness devices are great at reporting, but not always sufficiently encouraging), and by being a clique of owner and device, the fitness process does not inherently involve the advice or guidance of care professionals. For medical, health, care, and activity professionals, wearables create their own set of problems. Fitness trackers are not qualified medical

The promise of the fitness wearables of the future, then, may be this: to pack more holistic data collection sensors, clinically-approved algorithmic decision making capabilities, and encouragement into increasingly smaller devices. Moreover, successful wearables will summarise and communicate that information in a visual, clinically appropriate manner so that care providers can interpret it quickly, accurately, and easily. To achieve this, we envision a partnership between fitness tracker technologists and clinical providers that reaches beyond simply ensuring that caloric calculations are clinically sound (although this in and of itself is important), but integrates well into care environments literally– in terms of appropriate summary information tying smoothly into electronic health care records– and figuratively by supporting care providers’ ability to effectively guide and coach their patients.

professionals, they lack a holistic view of their wearers, and they are not usually integrated into providers’ health records systems. As a result, the trackers cannot adequately coach or communicate with those who could best shape a fitness regimen to an individual’s needs. Moreover, what is a care provider to make of a patient’s fitness data? During a time-limited office visit, when faced with an encouraged (or discouraged) fitness tracker, and a wearer who is toting reams of highly granular digital activity data on their smartphone, how is a care provider to respond? They have neither the time to review it nor the clinical certainty that the data is meaningful, and may be at a loss to do more. They may fall back on traditional admonishments to ‘eat less and exercise more,’ waving away data that fails to communicate its importance in a clinically relevant manner. The challenge for wearable designers, and for medical, care and health

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providers attempting to make sense of their patients’ data, is integration. The future of wearables is not simply a better device, or a device that collects better data, but one that can provide data in a manner that is appropriate for informing and encouraging patients and that is informative for clinicians. Great opportunities exist for partnership between technologists and clinical care personnel, and identifying what data providers would prefer to receive and how best to present it is an appropriate challenge for information and interaction design specialists. This brings a third, vital, component into the mix: interaction design. We’ve all encountered products, particularly

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Future of wearables is not simply a better device, or a device that collects better data, but one that can provide data in a manner that is appropriate for informing and encouraging patients and that is informative for clinicians.

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in the clinical realm that give the impression that they were designed “by engineers for engineers.” We know them by their ruthless efficiency and brutal aesthetics. For the fitness tracker of the future I would add “designers” to this ideal partnership between technologists and providers. If we can’t communicate it simply, then, as the saying goes, it doesn’t exist. This is especially important in lieu of the exponentially expanding types of data that fitness trackers and their partner devices (smart watches, smartphones) are able to capture. Current and future fitness wearables are moving far beyond simply calculating step-to-calorie ratios. In

INFORMATION TECHNOLOGY

conjunction with smart watches and smartphone data applications, fitness trackers contribute to an increasingly specialised data capture process that can measure and quantify menstrual cycles, blood sugar tides, caloric intake, moods, gait irregularities, and virtually any health-related data that the wearers care to capture, input, and track. The complexities for patients attempting to interpret their activity data and for care providers attempting to support their patients will only grow as this technology continues to evolve. Thus a shoulder-to-shoulder collaboration between technologists, providers, and user experience designers may prove uniquely beneficial, ensuring that what can be captured can be presented in meaningful and clinically relevant ways. Thus the future of fitness trackers and wearables depends on integration: with wearer’s lives, their health goals, and the increasing constellation of potential sources of data. As electronic health records become more ubiquitous, the temptation to broaden their boundaries will become technologically pressing (as this becomes more possible) and

clinically beneficial (as dental records, traditional EHR content, fitness and diet information and other disease- or condition-related data is captured more reliably and made available). Wearables’ success also depends on the form factor of the wearable and its ease of use. It would be foolish to downplay the importance of the materials design, technology, and interface challenges awaiting our ideal future wearable. What could be more intimate or in need of durability than something we choose to wear? Wearables are simultaneously a form of expression and a functional lifesupport. Visually, they are a personal statement and as such should be as variable as the uses they are put to. Are they a general all-purpose tool to be worn in any circumstance? Are they casual wear or formal wear? Can they be both? Form and function come together in wearables in unique and potentially dramatic ways. Coiled around a wrist or an ankle the physical and visual aesthetics of wearables are undeniably important. We may opt for an ugly wearable because it provides a function we value, but ultimately wearables’

success may be attributable not only to what they do, but to how stylishly they accomplish their intended functions. Conversely, there’s a truism in design circles that the best tools are invisible– valued more for their ability to support your tasks than to call attention to themselves. (A pencil or an unadorned teapot is a good example of this.) Future wearables might be functionally invisible — sensors woven into clothing, embedded in a blanket, a bandage, or an earring. But visible or invisible, the materials we choose to place next to our skin will reveal how we feel about their contributions to our personal style in relation to the functional value they provide. What will these successes mean? Achieving New Year’s resolutions, improved health outcomes, better disease and condition management, and more focus on life experiences than activity minutia! The most effective future wearables will conduct their data collection tasks reliably and with greater precision, provide an artful physicality and an aesthetically pleasing ease of use, and most of all present data in an easy

INFORMATION TECHNOLOGY

The ideal wearable of the future should:

Work: The scope of a wearableâ&#x20AC;&#x2122;s purview should be clearly defined and well executed. If it fails to function it will be left behind. Be Easy: Interfaces should be clear and understandable, interactions should be obvious and simple, and attendant resources (websites, apps) should be similarly efficient, understandable, and encourage both goal setting and meaningful exploration of data. Reflect Collaboration: A wearableâ&#x20AC;&#x2122;s success is not purely a result of technology-related factors. Success will come from a collaborative partnership between technologists, providers, and user experience designers in order to ensure that data is reliably collected, parsed in clinically appropriate ways, and communicated to both wearers and their advisors in summarised, straightforward, clinically meaningful ways. Think Ecosystem: Where and how a wearable communicates will determine its longitudinal utility. The ability to share meaningful, appropriate, summary data with electronic health records and decision making systems brings with it radical new opportunities and responsibilities. Pass the Sniff Test: Infamously, a popular early fitness tracker developed

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an unfortunate and persistent odour after several days of use, and washing did little help. As aesthetic contributions to our bodies, wearables should be comfortable, artful or invisible, and protect us from embarrassment, chafing, or other social or physical injury. Be Audience Appropriate: For whom is the wearable intended? Couch potatoes and marathoners view activity in very different ways. Motivating them to change sedentary behaviour (or form) requires different approaches and identifying core and edge audiences is a vital part of ensuing positive user interactions and experiences. Support Longitudinal Use: Behaviour change occurs most often through concerted effort over time. Wearables should support novices as they become experts and experts as they become masters. Wearables that support

Author BIO

to read, meaningful, and clinicallyrelevant formats. In summary, and in no particular order, here is our list of key tenets of the successful wearable of the future.

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behaviour change should be durable and reward/encourage individuals according to their evolving behaviour patterns. One size does not always fit all. As behaviours evolve, the wearable and its attendant information systems should as well. Connect Effortlessly: The strength of a wearable not only lies in its tabulation but its ability to communicate the relevance of those tabulations. Data transfer should be simple and reliable. Be Artful: Wearables should contribute aesthetic value to individuals and thereby enhance their courage when making behavioural change. Support Clinical Care: As data trackers proliferate, patients will increasingly want to share their data, and care providers will benefit from reliable, summary data relevant to patient care that is presented meaningfully.

Amy believes design improves the human condition. She cofounded the award-winning agency Mad*Pow in 2000 to bring her vision to health, financial services, technology, media, education, and hospitality industries. Mad*Pow works closely with Fortune 500 companies to improve customer experiences, leverage design to drive change, and facilitate human-centric innovation.

Chris Hass, Sr. VP of Experience Design, guides business development, human factors and accessibility research for Mad*Pow (madpow.com). He is president of the User Experience Professionalsâ&#x20AC;&#x2122; Association. Mad*Pow helps global companies improve customer experiences, drive change through design, and facilitate innovation in health, education, financial services, technology, media, and hospitality industries.

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Research Insights The Association between Sulfonylurea Use and All-Cause and Cardiovascular Mortality: A MetaAnalysis with Trial Sequential Analysis of Randomized Clinical Trials Authors: Dimitris Varvaki Rados, Lana Catani Pinto, Luciana Reck Remonti, Cristiane Bauermann LeitĂŁo, Jorge Luiz Gross Abstract Background Sulfonylureas are an effective and inexpensive treatment for type 2 diabetes. There is conflicting data about the safety of these drugs regarding mortality and cardiovascular outcomes. The objective of the present study was to evaluate the safety of the sulfonylureas most frequently used and to use trial sequential analysis (TSA) to analyse whether the available sample was powered enough to support the results. Methods and Findings Electronic databases were reviewed from 1946 (Embase) or 1966 (MEDLINE) up to 31 December 2014. Randomised clinical trials (RCTs) of at least 52 wk in duration evaluating second- or third-generation sulfonylureas in the treatment of adults with type 2 diabetes and reporting outcomes of interest were included. Primary outcomes were all-cause and cardiovascular mortality. Additionally, myocardial infarction and stroke events were evaluated. Data were summarized with Peto odds ratios (ORs), and the reliability of the results was evaluated with TSA. Fortyseven RCTs with 37,650 patients and 890 deaths in total were included. Sulfonylureas were not associated with all-cause (OR 1.12 [95% CI 0.96 to 1.30]) or cardiovascular mortality (OR 1.12 [95% CI 0.87 to 1.42]). Sulfonylureas were also not associated with increased risk of myocardial infarction (OR 0.92 [95% CI 0.76 to 1.12]) or stroke (OR 1.16 [95% CI 0.81 to 1.66]). TSA could discard an absolute difference of 0.5% between the treatments, which was considered

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the minimal clinically significant difference. The major limitation of this review was the inclusion of studies not designed to evaluate safety outcomes. Conclusions Sulfonylureas are not associated with increased risk for all-cause mortality, cardiovascular mortality, myocardial infarction, or stroke. Current evidence supports the safety of sulfonylureas; an absolute risk of 0.5% could be firmly discarded. Review registration PROSPERO CRD42014004330 Editors' Summary Background Worldwide, more than 400,000 people have diabetes, a chronic condition characterized by poor glycemic controlâ&#x20AC;&#x201D;dangerously high levels of glucose (sugar) in the blood (hyperglycemia). Blood sugar levels are usually controlled by insulin, a hormone released by beta cells in the pancreas after meals (glucose levels in the blood increase when food is digested and glucose is absorbed). In people with type 2 diabetes (the most common type of diabetes), blood sugar control fails because the fat and muscle cells that normally respond to insulin by removing excess sugar from the blood become resistant to insulin. Type 2 diabetes can often be controlled initially with diet and exercise and with antidiabetic drugs such as metformin (which suppresses glucose production by the liver) and sulfonylureas (which stimulate the secretion of insulin by the pancreas). However, as the disease progresses, the pancreatic beta cells become impaired, and many patients eventually need insulin injections to prevent hyperglycemia. Long-term complications of diabetes, which include an increased risk of cardiovascular

problems such as heart attacks (myocardial infarctions) and stroke, reduce the life expectancy of people with diabetes by about ten years compared to people without diabetes. Why Was This Study Done? Sulfonylureas have been used for decades to improve glycemic control in people with diabetes, but doubts about their safety were first raised in 1970. Since then, there have been conflicting reports about whether these inexpensive but effective drugs are associated with an increased risk of cardiovascular events and death. Because at least 20%–30% of people with diabetes in high-income countries take second- or third-generation sulfonylureas, such as glipizide and glimepiride, it is important to know whether sulfonylurea use increases the risk of a cardiovascular event or death by even a small amount. Here, the researchers evaluate the safety of the most widely used sulfonylureas by undertaking a systematic review and meta-analysis, with trial sequential analysis, of randomized clinical trials (RCTs) that evaluated second- or third-generation sulfonylureas for the treatment of adults with type 2 diabetes. A systematic review uses predefined criteria to identify all the research on a given topic, a meta-analysis combines the results of several trials, and trial sequential analysis is used to establish whether the sample size of a metaanalysis is sufficiently large to reach firm conclusions about the effect of interventions. What Did the Researchers Do and Find? The researchers identified 47 RCTs that met their criteria for inclusion in their study. In total, these RCTs involved 37,650 patients, 890 of whom died during follow-up. Meta-analysis of the results of these trials indicated that sulfonylurea use was not associated with an increased risk of all-cause mortality (death) or

cardiovascular mortality. Moreover, sulfonylurea use was not associated with an increased risk of myocardial infarction or stroke. Trial sequential analysis indicated that the sample size in the meta-analysis was large enough that sufficient information was included in the analysis to conclude that fewer than one in 200 patients were likely to have been harmed by the use of sulfonylureas. That is, trial sequential analysis excluded the possibility that—compared to placebo (dummy drug), diet, or an active comparator drug— sulfonylurea use was associated with more than one death (or major cardiovascular event) in every 200 treated patients, which the researchers defined as the minimal clinically significant difference. Importantly, this finding did not change when sulfonylureas were used as an add-on to metformin treatment. What Do These Findings Mean? These findings suggest that sulfonylureas are not associated with a clinically significant increased risk for all-cause mortality, cardiovascular mortality, myocardial infarction, or stroke. The accuracy of these findings may be affected by some aspects of the researchers’ analyses, such as the inclusion of studies in their meta-analysis that were not designed to evaluate safety outcomes. Moreover, because this study was not designed to compare different sulfonylureas, further studies are needed to evaluate whether all second- and third-generation sulfonylureas are associated with similar all-cause and cardiovascular mortality risks. Overall, however, these findings are reassuring, and the researchers conclude that sulfonylureas should continue to be used in patients with type 2 diabetes provided their efficacy in controlling hyperglycemia outweighs the risks of weight gain and hypoglycemia (low blood sugar) that are known to be associated with these drugs.

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Research Insights Additional Information This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi. org/10.1371/journal.pmed.1001992. • The US National Institute of Diabetes and Digestive and Kidney Diseases provides information about diabetes for patients, health-care professionals, and the general public, including information on treatments for diabetes (in English and Spanish) • The UK National Health Service Choices website provides information for patients and carers about type 2 diabetes, about treatments for type 2 diabetes, and about living with diabetes; it also provides people’s stories about diabetes • The charity Diabetes UK provides detailed information for patients and carers in several languages, including information on treatments for diabetes • The UK-based non-profit organization Healthtalkonline has interviews with people about their experiences of diabetes • MedlinePlus provides links to further resources and advice about diabetes and about medicines for diabetes; it also provides information about metformin and about glipizide, glimepiride, and other sulfonylurea drugs (in English and Spanish) • More information about this study is available from the PROSPERO International Prospective Register of Systematic Reviews; information about trial sequential analysis is also available Citation: Varvaki Rados D, Catani Pinto L, Reck Remonti L, Bauermann Leitão C, Gross JL (2016) The Association between Sulfonylurea Use and All-Cause and Cardiovascular Mortality: A Meta-Analysis with Trial Sequential Analysis of Randomized Clinical Trials. PLoS Med 13(4): e1001992. doi:10.1371/journal. pmed.1001992

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Academic Editor: Richard Lehman, University of Oxford, UNITED KINGDOM Received: August 3, 2015; Accepted: March 1, 2016; Published: April 12, 2016 Copyright: © 2016 Varvaki Rados et al. 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. Data Availability: All relevant data are within the paper and its Supporting Information files. Funding: This study was funded by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). CNPq had no role in the design and conduct of the study; the extraction, management, analysis, or interpretation of the data; or the preparation, review, or approval of the manuscript. Competing interests: JLG reports grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico, during the conduct of the study; grants and other from Eli Lilly, grants from Bristol-Myers Squibb, grants and other from Boehringer Ingelheim, grants from GlaxoSmithKline, grants and other from Novo Nordisk, grants from Janssen, outside the submitted work; no other relationships or activities that could appear to have influenced the submitted work are reported. DVR, LCP, LRR and CBL have declared that no competing interests exist. Abbreviations: NNH, number needed to harm; OR, odds ratio; RCT, randomized clinical trial; TSA, trial sequential analysis

Determinants of Quality of Life for Breast Cancer Patients in Shanghai, China Authors: Bei Yan, Li-Ming Yang, Li-Peng Hao, Chen Yang, Lei Quan, Li-Hong Wang, Zheng Wu, Xiao-Pan Li, Yu-Tang Gao, Qiao Sun , Jian-Min Yuan http://dx.doi.org/10.1371/journal.pone.0153714 Abstract Purpose To evaluate the association of social support status, health insurance and clinical factors with the quality of life of Chinese women with breast cancer. Methods Information on demographics, clinical characteristics, and social support status was collected from 1,160 women with newly diagnosed breast cancer in Shanghai, China. The Perceived Social Support Scale was used to assess different sources of social support for breast cancer patients. The quality of life was evaluated using the Functional Assessment of Cancer Therapy-Breast Cancer that consisted of five domains: breast cancer-specific, emotional, functional, physical, and social & family well-being. Multivariate linear regression models were used to evaluate the associations of demographic variables, clinical characteristics, and social support status with the quality of life measures. Results Adequate social support from family members, friends and neighbors, and higher scores of Perceived Social Support Scale were associated with significantly improved quality of life of breast cancer patients. Higher household income, medical insurance plans with low copayment, and treatment with traditional Chinese medicine for breast cancer all were associated with higher (better) scores of quality of life measures whereas patients receiving chemotherapy had significantly lower scores of quality of life. Conclusion Social support and financial aids may significantly improve the quality of life of breast cancer survivors.

Citation: Yan B, Yang L-M, Hao L-P, Yang C, Quan L, Wang L-H, et al. (2016) Determinants of Quality of Life for Breast Cancer Patients in Shanghai, China. PLoS ONE 11(4): e0153714. doi:10.1371/journal. pone.0153714 Editor: Robert M. Lafrenie, Sudbury Regional Hospital, CANADA Received: September 14, 2015; Accepted: April 1, 2016; Published: April 15, 2016 Copyright: ÂŠ 2016 Yan et al. 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. Data Availability: Due to identifying patient information, data is available upon request to the corresponding author Dr. Jian-Min Yuan. Funding: This work was supported by award number PWRq2012-24 of the Young Medical Talents Training Program of the Pudong Health Bureau of Shanghai (BY). Research reported in this publication was also partially supported by the National Cancer Institute of the National Institutes of Health under award numbers R01CA144034 and UM1CA182876 (J-MY). Grant number: PWZz2013-15. Funding agency: Pudong Health and Family Planning Commission of Shanghai Funding to QS. Competing interests: All authors declare that they have no competing or conflicts of interest.

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Research Insights Patient safety: the landscape of the global research output and gender distribution Authors: Moritz Schreiber, Doris Klingelhöfer, David A Groneberg, Doerthe Brüggmann Institute for Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University Frankfurt, Frankfurt, Germany Correspondence to Professor David A Groneberg; occup-med@uni-frankfurt.de Abstract Objectives Patient safety is a crucial issue in medicine. Its main objective is to reduce the number of deaths and health damages that are caused by preventable medical errors. To achieve this, it needs better health systems that make mistakes less likely and their effects less detrimental without blaming health workers for failures. Until now, there is no in-depth scientometric analysis on this issue that encompasses the interval between 1963 and 2014. Therefore, the aim of this study is to sketch a landscape of the past global research output on patient safety including the gender distribution of the medical discipline of patient safety by interpreting scientometric parameters. Additionally, respective future trends are to be outlined. Setting The Core Collection of the scientific database Web of Science was searched for publications with the search term ‘Patient Safety’ as title word that was focused on the corresponding medical discipline. The resulting data set was analysed by using the methodology implemented by the platform NewQIS. To visualise the geographical landscape, state-of-the-art techniques including density-equalising map projections were applied. Results 4079 articles on patient safety were identified in the period from 1900 to 2014. Most articles were published in North America, the UK and Australia. In regard to the overall number of publications, the

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USA is the leading country, while the output ratio to the population of Switzerland was found to exhibit the best performance. With regard to the ratio of the number of publications to the Gross Domestic Product (GDP) per Capita, the USA remains the leading nation but countries like India and China with a low GDP and high population numbers are also profiting. Conclusions Though the topic is a global matter, the scientific output on patient safety is centred mainly in industrialised countries. BMJ Open 2016;6:e008322 doi:10.1136/bmjopen2015-008322 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis Authors: Filipe Brogueira Rodrigues, specialty trainee and researcher, Joana Briosa Neves, specialty trainee, Daniel Caldeira, specialty trainee and researcher, José M Ferro, professor of neurology, Joaquim J Ferreira, professor of neurology and pharmacology, João Costa, professor of pharmacology Author Affiliations: • Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Av Prof Egas Moniz 1649-035, Lisbon, Portugal • Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal • Department of Medicine, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal • Department of Neurosciences, Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal • Center for Evidence-Based Medicine, Faculty of Medicine, University of Lisbon, Portugal • Portuguese Collaborating Center of the IberoAmerican Cochrane Network, Faculty of Medicine, University of Lisbon, Portugal Correspondence to: F B Rodrigues filipebrodrigues@ gmail.com Abstract Objectives To evaluate the efficacy and safety of endovascular treatment, particularly adjunctive intra-arterial

mechanical thrombectomy, in patients with ischaemic stroke. Design Systematic review and meta-analysis. Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, SciELO, LILACS, and clinical trial registries from inception to December 2015. Reference lists were crosschecked. Eligibility criteria for selecting studies Randomised controlled trials in adults aged 18 or more with ischaemic stroke comparing endovascular treatment, including thrombectomy, with medical care alone, including intravenous recombinant tissue plasminogen activator (rt-PA). Trial endpoints were functional outcome (modified Rankin scale scores of ≤2) and mortality at 90 days after onset of symptoms. No language or time restrictions applied. Results 10 randomised controlled trials (n=2925) were included. In pooled analysis endovascular treatment, including thrombectomy, was associated with a higher proportion of patients experiencing good (modified Rankin scale scores ≤2) and excellent (scores ≤1) outcomes 90 days after stroke, without differences in mortality or rates for symptomatic intracranial haemorrhage, compared with patients randomised to medical care alone, including intravenous rt-PA. Heterogeneity was high among studies. The more recent studies (seven randomised controlled trials, published or presented in 2015) proved better suited to evaluate the effect of adjunctive intra-arterial mechanical thrombectomy on its index disease owing to more accurate patient selection, intravenous rt-PA being administered at a higher rate and earlier, and the use of more efficient thrombectomy devices. In most of these studies, more than 86% of the patients were

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Research Insights treated with stent retrievers, and rates of recanalisation were higher (>58%) than previously reported. Subgroup analysis of these seven studies yielded a risk ratio of 1.56 (95% confidence interval 1.38 to 1.75) for good functional outcomes and 0.86 (0.69 to 1.06) for mortality, without heterogeneity among the results of the studies. All trials were open label. Risk of bias was moderate across studies. The full results of two trials are yet to be published. Conclusions Moderate to high quality evidence suggests that compared with medical care alone in a selected group of patients endovascular thrombectomy as add-on to intravenous thrombolysis performed within six to eight hours after large vessel ischaemic stroke in the anterior circulation provides beneficial functional outcomes, without increased detrimental effects.

Systematic review registration PROSPERO CRD42015019340. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/ licenses/by-nc/3.0/. BMJ 2016; 353 doi: http://dx.doi.org/10.1136/bmj. i1754 (Published 18 April 2016) Cite this as: BMJ 2016;353:i1754

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Healthcare Management AGM Conference……………....…………………………….07 APHM…………………………............……………….…….19 Clariden……………………………….. …………………..IBC GlobalData……………………………......…………………09 Infinity Exhibitions & Conferences Pvt. Ltd. ……….……..…IFC marcus evans………………………………………………..13 Markets and Markets………………………..………………15 Medical Fair Asia …………………........... ………….……OBC The Ideas Exchange…………………………………............29

AGM Conference…............................................................….07 www.agmconference.co.uk APHM…………….........................................................…….19 www.aphmconferences.org Clariden…........................................................................... .IBC www.claridenglobal.com GlobalData…....................................................................…..09 www.globaldata.com Infinity Exhibitions & Conferences Pvt. Ltd. ......................…IFC www.infinityexpo.in marcus evans……............................................................….13 www.marcusevans.com Markets and Markets…..................................................……15 www.mnmconferences.com Medical Fair Asia …........................................................ …OBC www.medicalfair-asia.com The Ideas Exchange…......................................................…..29 www.ideas-exchange.in

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