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Asian Hospital & Healthcare Management
ISSUE-16 2008
Foreword Online PHRs
Bridging the information divide Online PHRs can overcome the geographical limitations of existing EMR systems, while encouraging patients towards selfcare.
A
patient’s health record is perhaps the most important, yet most scarcely shared, aspect of the healthcare process. Whether in primary care or emergency, a doctor having access to the patient’s medical history is better equipped to provide the right care at the right time. As it happens, patient information is bound by the geographical reach of a hospital’s Electronic Medical Record (EMR) system. The internet has enabled an innovation that has the potential to change the scenario—placing patient records online and giving patient the control over their health information. Sensing the potential of this consumercentred innovation, companies like Microsoft, Google, IBM and Intel—to name a few—have already taken to online Personal Health Records (PHRs) in a big way. While Microsoft launched HealthVault in early 2008, Google introduced Google Health in June 2008. These services are in their initial stages and issues such as data security are still being sorted out. Since these services are provided free of cost, providers will have explore the right business model for the long run. However, there are no apprehensions whatsoever regarding their potential benefits. The data in an online PHR is built and managed by the patient. Given the ubiquity of the Internet, this data can be accessed from anywhere at any time. This is a blessing for both the patients—who have become increasingly Internet savvy and mobile—and for healthcare providers. With the entire patient history being available at the click of a button, a doctor, even if treating the patient for the first time, can be helped to a quicker and accurate diagnosis. As a consequence it is the patients who will gain most from PHRs.
Patient-doctor relationship stands to gain from online PHRs. Patients can exchange data with their doctor on a daily basis, which could result in reduction in visits to the clinic. More importantly, it allows the doctor to monitor the patient’s health and take corrective steps if necessary. In this issue’s cover story, we present to you insights into this promising trend in healthcare. It also features interviews with experts who have pioneered research in the field. This includes views from Bill Crounse, Senior Director of World Health at Microsoft, Claudia Pagliari, Senior Lecturer in Primary Care at the University of Edinburgh and John Halamka, Chief Information Officer and the Dean for Technology at the Harvard Medical School. By allowing the patient to control the health data, online PHRs could play a catalytic role in improving patient participation in healthcare. Designed with the patient in mind, online PHRs encourage selfcare. A typical PHR website provides health-related information to patients maintaining records on that website. It can also incorporate the principles of social networking on the Internet, thus enabling patient-to-patient interaction. Online PHRs have the potential to fill the information void that has existed on the patient’s side for so long.
Akhil Tandulwadikar Editor
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Patient Records Online Shared access for quality care
Prasanthi Potluri Editor
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Akhil Tandulwadikar Editor
Asian Hospital & Healthcare Management
Online Health Information Accuracy, quality and privacy
Celia Boyer Executive Director
45
Mayoni Ranasinghe Research Assistant
Health on the Net Foundation (HON), Switzerland
HEALTHCARE MANAGEMENT
MEDICAL SCIENCES
Health Tourism
6
The growth phenomenon
Integrated with primary care
Luigi Bertinato Director
20
Marilee Donovan Regional Coordinator Pain Management / Clinical Nurse Specialist
Marina Canapero Health Communications Consultant
Lindsay Kindler Clinical Nurse Specialist
International Health and Social Affairs Office Department of Health and Social Services, Italy
Kaiser Permanente, USA
Slow Medicine
13
Knowledge Transfer and Human Resource Development in Medicine
24
Sridevi Prekke Member, Editorial Team, Asian Hospital & Healthcare Management
New tools for early detection
Alexander v Smekal CEO, Meditrainment GmbH, Germany
27
Ivana I Vranic Specialist in Internal Diseases Cardiologist and Assistant Professor Medical School University of Belgrade Private Clinic HERTZ, Serbia
Interruptions at the Workplace
16
A risk worth managing
Gerry Armitage Senior Research Fellow, Patient Safety Bradford Institute for Health Research Bradford Teaching Hospitals Trust, UK
Asian Hospital & Healthcare Management
Emerging concept in elderly care
Cardiac Death Predisposition
CME and beyond
Chronic Pain Management
ISSUE-16 2008
Surgical speciality
Bariatric Surgery
Experience with medical tourism Arun Prasad Senior Consultant and Academic Coordinator Minimal Access & Bariatric Surgery, Apollo Hospitals, India
31
Contents diagnostics Radiology Beyond Anatomy
New value chain for personalised medicine
Baylor Emergency Department
33
Frederik Lars Giesel Physician Department of Radiology National German Cancer Research Centre Heidelberg, Germany
Providing the state-of-the-art services Todd C Howard President, t. howard + associates, USA
Hans-Ulrich Kauczor Professor and Chairman Department of Radiology University of Heidelberg, Germany
Quality and Safety
Mega trends in Asia
49
Jennifer Lau Industry Analyst Frost & Sullivan, Singapore
Medical Products Manufacturing in India
Philip Hoyle Director, Clinical Governance Northern Sydney Central Coast Area Health Service, Australia
Benchmarking and Measuring Patient Safety
52
Jacqueline McKenna Director, Nursing and strategic Planning Medway NHS Planning, UK
INFORMATION technology
G S K Velu Managing Director Trivitron Group of Companies and Metropolis Health Services India Ltd. India
Challenges in Managing Chronic Diseases Gregory Larkin Chief Medical Officer Indiana Health Information Exchange, Indiana
Alison Burdett Director Technology, Toumaz Technology, UK
Semantic Web and Translational Medicine
FACILITIES & Operations management
Vipul Kashyap Clinical Informatics R&D Partners Healthcare System, USA
Beyond the numbers
Creating the next generation healthcare enterprise
58
Role of architects
Telemedicine and Remote Monitoring Improving COPD patient care
62
Insights into Healthcare IT
Gary M Burk Principal
Transforming healthcare in Asia
Terrie L Kurrasch Senior Associate
H Stephen Lieber President and CEO HIMSS, USA
RATCLIFF, USA
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Michael Hansen-Nord Chief Physician, Odense University Hospital Hospital of Svendborg, Denmark
Russell A Sedmak Vice President Heery International, USA
The Hospital of the Future Isn’t‌
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EMRs enable better care
54
Revolution in healthcare delivery
Sustainable Hospital Design
75
The Medway model
Getting ready for growth
Medical Devices Meet Consumer Electronics
72
Creating a supportive culture
technology, EQUIPMENT & DEVICES Medical Device Market
68
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Issue 16 2008 Editors : Akhil Tandulwadikar Prasanthi Potluri Consulting Editor
: P Sudhir
Editorial Team : Sridevi Prekke Vandana Wadhawan Language Editor
: G Srinivas Reddy
Art Director
: M A Hannan
Visualiser
: Sk Mastan Sharief
Graphic Designers : K Ravi Kanth Ayodhya Pendem Copy Editor : Omer Ahmed Siddiqui Prity Jaiswal Production
: Suresh Giriraj
Head - Sales : Naveed Iqbal (Tele Sales) Rajeev Kumar (Field Sales) Sales Manager
: Sunita John
Sales Associates : Compliance
Vinod Kumar P Sirwani Sylas Makam K Vikas David Nelson Max Miller Bhasker Josyula Kiran Narra
: P Bhavani Prasad
CRM :
Rajkiran Boda Yahiya Sultan Savitha Devi Murali Manohar G Vijay Kumar
IT Team :
Shadaan Osmani Ifthakhar Mohammed Azeemuddin Mohammed Sankar Kodali Thirupathi Botla N Saritha
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healthcare management
Health Tourism
The growth phenomenon More affordable international travel and major advances in medical science, medical or health tourism is becoming less of a novelty and more of a global trend.
I
n 2007, over half a million Americans travelled abroad to receive medical treatment and since 2003, 1.29 million Britons aged 16 to 64 had dental treatment outside the UK because it was more economical. These are not isolated trends. Every year, increasing number of patients from around the globe seek healthcare abroad either for economic reasons or to find better quality treatment and overcome long waiting lists. The picture that emerges is of increasing mobile patients with greater choices of where to receive quality treatment at competitive prices.
Worldwide tourism growth
According to the World Travel and Tourism Council (WTTC), tourism is a key driver of 21st century’s economic activity and is the largest creator of jobs, wealth and investment around the world. Travel and tourism is the largest industry in the world and the
US alone contributes US$ 3.5 trillion to the world’s GDP and US$ 1.2 trillion to its GDP.
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Luigi Bertinato Director Marina Canapero Health Communications Consultant International Health and Social Affairs Office, Department of Health and Social Services, Italy
It is also the world’s largest export earner with foreign currency receipts from international tourism outstripping exports of petroleum products, motor vehicles, telecommunications equipment, textiles or any other product or service. In 2007, international tourist arrivals rose by 6 per cent reaching a new record figure of 898 million and overtaking 2006 figure by over 52 million arrivals. One significant feature of 2007 was the continuing healthy performance of emerging destinations backed up by one of the longest periods of sustained economic expansion.
healthcare management
Traditional and emerging source markets 2007
Globally, world tourism flow shows a significant shift from traditional source markets (Western Europe, USA, Canada, Japan) to alternative ones (Central and Eastern Europe, China, Republic of Korea, Singapore, Middle East, Mexico, the Russian Federation, India etc.) Tourism growth has been driven by emerging destinations in Asia, Pacific, Africa and the Middle East, while the more ‘mature’ regions of Europe and the Americas show a more moderate pace. The increasing trend of health tourism
The increasing trends of tourism coupled with health treatments abroad have led to a growth in the health tourism phenomenon. Health tourism (also called medical tourism, medical travel or global healthcare) is a term initially coined by travel agencies and the mass media to describe the rapidly growing practice of travelling across international borders to obtain healthcare. Such services typically include elective procedures as well as more specialised surgeries such as joint replacement (knee / hip), cardiac,
dental and cosmetic surgeries. Travel and leisure aspects typically associated with tourism are now being offered in the form of all-inclusive health tourism packages. In 2007, 51 per cent of all international tourist arrivals (430 million) were motivated by leisure, recreation and holidays. Business travel accounted for about 16 per cent (131 million), and 27 per cent represented travel for other purposes such as visiting friends and relatives, religious reasons and / or pilgrimages and health treatment (225 million). Travel for the purpose of undergoing health treatment abroad is clearly on the rise. Health tourism - An age old concept
The concept of health tourism is not new. The first recorded instance of health tourism goes back to thousands of year when Greek pilgrims travelled from all over the Mediterranean to the small territory in the Saronic Gulf called Epidauria. In the Middle Ages, pilgrims in need of care relied on a network of monasteries providing free, even if basic, care as they made their way slowly to centres such as Santiago de Compostela
International tourist arrivals Traditional and emerging source markets 2007
70,000 60,000 50,000 40,000 30,000 20,000 10,000 0
China
Russian
India
International Tourism Expenditure (US$ Million)
USA
Germany
UK
No. of trips abroad
Source: UN World Tourism Organization 2007 (UNWTO)©
Japan
France
Emerging source markets Graph 1
in what is now called Spain. In eighteenth century England, Mediterranean travellers visited spas as they were places with health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis. The situation nowadays is very different. First, many people are crossing borders, not on foot or horseback but by trains, cars and increasingly by low-cost airlines. Second, the scope of healthcare has changed beyond recognition with increasingly sophisticated pharmaceuticals and technology allowing many people to survive and in many cases to lead perfectly normal lives. Health tourism today - Driven mainly by costs
Highly competitive prices of medical treatment offered abroad continue to attract most medical or health tourists. According to the United Nations World Tourism Organization (UNWTO), depending on the location and procedure, a medical vacation can cost up to 50 per cent, 30 per cent, or even 10 per cent of what one would normally pay at home country. The cost of surgery in India, Thailand or South Africa can be a tenth or even less of what it is in the US or Western Europe. For instance, a heart-valve replacement costing US$ 200,000 or more in the US, can go for US$ 10,000 in India including return airfare and a holiday package. Similarly, a metal-free dental bridge worth US$ 5,500 in the US costs US$ 500 in India, whereas the total cost of a standard filling ranges from € 156 in England to € 8 in Hungary. The total cost includes x-rays, materials, drugs and overheads, as well as the dentist’s time. Cosmetic surgery savings are even greater: a full facelift that would cost US$ 20,000 in the US costs about US$ 1,250 in South Africa. A US$ 40,000 hip replacement in the US can cost US$ 6,600 in Costa Rica or US$ 4-5,000 in Cuba. Estimates of the value of medical tourism to India are as high as US$ 2 billion per year by 2012.
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In 2007, 77,000 UK travellers went to abroad Source: International Passenger Survey
43 per cent of the travellers sought Dental Care Source: Agency Treatment Abroad
Over half a million
Americans travelled abroad to
Medical and Dental treatment
Source: Wall Street Journal NBC Survey
The increasing costs of medicare in the US
Consequently, each year more people from the most industrialised nations such as the US are looking for healthcare treatment abroad either for economic reasons or to find better quality treatment and avoid long waiting lists. In a Wall Street Journal-NBC Survey almost 50 per cent of the American public said that the cost of healthcare is their number one economic concern. More and more US citizens are looking beyond their borders for cheaper and more timely healthcare. In 2007 alone, over half a million Americans travelled abroad to receive medical and dental treatment. Part of the reason for US citizens not covered by a universal healthcare system seeking medical care abroad lies in the increasing costs of medicare and private health insurance packages. Nearly 43 million Americans are uninsured and surveys show that the primary reason for this is the high cost of health insurance coverage. Almost 25 per cent of the uninsured reported to change their way of life significantly in order to pay medical bills. Countries promoting health tourism
Popular medical travel destinations
worldwide include: India, Brunei, Cuba, Colombia, Hong Kong, Hungary, Jordan, Lithuania, Malaysia, Philippines, Singapore, South Africa, Thailand and recently, Saudi Arabia, UAE, Tunisia and New Zealand. On the other hand, much sought after cosmetic surgery travel destinations include: Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Mexico and Turkey. In South America, countries such as Argentina, Bolivia, Brazil and Colombia lead in plastic surgery medical skills relying on their experienced cosmetic surgeons. Colombia also provides advanced care in cardiovascular and transplant surgery. New EU accession countries such as Poland, Hungary and Slovenia offer competitive dental tourism packages particularly to British, German, Austrian and Swiss nationals who can take advantage of budget air travel and cut costs. South Africa is taking the term ‘medical tourism’ literally by promoting their ‘medical safaris.’ The growth of so-called ‘5-star hospitals’
Most of us are familiar with the star-rating system for hotels, but there is also a growing phenomenon of privatelyrun ‘5-star’ rated hospitals around the globe in such far-flung places as Bangkok, Singapore, Manila, Kerala and Dubai. These hospitals operate in a highly competitive market and are run along the lines of 5-star hotels. They claim to offer not only medical expertise and state-of-the-art medical technologies, but also first-rate and modern facilities and a wide range of specialised medical and diagnostic services covering all medical disciplines, while guaranteeing more affordable and high quality care for patients. Increasingly mobile patients
A ‘new’ kind of European and World Citizen is slowly emerging where for instance, a citizen lives and works between two or more countries. This is the case of stockbrokers, bankers and
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The expansion of the
Schengen Area to 24 Member States in December 2007 runs alongside the movement of Citizens for work, tourism and study reasons across Europe.
managers who live in financial capital cities during the working week and return home to another country at the weekend or go on holiday to a third country. The term ‘Nylon’ (short for New York-London) has been coined to describe over 400,000 super-commuters who live and work between New York and London (6,500 km, about 5 hours flight), and the term ‘NylonKong” (short for New York-London-Hong Kong) describes commuters, often financial service executives, who commute regularly between London, New York and Hong Kong. There are no less than 187 direct flights that leave London for New York every week and 28 weekly flights from Hong Kong to New York. This category of upwardly mobile professionals on the move is a major target for health tourism. The increasing mobility of pensioners in Europe is also an emerging trend.
Europeans are increasingly looking beyond their national borders to receive more
timely and economical treatment in another Member State and combining the medical treatment with tourism and residing for long periods in the host country. This is the case of
800,000 pensioners from Northern Europe migrating to the South during the cold season.
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Challenges to patient mobility and health tourism
The increasing mobility of citizens in the EU and the growth of global health tourism present a number of challenges. Firstly, standards are important as far as healthcare is concerned and issues concerning international health accreditation, evidence-based medicine and quality assurance need to be addressed. In the US, Joint Commission and in the UK and Hong Kong, the Trent International Accreditation schemes provide certain guarantees of standards and quality of healthcare of affiliated hospitals and healthcare institutions. However, there is still a long way to go before such accrediting bodies can cover the vast range of healthcare providers worldwide. With the progressive introduction of the European Health Insurance Card in Europe on 1st June, 2004, EU citizens could obtain essential medical treatment while staying abroad temporarily or exercise their right to better quality and more timely planned care in another Member State if waiting lists force them to seek alternative treatment abroad. Treatment is provided in accordance with the rules of the Member State being visited and costs are reimbursed in line with the tariffs applied in that Member State.
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Asian Hospital & Healthcare Management
The impact of tourism on the Veneto Region, Italy
CaseStudy
Northern European retirees are taking up residence in South European countries and the Mediterranean for part of the year during the coldest winter months of the year. They are estimated to be over 800,000 annually in the European Union (EU). In the Lake Garda area of the Veneto Region in Northeast Italy, there are over 3,500 permanent residents from Northern Europe. According to the UK Office of National Statistics, one million Britons have decided to move overseas after retirement, with Spain being their popular choice. In the last 10 years, over 75,000 British pensioners have moved to Spain to establish permanent residence.
The Veneto Region in its capacity as a highly popular tourist destination, makes a very interesting case study of patient mobility and health tourism in Europe. The significant flow of tourists brings with it a series of healthcare challenges that regional healthcare services have to deal with, in some cases by organising specific services to respond to the high demand of seasonal tourist flows and long-term foreign residents and ensuring their good health. During the last decade, the Veneto Region of northeast Italy has become famous as a major tourist destination, thanks to three main attractions: Venice, as a city of art and culture along with Verona, Padua and Vicenza, the Mediterranean beaches of the Adriatic sea; the lake region (Lake Garda); and the Dolomite mountains. Economically, tourism has become one of the Veneto’s main resources. In 2006, spending by foreign visitors in Veneto totalled ₏ 3,845 million—15.9 per cent of total spending by foreign visitors in Italy. Nowadays, visitors to the Region can in case of a medical emergency choose from a wide range of health services provided by its Local Health Authorities (LHAs) in close collaboration with the Department of Health and Social Services and the Department of Tourism of the Veneto Region. The Veneto Region ranks number one among the Italian regions in terms of tourist flows (see Table 1). National and international tourist flows to the Veneto Region, year 2006 Origin of tourists
Arrivals
%
No. of overnight stays
%
Average no. days of stay
Italians
5,259,736
39
25,093,862
42
4.77
Foreigners
8,179,099
61
34,266,727
58
4.18
13,438,835
100
59,360,589
100
4.40
Total
Source: Veneto Regional Statistics Office data based on ISTAT 2006
Table 1
Looking at the tourist flows to the Veneto Region in 2006, we can clearly see the following: Foreign tourist arrivals are mainly from Germany (1,888,235), Austria (642,886), the UK (592,926), France (521,043), Spain (387,330) Non-EU countries. The USA (818,262), Japan (280,601) and Australia (118,053) make up the greater proportion of total overnight stays amounting to over 59 million.
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Purchasing across the European Union
of the Veneto Region in Italy outlined below) is a clear example of the extent of the tourism phenomenon, which implies actions at different levels (regional, national and European), further implying particular legal, organisational and regulatory approaches. Health tourism to the Veneto Region
The first English patients to go to France for hip-replacement therapy, paid for by the NHS
Cataract
NHS .................................... £880 Private ........................... £2,000 France . .......................... £1,000
The Veneto Region’s health services are facing challenges mainly from mass tourism, which brings with it a sudden and significant increase of demand on health services, particularly in the summer with different priorities depending on the type of tourism, for example cultural, seaside, agro or adventure tourism.
Hip
Seaside tourism is marked by large and seasonal concentrations of tourists, which affect facilities and services set up to respond to the increased demand. Each year in the Veneto Region, preparations for the summer season commence in March with the selection of multilingual health staff. A similar practice is carried out in ski resorts.
NHS ................................ £3,900 Private ........................... £7,600 France . .......................... £4,000
Knee
NHS ................................ £4,400 Private ........................... £8,500 France . .......................... £3,000 Source: European Observatory on Health Systems, McKee 2006
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Since 2003, a special ‘task force’ has been formed in the Veneto with the aim of broadening the knowledge of the tourism phenomenon and patient mobility, and to cope with the underlying administrative and
Asian Hospital & Healthcare Management
Conclusion
Trends clearly point to a continued expansion of medical tourism in the coming years. However, there is an urgent need to provide and compare private and NHS health services for tourists, and to be aware of the risks involved and the legal implications resulting from medical complications that may arise on the patient’s return to home. Furthermore, international standards of quality assurance and health accreditation need to be established to protect citizens worldwide and ensure them their rights to the best healthcare possible at the most competitive prices. We are now at the dawn of a new era in health tourism worldwide, where citizens have more options as regards where they choose to be treated and how to spend their money. By 2015, the health of the so-called Baby Boomer generation will have started to decline. With more than 220 million Baby Boomers in the US, Canada, Europe, Australia and New Zealand, this represents a significant market for cost-effective and high-quality medical care, and has enormous potential for global health tourism.
Luigi Bertinato is the Director of International Health and Social Affairs Office, Department of Health and Social Services, Veneto Region, Venice-Italy. He is involved in a number of European health and social care projects, in the area of health policy, e-health, health promotion and patient mobility.
A u thor
The right to safety and quality care is an essential element for all patients in Europe. Each individual has the right to choose among different treatment procedures and providers in various Member States and to receive treatment without any delay. This is true within national healthcare systems in accordance with article 22.2 of EC Regulation 1408/71 and to further rulings of the Court of Justice. The question is whether it always works in practice. Accessing healthcare in another European country should theoretically be a straightforward process, but it often creates problems both for patients and the healthcare systems involved. The experience of certain European areas with heavy tourist flows (as is the case
organisational problems. Its aim is to collect and provide data on the magnitude of the phenomenon of patient mobility between the Veneto Region and other regions or Member States and to analyse the impact of cross-border health demand and related health issues at the regional level.
Marina Canapero is the Health Communications Consultant, International Health & Social Affairs Office, Veneto Region. Since 2003, she has been collaborating part-time as a consultant in the International Health & Social Affairs Office of the Veneto Region in Venice, liaising with various departments of the Regional Health Ministry in various European health projects.
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Knowledge Transfer and Human Resource Development in Medicine CME and beyond
HR development could play a key role in providing quality healthcare. Care providers need to dedicate more resources to devise their HR policies and strategies.
Alexander v Smekal CEO Meditrainment GmbH Germany
T
he ongoing developments in medicine and healthcare present a continuous challenge for all stakeholders. Besides technical and structural changes, adequate education and training of employees, supply of medicine and healthcare are critical factors for growth. Educational and training programmes need to be adapted to regional and global healthcare requirements. The industry is facing high demand for training due to new markets and modernised equipment and technology. Hospitals are desperately searching for well-trained staff, while the healthcare professionals are looking for suitable opportunities to enhance their knowledge and skills. The concept of Continuing Medical Education (CME) has been introduced to help physicians update their knowledge and develop skills. Apart from the USA, Europe (European Accreditation Council for Continuing Medical Education (EACCME) and other countries have
taken to CME and developed their interpretation of it. In some states, CME is mandatory for physicians. However, it is unstructured and limited to medical content and the main focus of the system is to raise awareness of the need for lifelong learning. For individuals, the term Continuing Professional Development (CPD) better describes a structural approach from the point-ofview of a professional. Both programmes do not address the needs either of the healthcare system or of the employers and employing institutions.
The healthcare industry is facing high demand for training due to new markets and modernised equipment and technology.
To understand the actual needs and optimise medical education and training, one has to look at the present situation in terms of the requirements of the market and the demographic changes. Varying healthcare conditions from one country to another mandates healthcare providers to take a global view, which ultimately leads to medical tourism. The success of medical tourism
depends upon the terms of mobility of all involved stakeholders. Mobility and flexibility in global market place in reality are affected due to various ethnic, cultural, social, religious, individual, political and monetary factors. Possible changes of these factors may highly affect business models. Hence, all these factors have to be considered seriously while planning to develop healthcare structures and Human Resources (HR). To meet the growing demands of healthcare due to demographic changes, the countries need to either attract foreign healthcare professionals and services, or send their people who need healthcare abroad. However, it appears that they have not come up with any definite plan to deal with the situation. The ongoing speed of technical and structural development is faster than the duration of studies and training programmes in medicine and healthcare. Therefore, continuous or lifelong learning is mandatory in these fields. The development of trained medical personnel is much slower than the construction of hospitals and getting technical infrastructure in place.
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Medical education and training is mostly focussed on the medical key competences. Knowledge and skills in the different specific medical domains dominate education and training. Especially in Europe, training in communication, leadership, service orientation and business skills is not part of the medical education process. However, consolidation of the hospital and healthcare service market necessitates the need for medical professionals with broadened key competences. Hospital administration in the past was often divided into medical and administrative branches and competences, which worked in two parallel worlds. Modern hospitals, however, are led by an overall united administration with a clear strategy. This change is not reflected in education and training of healthcare professionals. There is, in most cases, no sustainable policy or strategy for HR development in hospitals or hospital groups.
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As stated above, both CME and CPD approaches have limited themselves to lifelong medical learning that focuses solely on the medical domain and the individual physician’s needs. The aspects and needs of a regional or global healthcare market are not reflected through these approaches. These aspects have to be addressed by the employer or employing organisation. It sounds curious, but HR development is rarely applied to medicine. Therefore, understanding structures and tools for HR development in medicine are underestimated and underdeveloped. A close look at two major healthcare markets reveals the problems they face in the development of HR in medicine. • Due to the increasing growth in the hospital buildings and infrastructure in Middle East, there is great need for well-trained healthcare professionals. The strategy to overcome the shortage was to engage foreign
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specialists. Rarely was a sustainable training programme organised in the region. As a result, the specialists stayed only for a short period of time. When they leave the place, they take their skills and know-how with them. The structures they build do not survive and therefore no sustainability is given • In Eastern Europe, healthcare infrastructure is growing, supported by partnering programmes. Advanced medical technologies, as in diagnostics or therapy, are being installed but there is no tradition to buy knowhow or soft skills. Regional healthcare professionals seek to enhance their knowledge and skills abroad. The knowledge transfer back home is limited. In both situations, the desperate need for strategic HR development in medicine and healthcare is evident. But what are the consequences?
healthcare management
First step is to increase the awareness and understanding of the specific situation, the needs and the possibilities. This also includes the possibility of training the staff. In most cases, change management helps to understand and value soft skills, workforce and communication. Untrained teachers who are not aware of modern learning and technology will not succeed if they are not carefully guided and trained. An overall policy and strategy has to be developed to create a sustainable solid base for training. The transfer of information, knowledge, skills, and finally competence requires training in a face-to-face setting, and technology-enhanced learning. Blended learning, combination of Self Directed Learning (SDL) and face-to-face training, including Information and Communication Technologies (ICT) is the way to build up structural and strategic education. The scenario of e-learning has to be based on a modern learning environment. Modern in this sense includes technical and learning aspects. Web 2.0 and 3.0 inspire technology-enhanced learning in terms of flexibility, interactivity, community aspects, knowledge management, open interfaces and mobile learning. New technology opens new ways of learning, but all the stakeholders have to learn how to make best use of it. Our learning approach at Meditrainment is very much influenced by ‘microlearning’. Based on the ideas of Theo Hug, Professor, Department of Educational Sciences, University Innsbruck/Austria, we developed a concept of small learning units as the base of individualised strategic learning scenarios in a personalised learning environment. We believe that each has his own way to learn. Therefore, technology has to be utilised to empower the individual. Learning is always driven
by personal reasons and motivation, never by technology. Technology can, however, act by different means as a motivator. We experience this right now in mobile learning. An overwhelming number of possibilities are offered, but only a few are accepted by the user. The technology can be used to make the learning unit interesting, easy and interactive. Based on a learning environment, all aspects of learning have to be addressed to the learner. The learner should be able to acquire and share knowledge, skills and competence. All of this needs to be evaluated and tested. In learning scenarios, simulation in learning
Sharing of competence in the sense of developing problem-based solution utilising knowledge and skills is the Holy Grail of educational transfer. as in testing is an essential feature. In medicine, some simulators already exist to train skills. Sharing of competence in the sense of developing problembased solution utilising knowledge and skills is the Holy Grail of educational transfer. A combination of face-to-face training and self-directed learning with interactive media and simulators can help to reach this goal. Important and essential for the success of such an approach is the interactivity, the amount of repetitions made by the user, and most of all, the persistent motivation. Community and game-based learning
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Implementing HR development in healthcare
will also play an important role in such scenarios. For strategic and policy-driven approaches to learning, all of the above mentioned aspects have to be addressed in a technical as well as structural way. Therefore, moderation and change management are the key to success. An external consultant should have a broad experience and understanding of the domains of medicine, healthcare, human resource development, management and interdisciplinary development. A person or team is rarely found speaking the same language as an IT-specialist, healthcare professional, administration, constructor, politician and patient. In the growing market, device makers, universities, IT-Industry, and national agencies try to gain market share. So far though, collaboration or moderation for the sake of a regional problem has not been seen. Most of them have very specific key competences and underestimate the interdisciplinary aspects. Mediating and consulting roles have to be given to specialised companies in the field of education and training in medicine and healthcare. HR development in medicine and healthcare will play an increasingly important role in the development of regional and global healthcare. More attention needs to be paid and more resources have to be all cated to devise policies and strategy in this field. HR development is the key to continuously providing healthcare for all.
Alexander v Smekal is the Cofounder and CEO of Meditrainment GmbH, Germany. He is a board member in radiology and nuclear medicine, emergency care and sports medicine, studies of healthcare science, occupational activities in medicine, research and lecturing in universities in Germany, Austria, Switzerland, Netherlands and USA. He is trainer and consultant for human resource development in medicine and healthcare.
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T
he Harvard Medical Practice study published in the New England Journal of Medicine in 1991 created a groundswell of interest in patient safety. Though not the first study of its kind, it was the first largescale randomised approach to patient safety. The impact of the Harvard study was felt outside the US and eventually in the UK as well. As part of government-led modernisation program, clinical governance was introduced to the British National Health Service (NHS) to promote quality, reduce risk and realise clearer lines of accountability. It was envisaged that making chief executives of NHS organisations directly accountable for maintaining quality would
force them to produce better patient outcomes. Organisational learning was central to the mission of governance. It was not surprising that a flurry of related policy directives followed. ‘An Organisation with a Memory’ was the British Department of Health’s first dedicated, strategic policy document focussed entirely on patient safety and adverse
Gerry Armitage Senior Research Fellow Patient Safety Bradford Institute for Health Research Bradford Teaching Hospitals Trust, UK
Interruptions
at the Workplace A risk worth managing While it is known that they can lead to errors, interruptions can also be imperative in high-risk domains such as healthcare, where patient safety and medical error reduction is now paramount. Human error theory can explain the concept of error and how errors occur at different levels in an organisation.
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events. It was based upon advice of an expert group, which drew on human error theory and their already established application to aviation and other high-risk industries. Human error theory accepts the inevitability of error, moving organisations and individuals away from blame and towards learning, while firmly acknowledging accountability.
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What is human error theory?
James Reason, Emeritus Professor of Psychology at Manchester University has explained that human error stems from the interplay of various contributory factors that exist at the level of individual performance (known as active failures), the immediate environment (or local workplace factors) and at a broader, organisational level (systems failures). Active failures include slips, lapses and mistakes. A slip is observable and unintended and not uncommon in a busy environment. Slips are essentially errors in the human automation process where there is no conscious control and a normal routine is disturbed.
Consequently, slips are potentially a part of all routine behaviours. Donald Norman reminds us that they also tend to take predictable forms, and are likely to be experienced by experts rather than novices (the latter being less able to automate), which has implications for the familiar assumption that new staff is less reliable. Experts are further compromised by the mental storage of many more pre-programmed instructions (or schemata) than their junior colleagues. A lapse is simply forgetting something. For example, a doctor knows well that a patient requires pain relief at fourhourly intervals but forgets to prescribe the analgesia at the times required.
Interviewees’ opinion about interruptions “When an incident happens, you look at the factors leading up to it, I think interruption, nine times out of ten is there …you just can’t concentrate on doing your medicines and nothing else… the way we do our medicines on here, the way we work, we work in three teams. We’ve got four qualified nurses on a shift. The senior nurse will be in charge and then there’ll be three trained nurses taking charge of nine or ten patients each. So there’s three nurses crowding round one trolley, all trying to do their medicines at the same time.” Staff Nurse, Acute Medicine “Your managers are one of the first who’ll sit down and say, ‘Right, we have to tackle these drug errors. Let’s put tabards on to stop you from being interrupted’, but they’re the first ones who are on the phone saying, ‘Actually, no, can I speak to her now.’” (GA) Do you find that in any way frustrating? Don’t let me stop you. “I was just thinking, I mean, it’s not just your managers. Obviously you’ve got to think of all the other interruptions you get on the phone. Surgeons will phone, they always want to speak to the Sister. It’s slightly different if you’re a staff nurse, obviously. So they all want to speak to me and if I actually told them all, say, ‘No, I’m on a medication round,’ it’s just...” (GA) Difficult? “…extremely difficult, yeah. It wouldn’t happen. And also it would make my job a lot harder as well, in some respects, if I said, ‘ I’ll ring you back,’ to every single person I got a phone call from.” Staff Nurse, Surgery “I think another defence is you should have a tongue in your head and you know how to say to somebody, just leave me alone while I do this, I’m doing some medicines, I’ll talk to you about your tea-break later, you’re obviously working a medication out or you’re doing your drugs, you’ve got the drug chart there and somebody comes in and starts chatting about Saturday night. Well, I’m always one to have a good natter, but you can imagine management, well, why weren’t you concentrating? Well, I was talking about my Saturday night out... I mean I’ve more recently sort of turned round to people and stopped what I’m doing and actually said, yeah, it was really good, I’ll come and talk to you about it in a little while, just let me do this. But not in a confrontational way.” Senior Nurse, Paediatrics
A third category of error is a mistake— an action proceeds as planned but does not achieve its intended outcome because the original plan was wrong. For example, a junior doctor may decide he doesn’t need to consult his formulary for the dose of a previously un-encountered antibiotic so he chooses the wrong dose due to lack of information. The key element is the decision—he has made a judgement but it has not led to the desired outcome. Local workplace factors are the phenomena that surround practitioners and sometimes merge to increase the likelihood of an error. They include unworkable processes, an inappropriate skill mix and poor documentation. Systemic failures such as chronic gaps in supervision or shortfalls in maintenance are examples that will originate in human decisions but, as Professor Reason has written, they are made at a strategic level. At this level, different influences stemming from group dynamics and—as witnessed in the US challenger disaster—from structural and cultural sources such as production pressures and bureaucratic accountability, might exist. Certain upstream decisions can then lead to numerous error-producing factors downstream. Research study
In a recently completed study, I examined the contributory factors in medication errors and their reporting in a large teaching hospital. Data were collected from a retrospective, random sample of just under 1,000 definitive drug error reports submitted over a period of five years. This was followed by 40 qualitative interviews with a volunteer and multi-disciplinary sample of health professionals. Of particular interest were the interview participants’ accounts of the contributory factors in medication error from which a hierarchy of importance emerged (See Table 1). In line with much of the literature on medication errors, the participants elucidated
Table 1
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a whole range of contributory factors. Interruptions and distractions, a relatively rare factor from the drug error report analysis, were far more prominent in the interview data. This may be related to an inclination to present written accounts in a particular style. Some implications
Twenty four years ago, Gilbert and Mulkay examined the way scientists described their experiments. They established a clear difference in content between written reports and interview data concerning the same scientific processes. Their documentation portrayed a world firmly governed by scientific laws, where the scientist’s actions are neutral. However, when interviewed about the very same experiments, they gave quite a different view of their various activities and judgements, admitting that their personal behaviours and social positions also exerted a tangible influence. They added that all sorts of variables impacted on actions. The literature on interruptions as a contributory factor in medical error is compelling and like the factors previously discussed, is a multi-disciplinary problem. Furthermore, policy makers such as the US Institute of Medicine (IoM) have highlighted the phenomenon as significant. Interruptions lead to specific types of error usually slips, which may then contribute to errors of omission—and can be significant—such as failing to give a medication or wash one’s hands. Nevertheless, interruptions may serve a function. Donald Norman and colleagues have explained that if interrupted, the human functions of storing, retrieving and processing thoughts are usually suspended. Consequently, recovering the original activity, if a new one is introduced, can be difficult. Interestingly, Mohammed Walji and colleagues at NASA have actually argued that interruptions are critical cues in multi-tasked environments such as healthcare and even promote
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productivity. Yet, to avoid interruptions being seen as an accepted element of practice, Walji has identified three conditions for what might be termed as ‘effective interruptions’. First, the person being interrupted must be interrupted at the right time, the task they are undertaking should not be spoilt as a consequence of interruption, and the interruption process should be carefully executed to enhance its persuasiveness. However, a notable caveat is supplied by Tucker and Edmondson who, on the basis of their multi-centred observational studies, have proposed that (ostensibly) resourceful and highly adaptable staff who normalise interruptions simply serve to hide away organisational weaknesses. My interview data exposed another type of interruption. Categorised here as social interruption, and rather like violations in comparison to slips, the social interruption is more likely to
be deliberate (or intentional) being a psychosocial rather than cognitive factor. Interruptions require two parties. Of course, the person being interrupted by a social question may not wish to be interrupted. Their inability to say ‘no, not now’ may similarly hide away organisational weaknesses, but may also be strongly suggestive of a lack of error wisdom. It is clear from this data that interruptions are a cause for concern. It may also be that reporting, if carefully structured, may be one means of identifying their role in causation and their effects. So what can we do?
To gain a better understanding of problems such as interruptions, which are essentially local workplace factors, we have the asset of human error theory. First, we know that interruptions can cause particular error types. This
Clinical Staff
Task Management
Drug Dispensing, Prescribing and Administration
Provides Clinical Reports and Handovers on Drug Therapy
Situational Awareness
Professional Style
Outlines plans and differences Allocates tasks Seeks input Checks understanding
Thorough preparation Anticipates therapy and updates drug documentation Makes contingency plans for problems Keeps broad perspective
Abides by professional code Aspires to high performance Stays conscientious and flexible Remains Self-aware and seeks feedback
Teamwork
Workload
Drug Handling
Balances rank authority Flexible and shows respect Actively monitors and supports Thinks independently
Recognises high workload Takes or makes time Deals with overloaded priorities Avoids distraction and distracting
Ensures that it is safe, effective and efficient Follows and amends overall prescription Is aware of side effects and contra-indications Manages errors, reports near misses and adverse events for learning
Communication
Decisions
Applied Knowledge
Shares information / ideas Actively listens Assertive when required Admits mistakes and doubts
Identifies problems / issues Involves others if needed Evaluates outcomes Uses structure in new situations
Technical Guidelines Protocols
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Effective team work also means that whatever the seniority of colleagues, they do not have an unconditional right to interrupt. As the skills list states, practitioners must be ‘assertive when required’. One’s professional style also demands that social interruptions do not interfere with critical activities. We cannot afford social interruptions to be normalised. This, however, demands cultural—not just procedural—change and is not easy. Effective leadership is crucial.
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knowledge can then provide a systematic trail from the outcome—a missed medication dose—to the likely contributory factors. Consider a practitioner slip alongside a problematic way of working like giving all patient medications when one team of nurses hands over to another; a point when staff availability is probably low and interruptions are high. Based on the above knowledge, we could then change practice but healthcare will never be interruption-free, indeed this would be counterproductive. Lessons can be learnt from the aviation industry where interruptions are conditional. Work I carried out with a British airline has led to the development of a drug therapy skills list to combat medication errors (Table 2) stemming from a pilot skills list. It acknowledges that interruptions can be distracting and they require avoidance, especially if they cause overload for the recipient.
Interruptions are a risk worth managing, but managers may not find staff detailing the risk in incident reports, unless of course they are encouraged to think more carefully about the impact of local workplace conditions on their performance. This might be achieved through more analytic reporting tools, which we are currently developing at the Bradford Institute for Health Research. Oh! and watch out for the expert practitioners, the spontaneous demands on their expertise means they make errors too!
Gerry Armitage worked as a registered nurse for 13 years in both junior and senior posts. Following this he spent a similar length of time working in higher education where he led undergraduate nursing programmes and developed new courses with the NHS, independent sector, and outside the UK. In 2007 he completed a 3 year research study funded by the Department of Health which culminated in the introduction of a drug error reporting scheme for an acute hospitals trust.
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umerous studies conducted in countries all over the world have shown chronic pain to be a prevalent and costly problem. The American Pain Foundation states that Americans get affected by pain more than diabetes, heart disease and cancer (American Pain Foundation). Another study suggests that the costs of healthcare for patients with chronic pain exceed the combined costs of treating patients with coronary artery disease, cancer and AIDS (Turk, 2002). The impact of chronic pain in the Northwest Region of Kaiser Permanente (a Health Maintenance Organisation in
the Pacific Northwest, United States) has proven to be just as significant. Kaiser Permanente Northwest (KPNW) has identified 67,000 members with chronic pain. In 2003, the organisation did a survey of members with various chronic diseases and found that those with chronic pain showed the highest impairment and reported the most significant negative impact on their quality of life. Members with chronic pain are hospitalised more, make more emergency visits and outpatient visits than an average Kaiser Permanente member, even those with other chronic illnesses.
Chronic Pain Management Integrated with primary care With the number of individuals in need of assistance for chronic pain increasing each year, only a small fraction of patients with chronic pain are treated directly by the Pain Clinic. In recognising the scope of the problem, in terms of prevalence, cost and human suffering, the KPNW Pain Management Clinic has created a programme to meet the needs of patients and care providers, all while keeping down costs of the overall organisation. Throughout the design and implementation of this pain programme, the KPNW Pain Management Clinic (PMC) has based its services on two facts of chronic pain care. The two facts are: 1) Research on chronic pain management has consistently demonstrated the
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need for a multidisciplinary approach for effective long-term results. 2) With the number of individuals needing assistance for chronic pain each year, only a small fraction of patients with chronic pain can be directly treated by the Pain Clinic. With these facts in mind, the KPNW Pain Management Clinic devised a programme that has consistently worked to accomplish two goals—to help members with chronic pain get their lives back and to help primary care providers treat members with chronic pain more effectively.
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Marilee Donovan Regional Coordinator Pain Management / Clinical Nurse Specialist Lindsay Kindler Clinical Nurse Specialist Kaiser Permanente, USA
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Programme overview
As suggested earlier, the KPNW Pain Clinic firmly believes in the value of a multidisciplinary team. Starting with three anaesthesiologists working part time, one nurse, one clinical nurse specialist and one social worker in 2000, the programme has grown dramatically. A team composed of four anaesthesiologists, one physiatrist, two internal medicine physicians, a psychiatric nurse practitioner, four social workers, two clinical nurse specialists, three pharmacists, three advice nurses, two triage nurses, procedural nurses and medical assistants provide care. The team provides support to all services of the pain management programme. Services offered by the KPNW Pain Management Clinic consist of several interrelated components. Each of these components works to meet the needs of the individual patient while providing assistance to the primary care provider responsible for ongoing management of the patient’s overall care. All consultations performed by PMC providers include an accompanying chart note to the patient’s primary care provider specifying recommendations or suggested services in order to
enhance a team-oriented approach. The clinic’s anaesthesiologists and physiatrist make recommendations and implement advanced pain management procedures from blocks to radio frequency procedures to implantation. The internal medicine physicians and pharmacists consult their patients and their primary care providers to either implement or recommend medication management plan for patients with complex medication needs. The clinic has one physical therapist that helps design treatment plans in collaboration with physical therapists throughout the KPNW system. Social workers, clinical nurse specialists and the psychiatric nurse practitioner consult Pain Clinic physicians or primary care providers for the management of patients with complex psychosocial needs and help develop treatment plans that optimise the resources and services of Kaiser Permanente. The clinic has three nurses devoted to patient advice. They answer patient questions, provide ongoing patient education by phone or email and assist in titration of medication. Two nurses triage more than 400 incoming referrals per month and ensure that the patients are directed to the service that
Model of multimodality care adapted by KPNW Cognitive Behavioral Therapy
Medical Therapies
Examples: knowledge about pain, Examples: medications, realistic goals, quite smoking, pacing procedures, surgery, implantation (use of timer, pedometer), counseling, mediation, relaxation techniques, treatment of depression Co-management of addictive disease
Patient Self Care
Physical Modalities Examples: exercise/stretch q1h; start where you are and go slow; positioning; aids (walker, splint), TENS, heat and cold, self massage trigger point therapy
Complemental Therapy Examples: acupuncture, hypnosis, chiropractic, herbals, elimination diet, energy work, Ayurvedic naturopathy
Figure 1
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Growth of pain clinic 1990-2008 25000 20000
10000 5000 Exceed Capacity Again
Improve Access
Add Washington Clinic
Add Salem Clinic
Add Complemental
Add Medication Management
National Work
Vohs Award
Merge Block & Groups
Add Groups
0 Block Clinic
Number of visits / year
15000
1995 2000 2002 2003 2004 2005 2006 2007 2008 2009 Major steps in evolution
best meets their needs. The clinic also has a partnership with a growing Integrative Medicine Program that consists of practitioners offering acupuncture, training in self-hypnosis, energy healing, ayurvedic medicine and neurostructural integration. For the sub-population of patients with both addictive disease and chronic pain, the clinic works closely with Addiction Medicine. At the core of the KPNW Pain Clinic are the multidisciplinary group visits that help patients learn how to manage their pain on a day-to-day basis. Forty series of eight structured group visits are available to members each year. These group visits help the primary care provider bring evidence-based pain management to members within their local area. These visits help members try a variety of therapies in order to develop an effective individualised multimodal treatment plan (See Figure 1). The groups are also co-led by PMC nurses, social workers, clinical nurse specialists, pharmacists, the psychiatric nurse practitioner and the physical therapist. Because of the commitment to multidisciplinary care, all groups are co-led by a team composed of group leaders from two disciplines. Each of
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2010 Figure 2
the first seven weeks presents new ways to manage chronic pain, emphasising the need for a multidisciplinary, multimodal approach. In the final eighth visit, a Pain Clinic practitioner and the patient work together to devise an individualised treatment plan. This plan serves as a guide for the patient and is also sent to the primary care provider as a way to enhance the working relationship between the patient and provider. Services for the primary care provider
While the PMC serves less than 10 per cent of patients with the most complex care needs, the primary care providers manage the majority of patients with chronic pain. In order to optimise chronic pain care to all individuals, the PMC is committed to help primary care providers, give more effective, evidence-based pain management care. To accomplish this goal, the staff of the PNC offers continuous education on pain management, consults individually via telephone or electronic messaging on questions of care, and provides tools and information to primary care providers. These tools are readily available to the
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primary care clinicians on their office computers. Every month at least one from the team consisting of physician, clinical nurse specialist, pharmacist, social worker or physical therapist is involved in educating practitioners through clinic inservices, department meetings or regional continuing medical education activities. The most effective education occurs on an individual basis through the discussion of care of patients dealing with complex bio-psychosocial needs. This communication is accomplished through e-mails via KPNW’s electronic medical record; phone conversations and multidisciplinary patient care conferences. Consultations with the PMC staff regarding complex cases allow primary care providers to feel supported in their daily work and assist in the development of care strategies in future. Outcomes
Over the years, PMC has tracked a variety of outcomes—pain relief, improved function and reduced healthcare utilisation. The electronic medical record now allows us to graph pain severity, functional interference over time (using the Wisconsin Brief Pain Inventory which is embedded in the electronic medical record) (Daut, CLeeland and Flanery, 1983). Because KPNW has had an electronic medical record since 1997, healthcare utilisation data is relatively easy to obtain. The initial evaluation of the pain management programme indicated that for patients who completed the series of pain management group visits, the utilisation decreased by approximately US$ 1,000 per patient each year. Evaluation of five years indicates that this improvement in utilisation persists for many patients. It was hypothesised that this reduced utilisation occurred because patients improved their skills to deal with their pain and felt more confident about their ability to manage the pain and changes in the pain over time (Donovan, Jacobs and Blake, 2002). External pressures have often determined other outcomes that need to be
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Growth and future directions
Owing to the success of the PMC’s services and the growing recognition of the need for aggressive pain management and the ageing of the population, the Pain Clinic has expanded to meet the growing needs of the KPNW population. Not only has the programme increased its staff by 500 per cent in eight years, but also the number of visits and their kinds has increased dramatically. The PMC believes that the best care is delivered closer to the place of the patient and the primary care provider. Moving more services to regional locations will offer decreased travel distances for patients in pain, offer greater opportunity for collaboration among PMC’s staff and
Pain management clinic - hub and spoke model North
INTG
Westside GROUP VISITS
CON
CORE
East
MED MGT
PROC
Goal is comparable services in all PCSAs; Ellipses indicate no services yet
regional primary care providers, and offer services specific to local needs. The PMC Multidisciplinary Groups have used this model of delivering Pain Management Clinic services at the site of the local clinic with great benefit over the years. The Pain Clinic currently offers some services at a section of the region with a goal of being able to provide most services closer to patients. (Figure 3) Conclusion
The KPNW Pain Management Clinic approach has many components that are transferable to other settings. The
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considered. For instance, in both the states of Oregon and Washington (where KPNW provides care), it is required that all patients taking opioids for chronic pain have a signed consent and opiate therapy plan. The current method of producing list of patients who need this document produced and signed will soon be replaced by a reminder that is generated electronically in the medical record when an opiate therapy plan is required. With growing concern about the adverse effects of methadone and high dose opioids in general, pharmacy records are being reviewed to determine the outcomes related to these medications. As the demand for pain management has grown faster than resources to provide services needed, the waiting time for a patient from the date of his / her referral to consultation has become a critical outcome. The number of patients who complete the series of group visits is compared to that of patients who were initially appointed. In 2008, it has become clear that the cost of fuel is resulting in far fewer patients attending the group visits. The Pain Management team proposed developing a DVD of the pain management group visits that could be used with telephone coaching as an alternative to group visits when patients cannot afford to attend the group visits in person.
Salem
Figure 3
KPNW electronic medical record makes it easier to do the right thing, but it is not essential. The essential components are: a commitment to help the patient in becoming an active partner using multiple modalities of care each day; providing care as close as possible to the patient by supporting the primary care efforts; basing care on scientific evidence whenever possible; flexibility and ongoing development of the programme in response to internal and external needs; and patience and persistence—the energy to persevere because it is the right thing to do.
Marilee Donovan has spent most of her career dedicated to improving pain management. She is co-founder and Regional Coordinator of the Kaiser Permanente Northwest Pain Management Program.
Lindsay Kindler has been a Clinical Nurse Specialist with the KPNW Pain Management Program since 2004. She is also a doctoral student at the Oregon Health Sciences University.
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Slow Medicine Emerging concept in elderly care
Slow Medicine advocates less-aggressive and compassionate approach towards the elderly patients. Despite many ethical and professional apprehensions, a start has been made.
from a measured approach. This could involve understanding their problems, medical and others, their values, their life, their choices and their living circumstances. For elders, Slow Medicine could be a gateway to conventional treatments, provided it is of their choice. Slow Medicine is a philosophy and also a practice. It demands time and regular attention. Many elements of the philosophy and the practice of Slow Medicine can be applied to help anyone approaching life’s end. The philosophy and practice of Slow Medicine serves elders well because their journey of late life is more complicated than that of middle age. Factors like patient’s age, strength and the severity of the ailment play a vital role in the practice of Slow Medicine. If one were to define a ‘successful outcome’ in Slow Medicine, accomplishing a patient’s preferences would be apt. According to Dr McCullough, “A successful outcome is one which reflects, on repeated re-assessment over time, the choices of the elder and his or her family.” Unanimous decision
Sridevi Prekke Member Editorial Team Asian Hospital & Healthcare Management
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ature knows best. Less is more. These two are the thoughts surfacing recently in elderly care through the concept of Slow Medicine, pioneered by Dr Dennis McCullough, a geriatrician and a faculty member at Dartmouth Medical School and the author of My Mother, Your Mother Embracing “Slow Medicine”: The Compassionate Approach to Caring for Your Aging Loved Ones. Slow Medicine is a less aggressive, family-centred and less expensive way of care that slots in all the requirements to be pursued for a quality end-of-life,
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especially for elderly patients. The elderly not only suffer due to ageing problems such as failing minds and bodies, but also because of an ill-equipped social healthcare system. The Slow Medicine model is rooted in the presumption that the choice of the elderly regarding their care should be appreciated. Philosophy and practice
The philosophy of Slow Medicine is to protect comfort of the patient rather than cure of an ailment. Slow Medicine shares with hospice care the approach of paying a great deal of attention to patients and their specific problems and needs. The difference, according to Dr McCullough, is that while hospice care focusses more on the very last days or weeks or months of care, Slow Medicine can be practiced over years or perhaps, in some cases, a decade or more. It is largely based on the belief that the best decisions about care come
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The concept of Slow Medicine calls for the involvement of the patient and patient’s family in taking a decision concerning the treatment that the patient should undergo. The principles of Slow Medicine include communication with elders, their family and doing one’s best to take decisions based on complete understanding of the patient and the situation the patient is in and maximising his / her comfort. So, patient’s consent and acceptance are vital to practicing Slow Medicine. For example, a person in his seventies, suffering from an ailment may not be willing to undergo intensive medical treatments; rather he /she would be seeking a quality life for the time left over. Another patient, in the same condition might like to extend his / her life as much as possible from the available resuscitating therapies. Thus, the patient’s perspective is always
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Dennis McCullough Geriatrician and Faculty Member Dartmouth Medical School USA
How can one assimilate a patient’s perspective in
How can Slow Medicine help in solving the problems of elderly patients? In late life, the elder, the elder’s circumstances and the problems the elder faces require that we not push for a fast decision, but allow time to help the elder; the family and healthcare providers achieve a deeper and truer understanding of what they must decide and provide. This is often not easy because it may require facing conflicts and differences of opinion and approach. It is expected that there will be continuing periods where there may be uncertainty about these choices and choices must be re-visited as needed.
choosing Slow Medicine? The patient’s perspective is always central to the practice. Even if an elder is partially disabled, for example, by a stroke or some cognitive impairment, the patient’s perspective must be sought through emotional and other physical responses— for instance, interest in eating, in relationships, etc. at this time of life. Do you think patient will be capable of taking a decision regarding what treatment he should undergo? In those instances where an elder may clearly be unable to participate in making a decision, the burden falls to those (family, friends, health professionals) who have sought to understand the elder over the late life period.
What are the circumstances that prompt the patient to choose Slow Medicine rather than conventional treatment? For elders, Slow Medicine can be a gateway to conventional treatments, when that is the elder’s choice. However, the practice of Slow Medicine may also lead to choices of ‘alternative medicine’ or ‘traditional medicine’ treatments or perhaps to ‘wait and watch’ approaches that simply focus on symptom relief and comfort (and commitment to whatever approach is chosen).
Slow Medicine doesn’t focus on saving the life of a patient; rather it focusses on quality of life and comfort of the patient. Then, is it proper to conclude that Slow Medicine is not an approach which can be practised in an emergency situation for an elderly? Although there are some emergency situations where Slow Medicine might not be practised to its full extent, there are always principles of Slow Medicine practice (communication with elder and family, kindness, doing one’s best to make
essential to the practice. Speaking about the patient’s perspective, Dr McCullough says, “The patient’s perspective must be sought through emotional and other physical responses—for instance, interest in eating, in relationships, etc. at this time of life.” The family and healthcare providers need to achieve a deeper and truer understanding of what they must decide and provide. Dr McCullough points out that
this understanding arises through discussions and reflections by elders themselves along with their ‘circle of concern’—families, other intimates and friends. In the whole exercise, it is imperative that healthcare professionals must be open to the whole idea of Slow Medicine as they are the essential drivers for Slow Medicine. They should be ready to involve the patient and his /her family. They should discuss the condition of the patient, the
decisions based on as complete an understanding of an elder and their situation, maximising comfort) that still hold true. If one has practised Slow Medicine along the way, emergencies as they occur are almost always better understood by the elder, the family and support persons and healthcare professionals. A patient in his 70s is advised to undergo an open heart surgery, only to prolong his life for few more years, of course, with all the risks that he faces during the first three months after surgery. What do you advise in such a situation? Perhaps the most important part of this process is that there is a clear understanding of the real risks of this surgery and the potential benefits and the patient and his or her advisers have enough time to really think about them and discuss them, repeatedly, if necessary. Then, the answer usually emerges. For an otherwise healthy person, at the relatively young age of 70, the decision might be straightforward; for the patient over 80 with other problems, it could be a very difficult decision which should be explored over time. I have had patients decide both ways, which is perfectly in keeping with Slow Medicine. The important work here is to allow the patient to make the best decision possible for him or herself, aided by thoughtful and patient professional and family counsel.
available alternatives and the pros and cons of the alternatives. The milieu of the patient should be well known to the patient himself and his family. Put on the brakes
In an effort to extend the life of the patient, family and physicians opt for intensive care, even if it means that the treatment could cause serious side effects. Some treatments hasten the downward
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course of patients’ health leading to prolonged period of dependence. Most of the elderly are afraid of the side effects of intensive care. Dr McCullough advocates a less aggressive alternative in such situations. For example, a manual breast exam is preferable to a yearly mammogram for the very old and home tests for blood in the stool to the draining routine of a colonoscopy. Slow Medicine encourages physicians to slow down when considering aggressive care that may cause high risks and limited rewards for the elderly. It is a return to the personal doctoring in an age of high-tech medicine. It edifies patients and families how to avoid hospitalisation and emergency room trips proposed for those with treatable ailments, not the usual downturn due to advanced age. And, the periphery of the treatment confines to the known surroundings of the patient, unlike the typical medical ambience which they resist the most. Ethical edge
Aggressive care in some cases saves life. A number of doctors opine that intensive care definitely prolongs life. This perception might not hold true in all cases. Still, mentioning only the cases of death would be biased and vice versa. Dr McCullough argues that “the decision to practice Slow Medicine can sometimes run contrary to what the ‘system’ wants most, which is a decision taken quickly to assure that high efficiency for the system occurs.” Slow Medicine is described as a lessexpensive way of providing care. This gives rise to the ethical question of valuing human life. Furthermore, estimating the time left approximately considering the circumstances—which could differ from case to case—may prove the assessment wrong. So, choosing Slow Medicine is ultimately the choice of the patient and the patient’s family. In that case, the question arises: how can the doctors allow the patient to take such a critical decision? Regarding the ethical side of the concept, Dr McCullough says that Slow
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Medicine blends the ethics of individuality i.e. autonomy, benevolence, truthfulness and non-malfeasance which focus on the empowered individual in making decisions with the ethics of character and commitment. These ethics emphasise the importance and value of ‘staying with’ an elder though all the ups and downs. He comments, “This ethical approach, ‘commitment to the very end’, in a partnership between elder, family and healthcare providers is presently less emphasised in our acute care-oriented medical systems.” Every patient and his / her circle of concern would wish a long life, but at what cost and what kind of life would that be? These are the questions that cross through the minds of those involved in the process of decision-making.
Resistance to change is common and it is the case with slow medicine too. But, as the patient population desiring this kind of care is increasing, the chances of sustainability of the concept are more. Time alone can prove how it nurtures the requirements of both the patients and the doctors. BOOK Shelf
My Mother, Your Mother: Embracing “Slow Medicine,” the Compassionate Approach to Caring for Your Aging Loved Ones
The resistance
The concept of Slow Medicine might not hold good in an emergency. But, Dr McCullough advocates the practice and states that though there are some emergency situations where Slow Medicine might not be practiced to its full extent, the principles of Slow Medicine practice still hold true. He says, “If one has practiced Slow Medicine along the way, emergencies as they occur are almost always better understood by the elder, the family and support persons and healthcare professionals.” Not only the ‘circle of concern’ of the patient, but physicians too tend to have a mindset of ‘what all can be done, shall be done’ to save and prolong the life of a patient at any cost. Their etiquette doesn’t allow them to think beyond the physical existence of their loved ones. They would always like to try out all the available options to extend the life of the patient. Hence, Slow Medicine may not be an easy option. All said, the idea of Slow Medicine is still foreign to many physicians who are proponents of aggressive treatments for patients’ ailments. In the process, medical care has grown almost tantamount to technology-oriented care.
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Author : Year of Publication : Pages : Publisher :
Dennis McCullough 2008 288 Harper
Description My Mother, Your Mother will help you learn how to: • Form an early and strong partnership with your parents and siblings; • Strategize on connecting with doctors and other care providers; • Navigate medical crises; • Create a committed Advocacy Team; • Reach out with greater empathy and awareness; and • Face the end-of-life time with confidence and skill. Although taking care of those who have always cared for us is not an easily navigated time of life, My Mother, Your Mother will help you and your family to prepare for this complex journey. This is not a plan for getting ready to die; it is a plan for understanding, for caring, and for helping those you love live well during their final years. And the time to start is now.
For more books, visit Knowledge Bank section of www.asianhhm.com
medical sciences
Cardiac Death Predisposition New tools for early detection
Those who die a sudden death, probably are never aware of the potential risk they carry. Recently, new tools for diagnosing those prone to SCD have been introduced. This marks a key milestone in the detection of sudden cardiac death signs among healthy individuals.
Ivana I Vranic Specialist in Internal Diseases Cardiologist and Assistant Professor Medical School, University of Belgrade Private Clinic HERTZ Serbia
S
udden Cardiac Death (SCD) continues to be an important medical challenge in Asia as well as in the developed countries—apart from Europe and the US. Since sudden cardiac arrest is no respecter of geographic boundaries, identifying individuals who are at risk and responding in time to those who suffer from this catastrophe far from hospital are the major problems. A generally accepted definition of SCD is natural death due to cardiac causes preceded by abrupt loss of consciousness, which lasts for an hour from the onset of acute cardiac symptoms. Epidemiological studies remain challenging because of persisting inconsistencies in data, variations in clinical recognition and its pathophysiological mechanisms of development. Epidemiology
Approximately 50 per cent of all Coronary Artery Disease deaths are sudden and unexpected. They comprise half of all SCDs. The other half that is not CAD-related have very low incidence of 0.1-0.2 per cent per year. Low incidence of disease in the other half is due to inherited conditions such as channelopathies (long QT syndrome, Brugada syndrome,
catecholaminergic ventricular tachycardia, and similar disorders), and hypertrophic cardiomyopathy as well as arrhythmogenic right ventricular cardiomyopathy. In an attempt to subcategorise the duration of symptoms preceding SCD, Kuller and colleagues showed that if the duration of symptoms is less than one hour between onset and death, 91 per cent of unexpected natural deaths were found to be due to cardiac arrhythmias. But, if the duration is two hours, only 12 per cent of deaths were sudden and due to cardiac causes. However, if the duration increased to 24 hours, 32 per cent of deaths were found to be sudden. Causes of SCD
The causes of SCD vary with the age of the patient and are enhanced by complex interplay between genetic polymorphism and environmental factors. Therefore, virtually any pathologic process that involves the heart may lead to it. The highest incidence of sudden death is between birth and six months of age (sudden infant death syndrome) and between 45 and 75 years of age. The incidence is 100fold greater in adults older than 35 years, than in young adults less than 30 years old. Men are more likely to die suddenly than women, possibly because of lack of oestrogen protection. It is interesting, though, that among other causes of death, cases with ‘no findings’ on autopsy encompass almost one-third of all sudden deaths in the population younger than 30 years of age. It suggests that there was no prior
warning sign and that death was the first and usually the only sign. Risk for SCD
The risk of sudden death among the general population aged 35 years and older is in the order of 1-2 per 1000 per year. Between the age of 40 and 65, there is a marked increase with CAD being the most important cause. In patients with a high-risk status, the risk of sudden death may be as high as 10-25 per cent per year. In adolescent and young adult populations, the risk is about one per cent (of that of the general adult population) and familial diseases, such as the congenital long QT syndrome, hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia and Brugada syndrome, play a preponderant role. Arrhythmogenic right ventricular dysplasia
Among others, Arrhythmogenic Right Ventricular Dysplasia (ARVD) is of special interest. It is the cause of sudden death in young athletes and otherwise healthy people during vigorous physical effort or even during rest and sleep. Unfortunately, valid World Health Organisation (WHO) criteria during last 14 years failed to detect ARVD at its early stage and recommended diagnostic methods were shown to have low sensitivity for majority of patients even in its overt phase (because of a lack of scoring system). Investigation of this population is further complicated by disease rarity and lack of large databases. Newly published research
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V sign pathognomonic of ARVD on ECHO
T sign pathognomonic of ARVD on ECHO
Figure 1
data give priority to vectorcardiography and ultrasound. The recent results published by Dr Jeff Safitz clearly demonstrate that patients with ARVD are 10 times more susceptible to mechanical stretch and electrical force than normal cardiomyocites, explaining why those patients are at risk for early and massive apoptosis. The possible explanation for this might lie in the existence of specific place in the heart exposed to most physical forces during cardiac cycle. Nevertheless, this place is the locus minoris rezistentiae during contraction and relaxation of the heart. It is presently the focus of ongoing clinical studies regarding two aforementioned methods in detecting early stage of ARVD / C. It is also registered by WIPO as SOPHIE methodology (suggesting wisdom to detect). Both of the aforementioned mechanisms are clearly present in ARVD. It is a genetic disorder followed by peculiar RV involvement and its structural and functional abnormalities (due to the replacement of myocardium by fatty and fibrous tissues), and electrical instability that precipitate ventricular arrhythmias and sudden death. However, all non-invasive and invasive methods of evaluating RV structure and function have inherent limitations, which are due to the complex anatomy of RV. Evaluation of the RV
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Figure 2
can provide important insights due to its complicated structure and the fact of being divided into three parts: inflow, outflow and the crescent-shaped, truncated main body. Not to mention the right ventricular free wall, which also has a variable, trabecular pattern that in combination with its retrosternal position limits precise measurement of cavity size and wall thickness. Nevertheless, Tricuspid Anterior Plane Systolic Excursion (TAPSE) has been shown to correlate with its overall function (in adults), particularly in systole, as assessed by ejection fraction, that can be objectively estimated by radionuclide ventriculography (done in a standard way). The recognition of mild, fruste, or localised forms of the disease remains a clinical challenge. It is difficult to diagnose ARVD in patients with minimal right ventricular abnormalities by echo or contrast angiography examination. So far, only V sign and T sign (Figure 1 and 2) by Dr Ivana I Vranic have been attributed as pathognomonic in ARVD but no other signs have been reported yet. Standardised diagnostic criteria have been proposed by the ISFC, however this condition may be overlooked by the insufficiency of its signs at the early stage of disease. New perspectives
Database started in 1998 in Serbia, (which encompasses 96 ARVD patients up till
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now), was discovered and has been investigated by Dr Ivana I Vranic, provides with some interesting new insights in relation to vectorcardiography (Figures 3 and 4). This database made it possible to discover a new pathognomonic sign in the early phase of SCD-prone patients when no other technique is able to detect. Very soon, this technique could be incorporated in a new medical equipment (used for risk stratification of SCD). Autonomic nervous system
The concept that neural activity exerts a potent influence on arrhythmogenesis in late 1970s has received strong affirmation in recent literature. Some important and fascinating new insights have been gained regarding the mechanisms of neurocardiac interactions and important practical tools from emerging concepts have been developed for human studies on neural influences on heart rhythm in health and disease. These elements provide basis for risk stratification in inherited arrhythmogenic diseases and implication for therapy. The entire neural control of the heart is enriched by afferent information, relayed centrally through vagal and sympathetic cardiac afferents. This sensory system, besides signalling haemodynamic changes through cardiac mechanoreceptors provides the basis for arrhythmia genesis.
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Heart rate variability
The analysis of heart rate variability could also provide valuable inputs for the estimation of the risk for SCD. The influence of autonomic nervous system on heart rate has been studied by employing the tool of Heart Rate Variability (HRV). The study Increasing degree of right bundle branch block
has shown that parasympathetic activity influences higher frequency component, whereas sympathetic nerve activity exerts lower frequency component. This parameter is capable of stratifying risk for mortality after myocardial infarction, or chronic cardiomyopathy, but has not been tested in myocarditis or other inherited arrhythmogenic diseases until recently by Dr Ivana I Vranic in ARVD patients.
Inclusion criteria for HRT analysis (G Shmidt et al., 1999): a coupling interval of less than 80 per cent of the average of the preceding five sinus intervals; a compensatory pause exceeding 120 per cent of the preceding sinus intervals; if they were embedded into two preceding and 15 succeeding N-N intervals; cycle length of more than 300 ms but less than 2000 ms; difference to the reference interval of less than 20 per cent. Results of HRT analysis in Sebian database
Heart rate turbulence analysis
(a) Normal QRS-vector and T loop; (b), (c), (d) Different degrees of incomplete right bundle branch block; (e) complete right bundle branch block
Figure 3
Here A and B are the first two normal intervals preceding the Ventricular Premature Beat (VPB) C and D the first two normal intervals following the VPB. Turbulence Slope (TS) is defined as the maximum positive slope of a regression line assessed over any sequence of five subsequent sinus-rhythm RR intervals within the first 20 sinus rhythm intervals after a VPB. A u thor
Type A right ventricular hypertrophy
Heart Rate Turbulence (HRT) is a new method for evaluating the risk of sudden death in patients with heart diseases (Shmidt et al., 1999). Earlier, it was the most powerful risk stratifier in patients with ischemic heart disease, diabetes mellitus, congestive heart failure, and idiopathic dilated cardiomyopathy, Chagas disease and in healthy adults. But this kind of studies has never been conducted with inherited arrhythmogenic diseases until recently by Dr Ivana I Vranic in ARVD patients. Turbulence Onset (TO) is the percentage difference between the heart rate immediately following PVC and the heart rate immediately preceding PVB.
(a) ASD, SOVS, VSD; (b), (c) ARVD
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Group
N*
ARVD with arrhythmia
36
ARVD without arrhythmia
60
Turbulence Onset (TO), % -5.8 ± 4.02
Turbulence slope (TS), ms/RR 17.0 ±10.38
-4.08 ± 4.60 38.56 ± 22.43
Table 1
Abnormal value of TO is high-specific criteria for the prediction of adverse phase of disease in patients with heart diseases. TS < 2,5 ms per RR interval may be used as a relatively specific tool for risk stratification of sudden death in patients with heart disease. Conclusion
There is diversity of clinical presentation of SCD data, but now possibilities abound with new methods, which can precisely detect people who are at high risk with recent advances in vector cardiography heart rate turbulance analysis. Sophie technology can be of much use to a wide spectrum of populace be it cosmonauts, scientists, sportspersons and highrisk patients. It can also be beneficial to insurance industry and professional sports companies, which buy players.
Ivana I Vranic is a Specialist in Internal Diseases and is pursuing her Doctorate from the University of Belgrade School of Medicine. Her areas of interest include Perioperative intensive care in cardiovascular surgery, ultrasound in cardiology, urgent medical diagnostics and therapy and advanced life support and resuscitation.
Figure 4
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(Normal: TO <0%, TS>2, 5ms per RR interval)
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S urgical specialit y
Bariatric Surgery Experience with medical tourism
E
xorbitant costs of healthcare in industrialised nations, ease and affordability of international travel, favourable currency exchange rates in the global economy, rapidly improving technology and standards of care in many countries of the world, and most importantly proven safety of healthcare in select foreign nations have all led to the rise of medical tourism. More and more people are travelling abroad as an affordable, enjoyable, and safe alternative to having medical, dental, and surgical procedures done in their home countries. Medical tourism is relatively cheaper in developing countries than in the developed countries. Going by the ‘McDonald index’, in India you get a burger for 40 cents at McDonalds, which would be more expensive in the US. Similarly, the cost of other products and services are proportionately lower for people coming from developed countries like the US. Likewise, a surgery for obesity which costs about US$ 50,000 could be done in India for just US$ 10,000 in the best corporate hospital using the same kind of technology used in USA and done by surgeons trained in the West.
Due to the current favourable Rupee / Dollar / Pound / Euro exchange rate, foreign clients can take advantage of the weak Rupee and save up to 75 per cent over the same treatment in their own countries with no compromise on quality. For the average Indian, private medical care is very expensive, but for the visitors from other countries, it is a bargain price considering what they would pay back home for an elective procedure with a top specialist. In other words, cheapness is relative and does not mean that the standards are in any way lower. While the globalisation of healthcare has given a sense of assurance to patients that they would get quality care, accreditations like that of the Joint Commission International (JCI) and presence of highly-trained doctors have added to the confidence. Treating obese patients
To start with, when an obese person seeking surgery for his / her weight loss decides to come to India, he / she would have already tried all other alternatives and would be fed up and depressed. The first contact is usually through Internet.
Arun Prasad Senior Consultant and Academic Coordinator Minimal Access & Bariatric Surgery Apollo Hospitals, India
Medical tourism for obesity surgery is still in its infancy and needs to be taken care of.
What actually they need at that moment is simple straight talk. The medical tourism agency should understand that these patients have to be dealt with sympathy and attended in a proper way. And, repeated questions are normal for this category of patients. The potential complications of obesity surgery and the hassles of travelling to a new country, which has a different culture, can stress any one out. It is important for the patient to have a tele / video conferencing with the surgeon who would be doing the surgery. Patients have to be counselled about the tests that need to be done. They are often put on a high protein low carbohydrate diet that makes them and their liver more fit for the surgery. This generally starts 2-3 weeks prior to their travel to India. Long travels and long waiting for transportation may create health troubles, the chief culprit being deep vein thrombosis. I usually ask my patients to start prophylaxis against this dreaded and common problem from the time they leave their home to the time they go back. One cannot do an ‘over’ prophylaxis.
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to sleep. They tend to drop their cards and proudly say, “call me any time if you have a problem”. The biggest problem is disposal of these cards and trying to figure out who is who. This act of pampering is often seen as an invasion of privacy by the patients. The members of the staff who deal with patients directly should ensure
that there is proper communication between them. The nurse who checks the temperature should reassure the patient. She should not dash out of the room to complete the record. I once had a panic phone call from a patient, who thought that something was terribly wrong with his blood pressure as the nurse dashed out after recording it.
The right approach • Adherence to predicted time and estimated cost are a few things at which Indians are extremely poor. This lapse is seen as unprofessional behaviour and can be very upsetting for the patient and also lead to loss of credibility. Do not create unrealistic expectations on these fronts. It is always better to make honest realistic statements. • Admission and discharge procedures should not be time consuming. Transport from reception to room and within the hospital should be swift and comfortable. • Food requirements should be special and good coordination is needed between the surgeon, endocrinologist and dietician. It is very confusing for a patient to hear different advices on one issue from these three departments. A standardised and mutually agreed diet chart should be formulated. • Physical activity, breathing exercises, physiotherapy should be well agreed upon and appropriate to the medical needs of these patients. Junior doctors are totally untrained to deal with patients of another country especially with obese patients. They need to be sensitised to the needs of this special group of patients. Psychological care is as important as the medical care. • Cleanliness and infection control is the biggest nightmare of all these patients. Repeated assurances about the equipment used, sterilisation and usage of gloves is necessary. The surgeon in charge is the best person to address this concern. • Postoperative pain control, communication and reassurance is needed. If possible, video conferencing with a close relative back home can do wonders in boosting the morale of these patients. Avoid overcautious approach as this could raise suspicions of something being wrong and something being hidden. • Billing and discharge procedures have to be smooth and reading material on postoperative care is very useful. Patients should not be abandoned at this stage and should be escorted to a hotel for recovery before they fly back. An email of good wishes and enquiry is always welcome. Medical tourism for obesity surgery is still in its infancy and we need to realise that this infant has special needs that need to be catered to if we want it to be a healthy adult.
A u thor
Once the patient reaches India after enduring the long journey, which is extremely cumbersome for a patient weighing over 200 pounds, he / she needs rest and time to get over jet lag. Most of the patients suffering from morbid obesity are shy and have very little experience of taking long flights. Never plan to take them from airport to operation theatre. There should be a cooling off period of one to two days to ease out the exhaustion and also to get over the cultural shock (and of course the jet lag of travelling east). All the staff in the hospital has to be geared to deal with these patients who are extremely sensitive to any kind of ridicule that may come from the ignorant. The problem of obesity is generally misunderstood in a developing country such as India as a self-inflicted problem of affluence and overindulgence. As a result, patients who come for the treatment are often ridiculed. However, the patients do not expect such insensitive behaviour from the staff of a professional hospital. For instance, a patient of mine was not upset hearing a snide remark from taxi driver about a possible flat tyre, but a ridicule from a ward boy, who was deliberately panting while taking her on a wheel chair, brought her to tears. Not just buying a bariatric operation theatre table will be enough to perform the operation. There are many other facilities that need to be upgraded like wheel chairs, toilet seats, room chairs, beds and all other infrastructural amenities. The entire team of nurses, ward boys, staff of the food and beverages department, dietician, physiotherapists, receptionist and junior medical staff need training and workshops on how to deal with these patients. Only after this, comes the more difficult job of detecting complications which though serious, manifest in a very mild manner that can go undetected till it is too late. Patients are sensitive to overcare. Various department in-charges have the habit of popping into patient’s room unannounced while he / she is trying
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Arun Prasad belongs to the first generation of laparoscopic surgeons from the time it started in the UK. Experience of over 5000 laparoscopic surgeries that include over 3500 cases of laparoscopic cholecystectomy, 1000 laparoscopic hernia surgery and rest advanced laparoscopic surgery including Thoracoscopic and Bariatric Surgery for weight loss including Gastric Banding, Roux en Y Gastric Bypass, Sleeve Gastrectomy and Mini Gastric Bypass.
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diagnostics
Radiology Beyond Anatomy
New value chain for personalised medicine Radiological imaging is capable of providing â&#x20AC;&#x2DC;functionalâ&#x20AC;&#x2122; information for biomedical characterisation of disease beyond volumetric visualisation of structure with high spatial resolution. Improved technologies enable further transparency beyond imaging interlinked with important economical aspects, such as Six Sigma for improved and efficient patient care.
Frederik Lars Giesel Physician Department of Radiology National German Cancer Research Centre, Heidelberg, Germany Hans-Ulrich Kauczor Professor and Chairman Department of Radiology University of Heidelberg, Germany
H
ealthcare providers in developed countries are facing the challenge of improved and efficient hospital management focussed on a bottom-up approach for patient flow and management. Patient management relies on best medical care right from the hospital entry point. This first contact and the subsequent hospital care are crucial and require expertise of high-level professionals and economic expertise. Today, imaging presents the opportunity for guiding the further diagnostic and therapeutic pathways and thus leads to dedicated and personalised medicine.
by multislice CT enable a real volumetric approach. The large number of source images represents an incredible amount of work for the radiologists and is unacceptable for clinical partners. This requires the extraction of information from high-resolution volumetric CT and has driven the development, implementation and integration of dedicated Computer Assisted Diagnosis (CAD) applications. They provide enhanced view of structure by multiplanar reformations, thin- or thick-slab maximum-intensity-projections, volume rendering, and virtual endoscopies. The sophisticated tools that have widespread application include detection and volumetry of pulmonary nodules (Figure 1) and virtual colonoscopy. Both CT and Magnetic Resonance
Imaging (MRI), provide whole body coverage and are useful to assess systemic, generalised diseases, e.g. M-staging in tumours and atherosclerosis. Information extraction
Apart from extraction of information from a single series, steps such as fusion, matching and registration of images and extracted information from different modalities (PET, CT, MRI), e.g. colourcoded parameter maps, are necessary to exploit the potential of complementary image information. MRI enables high spatial resolution and the detailed visualisation of structure with high spatial resolution and T1- or T2-weighting. The application of T1-, T2- proton- or diffusion-weighted sequences aims at the visualisation of
Tumour assessment using RECIST, WHO and volumetric analysis of pulmonary nodules on axial slices and 3D
Structural and volumetric visualisation
Computed Tomography (CT) is one of the leading imaging modality to visualise the structure of tumours. Novel volume acquisitions with almost isotropic voxels in sub-millimetres as provided Figure 1
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special properties of the tissue of interest, such as fluid or cellularity. Functional imaging, which relates mainly to volumetric imaging that generates a large number of images (Figure 2 and 3), is also called 4D imaging. Dedicated software and software engineering is required to extract the information, which is ‘functional’ in a broader sense. Time resolved series acquired during contrast applications enable morphological and functional insights of small and large vascular structures—so called magnetic resonance angiography (MRA)—and its territories and branches. ‘Perfusion’ MR imaging aims to capture tissue microcirculation by using endogeneous contrast or iatrogenic application of contrast agents (extra-cellular or intra-vascular) or even different contrast compartment mechanisms (one-, two- or multi-compartment model) on the basis of both T1-weighted or T2*-weighted sequences.
From such 4D-series (3D + time), perfusion is assessed qualitatively by visual evaluation, semi-quantitatively by analysing Signal Intensity (SI) or Signal to Noise Ratio (SNR) curves over time or by quantitative approaches that make use of more sophisticated pharmacokinetic modelling providing surrogates for microvessel density and vascular permeability. Both are regarded as indicators for the angiogenic potential of the tumour. Similar analyses are possible by contrast-enhanced CT (perfusion CT) that has entered clinical routine for stroke diagnostics and recently through the rapid improvement in CT-Scanner for cardiac imaging. Motion imaging is looking into cardiac and respiratory motion including the compliance of the myocardium (hypokinesia) and vascular walls. Appropriate triggering, e.g. by ECG or a respiratory belt is required. In aortic aneurysms the
MRI-based perfusion map in breast cancer
MRI-based perfusion map in malignant pleural mesothelioma
a) High perfusion indicated by high amplitude and exchange rate before chemotherapy
a) Marked hyperperfusion before chemotherapy
b) No spot of increased perfusion after chemotherapy, indicating ‘complete remission”
b) Increased perfusion indicated by high amplitude and exchange rate after chemotherapy, size (RECIST) unchanged, representing ‘progressive disease”
Figure 2
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lack of compliance of the aortic wall might serve as a predictor of the risk of rupture. On other occasions, resolved image acquisition protocols allow for the assessment of respiratory motion and especially the mobility of neoplasms, which might have substantial effects on high precision radiotherapy planning. Another novel functional MR technique is Diffusion Weighted Imaging (DWI), which provides additional insights into the microstructure of tissues simply by measuring the amount and direction of the diff sive Brownian motion of water molecules. It can be used for tractography (Diffusion Tensor Imaging or DTI) in the brain demonstrating the location and orientation of fibre tracts or visualization of recurrent cancer, especially in head and neck tumours, as it provides information on cellularity and perfusion.
Figure 3
diagnostics
Integration
Multidimensional imaging comprises targeted molecular imaging of individual tumour types and characteristics on the one hand and downstream surrogates of tumour biology, such as results from perfusion MR imaging, i.e. microcirculation and permeability that play a major role in oncological radiology on the other. The implementation of surrogate markers is a major challenge within the multidisciplinary concept of tumour diagnosis and treatment follow-up during dedicated therapies. Once achieved, it will reduce the need for specific molecular imaging. Improved and increasingly sophisticated approach will integrate imaging and non-imaging surrogates, and will fuse different worlds within the life sciences. Future radiology will supply detailed structural and functional information, such as perfusion or metabolism as a 3D coverage of two different volumes
(1) ‘whole body’ volume for staging and (2) ‘whole lesion’ volume for assessment of heterogeneities. In contrast to molecular biology, which mainly is unidimensional, and histology, which provides 2D information, radiology provides information regarding localization and extent in 3D. This situation demands for integration for such markers in large databases to enable a multidimensional matrix for prediction of prognosis or treatment response. Impact on treatment planning and personalised care
Continuous advances in therapeutic approaches necessitate new concepts in non-invasive image-based assessment. Nuclear medicine techniques, especially Positron Emission Tomography (PET), have recently gained importance with the combination of structural high resolution imaging from radiology (64-MSCT and higher) with a PET scanner (Figure 4).
In contrast, new functional imaging approaches such as dynamic contrast enhanced MRI (DCE-MRI) or Perfusion Computed Tomography (Perfusion CT) enable an additional tissue characterisation. These 4D (3D + t) high-resolution (spatial and temporal) imaging techniques are complementary to nuclear medicine. While PET enables assessment of metabolic activity 4D imaging using CT or MRI enables non-invasive insight of microvascular status in diagnosis of stroke or oncology. Perfusion imaging methodologies are of particular importance in the clinical setting, especially neo-adjuvant or adjuvant radio-chemotherapy in cancer including anti-angiogenesis. The combination of all these modalities enables a high level of individual patient care. The current transition to bio-medical imaging in radiology empowers medical professionals to respond more precisely to the individual disease status and predict the outcome.
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Economic perspective
CT-PET image fusion in liver metastasis for planning RFA treatment and follow-up a) CT-PET image fusion
b) Treatment planning of liver lesions in 3D-surfcce rendering on the basis of CT and PET data
Today, healthcare providers in the developed countries are facing the heavy burden of healthcare costs, which are mainly caused by increased technological standards and the demographic challenges. At the same time, healthcare is one of the biggest and most promising industry worldwide and is experiencing a major change from public service to private patient-focussed care (so called: personalised medicine). Particularly, the major terms like ‘individual patient care (diagnostics and therapy decision path)’, ‘process optimisation’, ‘market positioning’ and ‘Six Sigma’ play a major role for department heads and hospital managers. In particular, Six Sigma is one of the important tools in healthcare management to rule out deficits in service quality and performance on different levels that affect the total patient clinical value chain. Therefore, we would like to make the reader familiar with the term: The term Six Sigma is derived from the electronic industry and often focusses on three important indicators in particuConclusion
Apart from volumetric structural visualisation with high spatial resolution CT and MRI, these modalities are capable of providing ‘functional’ information for individual characterisation of disease. Adding the dynamic temporal component to such acquisition allows generating 4D maps (3D structure + time). Two important tasks have to be solved by CAD (1) registration of different image
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2. Measuring what is important 3. Using statistical tools to analyse the root causes for variation in quality and performance 4. Working together as a team for making improvements and implementing them over time 5. Monitoring and controlling the success and sustainability of the solutions. Clearly defined measures and data analysis allow for additional benefits to manage the hospital processes effectively to increase individual patient care.
series from different image modalities, and (2) extraction and integration of quantitative surrogates that can be used for characterisation, therapeutic decision-making, image-guided procedures and efficacy evaluation. This personalised medical value chain brings benefits to patient care from individual non-invasive 3D / 4D imaging-based surrogates and enables improvement of healthcare with innovative tools cost-effectively.
Hans-Ulrich Kauczor is a Professor and Chairman of Radiology at the University of Heidelberg, and Medical Director of Diagnostic and Interventional Radiology at the University Hospital Heidelberg. He is the CEO of the Steinbeis-Transferzentrum ‘Radiological Imaging: Consulting and Training.’
Figure 4
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1. Defining a problem
Frederik Lars Giesel is physician at the National German Cancer Research Centre, Department of Radiology, Heidelberg, Germany. Giesel is also working as a honorary visiting lecturer at the University of Sheffield, United Kingdom. His research focusses on pharmacokinetic and molecular imaging. He holds several patents for contrast media, undertakes various clinical trials and has broad expertise in industrial cooperation. Recently, he gained an international MBA degree to extent his expertise from medicine to economic.
A u thor
c) RFA of target lesions
lar to healthcare providers - Access to services, Service cycle time, and Cycle time associated with result reporting and discharge. In Six Sigma, higher sigma numbers correspond to fewer defect rates. At the Six Sigma level, there are only 3.4 errors per million opportunities, which is nearly error-free. Striving towards the Six Sigma level involves five major steps:
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Functions and Advantages 38
Allows patients to access their health information from any place at any time, so that they can easily monitor and manage their health and enables them to get better treatment for their ailments and diseases PHR contains medical and health information, drug information, family history, medical / health contacts, general health and demographic information, diseases and conditions, hospitalisations, surgeries, injuries, lab tests / results, screenings, health insurance information etc. Allows doctors to deliver better care to patients
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Reduces cost by avoiding the duplication of tests with proper maintenance of reports PHR helps in improving healthcare communications between patients and doctors Helps in scheduling appointments with the doctor Provides drug interaction, online prescription request and refills, and preventive service and appointment reminders. Manages information like identification and demography, personal contact, medical insurance, pharmacy insurance and contact with the medical care provider.
Patient Records Online Shared access for quality care
Online Personal Health Records signal a paradigm shift in the management of a patient data. By allowing easy access to patient information, online health records can enhance patient care and create a healthy doctor-patient relationship.
I
n healthcare, information, especially the one related to a patient’s health, is key to the care provided. Faulty treatments, in most cases, can be attributed to improper communication of critical data. The adoption of information technology by healthcare providers has resulted in reducing many of these errors. However, amidst all these developments, the patient has in some ways been left out. The data related to one’s own care is either not available with the patient or is beyond his / her comprehension. As a result, the patient is completely dependent on the doctor when it comes to making a decision regarding his / her treatment. However, the Internet has changed this scenario drastically. Today, information about diseases, treatments and medicines is available at the click of a button. Storing medical records online
Prasanthi Potluri Editor Asian Hospital & Healthcare Management
Akhil Tandulwadikar Editor Asian Hospital & Healthcare Management
Electronic Medical Records (EMRs) have made the storage and management of large volumes of health data electronically possible. Since, EMRs served only doctors, a tool to help patients manage their health information was still missing. This scenario changed with the introduction of online Personal Health Records (PHRs). Like in industries such as banking, the Internet is empowering consumers by enabling them to take control of their health information. This movement is a part of the ongoing trend of consumer-driven services that has been driving healthcare for the past few years.
Unlike EMRs, a PHR is created and managed by patients, their caregivers or family members. Other key players involved in PHRs are healthcare providers, medical equipment providers, insurers, pharmacies, employers and organisations providing health-related information. Drivers for PHRs
Not surprisingly, doctors have been endorsing PHR by switching over to digital and online records. The response to PHRs has been most visible in Europe and USA, where the move to consumercentred healthcare is taking place at a rapid pace. “In the US and Europe A US survey in 2005 by the Markle Foundation found that 60 per cent of respondents supported the creation of a secure online personal health record service.
major private healthcare organisations have come to recognise the potential value of PHR for improving customer satisfaction and loyalty, and as a mechanism for reducing and raising revenue,” says Dr Claudia Pagliari, Senior Lecturer in Primary Care, School of Clinical and Community Health Sciences, University of Edinburgh, UK. Also, many IT companies have shown interest towards providing online PHR services. Organisations like Kaiser Permanente, Microsoft, Google, IBM, Intel etc. have already made their services available. More companies are likely to jump into the foray as the
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Bill Crounse Senior Director Worldwide Health, Microsoft Corporation, USA
How do you think PHRs will affect Patient care? I see it as a very positive impact on patient care, I myself as a physician, practiced for more than twenty years before joining Microsoft and I have always believed that patient’s who are powered and engaged with their physician can have an enhanced dialogue and share information with their physicians, actually are people who end up with healthier outcomes and get better care. I think ideally we want our patients to be informed and to be copartners with us in managing their health. And PHR is one very important way to do that. Also, there are obvious advantages that can help speed workflow. Many of the scenarios for PHR involve being able to get that information, share that information with who ever you want to share it with. That of course includes your physician or your hospital meaning that in many cases properly configured, you won’t have to be filling out similar paper work every where you go because you can grant a doctor or a hospital access to your information. That’s the way we designed our Health Vault system. Microsoft’s Health Vault here in United States, is to give that functionality so the consumers really in control of the information and can grant access to a healthcare provider organisation or healthcare provider or a family member and they really have complete control on that information. How has the response of patients been to online PHRs? I can speak certainly for what are the experiences with Health Vault. We are very pleased with numbers of people who are establishing Health Vault accounts and availing themselves of the services, whether that is search for information or upload their medical information or connect with partners and services and devices that are made accessible through the Health Vault. So, we are at the beginning of a long journey; this won’t happen overnight. I should be clear, that Microsoft is not the only company this going to be the space. There will many others including provider organisations and payer organisations. But, I must add that I am extremely pleased be associated with a company that has put a firm foot in the water and has developed a service that people are so excited about.
How are PHRs likely to evolve in the coming years? If I may use the analogy of the Automated Teller Machine (ATM) if you think about early ATMs, when quite frankly nobody got too excited about them, originally they were ways that you could just go and look at information, you could look at your bank balance but you really couldn’t do very much. In a way, today’s rudimentary PHRs are a bit like that. In many ways today what asking consumers to sort of aggregate their own information and enter in to a Health Vault account or store it in a Health Vault or other kind of repository and there are not a whole lot of transactions going on. But, I think where we are moving, and you are suddenly be seeing this an announcement coming forward from our company and I am sure others, that it will become much more fluid much more transactional, in the same way that my banking accounts or my brokerage accounts today are highly transactional and the data is uploaded, downloaded data, but all of the partners that I work with in the ecosystem are exchanging data through this systems. That it would become much more automated when it does, then we will truly a have arrived at a point I think people will understand and avail themselves of the patient health records. Because today, I mean it’s going to be the highly engaged, highly motivated consumer who is going to want to manually to track down their health information and then upload it into some repository. The more idea system is, put in some information, but, my doctor contributes to that information, my dentist and hospital might contributes to that repository. So, that’s what we need to move. How will this affect the current healthcare scenario? I think what you are going to find around the world, and I’ll start-off speaking to developed countries around the world, developed economies that we hear more and more about consumers / patients demanding more transparency in healthcare; transparency in pricing, transparency in quality, transparency in services. I think that comes handin-hand with notion that government and payers of healthcare around the world are putting more and more responsibility on the consumers. If consumers of care are going to be put in that position, then they do indeed deserve greater transparency. And one of the ways we can deliver that transparency is through online services and through personal health records. And in the same way, I think the personal health records, in many ways, makes the patient or consumer more transparent to the healthcare provider because he / she has at his / her fingertips the data that they need to take care. So, I think it really benefits all sides of equation. And
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I think in the, let us say, in less developed countries I think even where medical resources may be less available or scarce or difficult to access, there’s all the more reason that it’s extraordinarily important for people to have a record of their information. And, it’s uncommon, I mean I know in many countries around the world, the norm is that there is a expectation that the patient is actually responsible for keeping their health record, the health system doesn’t take it upon itself to be the arbitrator or the repository for the health record, it’s for the patient who owns the data and actually it makes a lot of sense. Could there be any unintended consequences of making PHRs available online? I think the unintended consequence would come should there be breaches in security or privacy, which is why I would implore any one contemplating developing a service ore repository of this kind of information, to be extraordinarily cautious about privacy and security. We hold this information dearer than even our financial information. Indeed I think, and rightfully so, consumers need to be cautious, I think they need to be wary, I think that there’s a good reason to be concerned, particularly as we get into the area of genomics and DNA analysis and so forth and in risk assessment, you know science moves so forward that we start predicting disease states and people. We certainly don’t want people put in jeopardy being discriminated against on the job front or in the society. So, these are all things that patients in healthcare organisations and Governments and everyone needs to give deep thoughts to that we are prudent in developing systems with appropriate privacy and security because nothing is more important. Are the current data safety standards enough? One could argue that what has held us back in healthcare is not the lack of standards but may be too many standards. And that our standards bodies have moved too slowly and sometimes have been at odds with each other. We need to sort through that. Here again I think that technology and web services and XML is taking us where we need to go. You’ve also probably read about the investments Microsoft is making for example with technology called the () which we acquired, which is very good at aggregating lots of different kinds of data from lots of different kinds of sources and making it highly usable to end-users and the ability to analyse that data and make sense of it and turn data into information, information into knowledge and knowledge into wisdom. So, yes we need standards, there is no doubt about that, but I think that we are making good progress.
presence of PHRs spreads. This augurs well for patients as well as healthcare providers. The potential benefits of PHRs in Asia are numerous. Compared to their western counterparts, healthcare consumers in Asia have little or no control over their health information. “In the developing countries PHRs have the potential to become a transformative technology by balancing the power differential between consumers and providers of healthcare,” opines Dr Pagliari. Giving people control over their information could not only improve their awareness towards health-
care, but also encourage them towards self-care. Though there are some online PHRs in Asia, they are far and few in number. With sustained efforts from the IT companies, this scenario is likely to improve. Ubiquity of the Internet permits the patients to easily access their health records any time, online. Perspectives
A typical PHR website helps the patients in recording their health information and sending health data from their EMR to a doctor or a healthcare provider. It enables patients to actively participate in maintaining their own health checkups
The Networked PHR Specialist Doctor
Pharmacy Q
Hospital System Data Hub
Hospital B
Laboratory
Pharmacy Y
Specialist Doctor
Pharmacy X
Home Monitoring Devices
Hospital A
School Nurse
Payer Data Center (Health plan Medicare)
Scenario in India There has been an impressive growth in India’s healthcare sector. “Well–informed patients are now demanding their doctors in India to treat them with more respect and be more transparent,” says Dr Aniruddha Malpani, Medical Director, HELP – Health Education Library for People, India. However, EMRs are yet to become a part of the mainstream. Medical records are maintained mostly in the form of hand written text as in doctor’s consultation or typed text on paper. Whilst healthcare records are being made online and few companies are getting into developing online PHRs, India still has a long way to catch up with the technology and advancement in healthcare services. “In developing countries much patient care remains at the paternalistic end of the spectrum, increasing the potential of PHR to become a transformative technology by balancing the power differential between consumers and providers of healthcare,” says Dr Claudia Pagliari.
by providing information on diseases, prognosis, causes, symptoms, treatment, diagnosis, prevention, complications, etc. It also provides health management tools—assists a patient with the information contained in their record, helps the patient in booking appointments online with doctors and allows patients to choose home-based self-monitoring medical devices. “Integrated PHR systems that enable online appointment booking or results collection can enhance patient convenience and satisfaction,” adds Dr Pagliari. Microsoft’s HealthVault, for example, offers a way to connect, store and share the entire patient’s information in one place, without being tied to a closed, siloed database. Online PHRs also allow patients to interact and share experiences, which could further encourage self-care. A website providing PHR services also provides information about diseases and treatments. The availability of information on various diseases, conditions and treatments on the Internet has made patients more aware and demanding. This information, sourced mostly from organisations and focussed on research in these areas, is more reliable as it comes from a credible source. By giving the patient control over information related to their disease, PHRs add another dimension to this change underway in healthcare. Doctor-patient relationship
Perhaps the biggest change that an online PHR would bring to healthcare is in the patient-doctor communication. “Increased access to and control of personal data may raise patients’ motivation for self-care and improve doctor-patient communication and shared decision making,” says Dr Pagliari. With their ease of use, PHRs help in getting the patient involved in the treatment he receives. It allows the patient to report even the minor problems he or she had faced during th treatment to the doctor.
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Claudia Pagliari Senior Lecturer, Primary Care School of Clinical and Community Health Sciences University of Edinburgh, UK
How will PHRs affect the doctor-patient relationship? The issue of electronic health records often attracts public concern about the privacy and security of personal data. However emerging research indicates that giving patients access to their records can improve trust in doctors and healthcare organizations by increasing transparency and enabling the individual to question the data that are held about them. PHR also provide opportunities for patients to organize their own records and thoughts about their illness patterns, which can aid communication and shared decision making during the consultation. At the same time, integrated PHR systems that enable online appointment booking or results collection can enhance patient convenience and satisfaction. How will this affect the current healthcare scenario where doctors are not sharing patient information, especially in developing countries? Most western nations have seen a marked shift in attitudes towards the roles of doctors and patients over the last 10-15 years, accompanied by a move from the traditional paternalistic model of healthcare to a more patient-centred and collaborative
one. This reflects wider societal trends towards consumer empowerment, which encompass greater freedom of information and flexible services. Personal Health Records are entirely consistent with these trends, offering the promise of convenient access to one’s own data, the right to critically evaluate this information, and the opportunity to become a partner in the healthcare process. In developing countries much patient care remains at the paternalistic end of the spectrum, increasing the potential of PHR to become a transformative technology by balancing the power differential between consumers and providers of healthcare. While variable access to online PHR could increase the digital health divide, two factors offer hope that this will not be the case. Firstly, PHR are becoming available in multiple formats, including via mobile phone and wireless internet, and access to such services may be good even in areas where other technological infrastructure is underdeveloped. Secondly, early evidence from the USA indicates that the most economically disadvantaged groups may derive the greatest benefits from such technologies, which can ameliorate limitations in access to healthcare through supporting health self-management and offering cheaper opportunities for remote care. PHR also have the potential to increase the globalisation of healthcare; for example by enabling migratory workers to maintain access to their records and their healthcare providers via the internet; while multifunctional and interactive
PHR also offer opportunities for the purchase of cheaper or higher-quality care from providers in other parts of the world. How have the healthcare IT companies responded to this? Personal Health Records technology is a commercial growth area. In the United States and Europe major private healthcare organizations have come to recognise the potential value of PHR for improving customer satisfaction and loyalty, and as a mechanism for reducing costs (e.g. through fewer insurance claims) and raising revenue (e.g. through online consulting). This has lead to the growth in online, interactive PHR systems, such as Kaiser Permanente’s Health Online. Other commercial providers have stepped in to develop portable record management tools, such as the MedicAlert E-HealthKey which stores multiple records that can be viewed by an emergency healthcare team with the relevant software, as well as by the patient themselves using a home computer. In the United Kingdom commercial operators are offering patients access to their primary care record via USB smartcard and waiting room kiosks, as well as via the internet. It is unclear how this market will be influenced by the development of free online PHR systems, such as HealthSpace in the UK and iHealthRecord in the USA, although the differing needs of healthcare consumers will undoubtedly create multiple product niches.
Aniruddha Malpani Medical Director HELP – Health Education Library for People, India
Why is there a need for taking PHRs online? The healthcare industry is a service industry which was designed to keep people in good health. Today, unfortunately, it has deteriorated to becoming a sickness industry, which specialises in taking care of diseases. There are many reasons why matters have come to such a sad pass—and one of the most important of these is the fact that people
have no control over what healthcare services they receive. It’s high time the industry re-discovered its focus and put people back in control of their healthcare, by designing a consumer-driven healthcare industry. One of the key ingredients for this is the Personal Health Record. What are the benefits of making Personal Health Records available online? While paper records and online records are complementary, online records offer many advantages. 1. Much less expensive to setup 2. Easier to update
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3. Easier to access 24/7 from anywhere in the world 4. Do not get lost 5. Can be referred to in an emergency by a family member 6. They allow people to setup online communities and network with and share information with other people who have similar medical problems 7. The biggest benefit is that they allow data interoperability; so that in the future, the patient’s health record is automatically updated when the doctor’s or hospital’s medical records is updated, so that there is no need to enter the data multiple times
Corporation. This transparency would lead to reduction of medical errors. “Greater transparency of information may also enable the identification of errors by patients, which has potential to improve patient safety by highlighting unrecorded allergies, outdated diagnoses or inappropriate medications,” opines Dr Pagliari. Further, as the patient’s health information is recorded in the online PHR, the data would remain intact
Online PHR System
Provider
GoogleHealth
HealthVault
Microsoft
My HealtheVet
U.S. Department of Veterans Affairs (VA)
myPHR
American Health Information Management Association
WebMD
WebMD Health Corp.
ER-Card
ER Card, LLC
LifeSensor
InterComponentWare Inc.
Vendor Created, Clinic Hosted
John D Halamka Chief Information Officer and Dean for Technology Harvard Medical School, USA MyChart is the EHR product, developed by US based Epic Systems with The Palo Alto Medical Foundation (PAMF). The functionality requirements for a PHR were integrated with their EHR. PAMF became the first customer of MyChart, which was implemented at the end of 2000. Since then, over 90,000 patients have used PAMFOnline. Across the US, 2.4 million patients are using MyChart. MyChart enables the patients to view their diagnoses, active medications, allergies, health maintenance schedules, immunisations, test results (including graphical display), radiology results, appointments, and demographics. In many cases, relevant health educational resources are automatically linked to key terms or phrases in the patient’s medical record, such as a diagnosis of Diabetes. In addition, patients can communicate with the physician’s office to request an appointment, request a prescription renewal, update demographic information, update immunisation status, or update a health maintenance procedure. The patient can also request advice from an advisory nurse or from his or her own physicians. The most popular features of the integrated PHR are access to lab test results and communication with physicians. As of September 2007, 26,000 patients login to PAMF’s MyChart each month, sending 20,000 secure messages.
even when the patient changes his / her primary care physician. The record provides the doctor with the patient’s medical history, which helps the doctor get an overview of the case and plan treatment accordingly. In case of emergency, the treating doctor would have ready access to all the necessary information about the patient—thus avoiding possible medical errors. This is a dramatic change over what exists today in the EMRs, which may not be accessible across different networks. Privacy, confidentiality…
CaseStudy
By doing this, the possibility of the condition spiralling out of control can be checked and eliminated. The doctor can decide the course of action that needs to be taken and, if needed, an appointment can be fixed. Clear communication between the doctor and the patient helps build confidence into the relationship. “PHR greatly enhances the doctor-patient relationship,” says Dr Bill Crounse, Senior Director, Worldwide Health, Microsoft
The major challenge facing online PHRs is to chuck out security, privacy and confidentiality threats. The top concern of the consumer is the potential misuse of data from their health record. A few companies that offer PHR services, for example, could share the data with third-party firms without the patient’s consent. The privacy concerns, therefore, revolve around the ones who have an access to the information. An individual who signs up for an Internetbased service with password controls an untethered PHR. The privacy of his data depends on how best the service provider is able to guard the information. Potential threats from hackers also cannot be ignored. Individual provide their health information or sends pertinent documents to the PHR vendor to be filed in the record. Service providers, therefore, are making all possible efforts to meet existing data security standards, even as new ones are being put in place by various government and non-government organisations. In the US, for example, an online PHR system should at least have privacy measures equal to those in Health Insurance Portability and Accountability Act 1996 (HIPAA). The National Committee on Vital and Health Statistics (NCVHS) subcommittee has been conducting hearings on privacy and confidentiality and
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the Nationwide Health Information Network (NHIN), and additional recommendations will be forthcoming. Standards should cover all the key areas in making the PHR implementation easy and reliable. In response to the threat concern from health plan, employer or provider organisations handling data due to lack of portability, AHIP and the BlueCross BlueShield Association (BCBSA) of US have undertaken an initiative to adopt standards for the essential data content of PHRs as well as for messaging among them in order to make PHR data transportable among health plans. The standards from The Health Information Technology Standards Panel (HITSP) will be used as a part of Commission on Certification of Health Information Technology (CCHIT)
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certification criteria for Electronic Health Records (EHR) and PHRs over the next three years. In UK, Commons Health Committee is working on the development of the national electronic record system.
Online PHRs could solve the information needs of doctors at all levels of treatment.
Canada Health Infoway and the Canadian Standards Association have signed a cooperative agreement to advance health information technology standards in managing PHRs.
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The result…
Though there are concerns, healthcare consumers have shown interest in moving their PHRs online as it gives them a sense of control and involvement. PHRs could also play a vital role in improving healthcare delivery, promoting wellness and disease prevention. The journey towards creating online medical records—from unstructured medical records to paper-based medical records to computerised records and then on to online medical records now— has been charted over a period of almost a decade. Online PHRs could solve the information needs of doctors at all levels of treatment. Interoperability, the major hurdle to the proliferation of EMRs, could be a thing of the past with the Internet and the presence of universal guidelines for PHRs.
Online Health Information Accuracy, quality and privacy
Several e-Health initiatives are underway to empower the patient with the right information. The Internet, with its vast amounts of information, is a key player in turning the patient into an ‘informed patient’.
Célia Boyer Executive Director Mayoni Ranasinghe Research Assistant Health on the Net Foundation (HON) Switzerland
T
he ever-growing fields of science and technology have advanced the quality of human life in leaps and bounds in all aspects, from Internet banking to eco-friendly cars. The health domain has also been influenced in this wave of development in various aspects with discoveries in the field of research, new and improved diagnostics and minimally invasive procedures, to name a few. As always, there is room for improvement. The Patients’ and Citizens Task Force of the European Health Telematics Association (EHTEL) describes several possible ventures. One such improvement is through the use of Electronic Health Records (EHR). The patient should be master of the EHR as consent for information sharing on the EHR would be given by him / her. This consent should be taken at the onset, following which reviews would be done upon considering new conditions. If the patient suspects any information abuse, he / she would have the right to intervene and call for action. The patient would also have the right to restrict information sharing (but should be made aware that this may affect care)
and would not be discriminated or refused care as a result of this. Electronic communications and a log book facility are essential in such a record to enable proper information sharing in addition to providing a record of all such transactions. Also, cross-border issues should be addressed by the EHR, thus enabling the patient to access it regardless of his / her geographical location. Authenticating info-systems
Another foreseen venture is the information system within a clinical setting (which encompasses the EHR). Unlike new medications or devices, many information systems are not tested thoroughly before implementation, thereby increasing the risk of errors. Information systems to be implemented in the clinical sector especially require vigorous and independent testing before actual implementation, as well as the proper training of all who use it, to ensure that errors, such as faulty data entry and accidental security breach are minimal. The Internet has brought a wealth of information to the patient and provided a way to research aspects of medication and alternative management strategies. Indeed, the patient can often have more time to spend on this issue than a pressured and time-limited professional. This empowers the patient and provides greater control over his / her health. The concept of the ‘informed patient’ is one that needs to infiltrate the existing consultation and treatment
regime. The views of the patient need to be listened to and respected. Focus on homecare, safety
Patients requiring homecare can also benefit from the aspects of eHealth. Homecare is usually provided for the elderly and those with severe disabilities or debilitating diseases. Like in all other aspects of healthcare, in homecare as well, patient safety is paramount. To ensure this, patient should be informed about the benefits as well as the risks of homecare. The patient must be in control and privacy should always be respected. Any homecare technological device should be easy to use and developed bearing in mind the elderly or those with limited mental ability. Patients also require appropriate education and training in the use of such technology. The risks or benefits of the technology should be clearly defined and patients should have an option of declining any technology. Respect and sensitivity are vital to the success of homecare and should be constantly observed. Patient perspectives can bring new and practical solutions to eHealth issues. eHealth has to take into account the needs of all major stakeholders; the patient being one of these should be recognised as a key player. Personalised Information Platform for Life and Health Services (PIPS)
PIPS is an e-Health integrated project
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The PIPS system will enable: • Professionals to deliver just-in-time personalised healthcare services according to the individual’s personal health state, preferences and ambient conditions • Individuals to make informed decisions about therapies and nutrition at any time / place according to the real-time evaluation of their health state • Healthcare authorities to improve risk management in the healthcare systems as well as to get access to and generate valuable information assuring the global sustainability of the system.
aimed at the provision of innovative services to support the patient in his / her daily life. Started in January 2004, within the 6th Framework Program of the EU, it will be finalised in June 2008 and involves 17 partnering organisations from five EU member states, supranational organisations and other countries, such as Canada, China, Israel and Switzerland. The aim of PIPS is to create a new Health and Life knowledge and services support environment, improving current modes of healthcare delivery using the latest innovations in Information Technology. Its services are personalised according to the individual profile and are based on preventive / predictive medicine. The system is designed to develop innovative technological solutions ranging from continuity of care to education and impact on lifestyles. Bringing personal care to the fore
The scope of PIPS is to create a dynamic knowledge environment that gives value added feedback for personalised knowledge and services to improve the public welfare. Services are personalised and based on medicine, ranging from drug compliance to continuity of care. The technical infrastructure presents these significant core parts: • Knowledge Management - where the aim is to transform heterogeneous information sources into a trusted homogeneous valuable knowledge base • Decision Support - where the aim is to use intelligent technology to generate new personalised user-oriented
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knowledge and support action • Trust Infrastructure - which aims to integrate security protocols to protect sensitive information • User Interaction - where the aim is integrating a new generation of multimedia personal assistance devices (e.g. home telecare equipment, Internetenabled home appliances). In fact, PIPS is a virtual assistant supporting the individual in every moment and in any environment. It also provides interactive multimedia and multi-platform services tailored to their intellectual capacity and include services for children which create a healthier lifestyle through edutainment (education through entertainment); support in daily life through personalised nutritional advice, shopping lists, technological assistance like the Smart Shopping Cart; personalised motivation for physical activity through the use of various technological systems; drug compliance support with real time detection of drug intake and verification with prescriptions and self-monitoring through the continuously available and pervasive support for risk level controls of chronic disease management. The PIPS healthcare delivery model addresses societal challenges by facilitating the shift from treatment-oriented medicine to prevention-oriented healthcare for individuals. PIPS will be utilised by three levels of users: professionals, external experts and the end users. Empowering patients with targeted information
Information prescription, defined as
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health professional-directed information access, which has been tailored as much as possible to the individual patient with regards to personal content, language, intellectual / emotional capacity and locality, is being evaluated in the US and initiated in the UK. This is based on the argument that patients should be empowered with information so that they are able to make better decisions about their health and lifestyle and also take a more active role in managing their health. Also, due to the information overload on the Internet, patients should ideally be directed to correct information sources, so that they are not overwhelmed. Parts of the medical advice or information provided by the healthcare professionals are forgotten by the patients (40-80 per cent), while the rest of the information remembered is mostly incorrect. Therefore, it is essential that medical information be delivered at the right time and at the place of the individual. The objectives of Information Prescription are: to support the patient in self-care and disease management, improve health literacy (the ability to make sound health decisions in the context of everyday life) and to empower the patient in decision-making regarding his / her health. Information for every need
The type of information provided also varies, as it not only caters to individuals with varying needs but also to the same individual with different needs at different times. The different styles include practical information and advice on healthy lifestyles, information on treatment options and outcomes, advice on long-term self-care, local care and self-help and social care through peer support. The key concepts of Information Prescription are: it provides appropriate and targeted information at the right time to meet the needs of the individual in sound decision making; it is issued by professionals at strategic points in care pathways; it usually points to sources of information and
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The PIPS system Over the past 11 years, HON has accredited close to 6000 websites consisting of over a million Web pages in 32 different languages and has grown to become a household name, not only amongst webmasters, but also the general public. HON grown in terms of implementation of services, it has also increased its liaisons worldwide to include the World Health Organization (WHO) and the United Nations (UN), where it has consultative status to the Economic and Social Council of the United Nations (ECOSOC). In view of its pioneering work and long expertise, the HON Foundation has been chosen by the HAS (Haute Autorité de Santé or the French National Authority for Health) to implement the certification of French health websites according to the French bill passed on the August 13, 2004. This certification is performed by HON through the implementation of the HONcode. Now, more than ever, the HON Foundation and the HONcode play a vital role as new and extended treatment modalities come into play, such as the empowering of patients through provision of information.
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Health On the Net - Current initiatives
The Internet, with its vast quantities of information is now the largest global database and offers an immense amount of information on every topic conceivable. The domain of health is no different from all the rest and is filled with various websites advising the public on how to keep their diabetes in check, detoxify in one week, eat well balanced nutritious meals...the list is endless. This information overflow can be overwhelming to an individual who would not know what information to trust and what to disregard. The mission of the Health On the Net (HON) foundation is ascertaining which health websites could be trusted,
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Making information user-friendly
Due to the vast amounts of information available, it is imperative that quality information be filtered from this information pool for the benefit of the public, which will in turn educate them and thus result in a better-informed and responsible patient. i.e. a resourceful patient. With a usage growth of 250 per cent in seven years (2000 to 2007) and 1.1 billion Internet surfers in the world, the Internet continues to change the relationship between the health professional and the patient by making them co-players in the game, thus replacing the teacher / pupil relationship of old. These few examples present solutions which take into account the current situation i.e. a situation where the patient is able to access information related to their medical condition and can then take their own decisions regarding their medical care.
Célia Boyer is the Executive Director of the Health On the Net Foundation, has been serving at the HON since it’s inception in 1995. She is recognised as an expert in quality assessment of medical information on the Internet and has taken part in several projects and conferences-both European and International and has authored more than 50 scientific articles on the subject. Célia has a degree in Science and Applied Physics from the University of Luminy of Marseilles, France and an engineering degree from the Federal Polytechnic School of Lausanne, Switzerland.
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knowledge only (where these information sources would be accredited for reliability and trustworthiness); and it does not display or hold any information. Information Prescription would be in the format most convenient for the patient and could include printed information, SMS (reminders, encouragement), email (reminder, follow-up), DTV (targeted programming) and Web references. Information Prescription systems are currently being initiated in the UK where patients are sign-posted to relevant information at different stages of the care pathway such as the diagnosis and treatment. In the USA, doctors are provided with customised prescription pads containing the list of websites of the National Library of Medicine. The patient would be given such a prescription with advice on the websites relevant to his / her condition. Off course, one of the obstacles, which have to be overcome, is regarding the authenticity of the information provided. Guiding patients to reliable online information is of paramount importance and thus websites, which have already undergone rigorous testing and have been accredited according to a specification or code of conduct, would be provided as sources of information for patients.
and which cannot. Established in 1996 as a non-governmental organisation, HON implements one of the most well known codes of conduct. The HONcode made up of eight principles to which the website would have to adhere, in order to be accredited and thus be deemed as trustworthy. It is free of charge and though given voluntarily (webmasters request for accreditation of their website), it is in high demand because of the seal of quality and trustworthiness that it confers onto a site.
Mayoni Ranasinghe is a Research Assistant of online health information at the Health On the Net Foundation for the past year. Before that, she was a clinician in Paediatrics, Surgery, Internal Medicine and Sexually Transmitted Diseases in her native country, Sri Lanka. Mayoni obtained her medical degree (MBBS) from the Medical College of Medical Sciences, Pokhara, Nepal.
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Medical Device Market Mega trends in Asia
Faced with an increasingly ageing society and rising healthcare costs, countries in Asia Pacific are expecting cost-effective medical devices to be developed by local companies.
D
espite the fact that Asia has 60 per cent of the world population providing large market potential, Asian* healthcare expenditure constitutes only 15 per cent of the global healthcare expenditure. In 2007, the total global healthcare expenditure was at US$ 4.981 trillion. With a growth rate of 6.2 per cent as shown in Figure 1, the total healthcare expenditure of Asia is expected to be at US$ 791.7 billion by 2008. While some parts of Asia are experiencing high population growth, other countries such as Japan and China are facing the problem of accelerated ageing population. For instance, Japan is estimated to have 22.0 per cent of its population above 65 years by 2012 as compared to 20.6 per cent in 2007 (Figure 2). With the current Asian lifestyle, the prevalence of chronic diseases such as diabetes, cancer, obesity and cardiovascular diseases has increased significantly. Other diseases that threaten the region include auto-immune diseases, infectious diseases and neurological disorders. Accelerated ageing population and increasing prevalence of chronic diseases are the key drivers that contribute towards the increase in total healthcare expenditure on medical devices in the region.
Transformation device industry
in
the
medical
Zero-Defect reliability
When it comes to medical devices, reliability and safety are very critical. This is an industry where quality and reliability of the devices cannot be compromised. Even a low device-failure is unacceptable to the patient and the healthcare providers. For example, a current leakage of as little as 10ÂľA (10-6 A) on a pacemaker will cause a microshock to patient, which will eventually bring death to the patient in minutes. Therefore, reliability is critical for medical devices. Unreliable readings given by devices might lead to misdiagnosis, further leading to delay in treatments or false alarms.
To ensure zero-defect reliability of the medical devices, manufacturers use the Failure Mode and Effect Analysis (FMEA) tools. FMEA is used to evaluate the risks associated with the devices produced and to develop strategies to overcome them. Using flexible circuits instead of rigid circuits in medical devices is yet another option that could be employed by the manufacturers to increase the reliability of devices. Miniaturisation
Technology advances have made it possible to use smaller and thinner integrated circuit boards. Self-monitoring devices such as blood glucose meter and wrist blood pressure monitor now come with more functions that are smaller in size due to availability of denser and thinner printed circuit boards. Miniaturisation of
Total Healthcare Expenditure (Asia*), 2007-2008 800
Healthcare Expenditure (USD Billion)
Jennifer Lau Industry Analyst Frost & Sullivan, Singapore
791.7
790
CAGR : 6.2%
780 770 760 750
745.5
740 730 720
2007
2008
Year
Asia* â&#x20AC;&#x201C; Countries included in the statistic are Philippines, Malaysia, India, Indonesia, China, Thailand, Source: Frost & Sullivan Singapore, Taiwan, South Korea, Hong Kong and Japan. Figure 1
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plan include making public medical institutions ‘non-profit’; reducing the involvement of hospitals in the sale of drugs, increase the role and responsibility of government and establish basic medical care network for all Chinese citizens. These policies clearly showed the eagerness of the government to provide better healthcare infrastructure with better medical devices and facilities.
Percentage of population above 65 years (Asia), 2007-2012
Philippines Malaysia India Indonesia China Thailand Singapore Taiwan South Korea Hong Kong Japan
2007
Increased healthcare awareness
0
5
10 15 Percentage (%)
devices has made it possible to save space in the operating theatres or intensive care units that have limited space. Improved power sources
Power sources are critical for medical devices such as hearing aids and neurostimulators of a pain control therapy device. Batteries for these devices must be small, of right weight, easy to replace or recharged and have a reasonably long life span. For example, the rechargeable battery of a neurostimulator has 10 years of lifespan. Other batteries under development include biothermal battery that uses body heat to generate low current source of power, and nuclear microbatteries that use the decay of tritium and nickel-63 to generate power. Enhanced performance and features
In order for medical devices to be more marketable in the increasingly competitive market, these devices need to have breakthrough technologies. Medical devices are increasingly coming up with enhanced features and performance such as connectivity through wireless solution or LAN. Devices such as cochlear implant can be programmed wirelessly, and ultrasound images can be transferred from a patient’s bed to the nearest workstation through LAN or Wi-Fi.
50
2012
20
25
Source: Frost & Sullivan Figure 2
Medical device market drivers Large population population in Asia
and
increasing
ageing
Asia with its large population, is considered as a lucrative market for device makers . Further, accelerated ageing population in few developed countries, such as Japan, Korea and Taiwan will eventually increase its healthcare expenditure. Growth in economy amidst slowdown in US and Europe
Asia continues to experience economic growth amidst slowdown in the US and Europe. Investments in healthcare infrastructure
Realising the importance of disease prevention, the Asian governments invested billions of dollars annually to improve their healthcare infrastructure. For instance, the Ninth Malaysia Plan (2006-2010) is to work ‘towards achieving better health through consolidation of services’ whereby emphasis has been placed on sustainability, upgrading and maintenance of existing facilities and equipment, and improving the quality of healthcare. China announced its Healthy China 2020 plan in January this year, which aims to provide safe, effective, convenient and low-cost public health and basic medical care to both rural and urban citizens by 2020. Some key goals of the
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In recent years, the medical industry has experienced a paradigm shift from sickness care to healthcare. Higher priority is given to prevention rather than to cure. This phenomenon is also seen in Asia, where finding cures and fighting infectious diseases have become the priority. Asians are becoming more aware of their health, especially people in China, Hong Kong and Singapore, which were hit by SARS and Avian Influenza several years ago. Both the governments and people in Asia are now more receptive towards medical technology and encourage homebased monitoring. With advanced technology and communication systems available in most of the countries in the Asia, people now have access to the information resources available and are more demanding in seeking healthcare options. On the other hand, direct-to-customer marketing strategies of some pharmaceuticals and medical device companies have indirectly educated Asians on the healthcare options available to them. Employers, in their effort to increase company’s efficiency are becoming more aggressive in pushing for preventive care. This paradigm shift has increased the demand for medical devices in the healthcare industry. Emergence of private sector
High participation from private healthcare providers in developed countries in Asia promotes healthcare expenditure. For instance, Taiwan has fairly high participation of private healthcare, which contributes 65 per cent of Taiwan’s total hospital beds. Private involvement has enabled efficient healthcare delivery to the people, which could be clearly
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seen in the case of Taiwan. This private participation was driven by Taiwanese comprehensive National Health Insurance scheme, which has eventually helped to increase the healthcare quality. Market challenges Government purchases depress price
Most hospitals in the Asia rely heavily on government subsidy, and in most cases government purchases control the prices of medical devices. For instance, in Taiwan, huge pressure is put on National Health Insurance to reduce its account deficit, which leads to stricter medical examination. Unnecessary health screening such as MRI and blood screening are excluded from the insurance coverage, which leads to reduction in device purchase. Government restriction discourages the installation of medical devices that are considered by it as non-critical items. This causes initial barriers in introducing new medical technology into the region.
Competitions from local companies
Increased involvement of local medical device companies in countries such as Korea and China is a threat to the multinational companies. These companies, supported by their governments, are able to provide medical devices that suit local requirements at a price far lower than that offered by multinational medical device companies. Shortage of healthcare providers
In most of the Asian countries, the ratio of medical professionals to patients is still critically low. For instance, in Malaysia inadequate human resources in healthcare services were due to changing demographics and the emigration of skilled workers from government hospitals to private hospitals. On the
Even a low device failure is unacceptable to the patient and the healthcare providers.
Varying regulations
In addition to government control over the price, Asian countries have started to implement regulations following the increased concern of product safety when imported into these countries. Increased healthcare regulation has brought varying regulations in different countries. Most of the countries in the Asian region are now implementing and adopting different medical device standards. Some of these countries, such as China and Japan have taken a step further to develop their own regulations that suit their local requirement. These complicated regulation structures in these countries pose challenges to investors.
other hand, China faces imbalanced human resource distribution with shortages at central level and overstaffing at periphery due to its uneven population distribution across the country. Imbalanced human resource distribution makes rural areas short of essential medical devices, while urban areas are over-equipped. Geographic vastness of Asia
Geographic vastness of the Asian region poses challenges to distribution, logistic, communication and promotion activities of medical device companies. In most of the Asian countries such as
Thailand, Vietnam and Indonesia, the well-equipped hospitals are in the urban areas and rural residents barely have an access to medical services. Lack of penetration to rural part of Asia is due to poor transportation systems in these countries. Healthcare infrastructures in these countries are not well developed and may take another two decades to reach such a level. Vast geography with poor transportation increases the delivery time and operation costs. These factors have hindered the growth of medical device market. Market potential of medical device industry
The full potential of Asian markets can be realised by establishing key partnerships and alliances with the local companies, keeping mind the market drivers and challenges posed by the region. The fastest way to penetrate these highly protected, untapped Asian markets is through effective joint ventures with the emerging medical device companies of Asia. Geographically big Asian countries provide great opportunity for telemedicine and teleradiology. In view of the poor transportation facilities in parts of Asia, telemedicine and teleradiology could help in providing more efficient and timely medical care in rural areas. Companies should consolidate their distribution function throughout Asia in order to be more cost-effective and efficient in product delivery. In order to stay competitive in the local market, emphasis on Research & Development of medical devices should be combined with the manufacturing of medical devices.
Distribution costs in Asia have increased in recent years due to continuing high oil prices and inflation. Labour charges too have increased over the years compared to a decade ago, with the increasing demand for labour. Although the overall cost is still lower than Europe and US, the effect of the increase is significant.
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Increased distribution and service costs
Jennifer Lau joined Frost & Sullivan Asia Pacific Healthcare team as an Industry Analyst. She focusses on monitoring and analysing emerging trends, technologies and market behaviour in the Medical Devices, Medical Imaging and Healthcare Information Technology industry in Asia Pacific. Prior to this, Jennifer had 5 years of working experiences in Medical Devices Distribution environment in Malaysia and Brunei. She brings with her medical devices knowledge and experience of marketing strategies.
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G S K Velu Managing Director Trivitron Group of Companies and Metropolis Health Services India Ltd. India
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Medical Products Manufacturing in India Getting ready for growth What made you choose India to build your medical equipment park over other Asian countries? India, over the last five years, has been growing in the areas of Electronic Component manufacturing, Mechanical Fabrication, Biotechnology, Pharmaceuticals and Information Technology. These industries, in one way or the other, provide inputs to medical product manufacturing. As a result, India today is an attractive low cost destination for Medical Technology manufacturing. Soon India will be able to demonstrate its capabilities as an alternate manufacturing destination to China for many medical products. Taking this trend into consideration, Trivitron is in the process of building its first medical technology park in India. In its first phase, this park will be able to manufacture medical technology products cost-effectively to cater to the fast growing Indian medical technology market and also to several emerging markets across the globe. What is driving the growth of Indian medical devices market? Access to healthcare is improving in India because of the rapid growth of private healthcare providers and an increase in expenditure by the central and state governments on the provision
of healthcare. Privatisation of insurance sector has opened avenues for several private healthcare insurance companies. These are the two major factors driving the growth of Indian medical device market. Do you think the medical device industry in India is adequately regulated? Indian medical device industry has not been regulated appropriately as of now. However, the Government of India is has taken an initiative to regulate the market through the formation of the Central Drug Authority on the lines of the USFDA. Advanced medical technologies have a higher cost. In what way will hospitals benefit in such a scenario? Since advanced medical technologies are unaffordable for a major segment of the population in India, there is an
Soon India will be able to demonstrate its capabilities as an alternate manufacturing destination to China for many medical products.
urgent need for indigenisation wherever possible. This will make these technologies affordable to all segments of the population. What scenario do you envision for the Indian medical equipment Industry in the future? Indian Medical Equipment industry has a bright future in India with most of the segments experiencing Compounded Annual Growth Rate (CAGR) of over 15-20 per cent. What role can India play in the global medical equipment market considering its low cost advantage? India has an abundant talent pool in the areas of medicine, engineering and information technology. This, combined with infrastructure and labour arbitrage, will make India a preferred destination for Medical Equipment manufacturing for many global companies. India has always been a preferred destination for the lowâ&#x20AC;&#x201C;volume, high-mix category of manufacturing. With its English-speaking labour force and academic excellence in the areas of medicine, engineering, information technology, India can be a very good value proposition for top multi-national companies to manufacture their medical technology products for global requirements from India. Will mergers and acquisitions help the growth of Indian medical equipment industry? There are several small size Indian companies with long presence and technical expertise. Trivitron is looking at mergers and acquisitions as an option to consolidate Medical Technology industry in the country. Will the low cost of manufacturing in India translate into lower healthcare costs? Low cost manufacturing should definitely translate into lower healthcare delivery cost in India in the next 5-10 years time.
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Medical Devices Meet Consumer Electronics
Revolution in healthcare delivery Advanced semiconductor technology is transforming healthcare. At the vanguard is an entirely new way of monitoring the human body—wirelessly, intelligently and at low cost. Microchip-sized wireless body monitoring systems are offering quality of life for users and providing critical data for healthcare professionals.
Alison Burdett Director of Technology Toumaz Technology, UK
A
revolution in healthcare delivery is on its way. Advanced semiconductor technology is transforming the medical services market by enabling a new generation of technology solutions that leverage the economies of scale of consumer electronics, while delivering the robustness and medical compliance normally associated with expensive capital equipment. At the forefront of this new generation of healthcare technology is an entirely new way of monitoring the human body—wirelessly, intelligently and at low cost. Breakthrough silicon technology is enabling the development of new wireless devices, with its application across a vast array of healthcare management scenarios. Intelligent microchip-sized wireless body monitoring systems are set to enable a wealth of new healthcare applications, offering quality of life for users and providing critical physical, bio-chemical and genomic data for healthcare professionals.
is now huge demand for new systems which improve productivity, cut costs and support the shift of healthcare from hospital to the home and community settings. The global demographic trend towards ageing populations, coupled with less active lifestyles and fast-food diets, is leading to higher probability and earlier onset of chronic conditions such as Type 2 diabetes and cardiovascular diseases. This, in turn, is translated into a substantial increase in the proportion of resources required for a long-term, continuous care and a growing burden on healthcare infrastructures. Today, 75-80 per cent of healthcare expenditure is spent on chronic diseases, placing an unsustainable strain on healthcare providers’
Wireless Body Area Network
•Brathing •Activity •ECG •Heart beat
The New Wave – Pervasive and personalised healthcare
Demands on healthcare throughout the world are changing. As a result, there
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resources including hospital beds. With healthcare budgets already overstretched and few care takers—professionals and non-professionals—being available to meet the increased needs, forecast additional demands are simply unsustainable using current practice. Continuous monitoring has shown to enable more effective treatment of chronic disease, deliver improved patient outcomes and reduce the requirement for hospital visits and admissions. With the prevalence of chronic conditions set to escalate in coming years, the ability to harness non-intrusive, proactive healthcare monitoring and 24x7 diagnostic and intervention capabilities—at acceptable system cost levels—is becoming a key priority for healthcare providers.
•Insulin Pump
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•Blood pH •Glucose •Dissolved oxygen •Carbon dioxide •Temperature
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Sensium Application
Oracle Lite DB
Sync Client (mSync)
WiFi or GSM
Web Server (Apache HTTP)
Oracle HTB
Sensium enabled Digital Plaster
Sync Server (Mobile Server)
HTTP
Physician's Web browser
Mobile Server Repository
Digital Plaster
Converging on a new vision
The impetus for the emergence of the new global digital medicine market is convergence. Digital information standards now enable X-rays and scanned images to be stored, retrieved, communicated and analysed using Picture Archiving and Communication Systems (PACS). The development of interoperability standards for Electronic Medical Records (EMR) is also opening the way for greater patient / physician access to data and the provision of patient choice. Through interoperable EMRs physicians, pharmacies and hospitals can share patient information and deliver timely, patientcentred and portable care. In parallel, the ubiquity of wireless and mobile cellular networking is driving the clear trend for ‘unwiring’ the healthcare world and the increasing demand for mobile-based solutions, both in general ward hospital environments and in outpatient and care home scenarios. Now, disruptive semiconductor technology is enabling all these convergent trends to come together and create a nexus for major innovations in treatment, diagnostics and intervention. The transfer of this groundbreaking technology allows the advantage of economies of scale that semiconductor industry now enjoys to be passed onto healthcare markets for the first time.
Intelligent wireless body monitoring – Platform for a digital revolution
Health research has shown that our bodies are not constant. Nearly every physiological process fluctuates with our internal circadian rhythms; the body’s temperature, immune function and hormone levels vary according to the time of day or night. In addition, many diseases have daily rhythms, with symptoms more severe at certain times. As a result, taking data at single set time points provides limited insight into a condition or an individual’s overall health status. A growing recognition and understanding of the body’s sensitivity to timeof-day helps in improving the efficiency and safety of drug delivery. In every healthcare scenario, the ability to continuously—and remotely— acquire data necessary to undertake a more holistic clinical assessment of an individual is the key to defining highly personalised treatments and delivering improved outcomes. New ultra low-power system-on-chip technology lies at the heart of the digital medicine revolution. This technology enables a new generation of low-cost, non-intrusive wireless vital signs monitors that can continuously monitor multiple vital signs in real-time, allowing healthcare providers to remotely monitor patients via standard mobile devices such as PDAs and cellphones. With the ability
to deploy simple, reliable and affordable remote body monitoring devices, whole new areas of the medical services market are being created, including point-of-care diagnostics, tele-monitoring and the ability to self-manage chronic conditions. For healthcare professionals, this innovation is opening a completely new window on patient physiology enabling unprecedented levels of analysis and unlocking entirely new areas of knowledge and understanding into disease progression, diagnosis and therapies. Intelligent wireless infrastructure for healthcare and lifestyle management
New ultra low power system-on-chip technology is enabling a new generation of low-cost, non-intrusive body-worn wireless vital signs monitors for medical and professional healthcare applications. This breakthrough technology provides the complete wireless infrastructure to allow healthcare providers to remotely and intelligently monitor the human body in real time, via standard mobile devices such as smartphones and PDAs. The technology provides an intelligent data acquisition platform and a complete integrated solution for patient care – enabling the ubiquitous monitoring of physiological inputs from ambulatory and non-ambulatory patients, in both general ward and out-patient or telecare scenarios.
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Together with appropriate external sensors (for example, electrodes, 3-axis accelerometers, temperature sensors, pressure sensors, strain gauges, amperometric sensors and so on), this platform technology allows continuous, intelligent monitoring of multiple vital signs—such as ECG heart rate, body temperature, respiration and activity level—in real time allowing earlier detection and prediction of adverse events such as heart attack, falls or hypoglycaemia. Powered by low-cost thin batteries, body-worn monitors can process and extract key features of the data and intelligently integrate it into an electronic medical record (EMR) via a base station device using a power-optimised wireless operating and networking system. For healthcare professionals, this delivers unprecedented possibilities for proactive monitoring and improved quality of care at dramatically reduced cost. Traditional healthcare models are simply not able to offer this level of continuous care except in expensive ICU settings. This new technology unlocks a higher quality system of individualised patient care throughout the treatment and diagnostic cycle—from the hospital ward to the home. For patients, this transforms the opportunities for lifestyle-compatible, personalised healthcare as well as better therapeutic outcomes. Wireless Body Monitoring Infrastructure
In a Wireless Body Area Network scenario, one or more devices can continuously monitor key physiological parameters on the body. These small body-worn monitors can capture, dynamically process and filter ‘problem’ event data—such as irregularities in heartbeat or blood pressure—and report it wirelessly to a basestation device plugged into a PC, PDA or smartphone via an ultra low-power short-range radio telemetry link (much lower power than alternative short-range technologies such as Bluetooth or ZigBee). The data can
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The key enabling benefits of new platform technology • Gathering real-time information, not raw data √ On-chip signal processing to intelligently extract critical information from sensors • Ultra-low-power √ Patented AMx technology coupled with low-power radio and intelligent information handling results in non-intrusive, continuous monitoring • Low-device cost √ Ultra low-power and low voltage operation leads to devices powered by simple, low-cost “printed” batteries • End-to-end system √ Provides the low-power radio link from the patient to the telecommunications network and into the healthcare provider’s database/system
be further filtered and processed by application software. Using ultra low-power advanced mixed signal processing algorithms, these devices requires only a very small, low-cost battery, enabling them to be body-worn with complete freedom of movement. The system can be incorporated into a wide variety of lifestylecompatible form factors depending on market application and requirements. For example, a disposable monitor— offering days’ to week’s lifetime and requiring no battery change—or a nondisposable body-worn device. End-to-end Solution – Towards management of care by exception
Toumaz and Oracle Corporation are currently working together to link realtime vital signs information acquired by the Sensium system to the electronic patient record, using Oracle’s Health Transaction Base (HTB)—an information system designed specifically for healthcare markets and integrated with the first international standard for storing and sharing health information: the Health Level Seven Version 3 (HL7 v3) Standard. The integrated end-to-end system will allow key physiological data taken from multiple patients—both in general ward and out-patient care settings—to
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be integrated with existing health information systems, thereby becoming a total patient care package and clinical repository of data. In the general ward environment, vital signs data is transmitted either to the bedside monitor (in the case of non-ambulatory patients) or, for ambulatory patients, to the nearest basestation via the ultra low-power wireless link. Data from multiple basestations is then delivered over Ethernet or WiFi to the software-based server, which can be integrated seamlessly into the existing hospital IT system or database. In telecare or home monitoring environments, vital signs data is acquired from the mobile patient and transmitted to a standard mobile device (cellphone or PDA), which acts as a network node. From there, it can be sent over the standard cellular network to the server before being integrated into the hospital IT system. All acquired data can then be made available to hospital staff via the nurse’s station or wirelessly to a doctor’s PDA or Mobile Clinical Assistant (MCA). First metre healthcare – System architecture for Wireless Body Area Networks
By converging the IT system onto the individual and bringing the network into the ‘first metre’, intelligent inte-
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Personalised healthcare, boundless possibilities
As witnessed by the digitisation of the telecom industry, convergence creates unimagined technological opportunities. Today, popular social networking sites such as MySpace and Facebook are already changing the human fabric of the Internet. This evolving social networking model may even open the way to new healthcare dimensions in the future. Aggregating data from these sites or search engines like Google, and making this available or accessible from,
Cellular connection to sensium Server
Sensium Server
Basestation
Sensium Senium wireless link to mobile of PDA
i
iF
W
e
rn
he
Et
r to
Wi-Fi Bluetooth Etc.
or within, EMRs could see the emergence of new online communities that enable people to select medical therapies, personal training or recuperation programmes, and even access lifestyle or rehabilitation mentoring partners. With a growing focus on low-cost preventative care models, demand for personalised healthcare and continuous body monitoring is set to experience exponential growth. We could well see the emergence of a new breed of service provider organisation set up specifically to deliver integrated patient information and bio-sensor network monitoring services to the professional healthcare and wellness market. These services could incorporate a wide range of solutions, including monitoring, clinical data or alarm services, links to dedicated call centres or SMS and email functions. Developments in wireless body monitoring are already changing attitudes and assumptions about health and
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Identical devices to monitor at home and integrate data with hospital records
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grated platforms are creating a unique opportunity for the development of end-to-end telemedicine and health information systems that can meet the rapidly growing need for analysis and decision-making based on real-time data—offering the potential to deliver greatly improved healthcare outcomes at dramatically reduced cost. As a platform technology, this technology provides a viable cost model for long-term, preventative care that is also compatible with patient lifestyles, ushering in a new era of healthcare opportunities. The ability to continuously and wirelessly monitor makes 24-hour observation and analysis of an individual’s response to treatment possible, supporting recalibration of dosage quantity and timings. In future scenarios, by allowing two-way flows of information (for example, an uplink of raw or processed data and a downlink of requests or activation signals), intelligent wireless body monitoring platforms could offer further use in closed loop systems to control drug delivery and maintain key physiological parameters, such as blood pressure, within an optimum range. Adaptive treatment responses are crossing into other fields such as pharmocogenomics, which holds the promise that one day drugs might be tailor-made for individuals, or adapted to each person’s environment, diet, age, lifestyle and genetic make-up.
rn
he
Et
o et
User's existing IT system or database (Optional) Nurse's Station
PDA/MCA
healthcare delivery. The ultimate goal is for ill health to become largely predictable and capable of being managed, with the focus on prevention rather than symptomatic or event-driven therapeutics. This technology is now providing the platform for healthcare professionals to work in an embedded matrix of information, with patients becoming partners in managing their own health. As we move towards this digital medical future, the trends are very clear: the market opportunity created by a merging of the consumer electronics and healthcare industries is vast; and this is certainly just the beginning of a global healthcare revolution. Trademarks
Toumaz Technology Ltd. retains title and ownership of the following registered trademarks: Sensium® the Toumaz® logo; and AMx™
Alison Burdett was a senior lecturer in the Department of Electrical and Electronic Engineering at Imperial College before joining Toumaz Technology. Her expertise is in the design of high frequency analogue and wireless integrated circuits. She has designed commercially successful silicon chips for Mitel (now Zarlink Semiconductor) and LSI Logic as well as collaborating on research projects with a number of semiconductor companies including Ericsson Microsystems, Philips Research Laboratories Redhill, Panasonic System LSI Design Europe (PSDE) and Nortel plc.
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t’s getting harder to read a newspaper or watch the television without seeing news about the impact of global warming. While the debate about cause and effect is certain to continue, it is clear to a growing number of people that we must reduce the consumption of natural resources and the emissions of carbon into the atmosphere. Without question, building construction has a significant impact on the environment, not only in terms of how it alters the landscape, but also in terms of material and energy consumption and waste generation. Consider these numbers: over 65 per cent of the US’ electricity is consumed by building construction and occupancy. Globally, more than 40 per cent of the earth’s raw materials are consumed in the name of building construction and occupancy.
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Statistics like these are responsible for the world’s burgeoning interest in sustainable design and construction. Individuals and corporations are making a concerted effort to learn how to create buildings utilising sustainable technology, renewable resources and systems designed to reduce energy consumption and carbon emissions. There’s no better place to implement these principles than in the design and construction of hospitals and other healthcare facilities. Hospitals generate vast amounts of waste material in the form of food, paper and plastics, the majority of which is not recycled. As a building type, hospitals are relatively heavy users of materials, energy and water. Not only does this heavy usage drive up the cost of construction of most hospitals, it also results in increased operational expenses over the
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lifetime of the building, especially as the cost of natural resources continues to skyrocket. Of course, research has also shown that environment aids the healing process. Healthier buildings lead to healthier patients and staff. A growing number of hospitals are becoming more interested in a sustainable approach to healthcare design. There seems to be a lot of uncertainty, however, about implementing it. Concerns typically revolve around initial costs, schedule and return on investment. With an educated and organised design approach, implementing sustainable methods is not only becoming less costly, but also more the rule than the exception. The United States Green Building Council (USGBC) has developed a sustainable building guideline and rating system known as Leadership
F acilities & operations M anagement
Sustainable
Hospital Design Beyond the numbers
The new trend to design and build hospitals using sustainable technology, renewable resources and systems designed to reduce energy consumption and carbon emissions is making it possible to achieve higher building performance in terms of reduced energy consumption, improved indoor air quality and a supportive healing environment.
Russell A Sedmak Vice President Heery International, USA
in Environmental and Energy Design (LEED). This system and the USGBC staff serve as a technical resource for the design and performance of all building types. Recently, the organisation completed LEED guidelines specific to healthcare facilities. These resources allow architects, engineers, and owners to make informed design and operational decisions about the design and planning of hospital facilities. While several hospitals have achieved LEED standards using office building guidelines, only two have achieved a LEED Gold Certification, and none yet have achieved Platinum. A third hospital, currently under review for Gold Certification using the new healthcare guidelines, is the Medical Center of the Rockies (MCR), in Loveland, Colorado.
MCR, a 595,000 SF, 136 bed critical care facility, with combined centres of excellence in cardiac and trauma care, is an innovative example of a large new specialty hospital. Its 40-acre campus was developed from a vacant site and master-planned to ultimately accommodate a tripling of its initial size. Few hospitals have the opportunity to take advantage of the outdoor spaces like MCR does. A nature trail and wetlands, located directly in front of the facility, serve as part of the healing environment. However, even hospitals located in the tightest urban areas can take advantage of outdoor spaces by using concepts such as hardscaping, which requires less planting and maintenance and is more useful to patients, family and staff. There are ways to zone a site in terms of the intensity of plant material, and the degree of maintenance and irrigation
required if the facility sits on a large tract of land. Whatâ&#x20AC;&#x2122;s important to note is that not every part of a hospitalâ&#x20AC;&#x2122;s open space requires a manicured lawn or trees in order to create a high-quality outdoor environment. In fact, a diverse landscape adds interest and context to most sites. Regardless of site location, thoughtful storm water collection and flow management provides an opportunity for sustainability and protection of neighbouring land. Stored water on site can potentially be used for irrigation. In some climates, however, open, standing water can pose health risks, especially if left untreated. A new wetland was created at MCR to filter run-off before discharging surface water into a nearby wildlife sanctuary. Another important site consideration is the buildingâ&#x20AC;&#x2122;s placement and position, and the locations of public,
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MCR Layout 1. Emergency 2. Diagnostic Imaging 2
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4. Admin. / HR / M.I.R 5. Physician Services 6. Outpatient Cardiology 7. Chapel 4
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service and ambulance entries to best take advantage of solar orientation. Even in low sunshine climates, buildings have a warm side and a cold side. Wind is also something to be considered because it is another factor that contributes to energy consumption, maintenance costs and user comfort and safety. Building orientation also impacts daylighting. How the sun penetrates a building and how designers manage that direct solar access is extremely important for practical purposes, and can influence LEED credits. Not only does the use of natural light in patient care and staff support areas reduce energy consumption, it also provides an important connection with nature and supports a better healing environment. Outdoor ventilation is a consideration in most climates, although it can be difficult to manage from a temperature
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control perspective. Most new hospitals have thermostats for every patient room. If the zone control is compensating for an open window on a hot or cold day, the overall system load is only affected at the room with the open window. The physical and psychological benefits gained by allowing fresh air to come into a patientâ&#x20AC;&#x2122;s room are tremendous. Additionally, fresh air can improve indoor air quality. Interior areas without access to an outside wall can benefit from the use of task lighting versus overhead fluorescent lights. In a patient unit hallway for example, thereâ&#x20AC;&#x2122;s no reason to design for more than 25 foot-candles. A reduced lighting level in corridors not only saves energy but creates a sense of calm and comfort for patients and their families. It also tends to lower voices in the halls and in nurse stations. Another benefit is lower eye strain and reduced fatigue.
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10. Education / Offices 11. Main Lobby / Atrium 12. Main Entrance
Proper use and preservation of water in design can be an integral part of sustainability. Water is a powerful healing element and the symbol of life. Should a facility opt to incorporate water elements, itâ&#x20AC;&#x2122;s critical to pay close attention to design and engineering to minimise water consumption, leakage, maintenance and algae. Sustainable architecture also involves the use of renewable materials and products with lower Volatile Organic Chemical (VOC) emissions. This idea can also be taken one step further by using recyclable building materials wherever possible, because eventually these materials and their finishes will be replaced. Non-recyclable materials ultimately end up in a landfill. Durability and ease of maintenance are the two factors that impact sustainability and operational costs of the
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common. Vertical stacking reduces the building footprint and allows more natural light into the building. It is not only important from an operational and cost standpoint, but also because it reduces waste and demolition. A properly stacked hospital also reduces energy consumption by reducing the length of utility runs and reducing the building footprint overall, making it more efficient to operate and allowing a more efficient use of land. Ultimately, the twentieth century trend of building cheaply and quickly and prematurely disposing of worn structures will be replaced by the use of higher quality, longer lasting building materials and methods. This is great news for design professionals and the people and communities these facilities serve. More attention is being paid to the idea of green roofs. Not only do they impact sustainability, but also provide user comfort by allowing patients to look out of the windows to see grass, pavers, benches and people, instead of just equipment and roofing material. The environmental and energy savings utilising this form of building covering are substantial, and will eventually outweigh the concerns for the costs that incur in building structure, waterproofing, and landscape maintenance. Marketing and public relations can also play an integral role in educating the population, particularly in areas where there are several healthcare options. A sustainable facility can impact a hospital’s perception in the marketplace. Sustainable hospital design does have an impact on governmental approval processes, where development is more tightly controlled, especially as communities demand a higher building standard with less impact on the environment. A u thor
facility. Spending a little more money on higher-quality and eco-friendly finishes such as terrazao and stone, is often the most cost-effective decision. These types of materials are easy to maintain without chemicals. Typically, they last the lifetime of the building. If the project cannot afford products like terrazao in procedure areas, resilient sheet goods such as linoleum, which have low VOCs and are made from renewable resources, can be substituted. PVCs and vinyl flooring products should be avoided. Construction site recycling plays a major role in conservation and can generate LEED points. Until recently, many construction sites recycled only a small portion of their scrap material because there was neither a large market for recycling, nor the environmental consciousness to drive the process. That is changing quickly as recycling options for wood and drywall are becoming more available. During the construction of MCR, for example, a local pig farmer purchased the crushed gypsum from wall board scraps to mitigate the effects of animal waste on his land. MCR recycled over 75 per cent of its construction waste as a result of a concerted team effort established at the project’s inception. Enforcement by the owner and contractor, JE Dunn, was also critical to the recycling programmes' success. Design innovation creates additional opportunities for achieving sustainable design goals. With critical input from the owners, it’s possible to create an ideal floor plan that maximises flexibility and minimises circulation and wasted space. In hospital design, it is critical to create a circulation pattern to separate public from private zones which complicates the idea of efficiency. But by locating these two zones, or spines back-to-back and placing them at the core of the facility, they can be made shorter and work more effectively, even as the facility grows over time. As land value and land scarcity increases worldwide, vertical stacking of hospital floors will become more
In designing sustainable healing environments, it is also important to look at the elements which go beyond the simple numbers. It is vital to look at customer expectations and the ability of people to choose a healthcare provider. In order to provide high quality of care patients expect, hospitals have to be able to recruit and retain the best doctors, nurses and support staff. It is the ability of the hospital’s design to integrate all these needs in a way which is flexible and adaptable over its lifetime, so that it can continue to serve its mission, without substantial reconstruction. These are the most critical elements of a sustainable hospital. Overall, the future of sustainable hospital design is very bright. We have much ground to uncover in an effort to reverse the environmental trends of the last century, particularly in our most populated and industrialised countries. But with exceptional vision and leadership by architects, engineers and building owners, and with governmental support in each country, we can build a healthier and more sustainable world.
Russell A Sedmak has spent the majority of his 23 year architectural career as a leading healthcare facility planner and designer for Heery International. Of the firm’s many notable projects, he has most recently directed the planning and design effort for Medical Center of the Rockies (MCR), a 590,000 square foot regional tertiary care hospital specialising in cardiac and trauma services.
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The Hospital of the Role of architects Gary M Burk Principal Terrie L Kurrasch Senior Associate RATCLIFF, USA
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o administrator, patient or doctor today would recognise the hospital of the future. It isn’t a healthcare facility, as we know it. As a result of changes in technology and the general delivery system, consolidation, amalgamation and an ever-changing regulatory environment, the hospital of the future will not be the resourceintensive and richly utilised organisation as it is today. Instead, the hospital of the future is likely to be smaller, less expensive to construct and operate, and sustainable in design, utilisation and energy efficiency. It will most likely be part of a distributed healthcare delivery system, rather than a stand-alone organisation. As part of the anticipated healthcare reform movement, hospitals of the future will be resource-appropriate and their utilisation rates will be proportionate and relative to their demographics. As renowned author Regina Herzlinger points out in her 2007 book, Who Killed Healthcare, ‘The US healthcare system is in the midst of a ferocious war. The prize is unimaginably huge— US$ 2 trillion, about the size of the economy of China—and the outcome
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Centrally located in the Alta Bates Summit Medical Center campus in Oakland, California, the Breast Health Center is just footsteps from the main entrance to ease wayfinding for patients and their families.
will affect the health and welfare of hundreds of millions of people. Four armies are battling to gain control: the health insurers, hospitals, government and doctors. Yet you and I, the people who use the healthcare system and who pay for all of it, are not even combatants. And the doctors, the group whose interests are most closely aligned with our welfare, are losing the war.’
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Architects solutions
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Do design professionals have responsibilities within this era of reform? Most certainly. In the recent past, healthcare architects and hospital planners have focussed on the issue of universal access and the implications of that on utilisation and hence, building size. The larger problem confronting this society now
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Future Isn’t… The concepts for what the hospital of the future ‘is likely to be’ and ‘isn’t’ include distributed services, the ‘hospital at home’ project, ‘wearable hospital’ telemedicine innovations, ‘lean design’ principles and ‘cellular care.’ These concepts dictate the design professional’s responsibilities within an era of healthcare reform.
and well into the future is cost. In the healthcare field, cost drivers are multifaceted and generally include most or all of the following: • Labour and Benefits • Capital Expenses • Materials / Supplies • Services / Operations • Facilities Development • Reimbursement
• Uncompensated Care • Compliance and Unfunded mandates Architects can and should take an active role in the discussion about the kind of facility the hospital of the future would be. They could do it by: • Working with hospital leadership to understand the patient base of the future
• Seeking to design and build less expensive facilities • Designing facilities that are efficient to use and access and that cost less to operate • Committing to design buildings with net zero carbon footprints by 2030 • Designing facilities that make life easier for caregivers and healthier for patients.
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Hospital utilisation trends
Impact of healthcare policies
Another way for hospital architects to expand their sphere of influence is to understand and educate clients about key utilisation trends. Hospital resource utilisation results from both access and availability. Information from the Dartmouth Atlas of Health Care showed that the amount of time patients spent in a hospital varied greatly depending on where they lived and practice patterns of the local physician community. For instance, the patients who were chronically ill in Bend, Oregon spent only 10.6 days per year in the hospital, while those in Manhattan spent 34.9 days annually. Additionally, the Dartmouth study illustrates that physicians adapt their practice styles to the resources available to them, which can cause huge variations in healthcare costs. Medicare spending for chronically ill patients at the Mayo Clinic in Minnesota was only US$ 34,372 per patient, but that figure rose to US$ 64,900 at the University of California-Los Angeles (UCLA) Medical Center. This is because utilisation rates and physician visits were markedly higher at UCLA than at the Mayo Clinic (11.6 ICU days vs. 4.2 ICU days and 53 physician visits per stay vs. 24 visits per stay, respectively). In both these cases, enrollment in hospice care programmes was greater in Oregon and Minnesota than in Manhattan and Los Angeles, an obvious factor in the utilisation of hospital resources. Current trends in hospital management and construction cannot be sustained by the US economy. Without comprehensive community planning, the boom in US hospital building is replacing many outmoded facilities and adding beds to respond to the perceived needs of an ageing population. This trend aggravates and sustains the utilisation and practice patterns identified in the Dartmouth study. Higher utilisation results in higher costs due to greater expenditure of resources such as energy, capital and supply chain materials.
We all recognise the influence of policies and policymakers on the design of healthcare facilities, including the need for eight-foot corridors, one-hour fire safe corridors in nursing units, and accessible design that provides safe ergonomics for disabled and non-disabled staff alike. But these are just a few of the reasons that the hospital of today got to where it is. To fully appreciate the current state, one only has to reflect on legislation such as the Hospital Survey and Construction Act (also known as the Hill-Burton Act) of 1946 that provided federal grants and guaranteed loans to improve the nation’s hospital system and help to achieve a goal of 4.5 beds per 1,000 in population. These grants did not sunset until 1975 and every hospital in the country had benefited from this funding source. Before Health Maintenance Organizations (HMO’s) began providing insurance coverage, there was indemnity insurance—hospitals were paid what it ‘cost’ to provide care. Length of stay was not an issue and patients were routinely admitted to a hospital bed the day prior to a surgical procedure to complete their pre-surgical lab work and imaging. There were of course, Health Systems Agencies (established in 1975) to provide local direction and control of healthcare planning. The local agencies developed health systems plans that mandated the number of beds, operating rooms, ED stations and so on for each planning area. Some would argue that their effect was limited in terms of curbing and controlling growth. Certificates of Need (CONs) were created in 1974 to help control how hospitals spent their money; capital expenditure was limited and expansion plans had to fit into the local Health System Area (HSA) plans. Most states that had CONs have let them sunset because they, too, generally failed to meet their intended aim of reducing spending and expansion of services. These and other regulations helped to bring about the current state of the healthcare delivery system.
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Realising the hospital of the future through design
Hospital designers need to join the ‘ferocious war’ described by Harvard economist, Herzlinger. Designers can advocate for changes in their clients’ practices, push for smaller concentrations of healthcare resources and urge client groups to disperse their services to be more accessible throughout the community. Using their influence to educate policymakers and benefit consumers, designers may assist in making many of the following concepts a reality. The Advisory Board Company, an industry based think-tank in Washington, DC, proposed that because of the uncertain regulatory and reimbursement scenarios ahead, the hospital of the future will specialise in key services. This new organisational structure may result in
The Cardiology Family Resource Center offers a multimedia resource library, business center, two private counselling rooms, discrete waiting areas, and a hospitality room.
Cellular care concepts
Departmental care realities
Few care stations, many activities per station
Many care stations, limited activities per station
Cells configured with multidisciplinary care teams to produce measurable milestone outcomes in care pathway
Departments configured for specialisation, outputs not specifically coordinated with other events in care pathway
Little patient movement required
Extensive patient movement required
Cells do not ‘own’ the areas they work in and they can expand / contract their areas of service with patient demand, minimising process redundancy
Departments ‘own’ their space, thus they are fixed in a location, forcing redundancy of processes such as scheduling, registration and queuing
Cells are viewed as production centers
Departments are viewed as cost centers
Optimisation of the whole hospital
Optimisation of sections of the hospital, not the whole Table 1
lifting of the moratorium on physicianowned hospitals and slowing the growth of stand-alone comprehensive healthcare facilities. Instead, it will encourage the growth of ‘Centres of Excellence’ that can deliver patient care within existing facilities, dispersed throughout a community without the need to construct new
buildings. Other futuristic healthcare delivery options include: • Distributed Hospital, featuring broadening access points like a freestanding emergency department, a shortstay hospital, a ‘super’ medical office building and a variety of speciality hospitals
• ‘Hospital at Home’ where patients with certain diagnoses (such as congestive heart failure) are discharged from the ED and are accompanied by a nurse or MD home for the first 8-24 hours. Subsequently, a nurse or MD would visit the patient daily until he is discharged. This concept was studied by Johns Hopkins Hospital in 1996 and significantly lowered costs and patient’s length of stay • ‘Wearable Hospital,’ which utilises remote patient monitoring. This concept has resulted in a 23 per cent reduction in diabetes patients’ hospitalisation rates in a recent Veterans Administration study. While current technology requires patient activation to send data to the monitoring station, clinical trials are underway for wearable, automatic patient monitoring
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As patients move past the Breast Health Center admitting desk, they enter a waiting room finished in a rich gold patina.
systems that eliminate the patient’s role in transmitting the data. • Other ‘innovative disruptions’ on the horizon of healthcare delivery that are gaining momentum are medical tourism and retail clinics (e.g. doctor’s offices located in busy shopping centers for easy access). David Chambers at Sutter Health has developed a number of concepts for moving the industry towards a better future and sees architecture as one of the key means to achieve both better hospitals and lower costs. Under his guidance, Sutter Health has initiated a programme to develop a prototype hospital using tools for planning and design advocated by Chambers. A description of this process follows. Lean design
Architecture is central to the discussion of ‘lean design’ for the hospital of the
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future. It literally can remove the walls in a healthcare setting that cause silos between staff and fragmentation of care delivery. By designing patient units that allow for single bed service line adaptable environments, architects can facilitate the achievement of measurable milestone outcomes, create opportunities for care providers to work differently (in multidisciplinary care teams) and minimise patient movement. The ‘five big ideas of lean’ outlined here can be embedded into healthcare design and project delivery to remove waste in the capital programme: 1. Collaborate, really collaborate 2. Increase the connections of the participants 3. Develop a network of commitments 4. Optimise the whole and not the pieces / departments 5. Couple learning with action
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Planning for optimised patient care delivery offers a multitude of operational benefits, such as the reduction of steps and cycle times, elimination of patient handoffs, enhancement of the predictability of workflow and commitment to the ‘lean’ process, reduction of staffing requirements and improved quality of patient outcomes. It also equates to less facility space required, fewer dedicated or specialised function spaces and the dissolution of departmental fragmentation. Cellular care
Cellular care (also known as multidisciplinary team care) is likely to be the operational model for the hospital of future. Table 1 illustrates the efficiencies and outcome improvements to be gained by this new paradigm in comparison to the current healthcare delivery model.
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California’s hospital of the future
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Sutter Health, headquartered in Sacramento, California has embarked on a plan to implement and open prototype hospitals embodying the principles of lean design and cellular care. In order to break from the conundrums of current delivery methods, Sutter shared its models and objectives with multiple architectural teams. In the process, it split the design project delivery process into a competitive planning and predesign stage followed by implementation by the ‘winning’ teams. As the owner, Sutter prioritised the drivers for each project and they are: patient safety, staffing efficiency, cost project adaptability and flexibility. Project teams (including members from operations, programming and design and build firms) were assembled prior to proposing to participate in this collaborative process. Three teams were selected to compete for the opportunity to design Sutter Health’s prototype hospital and each team was awarded US$ 500,000 to develop their proposals. In the kick-off meeting, all the three teams were involved in determining the project’s metrics and actual delivery schedule. The prototype hospital objectives were outlined as: • Improve workflow efficiencies by 40 per cent (gained by reduced cycle times, elimination of unnecessary redundancy in patient flow and revisions to care
configuration based on cellular care concepts) • Reduce facility area per adjusted patient discharge by 30 per cent (realised through the elimination of unnecessary redundancy in patient flow, reduction of excess queues and spatial configuration of services for cellular care delivery to eliminate fragmentation in care model) • Reduce overall construction costs per bed by 50 per cent by developing design sets oriented toward high value to cost ratios • Reduce energy use per area by 25 per cent Sutter now has four prototype hospitals in design production and expects to bring them online within the next few years. They all appear to have met the objectives set out by the owner, and should be among the most cost-effective and efficient hospitals in the country upon completion. Conclusion
Healthcare designers and planners have ample opportunities for thought leadership in this arena. The hospital of the future most likely will include distributed services, a hospital at home prototype, wearable hospital telemedicine innovations, ‘lean design’ principles and ‘cellular care’ concepts. Instead of focussing on what the hospital of the future ‘isn’t’, architects.
Gary M Burk has been responsible for project and client management of healthcare facility planning projects, including utilisation analysis, facility assessment, space programming, user group interviews, planning standards development and master planning. He has more than four decades of professional experience, working as a practitioner in major architectural offices. Terrie Kurrasch has an extensive background in facility planning and healthcare administration. She has worked exclusively within hospital and healthcare organisations, and as a healthcare management consultant. Terrie came to Ratcliff after managing the implementation of the merger of Alta Bates and Summit Medical Centers.
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Baylor Emergency Department Providing state-of-the-art services
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Todd C Howard President t. howard + associates, USA
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he Baylor University Healthcare System is a Christian ministry of healing that serves patients by providing exemplary healthcare, education, research, and community service. It was founded on the principle of improving community health by addressing identified needs. The Baylor University Medical Center Emergency Department (BUMC ED) located in downtown Dallas, Texas has been operating near capacity for almost 10 years. The high number of patients combined with the dearth of resources made providing top-notch healthcare more difficult. To correct this issue, Baylor brought in North Carolina-based architect FreemanWhite and local architect t. howard + associates to perform a renovation and addition to the ED. Healthcare coverage for Texans ranks among the worst in the US, largely because so many Texans go uninsured each year. Twenty five percent of all Texans have no health insurance, which precludes them from having regular check-ups that could catch illnesses before they magnify into emergencies. Other insured workers have no medical leave, which leaves them with little opportunity to visit a physician regularly. These translate into high levels of ED traffic. In fact, a third of individuals in the US visit an emergency department each year. The Dallas Metroplexâ&#x20AC;&#x2122;s population has enjoyed nearly 30 per cent growth rate over the past decade and is still growing steadily. This adds to the number of people visiting the ED each year. When emergency strikes, few centres in Dallas are able to provide levels of patient care equivalent to the The Baylor University Medical Center Emergency Department (BUMC ED). It is one of only two Level One Trauma Centers in the North Texas Trauma Network. This designation signifies that the centre provides the highest of level of surgical care to trauma patients and maintains capable personnel in-house 24 hours a day, seven days a week for prompt
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CaseStudy
The Baylor University Medical Centerâ&#x20AC;&#x2122;s Emergency Department in Dallas, Texas has been operating at near capacity for almost 10 years. The high number of patients combined with the dearth of resources lead to an inevitable and unwelcome decline in service. To correct this issue, Baylor brought in local architect t. howard + associates and North Carolinabased architect FreemanWhite to perform a 75,000 sq.ft. renovation and addition to the ED. This more than doubled its capacity to care for patients and tripled the footage of the ED.
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diagnostics and treatment of the most critically injured patients. The increased demand on the BUMC ED over the years has caused the ED to outgrow its space, thus requiring larger work areas to alleviate overcrowding in order to maintain the high standards of efficiency and patient care. Prior to the ED expansion, patients sometimes had to wait for more than three hours to see a physician. One of the end goals was to significantly reduce the waiting time. With the aim of improving patient service, the BUMC board of trustees began planning the new ED in early 2005. FreemanWhite and t. howard + associates (THA), architectural firms with a strong healthcare focus, were brought on board to help fulfil the trusteeâ&#x20AC;&#x2122;s vision for the project. The ED went under the knife for a renovation and expansion of the existing department to increase patient volume and improve quality of care and staff retention for a comprehensive cost of US$ 53 million. The design team strategically planned to expand the area of the department from 33,000 sq.ft. to 78,000 sq. ft., more than doubling its patient capacity. The total number of beds increased from 34 to 87, majority of which are now private. A large trauma area was built to accommodate up to eight injured persons. One of the challenges the design team faced was making a noisy, bustling emergency room tranquil without disrupting workflow. A large waiting area was broken into several parts allowing families to congregate in relative privacy, while sub-waiting areas spread throughout the ED provide the family comfort and proximity. The private patient rooms, all equipped with enough seating for family members, a television, and a phone, helped speed the treatment process while increasing the care quality and sanitation. The orientation and equipment provisions are typical in each treatment area. Dimmable lighting allows maximum comfort and in place of privacy curtains, electrostatic glass becomes opaque at the flip of a switch.
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Furthermore, imagine patients needing to visit the ED and being able to call their doctor ahead of time and ask him / her to meet at the hospital. Patients who have doctors with practicing privileges at Baylor are permitted to the use of a new physicians' waiting area and are able to meet with their caregivers in a more efficient manner. This reduces the number of patients in the general waiting area. Treatment rooms are orientated around centralised care team stations to assist with operational efficiency during non-peak hours. The new silence in the ED will help alleviate stress in both staff and patients alike. Baylor wanted durable finish that added an inviting and professional look to their facility, without requiring a lot of maintenance. The ED is designed to welcome the patient through careful selection of colours. The wood elements and stainless steel used throughout the
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facility have a modern and approachable appearance. Visual monitors featuring calm virtual aquariums are spread throughout the larger waiting area. In times of high activity, the monitors transition to a dedicated Baylor channel with nature scenes and soothing music. Terrazzo flooring is one of the lowest maintenance solutions available and can survive the heavy scrubbing required in the ED. With lower maintenance finishes, patients and staff arenâ&#x20AC;&#x2122;t subjected to the constant noise of cleaning, waxing and buffing. To make the experience more personal, the Baylor Foundation focussed on bringing in artwork from local artisans for the ED. Individual art pieces can be found in each of the treatment rooms and numerous three-dimensional wall art pieces can be found throughout the facility, adding a feeling of brightness to the ED. Artists were commissioned to
One of the challenges the design team faced was making a noisy, bustling emergency room tranquil without disrupting workflow.
The ED also benefits from cuttingedge technology upgrades: four X-ray units, two CT scanners, an Ultrasound, a Lodox and upgraded lab services are now available within the department. Computers are located in every patient room, which increases the amount of time staff can spend with patients. With a large decontamination room, containment room and showers, the ED is prepared to face disasters and biological threats. A total body digital imaging system, Lodox Statscan is located
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paint one-of-a-kind watercolours featuring local landmarks. In addition to being visually stimulating add-ons to the ED, they also assist in wayfinding. Even though the ED is large, the design is simple. The care team pods are located in the centre of the facility with the treatment rooms lining the perimeter. These facilitate communication and increase efficiency among the staff. There are strong visual connections throughout the ED, so staff can clearly see inside the patient rooms and also from one care team station to another. In order to help patients and staff find their way easily, different colours are used for each care team pod. The design team helped cut down on visual chaos by creating niches in the corridors for drug distribution machines and crash carts. With everything having its own dedicated space the hallways get much calmer.
CaseStudy
in the trauma area allowing the trauma staff immediate access to the imaging equipment. In the unfortunate event of a patient passing away, a body viewing room is incorporated into the design. This small divided room allows patients’ families to view their loved ones when they are prepared and allows the staff space to speak with the family in seclusion without interruptions. The design team has incorporated vinyl flooring resembling wood, soft wall paint covers and furniture. The result is far preferable to a chaotic trauma room or a sterile morgue. It was important that the ED remain fully functional during the renovation and addition. Construction was carefully phased so as not to disrupt the ED’s ability to care for patients and the ED was able to treat 110,000 patients during the seventeen-month construction period. Other departments that had previously been located in the ED’s new space were seamlessly relocated within the hospital’s footprint without adversely affecting the hospital’s patient load capability. The design began in December 2005 and the final construction was completed in January 2008. Now, the waiting room in the ED is no longer overflowing. Patients aren’t subjected to wait for three hours. Baylor’s trustees and staff can comfortably accommodate additional increase of patients. This state-of-theart department rivals any ED in the country. The completion of the new ED will help the Baylor system to better serve their patients as well as the community.
Todd C Howard is the President and Founder of t. howard + associates architects (THA). He received his Bachelors degree in architecture from Texas A&M University and specializes in healthcare, educational, and not-for-profit design. Todd is an active member of numerous professional organisations, such as the American Institute of Architects, serving as the Dallas branch’s President Elect for 2008, Texas Society of Architects and the Dallas Architectural Foundation. Todd is also a passionate community volunteer. This year marks THA’s 10th anniversary.
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Quality and Safety
Creating a supportive culture A process-oriented approach, which sees care as both social and technical, naturally supports a positive quality improvement strategy and aligns the major subcultures.
Philip Hoyle Director Clinical Governance, Northern Sydney Central Coast Area Health Service Australia
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onsider a typical senior management meeting, and how care—which is, after all, the core business—is talked about. Care is typically talked about as delays, costs, issues, liabilities and perhaps, revenue or market share. Its beneficial purpose generally remains implicit. Conversely, consider a typical clinical meeting. Here, the ‘system’ is seen as a block to good ideas and a waste, with its positive role in coordination, resource allocation and system improvement unremarked. Similar fault lines can be observed in quality improvement. Official quality and safety strategies often boil down to exhorting clinicians to ‘please try to not harm people’, rather than a positive view of doing things well. Conversely, clinicians can be reluctant to buy into broad system issues beyond their own immediate sphere of influence or even their own profession. This divergence matters because, given the link between resource and clinical outcomes, the clinical and managerial cultures must come together if real progress is to be made. The challenge is therefore to recruit the organisation—not just its formal
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structures, but also its culture and practices—to continuously improve care. Given that one must start with the culture one has, rather than the desired one, the practical problem is how to link subcultures in a common, positive project of improving care. Where are we now?
The quality of healthcare remains highly variable. While excellent results are the norm, the reliability of healthcare processes generally remains low, with unreliability being estimated by the Institute for Health Care Improvement (IHI) at 1:10. That is, healthcare processes generally deliver the intended result only nine times out of ten. This estimate is corroborated by the thousands of avoidable deaths and injuries that happen each year, as well as by structured record audits. While there are major exceptions (consider the safety improvements in anaesthesia) even the best health systems perform well below what might be expected. Technical complexity is necessarily a factor, but as Gaba had noted, reliability in healthcare is also limited by cultural factors such as lack of accountability, structural secrecy, cultures that blame and, tellingly, the ‘normalisation of deviance’—the acceptance of poor quality as normal. AHRQ’s description of a high reliability organisation—safety as a top-level priority, recognition that activities are error prone, blame-free reporting, development of solutions through collaboration and resources directed to
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safety concerns—gives further insights into why reliability remains low. Improving our capacity for quality and safety is not just a matter of going out and setting up new quality systems. First, there is little evidence that quality interventions as such make a material difference. While this may reflect the difficulty of demonstrating cause and effect in complex evolving systems, it should give policy-makers a pause before making further large investments. Second, safety culture is a facet of the broader culture, and quality will be best improved by addressing broader cultural issues, in particular, how all participants in the health system, whether clinician, consumer, manager, funding agency or regulator, can collaborate to ensure the right care is delivered reliably in the right way. Cultural limits to quality and safety improvement
While there are exceptions, health services generally remain organised around professional relationships, resource inputs, external reporting lines and historical arrangements. A discourse centred on effective, integrated, efficiently resourced care does not arise naturally in these conditions. As Degeling and his colleagues have shown, the major sub-cultures often have conflicting values about important things. For example, most medical clinicians are deeply sceptical of teamwork (unless they happen to lead the team), while nurses generally
F acilities & operations M anagement
see teamwork as essential. Similarly, clinical doctors and nurses see quality as a private professional matter rather than belonging in the public domain while managers see (clinicians’) quality as a proper matter for the public record. Clinical doctors and clinical nurses generally reject resource constraints as the basis for an individual care decision, while managers are more willing to base decisions on available resources. The key point is that very powerful groups have polarised views on the very issues that must be dealt with if quality and safety are to be improved, namely, teamwork, quality, evidence and the basis of resource allocation.
their little party and they’ve got their little set-up nice so, stepping on toes is not my thing because you know you’re not going to get support further up, so why do it? It’s just too difficult and it’s real shame…” said a Nurse Manager. The implications for clinical leaders are profound. Unless middle managers are ‘authorised’ to lead by both the followership and those ‘above’, and unless senior management gives consistent support through difficult times, energy is diverted into survival rather than taking the system forward. The challenge is to engage and recruit divergent cultures in a common task of improving care.
So, what can be done? Given the polarisation of values, three broad options are: 1. Find a value that all share. This only works to a limited extent. For example, while in most healthcare systems everyone is committed to patient care, consensus falls apart when it comes to “which patient” and “what care”, especially if resources are scarce. 2. Impose an “official” value set. Prominent examples are “doctor knows best”, and “financial reality”. This approach can briefly optimise one element, but to an extent alienate those who don’t agree, to the extent that they may not participate at all or only emerge from the cave to throw rocks. 3. Harness the diverse sub-cultures. Recognising and harnessing diversity can positively link the various sub-cultures. While this is an attractive option and works well in some individual units, it is not easy to achieve at a broad organisational level
This dissonance is not theoretical. Middle managers, whether clinical or general, are subjected to pressures from above to avoid patient harm, to conserve money and to retain the workforce. They also experience pressure from below to protect their unit from outside pressure and to procure new resources and opportunities. This can create great personal stress and even alienation amongst the very people whose support is needed to ensure a safe, reliable system. A nurse manager’s comment reported in a recent study of a major hospital is revealing: “… I know a lot of the systems could work a lot better, but they’re playing
Harnessing diversity – The centrality of process
Official strategies aimed at improving quality and safety tend to be couched in what might be called ‘anti-negative’ terms—for example ‘please stop killing / infecting / poisoning / tripping people’. While such approaches play well in senior management and political circles, and indeed close loops on much ‘guilty’ knowledge (falls reduction, anyone?), they tend to be less than inspiring to clinicians, who soon tire of straining against system limits and topdown mandates. While increased vigilance and error trapping can make safety
gains, these are tiny compared to the gains from optimised care systems. The challenge is, therefore, to move from the ‘anti-negative’, to the ‘positive’, from ‘don’t harm’ to ‘let’s do the right thing’. This is more than a rhetorical gesture—to make the transition, it requires a rethinking of who ‘we’ are, what we manage, and how. Healthcare nearly can be described in terms of processes—a sequence of actions and events that tend to be repeated in similar circumstances. Typical examples are treatment of community acquired pneumonia, an elective surgical admission or normal childbirth. While such processes have a technical dimension, namely what is done in what order, they also have a social and cultural dimension—the values, expectations and interactions of those involved, whether nurse, doctor, consumer or manager. It follows that if operations are based on care processes, the various subcultures can be linked because it is clear who is involved, in what capacity, using what resources, to what effect, with what variation. Furthermore, a process-based system promotes organisation around the care produced rather than history, profession and resource inputs. Even more fundamentally, the values around which the system is built resonate with those involved: quality discourse can move from a post hoc source of guilt to a prospective responsibility, from ‘what went wrong’, to ‘what must we do right’. This re-orientation is more than sleight of hand. As Quinn points out, purpose-centred thinking—that is, what must be done to achieve the desired result—can greatly enhance leadership. A goal of quality and safety
While it is simple to state, ‘quality and safety are our highest goal’, as Marais points out, there is usually conflict between safety and performance goals, and in practice, a choice must be made between optimising performance and
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A positive vision Once the conceptual breakthrough of a positive, as opposed to an antinegative vision, is made, it is relatively a simple task to reorient formal quality improvement. A typical set of positive quality goals, suitable to inform business planning might be: Quality outcomes are recognised as a high level objective Best practice care is delivered Staff have the skills to deliver or support high quality care The organisation is a learning organisation Quality improvement is a valued activity Quality and Safety is integrated into operational systems and methods Policies support quality and safety Explicit care processes are systematically improved Risks are identified, assessed, communicated and managed Consumer expectations and needs are understood and our operational activities are informed There is internal accountability There is external accountability Quality & safety problems are found and understood Adverse events are identified, investigated and prevented There is positive engagement with the broader system
statement, such as ‘the ward environment will be conducive to eating’, with a set of subsidiary statements. Of course, extensive subsystems are now being developed (e.g. risk screening) but once again these are couched in terms of positives, rather than negatives. The approach does not ‘wish away’ constraints on achievement, such as resources. Rather, it allows them to be effectively risk managed. If, for example, a ‘standard’ in the nutrition policy cannot be met, then the risk, which is
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optimising safety. Furthermore, a wide range of external factors affect that choice as also internal influences, ranging from overt politics to mandated targets to the personal ambition of decision makers. In health services, there are interesting and complex ethical issues surrounding such choices. First, while the careers and reputations of decision makers may be at risk, the lives that are most affected are not usually involved in the discussion, at least at a policy level. Second, at a societal level, the tensions between access to services, quality and funding usually remain undiscussed: unrealistic expectations abound, and quality / performance trade-offs remain implicit. Third, in the absence of a societal consensus and overt policy, the burden of decision-making is typically passed down to clinicians and patients, whose marginal resource decisions are constrained by a system that neither the clinician nor patient feels able to influence. As Marais points out, the challenge is not to proclaim one goal to the exclusion of others, but to assess the risks and to know how much risk is acceptable. A simple example from my own organisation is our approach to improving inpatient nutrition. Earlier in-house research had shown avoidable problems with inpatient nutrition, with a significant impact on vulnerable patients. The typical approach in the past has been the ‘anti-negative’—one of developing a set of detailed policies and procedures designed to avoid the problem (in this case, malnutrition), with the hope that the staff would have the time, inclination and resources to follow. The positive approach is subtly, but crucially different. Rather than being a set of error-trapping procedures, the policy comprises a set of positive evidence-based standards, developed in consultation with consumers, clinicians, food service providers, managers and funders. Each standard is a positive
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now known as opposed to be buried, can be formally and accountably managed by acceptance, elimination or control. Conclusion
Quality, Safety and Improvement requires a supportive culture, but we must get started. We can start with the culture we have to create the one we want. This requires an understanding of our cultures and a practical way to engage them in a shared positive vision of where we need to be.
Philip Hoyle is a Director of Clinical Governance for Northern Sydney & Central Coast Area Health Service. Responsibilities within that role include quality, safety, risk management, policy systems and accreditation, as well as executive responsibility for research and disaster management. Philip’s obsession is the prospective design of health systems, so that clinical staff, consumers, managers and funders can combine to ensure the right care is delivered, first time.
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CaseStudy
Benchmarking and Measuring Patient Safety
The Medway model The Medway Nursing and Midwifery Accountability System (NMAS) is a model that calls nurses and midwives to account for their performance in relation to nursing care and patient safety.
Jacqueline McKenna Director Nursing and strategic Planning Medway NHS Planning, UK
T
he Medway NHS Foundation Trust is situated in Kent, approximately 40 miles east of London and 40 miles west of the coast of England. It is a large district general hospital and has regional services including Vascular and Neonatal services. It also has the busiest accident and emergency department in the county with over 80,000 attendances / year. The senior nursing team is stable and has worked together for a number of years. The Trust has been voted as one of the Nursing Times’ top 100 employers of nurses in the country for the last three years. In 2004, the Director of Nursing developed a system to measure the nurses’ performance. She had been inspired by reading the ex-mayor of New York Giuliani’s book Leadership (2003). In one of the chapters, Giuliani explains
how he helped New York become safer using a system called Compstat. The three criteria of such a system are: • Having an agreed set of indicators to measure the performance • Regular collection of data • Holding regular meeting to review the performance of the staff. It was thought that these criteria could be used as the basis of a performance improvement for nurses in the Medway NHS Foundation Trust. The Director of Nursing devised a proposal for the nursing staff. This proposal set out indicators that should be collected and discussed on a weekly basis. The proposal was sent to the Heads of Nursing, the matrons and the senior sisters for comment during the summer of 2004. There were many comments about the proposal, but by September an agreed model was ready to be imple-
mented. Table 1 provides the list of indicators that were agreed upon when it commenced. Work flow matrons followed in collating data based on indicators for four years from the beginning of September, 2004 WEDNESDAY Data is fed into a central database and then disseminated
FRIDAY Meeting held to discuss the data and performance
MONDAY Data is presented to the Director of Nursing
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Orthopaedic Documentation
SEPTEMBER 2004
110.00%
Number of patients with MRSA / Cdiff
100.00%
Bed days lost due to closure
90.00%
Hours lost due to short term sickness < three days
80.00%
Documentation review
70.00%
Current Mean 86.22%
60.00% 50.00%
Sept 04
Nurses not wearing uniform properly
Feb 05
Aug 05
Documentation Result
Mean
UCL
Number of people with pressure sores
LCL Graph 1
Trust Agency 600
400 300 200 100 0
Sept 04
Feb 05
Jul 05
Hours Agency Used
Mean
UCL
LCL Graph 2
Trust Agency 140 120 100 80 60 40 20 0 Hours Agency Ud
Mean
UCL
LCL Graph 3
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Number of nursing complaints Table 1
Current Mean 236.33hours
500
Hours of agency used
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Every week, two or three matrons were asked to discuss their data for the last eight weeks for each of the indicators. Those presenting were accompanied by the senior sisters in the area. If their performance improved, they were asked to share how they led the improvement. This enabled their colleagues to learn different techniques and allowed good practices to be shared across the organisation. If their performance over the last eight weeks deteriorated, they were called to account for the situation and explain why things did not improve and what they would do in future to rectify the performance. Once the matrons present the data, the Trust evaluates and scores each of the indicators. The matrons who did not present that week understood whether they have contributed positively or negatively to the overall performance. On the request of the matrons, the performance indicators were reviewed in April, 2005. The revised indicators are presented in Table 2. It was agreed that the indicators for MRSA, Clostridium Difficile and Pressure Sores would be more useful if they were classified according to those patients admitted with themâ&#x20AC;&#x201D;those acquired in the week in hospital and those who acquired them in hospital more than a week ago. The Trust made progress by reducing the
Trust Bank 4500 4000 3500 3000 2500 2000 1500 Current Mean 3047.17hours
1000 500 0
Apr 05
Jun 05
Sept 05
Hours Bank Used
Mean
UCL
LCL Graph 4
Nursing & Midwifery Strategic Direction Monitoring & Audit Observation Procedures Multi Disciplinary Working Education Saving Lives
Working with Estates & Housekeeping
Productive Ward Patient Shadowing
EOC SfBH
Care Planning
Efficiency
Essence of Care Infection Control
Service Redesign Budgets
HCC CNST NHSLA
Clinical Expertise
Productivity
Working to make a Defference
PEAT Environment
Infection Control
Appraisal
Recruitment and Retention
Clinical Supervision
Staff Experience
Staff survey
Clean / Tidy Areas
Recruitment
Customer Care NT Acute Trust Top 10
Audits
Monitoring
Performance Management
Patient surveys Complaints Patient Involvement
Dignity in Care
Service Star
Trainig & Development Programmes
Succession Planning
Good Attitude
Figure 1
involvement of the agency nurses so that the matrons could start measuring the use of bank nurses. They also thought that sickness should be counted within seven days rather than the first indicator of within three days. In September 2007, the indicators were reviewed once again and the fall in the number of patients was added as an indicator. The graphs demonstrate some of the initial achievements the organisation had in relation to the indicators. Graph 1 shows the progress of the orthopaedic wards in improving the standard of documentation. The decrease in use of bank nurses in the general surgical wards can be seen in Graph 2. Graph 3 demonstrates that there was a drastic decrease in the use of agency nurses across the Trust. The straight line in Graph 4 shows that there was improvement in the performance during late 2005. However, it is important to know where performance is stagnant (a straight line) because it shows that the interventions that have been made did not have the desired effect and, therefore, required corrective actions. The Medway NHS Foundation Trust is now implementing phase two of NMAS. This involves integrating all the nursing initiatives under a new strategic direction and identifying the performance indicators for all the aspects based on the original NMAS model. The strategic direction, which aims at an excellent patient experience, involves following aspects: • Competent staff • Clean environment • Customer care • Productivity • Staff experience. Each one of these aspects has a number of actions for each of the senior sisters. The senior sisters have 24 hour responsibility for the areas they manage and have also had their levels of authority agreed and clarified so that in the majority of their role they are able to act without having to ask line managers first. This is very important if they
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APRIL 2005
Usual NMAS Indicators
1. Admitted Number of patients with MRSA
Number of patients with CDiff
Environment
2. Acquired
Commode audit
3. New this week
Handwashing audit
4. Admitted
Patient’s view on clean environment
5. Acquired
Clinical expertise
6. New this week
Patient’s level of trust in nurses
8. Registered
Patient’s view on whether staff work together
9. CSW 10. Others
Customer care
11. Documentation review
Protected meal times Patient’s perception of respect and dignity
12. Nurses not wearing uniform properly
Productivity
Budget Annual leave management
13.Hours of agency used Saff experience
14. Hours of bank used Number of people with pressure sores
Observations audit Patient’s perception of pain management
7. Bed days lost due to closure Hours lost due to short term sickness <7 days
Environment audit
Vacancy rate Appraisal rate
15.Admitted
Mandatory training attendance
16. Acquired
Mentors/ward
17. New this week
Staff perception of leadership
18. Number of nursing complaints
Table 3
are to be held accountable for their performance. This is a major change in phase two—the senior sisters rather than the matrons are now held accountable for performance. For each of the five aspects of the strategy, there are ways to measure performance. These indicators have been added to the usual NMAS indicators (Table 3). These indicators not only cover factual figures on performance but also the patient’s and staff ’s feedback on care and leadership in the concerned area. The strategy is illustrated in Figure 1 below. To conclude, the Medway NHS Foundation Trust has seen many benefits from implementing NMAS. Some of them are: Flexibility: It has been demonstrated through the above description
that the system is not at all rigid and can change as the local or national healthcare agenda requires. The Trust has changed the indicators four times since its commencement to meet the needs of the staff. Relevant data: The data is collected and discussed on a weekly basis. Therefore, the nurses have to account for current performance. In many performance review systems, the data is reviewed on a monthly or sometimes A u thor
Table 2
quarterly basis and, therefore, is not effective. Agreed objectives: The indicators are agreed upon by the nursing staff and not imposed on them. As described above, the indicators have also been changed in response to the suggestions of the staff. Focussed on performance: The model allows nurses to spare some of their time to focus on improvement and update their knowledge of their respective areas. Weekly meeting: Weekly meetings with the senior nurses are considered beneficial to everyone. It is a very good forum for not only discussing performance but also to share good practice and focus the attention on the patient experience. Accountability: The purpose of NMAS is to improve nursing care and, patient safety. It also ensures that the nurses are accountable for the patient care in the concerned area. Transferable to other systems: The model proved successful in other systems as well. The model has been adapted in various systems in diverse organisations ranging from US police to UK nursing homes. In the UK, the model has been successfully adapted in acute care hospitals, thereby proving that it can be effectively used in community and mental health organisations as well. Improved patient safety: By improving the performance in relation to each of the clinical indicators, patient care has become safer. To summarise, NMAS has become totally embedded in the nursing culture of the organisation. It gives the nursing staff a framework for continuous improvement.
CaseStudy
F acilities & operations M anagement
Jacqueline McKenna is the Director of Nursing and Strategic Planning at the Medway NHS Foundation Trust, a post she has held since 2000 having previously been Director of Nursing at Southmead NHS Trust in Bristol. She was awarded the Health Service Journal patient safety award in 2005 for her innovative Nursing and Midwifery Accountability System which is a performance improvement tool for senior sisters and matrons.
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The majority of healthcare expenditure worldwide is spent towards treating chronic diseases like diabetes. Electronic Medical Records could prove effective in the management of chronic diseases, facilitating the delivery of quality healthcare to the patients.
I
rt Hea e as e Dis
Cancer
Diabete
s
Stroke
Chronic Respiratory Disease 80
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n global healthcare industry, it is worth mentioning that incomplete patient information often leads to errors, misdiagnoses, patient safety issues and cost inefficiencies. While serious efforts are made to reduce error rates and increase levels of patient safety, IT solutions such as the Electronic Medical Record (EMR) are emerging as enablers of high-quality, cost-effective healthcare delivery. But the question is, can EMRs really save money in both transaction-based and non-transaction-based healthcare systems? Let’s start with the landscape of EMR adoption. It’s no secret that the EMR adoption of 20 per cent in US is well behind that in most European countries as well as China, Japan and Australia, just to name a few. Last year, the Wall Street Journal Online / Harris Interactive indicated that a majority of Americans believe that EMRs can reduce healthcare costs while improving patient care. Yet, the number of US physicians using an EMR still hovers below 20 per cent. However, a question still remains unanswered—can EMRs really reduce costs and improve outcomes? In my
I nformation technolog y
Challenges in Managing Chronic Diseases EMRs enable better care Gregory Larkin Chief Medical Officer Indiana Health Information Exchange USA
opinion, an EMR is a partial, but important element in addressing global health costs and concerns. Implementation of a clinic-based EMR requires significant financial resources and can initially cause significant disruption in an officeâ&#x20AC;&#x2122;s established patient flow processes. Additionally, the typical installation of an EMR provides a new medical record system void of historic patient care data (which remains within the replaced paper-based system). To fully realise the potential of EMRs, their complexities need to be reduced, installation costs need to be lowered and historic care data needs to be easily captured. Health Information Exchange (HIE)
HIE is one way to resolve these complex issues. HIEs serve as a community-wide electronic warehouse, which gathers healthcare information from a broad array of providers: physicians, laboratories, pharmacies, hospitals and imagery centres (Xrays, MRI, CT etc). A HIE securely aggregates and accurately delivers lab results, reports, medication histories, treatment histories in a standardised, electronic format to healthcare providers.
The data thus integrated and presented in a user-friendly standard format, helps physician interpret the patientâ&#x20AC;&#x2122;s medical history easily. In the US, this ability to provide an integrated patient medical record is considered important. According to the Journal of the American Society for Information Science and Technology (JASIST), 66 per cent of clinical visits
in the US have unmet informational needs that are available elsewhere. HIE can help fill these gaps, creating an integrated clinical IT environment. The technology is feasible and is working in several metropolitan areas in the US. A recent report by the StateLevel Health Information Exchange Consensus Project found that more than 75 per cent of states have begun
Chronic Diseases - A growing concern The majority of healthcare expenditure worldwide goes towards treating chronic diseases. Chronic diseases such as heart disease, stroke, cancer, diabetes and chronic respiratory disease are responsible for more than 60 per cent of deaths globally and are projected to account for 47 million deaths annually in the next 25 years. One chronic disease that is playing a leading role in complications and deaths is diabetes. Although the US is expected to experience a far more rapid increase in diabetes, according to estimates from researchers at the World Health Organization (WHO) and several European universities, the greatest relative increases will be in the Middle East, Sub-Saharan Africa and India. The economic consequences of the worldwide rise in diabetes are alarming. The WHO estimates that during 2005-2015, income loss (in international dollars) due to diabetes could rise to as much as US$ 558 billion in China, US$ 237 billion in India, US$ 33 billion in Russia and US$ 33 billion in the UK. According to the Milken Institute, the cost of treatment and lost productivity caused by chronic illnesses in the US is more than US$ 1.3 trillion per year and if the similar conditions prevail the costs could reach US$ 6 trillion by 2050.
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Benefits of implementing HIEs
For patients and physicians across the globe, the benefits of EMR are numerous. The frustration of remembering names of the medicines and doses for patients would be a thing of the past. These records could prevent unnecessary repetition of tests and delay in access to the information related to the test results. The physicians will have information at their fingertips where it is most critical—at the point-of-care. In critical times when the patient may be unable to communicate with the physician or remember key medical information, HIE could provide much needed help to the patient.
In addition to being essential to realising the potential of EMRs (which can be populated with information via a HIE), the greater value in the data within a community. HIE lies beyond simple distribution. HIE may offer the opportunity to utilise these data in new and innovative ways, such as arming physicians with information to proactively reach out to their patients, all without requiring expensive new equipment or software packages to users. This is where the true value of health IT lies and offers the best opportunities for improving outcomes and demonstrating the value of health IT. In other words, the community’s long-term benefit of a viable HIE is the identification and improved management of chronic and disabling diseases.
/ her patients. An interesting additional benefit of this HIE-generated report is that the details of the patients with targeted chronic disease are constantly updated automatically. Such dynamic listing of the information in paper-based systems is very problematic Global healthcare improvements mandate more efficient chronic disease management due to both the high costs and significant subsequent disabilities and death. Chronic illness requires historic medical data to equip the care giver with a complete picture of the patient’s needs. HIEs equip both the community and the physician with the tools necessary for a high quality of care and optimum utilisation of healthcare resources.
Role of HIEs
As a physician, I am keenly aware that healthcare is about decision-making. Improving the speed and accessibility of information allows physicians to operate more efficiently, eliminate uncertainties and make better decisions. Technology by itself doesn’t do this, but it does facilitate it. The adoption of HIEs across the globe cannot be simply viewed as advancement of 21st century’s technology. Instead, HIEs will be instrumental in reducing the impact of disease burden on all communities. HIEs do much more than simply sharing medical data; they provide patient’s history and treatment no matter where the patient travels and provide community and individual disease care needs. Undoubtedly, as HIEs’ databases become expansive, they could play an important role in the discovery of life-saving discoveries.
HIEs hold the potential to improve community chronic disease management by the integration and transmission of the patient’s care history and needs. The concept for one such chronic disease management programme is underway in one US city. Physicians receive monthly reports with the complete details of their patients. They include details of all the patients, chronic disease they are suffering from, the patients who receive care compliant with the best standards and the patients who need care intervention. From these reports, for instance, physician could know if a patient with diabetes recently had any test to determine the disease control and also whether he needs a more aggressive treatment. Thus, physician could focus on the patients who are in need of better control and improve the diabetic care of all his A u thor
developing some form of HIEs. The Office of the National Coordinator for Health IT is leading the development of the Nationwide Health Information Network, a secure, nationwide, interoperable health information infrastructure that will connect providers, consumers and others involved in supporting health and healthcare. The Center for Information Technology Leadership estimates that a nationally standardised and interoperable HIE can save US$ 77 billion per year in the US. In addition to being implemented in an affordable and non-disruptive fashion, HIEs must also demonstrate value. In Indianapolis, Indiana, a metropolitan area in the US, it is estimated that the system saves US$ 26 per emergency department visit by not only eliminating duplicate tests, but also allowing the physician to make better and more informed care decisions. For example, the savings could reach US$ 450 billion a year nationally by helping physicians pick optimal therapies and alerting physicians to potential drug interactions. Other countries, too, are looking at implementing similar HIE solutions. China, Canada and the UK are some of the leading examples of countries that are supporting their national infrastructures to bring in interoperability among their HIEs.
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Conclusion
Gregory Larkin was the Director of Corporate Health Services for Eli Lilly and Company, a global pharmaceutical research and manufacturing company before joining the Indiana Health Information Exchange as its Chief Medical Officer, He is a Fellow of the American Academy of Family Practice, and a Fellow of the American College of Occupational and Environmental Medicine (ACOEM), and the President of the Indianapolis Medical Society.
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I nformation technolog y
Semantic Web and Translational Medicine Creating the next generation healthcare enterprise
Translational Medicine, which aims to improve communication between the basic and clinical sciences, coupled with informatics and semantic technologies will help in creating the next generation healthcare enterprise.
Vipul Kashyap Clinical Informatics R&D Partners Healthcare System, USA
T
he Web has revolutionised the way people look for information and corporations do business. The Semantic Web, being proposed as the next generation web, builds on the current infrastructure and attempts to give information on the web a well defined meaning. Simultaneously, the life sciences sector is playing host to a battery of innovations triggered by the sequencing of the Human Genome coupled with a more proactive approach to medicine. There is an increased emphasis on disease prevention and wellness of the individual as opposed to disease treatment and management; and significant activity has focused on Translational Research, which seeks to accelerate ‘translation’ of research insights from biomedical research into clinical practice and vice versa. The next generation healthcare enterprise - A vision statement
There is a great need to get away from the short-term goals of treating current
diseases and conditions, and focus on long-term strategies of enhancing the well-being and quality of life of an individual. In fact, it is a well known fact that adopting the approach of disease prevention will result in reducing the load on current healthcare infrastructure. From this perspective, the vision of the next generation healthcare enterprise may be articulated as follows: The Next Generation Healthcare Enterprise provides services across the Healthcare and Life Sciences (HCLS) spectrum targeted at delivering optimum wellness, therapy and care. These holistic services cut across biomedical research, clinical research and practice and create a need for the accelerated adoption of genomic and clinical research into clinical practice. A key consequence of this vision is that not only should the healthcare enterprise meet the current needs of a patient, but also anticipate future needs and implement interventions that can potentially prevent diseases and other adverse clinical events. This could be done by sequencing the genome of the patient and assessing the disposition of a patient towards diseases and adverse clinical events. This creates a need for knowledge sharing, communication and collaboration across the HCLS,
which is indeed the underlying goal of Translational Medicine. Translational Medicine
Translational Medicine aims to improve the communication between basic and clinical science so that more therapeutic insights may be derived from new scientific ideas and vice versa. Translation research goes from bench to bedside where theories emerging from preclinical experimentation are tested on diseaseaffected human subjects, and from bedside to bench, where information obtained from preliminary human experimentation can be used to refine understanding of the biological principles underpinning the heterogeneity of human disease and polymorphism(s). The products of translational research, such as molecular diagnostic tests are likely to be the first enablers of personalised medicine. Translation of genomic research into clinical practice
One of the earliest manifestations of translational research will be the adoption of therapies and tests created from genomics research into clinical practice. Consider a patient who suffers a shortness of breath and fatigue in a doctor’s clinic. Subsequent
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Information Flow
Test ordering guidance
Patient Encounter
1
New test results Genetics Decision Support
Therapeutic guidance
2
Clinical Trials Referral
4
Tissue-bank
5
Bench R&D
6
Clinical Trials Phase 1-4
7
3 Integrated Genotypic Phenotypic Database
Knowledge Acquisition
Figure 1
Information needs and requirements Step Number
Information Requirement
Application
Stakeholder(s)
1
Description of Genetic Tests, Patient Information, Decision Support KB
Decision Support, Electronic Medical Record
Clinician, Clinical Trials Investigator, Patient
2
Test Results, Decision Support KB
Decision Support, Database with Genotypic-Phenotypic associations
Clinician, Patient, Healthcare Institution
3
Database with GenotypicPhenotypic associations
Knowledge Acquisition, Decision Support, Clinical Guidelines Design
Knowledge Engineer, Clinical Trials Investigator, Clinician
4
Test Orders, Test Results
Clinical Trials Management Software
Clinical Trials Investigator
5
Tissue and Specimen Information, Test Results
LIMS
Clinician, Life Science Researcher
6
Tissue and Specimen Information, Test Results, Database with Genotypic – Phenotypic associations
Lead Generation, Target Discovery and Validation, Clinical Guidelines Design
Life Science Researcher, Clinical Trials Investigator
7
Database with Genotypic – Phenotypic associations
Clinical Trials Design
Clinical Trials Designer Table 1
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examination of the patient reveals the following information: • Abnormal heart sounds that could be represented in a structured physical exam leading to the ordering of an ultrasound • Discussion of the family history with the patient reveals that his father had a sudden death at the age of 40, but his two brothers were normal and healthy • The ultrasound may reveal cardiomyopathy based on which molecular diagnostic tests (to screen genes such as MYH7, MYBPC3, TNN2, etc.) for genetic variations may be ordered • If the test is positive for pathogenic variants in any of the above genes, the doctor may recommend the test for first and second degree relatives of the patient and select treatment based on the above-mentioned data • When a patient is detected to as a high-risk candidate for sudden death, he / she is put under therapeutic protocols based on drugs such as Amiadorone or Implantable Cardioverter Defibrillator (ICD). In this case, molecular diagnostic tests may indicate a risk for cardiomyopathy and phenotypic monitoring protocol that may be indicated. Information needs and requirements
See Figure 1 for information flow to identify various stakeholders and their information needs. The aggregation of data for identifying patients for clinical trials and tissue banks leads to knowledge acquisition especially to create knowledge bases for decision support. This also helps to map genotypic and phenotypic traits. An enumeration of the information requirements is presented in Table 1. Service-oriented architectures for translational medicine
Each requirement identified in terms of information items has multiple stakeholders, and is associated with different
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Service-oriented architecture for translational medicine
R&D
PORTALS
DIAGNOSTIC Svs LABs
LIMS
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EHR
TRANSLATIONAL MEDICINE
DIAGNOSTIC TEST RESULTS ASSAY INTERPRETATIONS
ASSAYS ANNOTATIONS APPLICATIONS COMPONENTS
CLINICAL TRIALS CLINICAL CARE
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Order Entry/Fulfilment
Genomic Analysis
TOOLS Service Creation and Provisioning
Patient Administration
SERVICE DISCOVERY, COMPOSITION AND CHOREOGRAPHY
Ontology Engine Services
SERVICES
Rule Engine Services
Decision Support Services
Medication Services
Matadata Annotation Ontology Data Mapping
Knowledge Management Services
Ontology Mapping DATA AND KNOWLEDGE INTEGRATION Knowledge Acquisition and Authoring
DATA AND KNOWLEDGE REPOSITORIES
Laboratory Data
Clinical Data
Metadata Repository
Database of Genotypic/ Phenotypic Associations
Ontologies
Knowledge Bases and Rule Bases Figure 2
RDF representation of clinical and genomic data
"Mr.X"
"Paternal"
name
Patient (id=URI1)
Patient(id=URI1)
type
degree
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Person (id=URI2)
MolecularDiagnostic TestResult (id=URI4)
has_family_history Family History (id=URI3)
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"Sudden Death" EMR Data
identifies_mutation MYH7 missense Ser532pro (id=URI5) LIMS Data
90% evidence1
indicates_disease Dialeted Cardiomyopathy (id=URI6) evidence2 95%
Figure 3
contexts, such as: (a) domains such as genomics, proteomics or clinical information; (b) activities, such as biomedical research or clinical practice; (c) applications such as the EMR and LIMS; (d) services such as decision support, data integration and knowledge-, provenancerelated services. The components of the conceptual architecture, as illustrated in Figure 2, are as follows: Portals: This is the user interface layer and exposes various personalised portal views for various stakeholders such clinical researchers, lab personnel, clinical trials designers, clinical care providers, hospital administrators and knowledge engineers. Applications: The two main applications, viz. the EMR system and LIMS are illustrated in the architecture. Service Discovery, Composition and Choreography: Newly emerging applications are likely to be created via composition of pre-existing services and applications. This component of the architecture is responsible for managing service composition and choreography aspects. Services: The services that need to be implemented for enabling Translational Medicine applications can be characterised as (a) business or clinical services, e.g. medication and clinical decision support services; and (b) infrastructural or technological services, e.g. ontology and rule engine services. Data and Knowledge Integration: This enables integration of genotypic and phenotypic patient data and reference information data, which could enable clinical care transactions and discovery of promising drug targets. Examples of knowledge integration would be merging of ontologies and knowledge bases to be used for clinical decision support. Data and Knowledge Repositories: These refer to the various data, metadata and knowledge repositories that exist in healthcare and life sciences organisations. Some examples are databases containing clinical information and results of
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Merged RDF graph that itegrates genomic and clinical data 90%, 95% evidence
Dialated Cardiomyopathy (id=URI6)
"Mr.X"
ma
y_s
uffe
r_fr
om
"Paternal"
name
1
type
degree
indicates_disease Structured Test Result (id=URI4)
has_structured_ test_result
indentifies_Mutation
e gen
_
MYH7 missense Ser532Pro (id=URI5)
has
Patient (id=URI1)
related_to
has_family_ history Family History (id=URI3)
Person (id=URI2)
associated_ ralative problem
"Sudden Death" Figure 4
Data and information integration
We will describe this with the help of an example, an approach for data integration based on semantic web specifications such as the Resource Description Framework (RDF) and the Web Ontology Language (OWL), to bridge clinical data obtained from an EMR and genomic data obtained from a Laboratory Information Management System (LIMS). The first key step in semantic data integration is the definition of a domain ontology spanning across multiple domains; or creation of inter-ontology mappings across multiple ontologies that reflect different perspectives e.g. research and practice a given (clinical) domain. The RDF graphs illustrated in Figure 3 represent clinical data related to a patient with family history of Sudden Death. Nodes (boxes) corresponding Patient ID and Person ID are connected by an edge labelled related_to modelling the relationship between a patient and his father. The name of the patient (‘Mr.
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X’) is modelled as another node, and is linked to the patient node via an edge labelled name. Properties of the relationship between the patient ID and person ID nodes are represented by reification (represented as a big box) of the edge labelled related_to and attaching labelled edges for properties such as the type of relationship (paternal) and the degree of the relationship. Genomic data related to a patient evaluated for a given mutation (MYH7 missense Ser532Pro) is illustrated. Nodes (boxes) corresponding to Patient ID and Molecular Diagnostic Test Result ID are connected by an edge labelled has_structured_test_result modelling the relationship between a patient and his molecular diagnostic test result. Nodes are created for the genetic mutation MYH7 missense Ser532Pro and the disease Dialated Cardiomyopathy. The relationship of the test result to the genetic mutation and disease is modelled A u thor
laboratory tests for patients. Metadata related to various knowledge objects (e.g. creation data, author, category of knowledge) are stored in a metadata repository.
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using the labelled edges identifies_mutation and indicates_disease respectively. The degree of evidence for the dialated cardiomyopathy is represented by reification (represented as boxes and ovals) of the indicates_disease relationship and attaching labelled edges evidence1 and evidence2 to reified edge. Multiple confidence values expressed by different experts can be represented by reifying the edge multiple times. The end user previews them and specifies a set of rules for linking nodes across different RDF models. These simple rules may include: merging of nodes that have same IDs or URIs, introduction of new edges based on pre-specified declarative rules specified by subject matter experts and informaticians. New edges that are inferred (e.g. suffers_from) may be added back to the system based on the results of the integration. Sophisticated data mining that determines the confidence and support for new relationships might be invoked. This integration process results in generation of merged RDF graphs as shown in Figure 4. Conclusion
There is a growing realisation that Healthcare and Life Sciences is a knowledge-intensive field and the ability to capture and leverage semantics via inference or query processing is crucial for enabling translational medicine. Given the wide canvas and the relatively frequent knowledge changes that occur in this area, we need to support incremental and cost-effective approaches to support ‘as needed’ data integration. Personalised / Translational Medicine needs Semantic Web technologies to be implemented in a scalable, efficient and extensible manner.
Vipul Kashyap is a Senior Medical Informatician in the Clinical Informatics Research & Development group at Partners HealthCare System and is currently the Chief Architect of a Knowledge Management Platform that enables browsing, retrieval, aggregation, analysis and management of clinical knowledge across the Partners Healthcare System. Vipul has worked on semantics and knowledgebased approaches for information and knowledge management.
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Telemedicine and Remote Monitoring
Improving COPD patient care The medical world is in urgent need of providing new ways of dealing with the challenges of the profession. IT and sharing of competences among the staff must be part of the solution.
Michael Hansen-Nord Chief Physician Odense University Hospital Hospital of Svendborg, Denmark
E
ven though IT communication systems like mobile phones and Internet are well established in most parts of the world, their usage by the medical profession is fare from optimal. The doctors just do not seem to care! How come? Why do we not take these tools, right at hand, into our world? The obvious reasons ought to be well known: lack of specialists, lack of services to patients living at a distance from hospital, growing number of elderly people in need of chronic care and lack of money. But other factors seem to be the bigger challenge: the urgent, evident need of change of culture and the need to share competence among the staff of a hospital. Furthermore, it has been argued that the patients are not ready to cope with the IT-solutions. This is far from the truth. The fact is that if handled properly these problems can be overcome. The patients and the population are ready! They already have, or will soon get access to sophisticated communication systems and will expect the medical
Image Courtesy : University of Queensland, Centre for Online Health Work, Australia
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world to go along and offer professional support whenever and wherever they need it. In other words we have to deal with the growing demands of accessibility. Organisations, who will not adapt to these demands, will sooner or later get into serious problems. Care providers need to realise that the medical world is changing from a market of supply to a market of demand. In other words, we have to accept a set of guidelines that can be referred to as the patient principles: • That we at any given time can offer the patients the most competent treatment • That it happens within standards and recommendations • That it happens within the economic resources • That it counts for every patient • That health professionals adapt to the customers’ expectations Sharing competence is a very important issue in adapting to IT solutions. It is obvious that doctors must focus on patient matters, wherever their knowledge is needed. However, many specialists perform consultations that could be performed by trained nurses just as well.
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In my medical department, we have worked seriously on this issue for many years and today about 50 per cent of all outpatients are consulting the nurses. For 5 years, we have been running out patient clinics at a distance on a small island, 3 hours travel from our hospital. A good example of this is patients suffering from type 2 diabetes on a near by island: a specialist nurse travels to the island twice a month and takes consultations. Whenever she requires the consultation of an endocrinologist, she connects via the Internet to the hospital and gets the doctor online for support. The doctor then takes over the consultation, talks to the patient and provides the necessary treatment. A simple solution and yet the treatment of patients with type 2 diabetes has improved considerably. The HbA1C has fallen from 8.7 to 7.2 per cent in the population. This is astonishing! Another such example deals with patients suffering from suspected heart failure. A specialised trained nurse goes to the same island, equipped with a portable echocardiograph. She makes the ultrasonic investigation and concludes whether the condition is normal or abnormal. Whenever an abnormal investigation occurs, she connects to the cardiologist on duty and shows him the result of the ultrasonic investigation. The cardiologist then makes a decision on the issues and takes over the consultation. All the normal investigations are afterwards shown to the cardiologist. In the last five years, 75 per cent of the referred patients had a normal echocardiography and could be discharged instantly. In addition, the amount of medication for heart failure rose to the expected level for patients suffering from the disease. All
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this is well documented in our regional prescriptions database. Let us turn to another issue: sharing competence and assisted IT solution have proved to be of great value in minimising the amount of ‘in days’ in the medical ward for the severely ill chronic patients. Several studies have proved that Assisted Home Care (AHC) is as good as continuing hospitalisation for about onethird of the patients admitted because of exacerbation of Chronic Obstructive Pulmonary Disease (COPD). The goal is to seek solutions that are safe for the patients, save time for the specialists and bring down the costs. Our medical department, together with MedCom International is conducting a project, which brings ICT tools into healthcare and thus, in a cost-efficient manner, facilitates high-quality care for chronic patients by offering hospitalisation at home. The objective is to compare AHC with hospitalisation at home under the surveillance of a newly developed briefcase that enables the hospital to be in contact with the patient through ICT. The project focusses on COPD (often referred to as smokers’ lung disease) patients and the overall goal is to reduce the length of hospital stays for a patient group, to reduce cost and, more importantly, to improve the quality of life for the patients. During the summer of 2006, our medical department and GITS, a Danish IT company, developed a patient briefcase, which makes it possible to take care of COPD patients in their own homes. The ICT equipment allows live images / sound as well as data measurements from medical equipment (e.g. Spiro meter and devices to measure oxygen saturation) to be quickly transferred to the hospital either via the Internet or a satellite connection. At the hospital, the doctor can evaluate and guide the patient as if the patient was present at the hospital. The data transmitted from the patient’s home enables the hospital to perform a
Image Courtesy: University of Queensland, Centre for Online Health Work, Australia
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Technology used
The patient briefcase (MediSat®) is a specially developed, portable communicating item that includes video-conference equipment, three buttons (on / off, call me and sound adjustment) and medico technical equipment, connections to the specialist via ADSL / LAN or satellite, A mobile phone with the specialist on duty to receive calls from the patients and a computer with electronic medical health record at hand and videoconference equipment. Methodology
The population of the Svendborg Hospital consists of five municipalities. Two of these, (A) have made agreements with the medical department to participate in the project, and the other three municipals (B) have been given the part as controls. Every patient, admitted to the department because of exacerbation in COPD, is evaluated through a validated test to part them into one of three groups: • Group 1 is supposed to be discharged within 48 hours • Group 2 consists of candidates who require invasive air support and • Group 3 consists of those who need to be admitted into the medical ward for more than 48 hours and not needing invasive air support. Patients from group 3 are offered an early dismissal within 48 hours supported by the portable IT solution which enables the patient to ask for urgent assistance and provide for hospitalisation at home with regular rounds by a specialist at fixed times. During the first 24 hours of admission, the patients are instructed in how to use the briefcase. The aim was to include 50 patients with the briefcase at home and 50 patients with assisted home care solution with the controls of the patients from the B municipals. The evaluations focussed on 1) safety of the technology 2) patient experience 3) savings on in-
time in the medical ward 4) savings on economy compared with continuous admittance / assisted home care-solutions 5) experiences from the hospital staff 6) number of patient readmitted within the first 30 days. The study is to be followed by a regular randomised study. Evaluation
1. Patient’s satisfaction is evaluated by an interview, conducted by a third party (a department of quality) and finally a control-visit in the outpatient clinic four weeks after the briefcase has been withdrawn 2. System effectiveness is evaluated by the number of re-admittances within the first four weeks, compared to a control group 3. The different technologies of the briefcase are continuously evaluated by surveillance of reliability 4. The costs of the different solutions Results (47 patients with the briefcase)
1. The patients feel safe and comfortable at home 2. Everyone asked will participate 3. Reduction in number of patients who were readmitted within the first month by more than 50 per cent 4. Reduction in ‘in-days’ by 5 days on an average 5. Improved staff-patient relations 6. Reductions in expenses The study is still in progress. Perspectives
Chronic patients have to be offered services of surveillance, either by education
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systematic monitoring and control the quality of the treatment.
or by offers from the specialists…or both! I believe that educational programmes can improve the competence of these patients and evolve them to be alert of their own symptoms and react properly to hard-core medical measurements. The last part can be supported by surveyed IT systems that makes early intervention possible and thereby either improve the everyday status or even avoid admission into hospital units. Furthermore, the specialists can considerably improve care by using their skills wherever needed and not on problems which could be handled by nurses. Conclusions
All over the world, healthcare providers have to deal with the growing demands for medical services. We can do this by developing solutions, which are cheaper and seek solutions where the population gets more value for money (the average in-bed time for patients in medical departments vary an astonishing 9-7 to 4-2 days even in Europe!). Many options are right at hand and well documented yet they are not used. We could, for instance, start by adapting to the growing access to IT-solutions used in other parts of the society. Many IT-systems are already there for medical purposes, but the use is limited to hard-core fanatics within the healthcare sector and to very local initiatives. That is just not good enough! The doctors also have to learn, that sharing competence with nurses does not mean loss of prestige but helps reaching the overall goal: improving healthcare to the population that we are meant to serve. We are in urgent need of support from the government and from the medical profession.
Michael Hansen-Nord has been chief physician at one of Denmark’s largest medical departments, leading a team of 84 doctors, for the last 7 years. Since 2003, he and his team have been working with the Danish Center of Health Telematics (MedCom). The first e-health programme, they took part in was the Health Optimum, the e-health project of 2005 in the EU. The present focus of his team is the chronic patient with more than 2 admittances a year with the aim of reduction of in-bed-time and re-admittances.
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nowledge is not constrained to national or geographic boundaries. While we must recognise cultural, national, societal and other variations, best practices are applicable everywhere. More than 1,500 health information technology professionals from 31 countries discussed on topics: clinical leadership and governance, e-health, EHR, EMR, EPR, PHR, IT strategy and innovation during HIMSS AsiaPac08 conference. The group of healthcare leaders and professionals who gathered during this event looked at the evolution of healthcare with a unified philosophy: healthcare delivery can be improved with the use of information technology. Following are some of the basic principles that offer a picture of healthcare that applies to everyone. Use a bottom-up approach
Dr York CHOW, SBS, JP, Secretary, Food and Health, Government of the Hong Kong Special Administrative Region and Shane Solomon, Chief Executive, Hong
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Kong Hospital Authority (HA) suggested four key ‘factors in action’ that helped transform the Clinical Management System in Hong Kong. One of them was, transformation of healthcare is bottomup, rather than top-down, development process. “Users are involved right from the beginning and are put in the driver’s seat throughout the design, standardisation, development and implementation process,” said Dr CHOW. “We engage the users from the outset and allow the whole process to be driven in a bottomup manner by user groups—which is painstaking and time consuming.” He also explained that this process is worth it because “it secures the buy-in and ownership of the users themselves to the need for change.” In countries where healthcare systems are largely centralised under a governmental authority, this concept can be a challenge. When most of the planning and IT adoption is driven by a regional health authority or federal level ministry, switching to a process that starts with the end user can be difficult. Government
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officials must give up certain elements of control in hope for a better outcome through the end user’s commitment that is secured from the bottom-up approach. Focus on the patient
Private sector management models have been both a source of revelation and consternation to the healthcare industry. Dr TAN Yung Ming, Product Development Manager at Health Group, Singapore and CHEW Kwee Tiang, Chief Operating Officer at Alexandra Hospital explained ‘Lean Healthcare IT Systems: The Toyota Way.’ Using this business strategy from the Toyota Production System (TPS), Alexandra Hospital in Singapore has emphasised on the following principles: • The customer is at the heart of the organisation’s philosophy • The organisation continuously reflects and learns • The organisation sees processes end-to-end and removes silos. Looking at healthcare delivery from the patient’s perspective presents
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Insights into Healthcare IT
Transforming healthcare in Asia Healthcare delivery can be improved by focussing on clinical leadership and governance, e-health, EHR, EMR, EPR, PHR, IT strategy and innovation. H Stephen Lieber, President and CEO, HIMSS, USA
an entirely different approach to care because the focus is on the person, not the process. The TPS approach uses a value stream map that distinguishes value-added versus non-value-added activities. Thus, TPS is a management philosophy that requires the creation of an organisational culture where everyone is involved. A study from Tefen USA found that this number may be even higher for those over the age of 65 who have more hospital stays than that of the general population. The data from this study reveals that elderly population has nearly three times as many hospital days per thousand as the general population. In addition, 62 per cent of 50-64 yearolds indicate that they have at least one of six chronic health conditions: arthritis, cancer, diabetes, heart disease, high cholesterol and hypertension. This patient-centred approach takes on a role reversal as the population ages throughout the world. Demand increases for quality healthcare delivery to manage the health and the care of these individuals. For example, in the
US, a recent report from the Centers for Medicare and Medicaid Services (CMS) predicts that unless decisive action is taken, total US healthcare spending will double to over US$ 4.3 trillion by 2017 or nearly 20 per cent of the nation’s gross domestic product. Chronic disease management is one of the primary benefits of the EHR, but the patient must truly be part of this process. Shane Solomon, Chief Executive, Hospital Authority, Hong Kong, said that “healthcare can do more,” to help improve the delivery of care. “We have created the passive, disempowered patient, waiting in hospital for the doctor or nurse to tell them what to do,” said Mr. Solomon. This philosophy made sense when hospitals mainly cared for those with infectious diseases and patients were uneducated and unable to care for themselves. He suggested a co-production approach to healthcare, where “you should not only be able to read your own health record, but you will contribute to creating it.” As he explained, to do this, the patient needs information.
The patient must also take an active role in recording their blood pressure, weight or blood glucose levels. “This electronic health record will link to authoritative sources of information for the condition, and other forms of patient support and education.” Mr Soloman’s vision is not unrealistic and in fact, as he indicated, there are prototypes of these initiatives already emerging throughout the world. This changing focus on the patient in regards to health information is evident. The very strong historical culture of hospital or physician ‘ownership’ of a patient’s information is giving way to this shared ownership concept— slowly, but surely. Personal Health Record (PHR) applications are in their infancy, but there are some very powerful proponents of these applications: Microsoft and Google to name two. The increase in number of these applications will have an impact on institution-based Electronic Medical Record (EMR) systems and anticipation of the relationship between PHRs and EMRs will be important.
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Come together on health IT standards
Quality healthcare with a local focus
Standards make interoperable exchange of information possible and enduring. In fact, together standards and organisations are working to develop effective standards for healthcare. Providing an update on global health IT standards development, Dr Yun Sik KWAK, Medical Informatics, Kyungpook, National University, Republic of Korea explains that there are various HL7 standards, such as V2.X and V3 that have been introduced to help establish integrated and connected health information systems. Dr KWAK is also the Chair, ISO / TC215, Health Informatics, Republic of Korea. Dr KWAK and Audrey Dickerson, Secretary, ISO / TC215 Health Informatics (USA), and Manager, Standards Initiatives, HIMSS opined that both HL7 and ISO are separate but collaborative Standard Development Organisations (SDOs), which recognise that developing countries depend on standardisation for some of their IT infrastructure in hospitals and in their clinics, for health IT systems and devices. In addition, telemedicine has been used as a consultant network in some countries, especially China, where the network is advanced to assist local doctors with diagnosis. Many developing countries are completing their initial work in healthcare IT, often seeing what other countries have done and how those successes can be applied in their own countries. But involvement by the healthcare community in international creation of standards is critical. As healthcare becomes more of a global business, commonality of health standards will grow. Engagement with HL7, ISO and other standards development organisations will pay dividends in the Asia Pacific and other regions as they move further down the path of IT adoption.
While quality is the constant in patient care throughout the world, many other variables change based on location, availability of staff, medicine, hardware, software, and even a building, to provide that care. Dr Alvin Marcelo, Director, National Telehealth Center, University of the Philippines, Manila, who dealt with the problem of shortage of health workers in the Philippines due to their increasing migration to other countries, opines that the biggest challenge in the Philippine is, ‘human capacity’ not ‘infrastructure.’ As a result, open source software and SMS / MMS telereferrals, a simplified technology that demands less tech support, were put in place. He focussed on capacity-building to eliminate the
Looking at healthcare delivery from the patient’s perspective presents an entirely different approach to care.
fear or avoidance of personal computers (PCs). He said that he was able to expose rural health workers to “practical applications that related directly to the nature of their work,” a process that allowed them to “evaluate the quality of their data and to plan for improvement.” In healthcare, it is easy to forget, or perhaps not recognise, that learning how to manage technology takes time. Dr Marcelo found that he had to invest in the healthcare workers of his country instead of signing an expensive licensing agreement. And, he chose to invest in healthcare workers. In Asia, workforce shortage and training issues vary from one region to another. The valuable lesson learnt in managing the labour shortage focusses on the critical need to develop a culture of continuous professional improvement,
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whether using expatriate workers or developing the skills of nationals with quality education and training. In either case, healthcare is a complex activity requiring many skills and extensive knowledge. Continuing education is an investment in the future. How privacy works for EHRs?
Elisabeth Harding, Director, Legal & Governance, University Hospital, Dubai Healthcare City, United Arab Emirates, advises healthcare professionals that it is important to understand what privacy of patient health information means and how it works at the point-of-care, but so should the patient. She explained that “privacy legislation is not about keeping things ‘private’ or ‘secret’ but about ensuring that information is used consistently with the purposes for which it was obtained.” The Hippocratic Oath introduced in the 4th century BC, indicates that privacy was a concern then, and now. Physician Hippocrates stated that, “All that may come to my knowledge in the exercise of my profession or in daily commerce with men (now people), which ought not to be spread abroad, I will keep secret and will never reveal.” She advises physicians to help patients, and healthcare employees, understand why information is being collected. “If people (you and I) trust what is being done with our information, then generally there is not a problem with sharing our information in the course of providing care and treatment (in its broadest sense),” she said. She advises healthcare providers to make sure the patient understands why information is being collected because, “transparency is essential to build trust.” Andrew M Wiesenthal, Associate Executive Director, The Permanente Federation, said that his organisation, Kaiser Permanente, learnt early in its EHR implementation process that information technology is a strategy, not a goal.
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one of a “complete healthcare business system that will enhance the quality of patient care.” That conclusion comes from understanding the following points. • Deploying an EHR is a strategy, not a goal • Distributed development with subsequent integration is achievable but very difficult and very expensive • Interfaces to legacy system are always more difficult than predicted • The organisation is a healthcare
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Kaiser Permanente began this process in 1970s with new applications or technology introduced in certain regions throughout these years. This integrated healthcare delivery system serves eight regions that include nine states and the District of Columbia with more than 32 hospitals and medical centers and more than 435 medical offices. In 1997, the EHR implementation process became a corporate goal of Kaiser Permanente. In 2002, Kaiser reassessed its progress and asked key questions on the system needed and on clinical and operational goals. In 2003, the organisation introduced the Kaiser Permanente HealthConnect™ integrated healthcare delivery system. Dr Wiesenthal’s assessment of what worked—and didn’t work—has global applications because his summation of the electronic health record at Kaiser is
delivery system, not a software development firm. All of us in the healthcare industry continue to strive for the best patient care that we can deliver with the 'how-to' equation differing on the basis of budget to time in the day. But technology has brought the world together in many industries, including healthcare. The six points presented here offer some guidance based on lessons learned from our peers in the field.
Stephen Lieber is President and CEO of the Healthcare Information and Management Systems Society (HIMSS). Lieber also serves on the Board of Directors of HIMSS and its two related corporations, as well as other corporate, nonprofit and coalition boards and groups. He is one of the founders of the Certification Commission for HIT and the Health Information Technology Standards Panel, which are both US federally-funded initiatives supporting the US interoperability effort.
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Microvascular complication is a major concern for most of T2D patients. In addition to BP and glycaemic control, diabetic dyslipidemia (abnormal levels of TG, HDL and Sd-LDL lipid subfractions) plays a key role in the development of microvascular complications, especially diabetic eye disease. Following are some of the microvascular complications: 1. The apparition of retinopathy leading to macular oedema is directly related to TGs levels 2. Retinopathy is equally associated with low levels of HDL-C 3. Small dense LDLs are directly related to retinopathy. In addition to this, low grade inflammation and endothelial dysfunction are frequently observed in patients with T2D and are equally associated with microvascular complications. New data has just confirmed that Lipanthyl® is the first lipid modifying agent shown to protect diabetic eye disease. The recently published FIELD study in 9,795 subjects with T2D with adequate glucose and BP control demonstrated a significant reduction of 31 per cent in the need for first laser therapy for diabetic retinopathy (p=0.0003) after five years of treatment with Lipanthyl®. The latest sub-analysis of the FIELD study reviewed the reasons for the use for laser therapy in all the patients who underwent a laser treatment for diabetic retinopathy. • Lipanthyl® significantly reduced the requirement for a first course of laser therapy by: 31 per cent overall (p=0.0002), 31 per cent (p=0.002) for maculopathy and 30 per cent (p=0.015) for proliferative retinopathy • Lipanthyl® significantly reduced the cumulative use of laser therapy by: 37 per cent overall
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Lipanthyl® (fenofibrate) is the first lipid lowering agent which reduces both macro and microvascular complications of your patients with T2D. Latest FIELD Outcomes. (p=0.0003), 49 per cent for patients without prior retinopathy at baseline (p= 0.0002) Current aggressive multifactorial intervention with OADs, antihypertensive drugs and statins reduces both macro and microvascular complications in patients with T2D, but leaves them at an unacceptable residual level of risks. In addition to standard therapies, Lipanthyl® further reduces the macro and microvascular residual risks of patients with T2D: 31 per cent reduction in the need for first laser treatment for diabetic eye disease, a 14 per cent reduction in the progression of albuminuria, a 38 per cent reduction of non traumatic amputations, and a 26 per cent reduction of CVD events in patients with low HDL-C and elevated TGs. The co-administration of Lipanthyl® with a statin provides the patients with an optimal control of all lipid parameters with a good safety profile as confirmed in the FIELD trial: 1. Up to 46 per cent reduction in LDL-C 2. Up to 37 per cent reduction in TC 3. Up to 50 per cent reduction in TGs 4. Up to 22 per cent increase in HDL-C Lipanthyl® is a PPAR® activator (Peroxisome Proliferator-Activated Receptor) result in the following outcomes: • TG; TC/HDL, HDL; Small LDL Inflammation • Endothelial function References: FIELD study: Lancet, 2005, 366: 1849-61FIELD sub-analysis: Lancet. 2007 Nov 17;370(9600): 1687-97, Athyros et al. Diabetes Care 2002; 25:1198-202, Keating GM et al. Drugs 2007 ; 67 (1) : 121-153
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Diagnostics Inverness Medical Innovations, Inc. . ................................... 9, 11 Siemens . ............................................................................................ IBC Solvay Pharmaceuticals GmbH ............................................. OBC Facilities & Operations Management Ratcliff Architects .......................................................................... 67 Siemens . ............................................................................................ IBC Healthcare Management Inverness Medical Innovations, Inc. . ................................... 9, 11 Messe Düsseldorf Asia Pte Ltd .............................................. 37 Siemens . ............................................................................................ IBC Information Technology Binary Spectrum ............................................................................ 93 Siemens . ............................................................................................ IBC Sofscript Systems & Services Ltd . ....................................... 44 Srishti Software Applications Pvt. Ltd ................................ 47 Medical Sciences Shimadzu (Asia Pacific) Pte Ltd ............................................. 29 Solvay Pharmaceuticals GmbH ............................................. OBC Surgical Speciality Shimadzu (Asia Pacific) Pte Ltd .............................................
SuppliersGuide
Products&Services
Company
Company Electrolux Professional SpA
29
HealthcareEvents
August 2008 August 24 - 28 SICOT/SIROT 2008 XXIV Triennial World Congress Venue : Hong Kong Convention and Exhibition Centre Organisers : International Society of Orthopaedic Surgery and Traumatology-SICOT Email : congress@sicot.org Web Link : www.sicot.org
September 2008 September 17 - 19 HospiMedica Asia 2008 Venue : SICEC-Singapore International Convention & Exhibition Centre, Suntec, Singapore Organisers : Messe Düsseldorf Asia Pte Ltd Email : hospimedica-asia@mda.com.sg Web Link : www.hospimedica-asia.com
IFC
www.electrolux.com Inverness Medical
9,
11
29
IBC
www.determinetest.com/print Shimadzu Asia Pacific Pte Ltd www.shimadzu.com.sg Siemens www.siemens.com Solvay Pharmaceuticals GmbH
OBC
www.solvay.com Srishti Software Applications Pvt. Ltd.
47
www.srishtisoft.com Messe Düsseldorf Asia Pte Ltd
37
www.hospimedica-asia.com
93
67
44
www.binaryspectrum.com Ratcliff Architects www.ratcliffarch.com Sofscript Systems & Services Ltd www.sofscript.com
To receive more information on products & services advertised in this issue, please fill up the "Info Request Form" provided with the magazine and fax it, or fill it online at www.asianhhm.com by clicking "Request Client Info" link.
1. IFC: Inside Front Cover 2. IBC: Inside Back Cover 3. OBC: Outside Back Cover
October 24 - 28 12th Asian Oceanian Congress of Radiology (AOCR 2008 SEOUL) Venue : COEX, Samsung-dong, Gangnam-gu, Seoul 135-731, Korea Organisers : Asian Oceanian Society of Radiology (AOSR) Email : info@aocr2008.org Web Link : www.aocr2008.org October 26 - 28 Abu Dhabi Medical Congress Venue : Abu Dhabi National Exhibition Centre, Abu Dhabi, UAE Organisers : Institute for International Research Email : info@iirme.com Web Link : www.abudhabimed.com October 30 - 31 8th Asia-Oceania Congress of Medical Physics & 6th South-East Asian Congress of Medical Physics Venue : CHORAY Hospital, Ho Chi Minh city Organisers : CHORAY Hospital Email : cdtbvcr@hcm.vnn.vn Web Link : www.choray.org
October 2008 October 2 - 5 9th Asian Congress of Urology Venue : The Ashok Hotel, New Delhi Organisers : Urological Society of India Email : acu2008@gmail.com Web Link : www.acu2008.com
Asian Hospital & Healthcare Management
Binary Spectrum
Technology, Equipment & Devices Electrolux Professional SpA ..................................................... IFC Inverness Medical Innovations, Inc ...................................... 9, 11 Shimadzu (Asia Pacific) Pte Ltd ............................................. 29 Siemens . ............................................................................................ IBC
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Asian Hospital & Healthcare Management
ISSUE-16 2008