y ni is ver su s e ar
an
Issue 18
2009
ÂŁ12 â‚Ź18 $25 Rs.300
Interoperability
Importance of Traditional Medicine In the age of technology
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robots
Lean in Primary Care
e - h e a lt h
Sustaining transformation
a c c r e d i t i n g h e a lt h i n f o r m at i c s
MR Diffusion and Perfusion
Can they replace PET?
Foreword From possibilities to reality In 2008, healthcare continued to struggle with the adaptation of Information Technology. Will 2009 be any different?
A
recent New York Times article highlighted the adaptation of Information Technology (IT) by the Wisconsin, US-based Marshfield Clinic. Considered to be one of the pioneers in adapting IT, Marshfield introduced mandatory Electronic Health Records (EHRs) way back in 1994. Today, 795 doctors working with the Clinic use Tablet PCs and it has all but done away with paper charts for patients. This could be termed as the ideal scenario where IT has completely transformed the way healthcare is provided. Unfortunately, while this is true for Marshfield and a few other providers, the same cannot be said about the rest of the US healthcare system. This is true for healthcare systems around the world, including the ones in Asia. Investments IT is still considered to be a privilege by many providers who prefer to manage records on paper and insist on the patient visiting the doctor or the hospital. In such a scenario it’s difficult to imagine a healthcare system that leverages the benefits of IT to the full. Efforts by the governments and policy makers to resolve this situation cannot be doubted. Countries around the world are busy working on developing their own solutions for integrated healthcare delivery and it won’t be wrong to say that incorporating IT (or Telemedicine) is considered as one of their top priorities. However, success stories are yet to come to the fore. Notable advancements have been made in countries like Singapore and Australia. While the former has set aggressive goals with regards to EMRs, the latter is focussing on e-Health. Developing countries like India and China face problems at a much basic level. The governments here are focussing on increasing access to healthcare for the masses. This is a reasonable goal, but incorporating IT into this framework in the initial stage
itself could prove to be beneficial in the long-term. For example, Telemedicine is the best way of reaching rural areas and investing in developing the infrastructure for this would be ideal. One of the exciting developments of the year gone by was the introduction of online Personal Health Record (PHR). At a time when healthcare technology providers are grappling with the problem of interoperability for sharing data across healthcare IT systems, the Internet could prove to be the best possible solution to this problem, thanks to its ubiquity. Another important benefit of providing patients’ health records online is that it places the onus of maintaining health information on the patient, thereby making them an integral part of the healthcare system. As healthcare continues to move slowly, but steadily, towards a more IT-oriented framework, possibilities abound. It will be interesting to see how things workout over the next one year. The anniversary issue of Asian Hospital & Healthcare Management has a special focus on Healthcare IT with a spread of insightful interviews, articles and features. I, along with Prasanthi Potluri, would like to thank all our authors over the years for helping us bring out four issues of the magazine successfully. We hope to carry forward this endeavour with many more issues of the magazine as we track the changing landscape of healthcare.
Akhil Tandulwadikar Editor
Asia
Pradeep chowbey, Sir Ganga Ram Hospital, India
53 Learning from the Global Experience Steven Yeo, HIMSS Asia Pacific, Singapore
54 Start with the Basics
Peter Gross, Hackensack University Medical Center, USA
UAE
India
Australia
IT Sp eci al
Contents
52 Ready for Transformation
55 Driven by e-Health Sisira Edirippulige, University of Queensland, Australia
60 An Optimistic Outlook Krishna Ganapathy, Telemedicine Society of India, India
62 An Innovative Transformation John R Hawkins, Abu Dhabi Health Service Company (SEHA), UAE
64 Interoperability - Healthcare IT’s big challenge David W Bates, Brigham and Women’s Hospital, USA and
66 Interoperability - Banking on market demand Gerard Anthony Dass, Nortel Asia, Australia
Healthcare Management
Medical sciences
06 Commissioning for Improved Patient Safety Rise of a new era
20 Importance of Traditional Medicine In the age of technology
Martin McShane, NHS Lincolnshire – Commissioning, UK
Beverly A Jensen, UAE University, UAE
09 Lean in Primary Care Sustaining transformation
23 Contrast Echocardiography Current indications
John A Bibby, Beverley Slater Improvement Foundation, UK
Robert Olszewski, Military Medical Instytut, Poland Harald Becher, Oxford University, UK
12 Emergency Services in India Counting on betterment
Surgical Speciality
Prasanthi Potluri, Asian Hospital & Healthcare Management
28 Heart Valve Surgeries Innovations and new developments
16 Personalised Healthcare A transformational opportunity
Timothy Gardner, Christiana Care’s Center for Heart & Vascular Health, USA
LiHui Xu, Henry Zheng, Steven G Gabbe, Clay B Marsh The Ohio State University Medical Center, USA
28
76
20
Diagnostics 32 MR Diffusion and Perfusion Can they replace PET? Marco Essig, German Cancer Research Center, Germany
36 Cardiac Computed Tomography Emerging cardiac devices and technologies Jeffrey M Schussler, Baylor University Medical Center, USA
A s ia n H o s p i ta l & H ea lt hcare M a nage ment
ISS Ue - 18 2009
68 Adoption in Asia Pacific Sourabh Kankhar, Frost & Sullivan, Singapore
70 A Look into the Future Ian Neild, BT, UK
76 Enhancing Self-Management of Chronic Low Back Pain Role of a patient-centred website Sara Rubinelli, Maria Caiata Zufferey, Peter J Schulz University of Lugano, Switzerland
78 Benchmarking and Accrediting in Health Informatics Driving up quality and reducing risk Di Millen, NHS Connecting for Health, UK
82 Patient Proxies in Decision-Making What computers can’t capture
F e at u r e s
Anne Croker, Franziska Trede, Joy Higgs Charles Sturt University, Australia
85 86 88 90 90
IT Bookshelf Industry Reports Featured Healthcare IT Articles from 2008 Happenings in 2008 Profiles of IT Companies
40 The Innovator’s Prescription How Asia can disrupt the global healthcare Alexandra Leichtman, Jason Hwang, Clayton M Christensen Innosight LLC, USA
Technology, Equipment & Devices 44 Orthopedic Medical Devices Emerging technologies and trends Frost & Sulllivan
Facilities & operations management 46 In and Out of the Emergency Room Streamlined design of patient flow
Features
James W Harrell, GBBN Architects, USA
92 Featured Non - IT Articles from 2008 92 Techno Trends 95 Healthcare projects
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Advisory Board
Editors Akhil Tandulwadikar Prasanthi Potluri Language Editor G Srinivas Reddy Copy Editor Prity Jaiswal Art Director M A Hannan Visualiser Sk Mastan Sharief Designer Ayodhya Pendem Sales Manager Rajkiran Boda
John E Adler Professor Neurosurgery and Director Radiosurgery and Stereotactic Suregery Stanford University School of Medicine, USA
Sales Associates Sylas Makam Murali Manohar Savita Devi Asst. Manager, Compliance P Bhavani Prasad CRM Yahiya Sultan Vijay Kumar Gaddam Subscriptions Head Sasidhar Kasina
Sandy Lutz Director PricewaterhouseCoopers Health Reseach Institute, USA
Malcom J Underwood Chief Division of Cardiothoracic Surgery, Department of Surgery The Chinese University of Hong Kong Prince of Wales Hospital, Hong Kong
IT Team Ifthakhar Mohammed Azeemuddin Mohammed Sankar Kodali Thirupathi Botla N Saritha Finance A Bhasker Reddy Chandra Shekar Inguva Managing Director Ashok Nair CEO Vijay Chintamaneni
Asian Hospital & Healthcare Management is published by
A member of Confederation of Indian Industry
In association with
Peter Gross Senior Vice President and Chief Medical Officer Hackensack University Medical Center, USA
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Pradeep Chowbey Chairman Minimal Access, Metabolic and Bariatric Surgery Centre Sir Ganga Ram Hospital, India
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Healthcare Management
Commissioning for Improved Patient Safety Rise of a new era Ensuring the delivery of healthcare as safely as possible has become top priority for the NHS. The commissioners have an important role to play in planning and monitoring services on the basis of quality and outcomes to restore primum non nocere (first, do no harm)as a policy to its rightful place in the health system. But how should commissioners set about their task? Martin McShane Director of Strategic Planning and Health Outcomes NHS Lincolnshire – Commissioning, UK
A s ia n H o s p i ta l & H ea lt hcare M a nage ment
T
he end of the 20th century may well be seen as marking the decline of one era in healthcare and the rise of a new era in which excellent commissioning is required to meet the challenges of increasing life expectancy, changing patterns in disease and developments in treatments and technology. Advances in treatment and technology together with the increasing expectation of society mean that healthcare costs are being driven relentlessly upwards. A larger proportion of GDP is being consumed by healthcare worldwide and the UK faces the same challenge as numerous other countries. How to make the best use of the resources being committed to improve health services and health outcomes for its citizens. The need for effective use of resources is coupled with a greater desire for quality. The ‘information society’ is rejecting the paternalism of the 20th century health system and increasingly arming itself with readily accessible insights and knowledge from the World Wide Web as to what constitutes not only effective but also safe, high quality care. In these circumstances, as societies change and people’s expectations rise, health systems must adapt and evolve to meet these changing needs and new challenges. The publication of To Err is Human in 2000 by the Institute of Medicine and An Organisation with a Memory
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in the same year by the Department of Health in the UK marked increasing awareness of the importance of and need to address safety in modern, complex health systems. Momentum has grown following these publications, spreading understanding of the important need to address safety in healthcare throughout the professions and public. The National Patient Safety Forum, set up following the publication of Safety First, jointly chaired by the Chief Executive of the NHS in England and the Chief Medical Officer, signals the highest leadership and priority the NHS is giving safety for patients. Fundamental to improving safety is the realisation that it is not, predominantly, the responsibility of an individual. Neither is it solely attributable to a team. Both, of course, do have responsibility for safety: in a complex and demanding environment, excellent team work will improve safety. However, there is abundant evidence to demonstrate that the best way to drive improvements in safety is through ensuring that the systems and processes being used by organisations make safety a priority. How can that be engendered? What will ensure a focus on safe systems and processes? In any industry, regulation has a vital role to play. Alongside an increased awareness of the need to design health systems that are safe, there has been an increase in regulation as well. In the UK, the
Healthcare Management
Commission for Health Improvement was replaced by the Healthcare Commission, which is shortly due to be replaced by the Care Quality Commission. Each reorganisation has expanded the reach of the regulator. However, regulation alone will not deliver a safe system. There is an old saying that ‘he who pays the piper calls the tune’. Commissioners who finance the system, alongside regulators, have a critical role in improving patient safety as well as securing the most effective use of resources. The need for better commissioning has been recognised in the UK and the Department of Health in England has launched an ambitious programme to develop ‘World Class Commissioning’. For the first time, a vision and defined set of competencies have been clearly articulated for commissioners. Several of these competencies have direct relevance to improving patient safety, for example: Recognised as leaders of the local health system. As leaders of the health system, commissioners have a vital role in signalling their intention to prioritise and value safety; to embed and ensure Primum non nocere (First, do no harm). Organisations move in the direction of the questions asked of them. Commissioners need to ask the right questions throughout their planning, procurement and performance management of the health system.
This is a cultural shift in what has, traditionally, been a provider-led system. Commissioners must develop skills to lead the health system and it is well established that leaders who champion safety will improve safety. Proactively seek and build continuous and meaningful engagement with the public and patients, to shape services and improve health. Shaping health services that deliver safe care inevitably demands changes, which, unless set in context, communicated and explained, may well be opposed by communities and individuals. Parties with vested interests will also oppose change that threatens them and may seek to manipulate public opinion. Commissioners need to understand this and ally themselves with the public and patients they serve; otherwise, reconfigurations for safer services may be delayed or prevented, leading to avoidable harm.
Patients have another powerful and often underutilised role which commissioners could and should harness. The importance of the patient story has been used by Sir Liam Donaldson, Chief Medical Officer, very effectively to illustrate and engage the public and professionals in safety. The National Patient Safety Agency through its work on encouraging reporting of incidents from organisations, staff and the public, is alerting the health system to issues that need addressing. Commissioners need to be friendly with patients and proactively seek out their views and also make sure that the systems are in place to receive their complaints. Lead continuous and meaningful engagement with clinicians to inform strategy, and drive quality, service design and resource allocation. Professor Chris Ham from the Health Services Management Centre at Birmingham University in England describes an ‘inverted pyramid of power’ which exists in any health system due to the important role that clinicians play in decision-making and committing resources. Doctors, nurses and allied professionals, with their close contacts with patients, could help commissioners in effectively implementing the safety procedures. Hence, commissioners should work in close coordination with clinicians and ensure that they are committed to improve safety. Commissioners need to work with and align the decisions they make with professional values and insights, to stimulate a cycle of continuous improvement.
World class commissioning vision Better health and well-being for all • People live healthier and longer lives • Health inequalities are dramatically reduced Better care for all • Services are evidence based, and of the best quality • People have choice and control over the services they use, so they become more personalised Better value for all • Investment decisions are made in an informed and considered way, ensuring that improvements are delivered within available resources • Commissioners work with others to optimise effective care
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Healthcare Management
1. Are recognised as the local leader of the NHS 2. Work collaboratively with community partners to commission services that optimise health gains and reductions in health inequalities 3. Proactively seek and build continuous and meaningful engagement with the public and patients, to shape services and improve health 4. Lead continuous and meaningful engagement with clinicians to inform strategy, and drive quality, service design and resource utilisation 5. Manage knowledge and undertake robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements 6. Prioritise investment according to local needs, service requirements and the values to the NHS 7. Effectively stimulate the market to meet demand and secure required clinical, and health and well-being outcomes 8. Promote and specify continuous improvements in quality and outcomes through clinical and provider innovation and configuration 9. Secure procurement skills that ensure robust and viable contracts 10. Effectively manage systems and work in partnership with providers to ensure contact compliance and continuous improvements in quality and outcomes 11. Make sound financial investments to ensure sustainable development and value for money
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A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
A u t h o r
World-class commissioning competencies
This bottom-up approach to influence commissioning has been exemplified by the recent review of the NHS in England led by Lord Ara Darzi, who is not only a health minister but also a practising surgeon. Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvements in quality and outcomes. In order to improve patient safety, commissioners should work closely with their providers. World class commissioning is unlikely to be of any use unless it supports world class provision. Commissioners must work collaboratively with their provider organisations to understand barriers which need to be overcome and incentives and sanctions required to manage the health system appropriately and safely. To do this well requires effective use of information. Quality improvement is nourished by information but that information needs to be compelling—the sort of information which will stimulate change in systems and behaviour. Astonishingly, the NHS spends one hundred times more on research than it does on audit. Feedback in the form of case studies, significant event reviews, audit or the other established methodologies for quality improvement needs to be valued and supported by commissioners. Embedding them within the contracting process and working with clinicians to identify which measurements will drive improvement must be integral to deciding how to invest, another important competency. Making sound financial investments to ensure sustainable development and value for money.
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Ultimately, commissioners have to create an understanding that safer, better quality care is also cost-effective care. Information alone does not provide answers but helps the right questions to be asked. The work being done nationally in the UK by the NHS Institute for Innovation and Improvement is providing commissioners with a wealth of information. The question is; how is such information to be used? Surely it means collecting and using information for improvement rather than for judgement. This is perhaps the most difficult and biggest challenge to commissioners as there is constant fear among organisations and professionals that this information may be misused. There appears to be a predominant culture in many health systems to simply use information for judgement in an adverse and confrontational way. This needs to change. Therefore, commissioners should support a system that is not driven by fear but by a continuous drive to improve safety and outcomes. Crossing the Quality Chasm (Institute of Medicine 2001) has an appendix entitled Redesigning Health Care with Insights from the Science of Complex Adaptive Systems. Commissioners need to become adroit at using their levers and those exerted by other agencies in order to competently influence the complexities of the healthcare system they are shaping, to obtain safe and effective services, delivering the best possible outcomes for their customers. Providers who understand this new context and rise to the challenge of working collaboratively with commissioners will flourish and prosper and, most important of all, patients will benefit.
Martin McShane has had over 20 years of frontline clinical experience. Supported by the NHS, he developed an interest in commissioning. He is currently working for NHS Lincolnshire which commissions services for 750,000 people with a budget of ÂŁ1 billion. He is a member of the NHS National Patient Safety Forum.
Healthcare Management
Lean in Primary Care
Sustaining transformation Lean approaches have been widely adopted by hospitals, but application in the primary care setting has received less attention. Primary care can use a Lean approach to structure and sustain quality improvement work but, as with all quality improvement approaches, needs energy and committed leadership. John A Bibby Clinical Advisor Beverley Slater National Knowledge Management Lead Improvement Foundation, UK
P
rimary care has altogether a different quality improvement environment and a different organisational and management structure compared to a hospital care setting. It reflects a different role, purpose and a different organisational culture. See Table 1 for characteristics of primary care general practice in England. A hospital has many specialist teams within the same organisation (and under the same management), each delivering a limited range of patient pathways. In contrast, each primary care team is a small independently managed hub that links to a huge range of potential pathways and onward referral points. The quality improvement strategy, managed and practiced in primary care on a day-to-day basis is necessarily different from the approaches that are taken in a hospital setting. In particular, a hospital that is implementing a quality improvement strategy is in a position to provide dedicated improvement support and expertise. Some commentators (Westwood and Silvester, 2007) argue that this sort of support is essential. But for small primary care teams, this is less likely to be available, and there is greater emphasis on the quality of the leadership from within the primary care practice itself. What do patients really want?
Over the recent years there has been an increase in attempts being made to
find out what patients value the most. This links to a policy in the UK to focus directly on improving patient experience. The methods used may involve paper questionnaires, real-time electronic data collection, various focus groups or patient participation groups. A useful development was the use of discovery interviews (a technique of in-depth interviews with patients to inspire quality improvement) and more recently the model of experience-based design (Bate & Robert, 2006) where patients record episodes of emotional importance by either using video, audio or written media. These emotional ‘touch points’ are then discussed in a facilitated meeting between the patient and care provider. This process has led to a greater understanding by clinicians of what is valuable to their patients. These insights are then the basis for eliminating waste and confidently directing resources towards what increases value to patients (see Table 2 for a summary of Lean principles applied to healthcare). Increasing patient value in primary care
Delays in the patient journey (at all stages from presentation, through diagnosis, to treatment and aftercare) are the most significant ‘non-value adding’ challenges to any healthcare system, as they increase the risk of adverse outcomes and errors being associated with significant inconvenience and cost. The following examples
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Healthcare Management
of increasing patient value and reducing waste are taken from the author’s own experience in primary care practice. Example 1: Helping GP appointments to run on time An example of the 5 Ss (sort, simplify, shine, standardise, sustain) Recently, a local peer support system has been set up for GPs to see how colleagues manage their appointment times without getting late. A significant learning from this has been the finding that those doctors that run on time have their consulting rooms in order, with all forms and equipment handy and with very little need for the doctor to leave the room during the consultation for equipment or patient details. Example 2: Streamlining processes with suppliers An example of managing the value stream The practice has developed an arrangement with the pathology laboratory that if a haemoglobin test is low the laboratory will automatically undertake a B12 / foliate and ferritin assay without the need for a further blood test. Previously, either all these blood tests were ordered on suspicion of anaemia (wasteful ordering of tests), or just a Hb was ordered and the patient was asked to return for further blood tests when the low Hb was discovered (wasteful of patients’ time and introducing delay). In addition, electronic links enable the GP to see the results within minutes of having been processed by logging into the hospital pathology system. Example 3: Patients getting appointments on the day they need An example of a pull system Traditionally, general practice has suffered due to appointment systems that appeared to be designed to control a perceived high demand. Many different approaches to the problem were taken but all had a basic flaw. In order to protect ‘today’s’ appointments, various sanctions or ‘carve outs’ were imposed, hence reducing routine appointments and pushing work onto subsequent days. The problem is not really
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A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Development of quality improvement Many shared tools but differences of emphasis 1920s
W Shewhart—Statistical process control
1950s
W E Deming—System of profound knowledge Toyota Taichi Ohno
Juran
Toyota production system (‘Lean thinking’)
6 Sigma
Service lean
2008
‘Lean Six Sigma’
Goldratt Theory of constraints
TQM BPR
Characteristics of primary care general practice in England Structure
Role and purpose
Practices run by generalist doctors (general practitioners) in independent teams with nurses Contracted to provide NHS services free at point of service Small organisations, independently owned and managed (5-50 staff) Diagnosis and gate-keeping of referrals to specialists Primary care management of chronic conditions Coordination and continuity of care to patients on the practice list Commissioning of specialist and community services Table 1
Lean principles and quality improvement tools Similar or related quality improvement tools
Lean principles applied to healthcare
Lean tools / concepts
1. Identify customer value
Identify value to the patient
Value stream mapping
Experience-based design Emotional mapping
2. Manage value stream
Manage the patient journey
3. Align processes to facilitate flow
Facilitate the smooth flow of patients and information
5 Ss (workplace organisation) 7 wastes Visual workplace Distance walked
Process mapping Capacity and demand analysis
4. Introduce pull between steps
Introduce pull in the patient journey
Pull systems
Advanced access
Rapid improvement events (incorporating all of the above)
Whole system redesign initiative and collaborative using rapid change cycles
5 Lean principles
5. Pursue perfection—continuously reducing waste by developing and amending processes
Table 2
one of an overall lack of capacity for the demand (If this was the case, then the waiting list would continue to increase). The problem is one of a mismatch between capacity and demand on a daily basis. Lean principles have been used in the ‘Advanced Access’ approach, supported and devel-
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oped by the Improvement Foundation, and now employed by many practices in NHS primary care (Improvement Foundation, 2008). This involves: 1. Carefully measuring daily demand over a period of weeks to see how this varies from day to day
Healthcare Management
Sustaining Lean in primary care
The fifth Lean principle is to pursue perfection, continuously, reducing waste by developing and amending processes (Table 2). This then is the challenge: how to make improvement a habit and a continuous process? Applying a set of Lean tools or using a one-off Kaizen Blitz (rapid improvement event) will not in itself deliver
Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in an improvement?
Act
Plan
Study
Do
Source: Langley et. al. (1996) The Improvement Guide. San Francisco: Jossey Bass
Figure 1
sustainable continuous improvement. For sustainable quality improvement in primary care, there is a key requirement for someone within the practice who is able to lead, encourage and develop an improvement culture. This may be a
A u t h o r s
2. Removing the backlog of appointments by a one-off concerted increase in capacity 3. Re-shaping demand by providing different types of consultation (using nurses, providing telephone or email consultations) 4. Matching capacity to the calculated demand on a daily basis 5. Monitoring the system daily and having contingency plans in place for situations where capacity could fall (for example, doctors’ holidays) Instead of postponing work to another day, the work will be completed on the same day. The calculated demand (both type and volume) from patients acts as a trigger to ‘pull’ the correct capacity into place. The result is that patients are seen on the day they want to be seen, staff are less stressed and there is less waste in the appointment system. Example 4: Streamlining clinical communication across boundaries An example of managing the value stream In the author’s practice, recent improvements in the electronic patient record have meant that if an opinion is required from a renal consultation at the local hospital, then instead of taking several weeks, (sending a referral letter, then the patient attending the hospital, and the consultant sending a letter back to the GP) the system has been redesigned by removing many intermediate stages so that when a GP has a query about what to do next, he sends an electronic message to the consultant and gives the consultant access rights for a few days to look at the patient’s electronic record. The consultant reviews the problem with access to the complete patient record including all previous investigations and medications. He then types directly into the primary care record from his office in the hospital and an electronic message is sent to the GP informing him of the opinion. The consultant’s access to the record is then terminated. This process adds value to the patient, saves time and saves patients from travelling to the hospital
clinician or a manager, anyone with a passion for quality improvement. The leader’s task is to set the environment for learning, communicate the benefits of continuous improvement, provide the right support and demonstrate how to learn. Hines and colleagues’ 2004 review of Lean thinking shows how Lean has evolved from its narrow origins in 1950s car manufacturing to the extended application in service industries (such as health) today. Real understanding of the customer value stream was developed during the 1990s. With this understanding now driving business processes, rather than relying on a mechanistic application of specific Lean tools, present day Lean draws on a range of tools from diverse management approaches. One such quality improvement tool that has great value in setting a learning culture and sustaining improvement in primary care is the improvement model, with the ‘three questions’ followed by Plan-Do-Study-Act (PDSA) rapid change cycles (Figure 1). Conclusions
Lean in primary care is more likely about applying ‘Lean thinking’ flexibly rather than a programmatic step-by-step application of Lean tools. The Lean approach can be used by primary care to structure and sustain quality improvement work but, as with all quality improvement approaches, needs energy and committed leadership.
John A Bibby is the Senior Partner in a primary care practice in Shipley, West Yorkshire. He is also clinical lead for the Improvement Foundation, a body that facilitates service redesign within the health and public services, throughout the UK, Australia and Canada.
Beverley Slater is National Knowledge Management Lead for the Improvement Foundation, where her role focusses on generating and disseminating knowledge about improvement. She has eight years of experience in leading quality improvement initiatives in local healthcare systems, including the UK Primary Care Collaborative and the international US-led Pursuing Perfection initiative.
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I
t is terms like ‘The Golden Hour’ and the ‘Platinum Ten Minutes’ that typify the importance of Emergency Medical Services (EMS) all over the world. It is a well-accepted fact that a patient who receives basic care from trained professionals and is transported to the nearest healthcare facility within 15-20 minutes of an emergency has the greatest chance of survival. EMS is an essential part of the overall healthcare system as it saves lives by providing care immediately. It’s this recognition that has led to research and development in EMS. Over the years several advancements have been made and research is underway to create services that provide medical assistance to patients at the earliest. However, the state of EMS varies drastically from developed to developing countries like India. In spite of the development in the healthcare sector over the past decade, India is yet to create a single, comprehensive EMS that can be accessed throughout the country.
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A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Globally prearranged emergency services
Emergencies typically occur in cases like road accidents, cardiac problems, convulsions and so on. Trained technicians or paramedics provide first aid to the patient i.e. pre-hospital care and shift the patient to an appropriate facility. EMS can be provided in two forms—treatment to in-patients and pre-hospital services. Pre-hospital medical services include ambulatory services, transportation of the patients to or from places of treatment and acute medical care (also called first aid). Ambulance services were largely unregulated prior to the 1970s. But over the last 2-3 decades, a largely regulated system has emerged around the world. Earlier, emergency services were being provided only with the means of road transport through hammocks and automobile. In 1972, a modern emergency medical helicopter transport—air ambulance was introduced in the US. Later, more standards were formed to make services better. India also has a helicopter ambu-
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lance service available in the metros and is expanding it to the rural areas. The prearranged emergency services currently operate via an emergency services contact system with dedicated telephone numbers. Country
Medical emergency no.
UK
999
Ireland
999
Poland
999
Hong Kong
999
Malaysia
999
China
119
Japan
119
Republic of Korea
119
Singapore
995
UAE
998 or 999
The most common European countries
112
Australia
000
USA
911
Canada
911
Healthcare Management
Emergency Services in India
Counting on betterment India requires a better emergency medical service to meet the growing number of emergencies. What exists currently in the form of fragmented services across the country falls way short of meeting the requirement. Scenario in India
As compared to developed countries with proper emergency systems in place, there is no single system which could play a major role in managing emergency medical services in India. There is a fragmented system in place to attend the emergencies in the country. 102 is the emergency telephone number for ambulance in parts of India. There are different emergency numbers in India’s 28 states and seven Union Territories. Hospitals in the country provide different telephone numbers for ambulance services. Clearly, India is in need for proper emergency medical service that can be accessed from anywhere in the country. The existing fragmented system falls terribly short of meeting the demand. Trauma continues to be one of the major causes of death in India. To avoid preventable deaths and disabilities, India has planned to have a common effective system that could provide emergency care with equity of access. In a bid to address this problem, The Centralised Accidents
and Trauma Services (CATS) was set up by the Delhi Government in the early 1990s. This service was later expanded throughout the country. Unfortunately, it didn’t succeed despite having a toll free number (102) that was made available through various media. More recently, NGOs and hospitals have come forward to provide their own EMSs. There have been considerable efforts by states across India to develop emergency services. Organisations like Emergency Management and Research Institute (EMRI) and American Association of Physicians of Indian Origin (AAPI)’s EMS are banned by corporates. EMRI is an exception in the otherwise struggling EMS system. EMRI was founded in 2005. To begin with, its operations were limited to Hyderabad and Andhra Pradesh with a vision of responding to 30 million emergencies and saving 1 million lives a year. EMRI handles medical, police and fire emergencies through its 108 emergency service. Satyam is the technology partner
Prasanthi Potluri Editor Asian Hospital & Healthcare Management
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of EMRI. EMRI has also entered into PPP with Indian Emergency Number Authority, National Emergency Number Association, American Association of Physicians of Indian Origin (AAPI), Shock Trauma Centre, Stanford University USA, Singapore Health Services, City of Austin in Texas, USA and Government of Andhra Pradesh. EMRI also comprises a research institute, which does medical research, systems research and operations research. Through this, EMRI provides research papers for prevention and management of emergencies. EMRI’s other services includes free medical advice on phone on another toll free number 104 with access to more than 200 medical doctors and several more paramedics. It has entered into a partnership with Stanford Hospital, the School of Medicine for training 150 paramedics and 30 paramedic instructors over a two-year period in India. Though a positive, this is unlikely to meet the demand for paramedics in the country. “So far neither of these two services in Mumbai (AAPI) or Hyderabad (EMRI) have the kind of human resources and massive training programmes needed”, concurs Dr N Bhaskara Rao, Chairman, Centre for Media Studies, New Delhi. In 2007, with the extension of Ambulance Access for All (AAA)’s services, American Association of Physicians of Indian Origin (AAPI) founded Emergency Medical Service (EMS) for Mumbai. AAPI
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has collaborated with the Confederation of Indian Industries (CII) and signed an MoU to endorse the growth of the healthcare sector in India, especially in rural areas. This agreement is to provide knowledge and technology transfer and provide EMSs to develop healthcare facilities in India. Another such facility, Life Support Ambulance Service (LSAS) operating in Mumbai for three years in association with London Ambulance Service, UK, has now made inroads into Kerala and has 500 ambulances that can be reached on a toll free number 1298. Recently, the Gujarat state government set up the Gujarat Emergency Medical Services Authority (GEMSA). Institute of Kidney Diseases and Research Centre (IKDRC), U.N. Mehta Institute of Cardiology and Research Centre, Gujarat Cancer Research Institute (GCRI), EMRI and Public Health Institute, Gandhinagar have entered into several other PPP projects to improve the emergency services in the state. But these examples are far and few in a largely fragmented system. The lack of a common emergency number across the country is a major hurdle in creating a reliable emergency service. The fact that there isn’t clarity in the Ministry of Health about the importance of a common EMS does not help either. Says Dr Rao, “The Ministry does not have basic data on ambulances for emergency medical services in the country. This is despite the state-wise studies on ‘health infrastructure’ that were conducted recently.” Clearly, there is an urgent need to appraise the situation and implement corrective measures that can help put in place the required infrastructure as soon as possible.
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Meeting the demand?
In spite of the work going on in the area of EMS, the question still remains: is it meeting the requirements? The answer is no. Though there has been a considerable improvement in emergency services in India, but there is still a long way to go before a comprehensive EMS is implemented across the country. “Available emergency services are not sufficient to meet the demand as one ambulance is needed to cover a population of 50,000 to 100,000,” says Mr Venkat Changavalli, CEO, EMRI. Still numerous deficiencies exist in the emergency services across the country. “India should have far more accessible and reliable emergency medical services irrespective of geographical factors,” says Dr Rao. Another important component missing in the current system, and one that will be needed in the longrun, is a body to regulate the EMS in the country. “LSAS in Mumbai claims that it had saved 22,000 lives in three years while EMRI in Hyderabad claims saving 55,000 lives in one year,” says Dr Rao, but there is no way to validate these claims and introduce corrective measures. Awareness
Awareness of the available services and preparedness are mandatory among the general public for the success of an EMS service. People also need to take initiative in knowing about the services being provided by available EMS. Indeed, an EMS that people are not aware of is as good as non-existent. One of the reasons for the success of EMRI is that 108 is widely recognised and has a great recall among citizens. “People’s participation is as important as blood donation and such cooperation is an important aspect of emergency medical relief service,” says Dr Rao. In 2006, American Academy for Emergency Medicine in India (AAEMI) made efforts to educate, impart knowledge and expertise to emergency care workers in Indian hospitals. It was aimed to increase the awareness and importance
Healthcare Management
Helicopter Ambulance Service One ambulance per 100,000 people norm for ‘pre-hospital emergency medical response services’ is what the Chief Minister of Delhi had recently talked about. The traffic system being what it is and how it is worsening in most cities of India, it is high time that we start experimenting with helicopter services for emergency medical services in metro cities. Hindustan Aeronotics Limited (HAL) could be approached to design a helicopter with medical relief facilities including oxygen storage to accommodate more people and other paraphernalia and with maneuverability
to land and take off easily even from urban ghettos. We already have medical relief rail and compartments for massive emergency situations. As more and more road accidents often involving groups of people get reported, the present architecture of ambulance services will not be able to cope with and cater to even as mere patient transport vehicle. And then the number of disasters are on the increase—floods, fires, earthquakes, etc and then now terrorist attacks, communal conflicts besides increasing road accidents. N Bhaskara Rao
of Emergency Medicine. But this and other similar programmes are restricted to a few regions. Thus arose a need for an awareness creation programme across the nation that filled this gap. Legislation for emergency services
The demand for legislation for EMS has been rising steadily in India. Supporters of such legislation opine that it would mandate a common access number, formation of an EMS council, trained paramedics, gradation of ambulance and hospitals, network of hospitals and define physical and human resources needed for the service. This could help save lives by making access easy for all the patients. Methods, technology, personal skills need to be standardised with formation of legislation in emergency services to provide protection for the providers. Associations like Society of Emergency Medicine-India (SEMI) and American Association of Physicians of Indian Origin (AAPI) have submitted proposals for EMS legislation to the Central Government and State Government of Gujarat, Maharashtra and Andhra Pradesh. A word of caution comes from Dr Rao as he says “making emer-
gency medical service legally compulsory without ground level preparedness will not be enough.” He adds that people need to be aware of their responsibilities towards fellow citizens—insist on and be aware of the best emergency service available. Conclusion
The importance of a reliable EMS cannot be overemphasised, especially in India where the government has the responsibility of caring for a majority of the population. It can be argued that a nation of a billion people has been deprived of a decent EMS for too long now and it is high time the government takes definitive action. The success of a few services is evident enough of the need for EMS and what it will take to ensure that it works as expected. In a healthcare system that is sprouting and experiencing the benefits of involving private players, a public-private partnership framework could be the right way forward for policymakers. At a time when the emphasis on preventing damage is greater than ever, the provision of pre-hospital care will be the key to ensure that lives are not lost due to avoidable circumstances.
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Personalised Healthcare A transformational opportunity Despite increasing healthcare costs, healthcare suffers from suboptimal quality and inefficiency. Personalised Healthcare offers the transformational opportunity. This article discusses the science, enabling technologies, opportunities and challenges of moving Personalised Healthcare forward. LiHui Xu Program Director Henry Zheng Director Operations Steven G Gabbe Senior Vice President Health Sciences Clay B Marsh Professor Center for Personalised Healthcare The Ohio State University Medical Center, USA
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ncreases in healthcare spending appear to be a global concern. For example, the rising costs in Asia are being driven by many of the same factors that have triggered the spiralling of medical costs in developed countries. Factors include ageing societies with more chronic disease, rising technology costs; high patient expectations of care; and more frequent coverage by third-party payers such as insurers or employers. However, the quality of healthcare does not necessarily correlate with the total spending. Take US as an example, total healthcare costs in the US were US$ 2.2 trillion in 2007, representing 16 per cent of the Gross Domestic Product (GDP), an amount expected to reach US$ 4.2 trillion in 2016. Despite this vast spending, our healthcare system suffers from suboptimal quality and inefficiency, as evidenced by the World Health Organization (WHO) ranking healthcare in the US 37/191 countries in performance. Furthermore, studies show that prescription drugs are effective in fewer than 60 per cent of treated US patients. The current trend is unsustainable and ineffective, emphasising the need for transformational change to create value-based, patient-centric healthcare. Reversal of this trend will require Personalised Healthcare. It incorporates individual genetic, behavioural and environmental information to define individual prescriptions for health maintenance, disease prediction, prevention, and tailored therapy. In addition, it considers individual environments, health-related behaviours, cultures and values. This approach is revolutionary and will fundamentally transition medical practice from illness to wellness. Equally important is
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patients’ control over their own health by their personal prescription for health, incorporating approaches for their unique risk of disease. Scientific advances are leading the way to Personalised Healthcare
Rapid advances in platform technologies, such as Single Nucleotide Polymorphism (SNP) analysis, the ‘-omics’ such as genomics, microRNA (miRNA) analysis and systems biology and network analysis, offer the potential for revolutionary change in the practice of medicine. Landmark projects, such as the Human Genome Project completed in 2003, have laid the groundwork for researchers to identify genetic causes and genetic contributions to complex human diseases. For example, genome-wide association studies have uncovered new genes linked with common diseases, including coronary heart disease, type 1 diabetes, type 2 diabetes, rheumatoid arthritis, Crohn’s disease, bipolar disorder and hypertension. Identification of disease-specific genes could lead to clinical interventions to improve outcome. In addition to genetic research, ‘-omics’ technologies, such as transcriptomics, proteomics and metabolomics have grown rapidly. These powerful tools allow researchers to link phenotype with dynamic protein production, geneprotein and protein-protein interactions to identify markers and molecular targets in health and disease. Beyond gene and protein activation as disease triggers, underlying regulatory genetic events have drawn significant attention. For instance, miRNAs, small non-coding RNAs of 21-23 nucleotides that bind complementary sequences in target genes and cause mRNA degradation
Healthcare Management
or inhibition of target protein production, are involved in the regulation of gene expression in cell proliferation, differentiation, and apoptosis. miRNAs are implicated in tumorigenesis through regulating the expression of tumour suppressor genes and oncogenes. miRNA expression is abnormal in chronic lymphocytic leukemia, solid organ tumours like lung cancer, and non-tumour diseased tissues. A recent study suggests miRNAs mediate cancer chemoresistance or sensitivity. These tools may revolutionise disease classification, diagnosis, monitoring, prognosis, and potential treatments to drive personalised care. Similarly, miRNAs also regulate epigenetic regulation of gene transcription, another actively explored regulatory process in the genetic underpinnings of complex human disease.
Mainstream research focusses on identifying individual gene(s), molecule(s), or pathway(s) that lead to disease. The rise of systems biology tools facilitates dissecting the organisation, regulation and structure of complex systems, such as dynamic gene and protein networks that underlie human health and disease. This approach has great potential in bringing predictive and preventive medicine to reality. Information technology and biomedical informatics are key enablers of Personalised Healthcare. Electronic and personal health records make complete and current patient information available when and where it is needed. Electronic patient phenotyping provides the opportunity to interface genetic and ‘–omic’ information with patient-specific
outcomes to create novel approaches to promote health and prevent disease. These tools support clinical decision-making by clinicians and healthcare providers, thus delivering the best individualised care for each patient. Equally important is that Personalised Healthcare promises to place information technology in the hands of consumers / patients empowering them to take control of their health and managing wellness. Personalised Healthcare is already happening, but at a slow pace
The rise of personalised medicine is the result of unprecedented advances in biomedical research and technologies, such as DNA sequencing and ultra-high throughput screening. Technological breakthroughs have dropped the price
Global perspectives on Personalised healthcare The US Department of Health and Human Services (HHS) plays a leading role in advancing Personalised Healthcare. In particular, the HHS has issued two reports with the first one released in October 2007 and the second in November 2008, demonstrating a strong focus and commitment to delivering the best care possible to each patient. Michael Leavitt, Secretary of HHS, stated that Personalised Healthcare is not a niche concern. Its promise is central to the future of healthcare. Under the HHS leadership, National Institutes of Health and the Food and Drug Administration have both embarked on the journey to Personalised Healthcare. The NIH roadmap and FDA critical path are all part of the efforts for this initiative. Inspired by the vision, both academia and industry are advancing Personalised Healthcare research, education and clinical practice. Among many of the academic centres, The Ohio State University is committed to developing and creating the future of medicine by improving people’s lives through Personalised Healthcare. Our commitment is to help people maintain healthier, happier, and productive lives. To do so, we are implementing an innovative programme to promote the active participation of individuals in their own ‘personalised’ health maintenance and to use genetic tests and health markers to predict and prevent disease. In addition, Ohio State is developing a general patient informed consent to prospectively collect patient’s biologic specimens and DNA samples for medical research. This biobank will be linked with the patient clinical database to make it highly useful for translational research, such as human cancer genetics,
individualised cancer therapy, advanced lung disease and sepsis, cardiovascular diseases, women’s health, pharmacogenomics and diabetes mellitus. The data generated by these research programmes will then be incorporated into the electronic medical record to support clinical decisions. Personalised Healthcare or Personalised Medicine has become a global initiative. Other countries, such as the UK and Canada, have also embarked on this exciting initiative. Furthermore, countries in Asia, such as China and Japan, have played a critical role in the international HapMap project. The goal of the project is to develop a haplotype map of the human genome, the HapMap, and provide researchers around world with free access to the data to find genes affecting health, disease, and responses to drugs and environmental factors. Combined phase I and phase II projects have identified over 3 million SNPs in 269 individuals, including Han Chinese, Japanese, Nigerian, and European. The data will provide important information to guide genome wide association studies and to identify genetic variations in different ethnic groups. Finally, as part of the 1000 Genomes initiative, Asian countries, such as China, are playing an increasing role in funding genomic research and technologies. Given the low cost of labour and their intellectual prowess, China and India are on the rise to develop research powerhouses. However, science and technology have always outpaced public policy, regulation and clinical medicine. Integrating genetics / genomics into clinical practice will be at slower pace than we wish, especially in the developing countries, given the disparity of their healthcare system.
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from US$ 3 billion to sequence the entire human genome to US$ 60,000. Several countries and commercial entities are investing in technology to reduce the cost of sequencing a person’s complete genome to US$ 1,000. Price reduction in this technology will enable each person to obtain a blueprint of their genetic code in the near future. Moving towards the goal of individualised predictive, preventive and personalised care, researchers have developed genetic tests that can be utilised to diagnose, predict and identify carriers of genetic disease and also determine the risk of adverse medication reaction. Over 1,000 genetic tests are currently available and more are being developed. A current example is testing for BRCA1/2 mutations in women with a family history of breast cancer or ovarian cancer. If a women tests positive for BRCA1/2 mutations, she has an estimated lifetime risk of 36-85 per cent for developing breast cancer, a 16-60 per cent for ovarian cancer, and should be closely monitored for these diseases. In addition, companies such as 23andMe, Navigenics, and deCODE Me, continue to develop tools for genetic analysis marketed directly to consumers and physicians. These tests allow consumers to evaluate their genetic risk of disease and genes defining personal traits. Consumers can take control of their own health by understanding their predisposition to disease and modify their lifestyle accordingly, providing potential long-term benefit. Pharmacogenomics / genetics is a promising area for Personalised Healthcare, translating scientific discovery into clinical application. Pharmacogenetic testing presupposes the availability of validated genetic tests, with data linking the presence or absence of specific variants with a specific outcome, such as improved therapeutic response or reduction in adverse events. A topical example is the genotyping of CYP2C9 and VKORC1 in guiding the titration of the anti-coagulant warfarin towards the optimal maintenance dose.
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Despite decades of experience and careful monitoring, the adverse events of warfarin are still among the highest of all commonly prescribed drugs. The challenge of administering warfarin is due to the wide (20-fold) inter-individual variation in dose requirements, the narrow therapeutic range, and the risk of serious bleeding from overtreatment, or risk of repeat thrombosis from under-treatment. Studies show that age, gender, sex, race, body mass index, smoking, diet, and drug interactions, have a significant impact on warfarin sensitivity. Variability in warfarin response can result from polymorphisms in vitamin K epoxide reductase subunit 1 (VKORC1), the pharmacologic target of warfarin. In addition, patients with genetic variants of CYP2C9, involved
The rise of Personalised medicine is the result of unprecedented advances in biomedical research and technologies, such as DNA sequencing and ultra-high throughput screening. in warfarin metabolism, require lower doses of warfarin because of reduced drug clearance. By applying genotype biomarkers at the beginning of warfarin treatment, one can shorten the time to reach the proper warfarin dosage, thereby reducing adverse drug reactions (ADRs). Based on these findings, the US Food and Drug Administration changed the labelling information for warfarin to recommend genetic testing of CYP2C9 and / or VKORC1 genes. Increasing the awareness
As research in Personalised Healthcare advances, educating healthcare providers and consumers is the key to improve healthcare delivery. There is a lack of knowledge and utilisation of clinical
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genetics, genetic testing and genetic counselling in the medical community and the public. Therefore, it is critical to develop Personalised Healthcare-related educational programmes through continued medical education and integrate this curriculum into medical education for medical students, residents and physicians. Personalised Healthcare promises to be a predictive, preventive and participatory, and personalised—‘P4’—medicine. To be truly participatory and personalised, seamless and logical information technology interfaces and tools are essential. The development and application of these tools and education targeted to Personalised Healthcare is lacking. The power of Personalised Healthcare in improving people’s health and saving cost rests on transforming medicine to disease prediction, prevention, and wellness. This will require re-engineering current healthcare reimbursements and delivery to bring healthcare to each home and community on demand. It is not just the right medicine at the right time, but more importantly, a health and wellness intervention strategy that prevents the onset of diseases. This strategy will not work without key public-private partnerships to create the tools to start a social epidemic of change in healthcare delivery. Issues and challenges
Although Personalised Healthcare offers a transformational opportunity to change the current healthcare system, many issues or challenges must be addressed before it can become a reality, including lack of public policy, regulation, reimbursement, education, standardisation of healthcare information technology such as electronic medical records, clinical validation, adequate funding for research, and privacy concerns. Each of these challenges must be dealt with by all of the stakeholders, including physicians, scientists, healthcare organisations such as hospitals and health networks, private insurers, public
Healthcare Management
insurance providers such as Medicare and Medicaid, pharmaceutical and diagnostic companies, state governments, the federal government, and, most importantly, patients.
LiHui Xu is currently the program director at the Ohio State University Center for Personalized Healthcare. Prior to that, Xu was the Chief Operating Officer of a biopharmaceutical company. From 1989-2001, she was a postdoctoral fellow and a research assistant professor at University of North Carolina at Chapel Hill.
Personalised Healthcare holds the promise of transforming the current healthcare delivery into a value-based and patientcentric healthcare. While advances in science and technology continues at a dramatic pace, other areas such as public policy, regulation, reimbursement, education and clinical validation will continue at a measured pace. This will require all stakeholders in the healthcare arena to work together in years to come to overcome these hurdles and challenges before Personalised Healthcare can become a reality.
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Summary
Henry Zheng is the director of operations at The Ohio State University Center for Personalized Healthcare. Zheng has served in numerous leadership positions since joining OSU in 1997, as senior planning manager, business performance officer, director of Technology and Commercialization Partnerships and director of Data Analysis and Information Services. Steven Gabbe recently joined the Ohio State University as senior vice president for Health Sciences and Chief Executive Officer of the OSU Medical Center. Prior to that, Gabbe was Dean of the Vanderbilt University School of Medicine. From 1987-1996, he was professor and chair of Obstetrics and Gynecology at OSU.
Clay Marsh came to The Ohio State University in 1985. He is currently professor and vice chair for research of Internal Medicine, director of the Center for Critical Care, and director of Pulmonary, Allergy, Critical Care and Sleep Medicine.
References are available at http://www.asianhhm.com/magazine
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Importance of Traditional Medicine In the age of technology Most nations, except the US, have natural medicine traditions known and widely practised by the populace. With the increasing availability of Western technocentred medicine, there’s a seduction in favour of ‘modern’ medicine over traditional treatments. Health outcomes in the US indicate the risks on this path and the importance of staying patient-centred. Beverly A Jensen Associate Professor Communications UAE University, UAE
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T
he purchase and installation of new technology in any environment generates excitement— whether it’s in the office, school, hospital or home. Owning the latest technology is exciting. There is a certain seduction in owning the ‘latest and greatest’ technology. And for decades, the sales departments of manufacturers have played the ‘status’ card in their persuasive sales pitches. In the education field, school storerooms around the globe are filled with equipment that no one on site was trained to use properly, and no one was trained to maintain or repair. Over the last 50 years a revolution has occurred in healthcare with pacemakers, artificial joints, organ transplants, and now, a whole new horizon is opening with stem cell research. However, just as in education, many developing countries find themselves flooded with sophisticated medical equipment they can neither fully utilise nor maintain. The technology salesmen have sold medical equipment even to the nations in which the local health issues do not warrant such expenditure, As a result, technology sales usurp the resources that are available for basic healthcare. This misallocation of resources happens not only in the US but also in every other nation.
Healthcare in Asia will be most successful if the traditions of Ayurveda, Chinese medicine, and other tried-and-tested indigenous medical treatments remain at the forefront in medical care.
The development of national Health Information Technology (HIT) programmes, on the other hand, could help to reduce healthcare costs and improve safety in delivery to patients. Others nations’ experiences in developing national HIT provide immediate and salient lessons for organisations and nations just beginning the process. Still, the implementation of any technology carries the risk of diminished attention to the patient’s well-being. The evolution of medical care in the US over the past 60 to 70 years is a demonstration of myopia brought on by focussing on the wonders of technology. Until the mid-1930s the American Medical Association coexisted fairly well with naturopaths and other health practitioners. Many MDs incorporated forms of natural healing into their practices, such as herbs, baths, breathing and exercise programmes. As the chemist labs cranked up in the 1930s, MDs began prescribing pharmaceutical drugs instead
of homeopathic or herbal remedies. Between the two world wars, great strides were made in surgical techniques. Advances in surgery and the development of pharmaceutical drugs combined to sweep mainstream medicine towards a more technological approach to healthcare. By the end of the 20th century the consequences have grown dire. Deadly reliance on pharmaceuticals
Americans, who are only 4 per cent of the world’s population, consume about 50 per cent of the world’s pharmaceutical drugs. A study of US hospital emergency room visits published in 2006 showed that 700,000 ER visits annually are due to interactions or contraindications of pharmaceuticals. Since most ER admissions are undiagnosed or misdiagnosed, the authors of the article in JAMA (18 October, 2006) suspect this number is an underestimation. Add to the 700,000 visits to ERs, 100,000 deaths annually from pharmaceuticals. So, every year nearly one million Americans are killed or seriously injured due to use of pharmaceuticals, but you won’t read this in the mainstream American media. The public’s health has become secondary to business interests: pharmaceutical advertising is a major revenue source for broadcasters and print media since 1998, and American media are almost entirely owned by conglomerates. The loss of other medical models
With American medical education heavily supported by the pharmaceutical companies and medical students learning no other forms of treatment but ‘pills and scalpels’ common sense, non-tech treatments and traditional treatments for health are being forgotten.
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The price of technological health solutions
The cost of medical testing points to another major reason to keep one’s perspective on use of technology—escalating costs. In 2003, US spending per capita was US$ 5,635, two-and-a-half times the median for other industrialised nations (the OECD members). As a per centage of the gross domestic product, the US spends nearly twice the expenditures of other nations (15 per cent vs. 8 per cent). With all these expenditures, up to 60 million Americans do not have enough or no health coverage at all or during the year. These were the figures before the financial crisis which is putting millions more out of work, and health insurance in the US is tied to employment. Over 80 per cent of Americans told the Commonwealth Fund in 2008 that the US healthcare system needs a major overhaul, and two-thirds of the population has problems in paying
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Integrate techno-model with traditional medicine The great majority of Americans know only of the techno-model of medicine for three generations now. Most are ignorant of any other means of taking care of themselves except chemical medicines, but the expenses and painful outcomes are causing a slowstirring revolt. Asia is fortunate to have several traditions in health treatments that have been successful for thousands of years. Healthcare in Asia will be most successful if the traditions of Ayurveda, Chinese medicine, and other tried-and-tested indigenous medical treatments remain at the forefront in medical care. Technology is best regarded as a supplement, an aid in diagnosing and treatment but not the centre of healthcare. A holistic view of the patient should remain at the centre. Keeping the patients responsible for their own health will improve health outcomes. Contributing to the diagnosis and jointly making decisions with their doctors aids patients in their recovery. An actively involved patient is a faster-healing patient. Asia has the tradition of taking charge of one’s own health. That must not be lost in a technologycentred health system.
medical bills or they don’t seek medical services due to costs. American model – Unhealthy outcomes
For all this technology and money spent, the outcomes of American healthcare are so poor that the US is not even ranked among other industrialised nations. The WHO ranked the US 37th in the last survey, two notches above Cuba. Like many US universities, American medical schools are setting up campuses overseas. And the American medical institutions are leading their foreign clients right down the same path that has put US healthcare where it is now—no longer ranking among industrialised nations. The World Organization of Family Doctors met in Dubai in February 2008. Dr Richard Roberts, a Wisconsin physician and president-elect of the organisation, told the Gulf News that the UAE risks making the same mistakes as the
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At a health conference in September 2008, an executive of the Robert Wood Johnson Foundation told the 700 in attendance a story of his patient whose stool tests indicated possible cancerous cells. He was advised to have a colonoscopy, but he had limited funds, and Medicare wouldn’t cover the full cost. Unable to obtain an estimate of his personal costs for the test from area hospitals, he chose instead to buy a much-needed furnace for his home instead of getting the test. Apparently the MDs couldn’t recommend any other courses of action, other than a colonoscopy and chemotherapy, so the patient died of colon cancer within two years. Health practitioners trained in natural, non-tech treatments (as well as educated consumers / patients) would have advised the above patient to do a colon cleanse. Herbal colon cleansing has been known to flush out cancerous cells. In any case, the outcome couldn’t have been worse than that from the AMA route, which was death.
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US by putting more emphasis on development of medical specialities than on primary healthcare. This Gulf nation is restructuring its healthcare system—with legions of advisors from Harvard Medical School, Cleveland Clinic, and Johns Hopkins University. Dr Roberts told the Gulf News, “The UAE is making the same mistakes as the US, listening to (the likes of ) Harvard and Cleveland Clinic. It’s like a nuclear arms race. Everybody will be trying to top everybody with their special this and special that.” The warning regarding medical specialisation is part of the technology domain. Primary care or family medicine physicians are trained to consider the whole person. I have compared the medical specialists to blind men trying to describe an elephant—they can only ‘see’ that area that is their speciality and have no comprehension on how the whole system works.
Beverly A Jensen is the founder of www.WomensMedicineBowl.com. She has worked as a communications strategist and program manager in development projects in Africa, the Middle East and Eastern Europe since 1993. Currently she teaches strategic communication and health promotion in the UAE.
Medical sciences
Contrast
Echocardiography Current indications Contrast agents have been shown to be useful to improve the image quality in echocardiography. The development of new ultrasound contrast agents and imaging techniques has enabled the bedside assessment of myocardial function and perfusion. Robert Olszewski Consultant Cardiologist Military Medical Instytut Warsaw, Poland Harald Becher Professor Cardiac Ultrasound Oxford University, UK
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or almost 40 years, Cardiac ultrasound has been demonstrated to be a promising diagnostic tool to evaluate patients with pericardial, valvular heart disease and patients with ischemic heart disease. However, inadequate endocardial visualisation occurs in up to 20 per cent of cases during echocardiography and it fails to produce diagnostically useful images. Contrast agents have been shown to be useful to improve the image quality (endocardial definition) in 2D and 3D echocardiography. This problem is even greater in patients referred for stress echocardiography when subjective assessment of regional wall motion is dependent on the quality of the images recorded. In stress echocardiography optimal endocardial border delineation is needed in all segments. Images are worse during stress because of cardiac movement and also hyperventilation. Although image quality has been improved with the introduction of harmonic imaging, the quality of many studies still remains inadequate. To improve the quality of images, millions of contrast agent applications have already been given to the patients since 90s. Available contrast agents in echocardiography
At present, three contrast agents are licensed for left ventricular (LV) opacification and endocardial definition: SonoVue (Bracco Diagnostics Inc, US), Luminity (Lantheus Medical Imaging; trade name Definity in US) and Optison (GE Healthcare, US). The latter
is currently not available. All these agents provide intensive opacification of the left heart chambers when administered intravenously. Although infusions are preferred for assessment of myocardial perfusion, bolus injections of agents may be satisfactory for left ventricular opacification in many cases. All agents are suspensions of microsheres filled with a perfluorocarbon gas and have a similar size as red blood cells. The dosages of contrast needed for LV opacification are minimal (0.1-0.3 ml) compared to those in other imaging modalities, such as Xray for instance. These small dosages are possible because of very sensitive contrast specific imaging technologies, which have been implemented in all state-of-the-art ultrasound systems. Assessment of myocardial opacification – An integral part of contrast echocardiography
Ultrasound contrast agents have been licensed for improvement of endocardial border definition by left ventricular opacification. But left ventricular opacification is inevitably associated with myocardial opacification—in particular when the newer contrast specific imaging modalities are used. Assessment of myocardial opacification provides very important information on top of the evaluation of the wall motion. Questionable findings of wall motion can be clarified by assessing left ventricular opacification and vice versa. Homogeneous myocardial and quick opacification of the myocardial vessels
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after LV ventricular opacification indicate normal myocardial perfusion and provide further confirmation of a normal wall motion study. This is particularly helpful in stress echocardiography. Reduced opacification in the subendocardial layers usually indicates reduced perfusion and is often easier and earlier to appreciate than a new wall motion abnormality. For rest echocardiography, the assessment of myocardial opacification is also very helpful. In an akinetic segment, lack of myocardial opacification indicates viability. Thrombi can be distinguished from tumours due its lack of opacification. Contrast application is only useful, if it alters patient management
The threshold for ultrasound examinations is usually very low and the results of the examinations do not always affect the patient management. Considering the extra time, additional costs and small risk of intolerance, contrast echocardiography needs a more disciplined approach. There are a lot of patients, in whom echocardiographic images are not optimal due to factors such as obesity, lung disease, recent thoracic surgery or positive-pressure ventilation. Nevertheless, echocardiography still gives the correct answers to the clinical questions. According to the guidelines of the American Society of Echocardiography, there is an indication for contrast echocardiography when the endocardial border definition in two or more segments is poor. In some patients poor visualisation of two myocardial segments may change management, in others Stress examinations present altogether different situation. For this kind of examination, image quality is crucial; suboptimal images of the LV cannot be accepted. The complexity of protocol and the risks of ischaemia can only be justified if the test is diagnostic. Therefore, high image quality is vital. In these patients, contrast administration is of great importance in delineating the endocardial border in all segments, thus changing the
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way patient is managed. These considerations are reflected in the most recent published guidelines of European Society of Cardiology (ESC), British Society of Echocardiography (BSE) and the American Society of Echocardiography (ASE) for the clinical application of stress echocardiography. Therefore, the use of contrast agents is highest in stress echo departments—at the John Radcliffe hospital about 60 per cent of all stress echocardiograms are performed with contrast. In the rest, contrast echocardiography is useful when minor changes of LV volumes and ejection fraction change management. Many studies have demonstrated that contrast-enhanced assessment of LV volumes and LV ejection fraction compares favourably with the accepted gold standard of cardiac magnetic resonance imaging. Monitoring of LV function during treatment with cardiotoxic drugs like Herceptin is a good example for the need of accurate assessment of LV function. In patients with poor acoustic windows, the reproducibility of contrastenhanced studies is comparable to MRI recordings.
Only four fatal events with Definity occurred within 30 minutes after the application of contrast in a total of 2 million vials used. But even if we assume that all four cases are related to the ultrasound contrast agent, the fatal event rate would be only one in 500,000 for Definity and zero for Optison. This rate is far less than the fatal event rate in exercise and Dobutamine stress echocardiography. Meanwhile, several studies were conducted on more than 20,000 patients demonstrating the safety of ultrasound contrast agents during stress echocardiography and myocardial perfusion imaging using the flash-replenishment technique.
Safety of contrast echocardiography
For ultrasound, side effects have been reported in contrast agents, but they are usually mild. However, rare allergic, potentially life-threatening reactions may occur and the investigators have to be prepared for such an event. In April 2008, the US Food and Drug Administration (FDA) performed a safety review of the US approved perflutren microsphere contrast agents (Definity and Optison) and revised a previous black box warning. The new contraindications are much less restrictive than the previous contraindications and satisfy the needs of clinical echocardiography. The FDA revised the benefit / risk assessment for patients with unstable conditions and acknowledged that some of the fatal events may be coincidental and not related to the contrast media.
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Available imaging techniques Harmonic imaging has been developed primarily as a contrast specific imaging modality that can be used with a transmit power (mechanical index <0.6) lower than that used for non-contrast imaging (mechanical index >1.0). Harmonic imaging has become the standard imaging technique for native echocardiography. For clinical contrast echocardiographic studies, the contrast specific imaging modalities should be used (see next paragraph). Harmonic imaging may be used only if they are not available. In order to use it for contrast studies one has to reduce the transmit power. However, the transmit power is
Medical sciences
Data collected during Post-Marketing Surveillance referred to more than 200,000 of SonoVue vials used, indicate that serious adverse events (SAE) are rare (0.01 per cent). The signs and symptoms of most of these SAEs indicate an underlying allergy-like mechanism and they were considered by the European Medicines Agency (EMEA) in the context of idiosyncratic, hypersensitivity reactions. This kind of reactions (allergy-like) is well known from wide reports in literature to occur with other medical imaging agents such as X ray or MRI contrast media. Risk / benefit considerations
Assessment of risk / benefit means to
compare the risks of the procedureâ&#x20AC;&#x201D;here contrast echocardiographyâ&#x20AC;&#x201D;with the risks of an incorrect diagnosis when not using the contrast agent. If, for instance, a new wall motion abnormality is not detected in stress echocardiogram because the wall is not adequately imaged, the diagnosis may be inaccurate and subsequent management of the patient may be wrong. Although it appears to be very convincing that patients with a missed diagnosis of coronary artery disease have an unfavourable outcome, there is only limited data to quantify the extent to which this might happen. It appears to be easier to assess the risk / benefit when we consider false positive studies. Usually coronary angi-
Improved endocardial delineation following SonoVue infusion: 4, 2 chamber (top left and right), short axis view and multiple plane view bottom right and 3D reconstruction left, obtained from a native real-time contrast 3D dataset. The stress recordings show perfusion defects (arrows). Notice the excellent delineation of the endocardial borders.
Comparison with other imaging technologies
Figure 1
still relatively high and can cause destruction of the contrast in the near field of the transducer as well as tissue signals of the myocardium, which impair the delineation of the endocardium. Latest developments, such as Power Modulation and Power Pulse Inversion, which use very low non-destructive transmit power techniques (mechanical index <0.2), allow for real-time imaging without the limitations of harmonic imaging. As tissue returns are not displayed, unlike with high powered techniques, they are ideal for accurately delineating the left ventricular borders. Low power-contrast specific techniques display the contrast within the cavities and the myocardial blood within the intra-myocardial vessels. The blood
ography is requested in the case of a false positive stress echocardiogram. This will expose the patient to significant radiation and there is a procedural risk, which certainly exceeds the risk of an adverse event when using an ultrasound contrast agent. Therefore, it is very important to take a decision whether to continue in a study, which has suboptimal images or do other kind of choice considering all the possibilities in the context of ensuring to the patient the most adequate medical treatment. Even when the risk of serious adverse events is very low, there should be a clear benefit from the application of the contrast agent to justify its use. In patients undergoing stress echocardiography, the benefit of using a contrast agent certainly overweighs the small risksâ&#x20AC;&#x201D;in particular when the current contraindications are not ignored. Contrast echo closes the gap between native echo and cardiac MRI in patients with poor acoustic windows.
volume within the myocardial vessels makes up only 7 per cent of the myocardial tissue. Therefore, the myocardial opacification is always much less intensive than the cavity opacification and provides an excellent contrast for endocardial delineation (Figure 1). The myocardial contrast is also very useful for assessing thickening of the myocardium and myocardial perfusion. Whenever available, low power contrast specific imaging techniques should be the first choice. These contrast specific imaging modalities are available in all state-ofthe-art ultrasound machines. The settings of the ultrasound scanners and the contrast dosages are well standardised and make contrast echocardiography an easy to use technique.
There are three aspects, when different imaging technologies are compared: the accuracy, the risk / benefit and the costs / effectiveness (Table 1). Cardiac MRI, CT and nuclear methods are known to be considerably more expensive than contrast echocardiography. Several multicentre, and numerous single centre trials as well as series of case reports have demonstrated the accuracy of contrast echocardiography for assessment of LV volumes and ejection fraction (overview in 6) . The reproducibility of contrast enhanced echocardiography is as good as that of MRI. For assessment of global and regional LV function, controlled large trials are conducted on a large number of patients. The accuracy of stress echocardiography is not worse compared to myocardial scintigraphy. Multi-slice CT is a new technology and a better option to display the coronary arteries compared to myocardial ischemia. There is an ongoing debate whether
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Medical sciences
Echocardiography is the method of choice for repetitive cardiac imaging
In many patients the clinical course requires several appointments for cardiac imaging. Radiation dosages become an issue in patients, who need coronary angiography and coronary interventions. This has to be taken into account, when the patients need functional imaging. MRI and echocardiography should rather be used instead of nuclear methods. Contrast application can close the gap between MRI and echocardiography in those patients with suboptimal images. Moreover, contrast echocardiography remains a very cost-effective test and can be easily integrated into the workflow of an outpatient appointment of the treatment on a ward. Cost-effectiveness of contrast echocardiography
Cost-effectiveness of contrast echocardiography has been demonstrated in patients with difficult acoustic windows. Appropriate use of contrast for image enhancement is cost-effective because it substantially improves the image quality (and helps to avoid false-positive and
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Indications for contrast echocardiography – Suboptimal image quality of native recordings Clinical question
Competing imaging method
LV volumes
Cardiac MRI, blood pool scintigraphy, cardiac CT
LV ejection fraction
Cardiac MRI, blood pool scintigraphy, cardiac CT
LV masses/thrombi
Cardiac MRI, cardiac CT
LV hypertrophy
Cardiac MRI, cardiac CT
Regional LV function (rest)
Cardiac MRI, gated SPECT
Regional LV function (stress) Severity of CAD
SPECT, stress MRI, cardiac CT
Viable myocardium
PET, Cardiac MRI, gated SPECT
Aortic stenosis-severity
TEE, cardiac MRI, cardiac CT
CAD = coronary artery disease, CT = computed tomography, LV = left ventricle, MRI = magnetic resonance imaging, SPECT = single photon emission computed tomography, TEE = transesophageal echocardiography, PET = Positron Emission Tomography Table 1
negative findings) and favourably impacts the practice of performing additional tests for the same clinical indication. Thanigaraj et. al. estimated savings of US$ 238.00 / patient undergoing contrast enhanced stress echocardiography when baseline images are suboptimal. This raises the question whether contrast agents should be used in all patients referred for stress echocardiography. However, the use of contrast in all patients who were analysed with a model based on previously published patient outcomes was not cost-effective. Tardif et. al. demonstrated that contrast echocardiography has a similar success rate compared to nuclear perfusion imaging in diagnosis CAD, but has a 28 per cent (~US$ 170 Can) lower
A u t h o r s
non-invasive coronary angiography is really providing the best information for the patient management. But there is consensus that functional assessment of coronary stenoses with a stress tests cannot be given up. Contrast echocardiography could hardly be advocated if there is an imaging technology for the same indication with similar accuracy but a better risk / benefit ratio. There are immediate risks in using contrast agents during MRI, CT and SPECT examinations and longterm risks from the radiation by SPECT and cardiac CT. The latter may become important, if repeated examinations are necessary. For single test, however, the incidence of side effects appears to be very low for all imaging technologies. Therefore, it is difficult to establish a significant superiority of one method over another concerning safety.
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cost and has the potential of additional cost savings through the elimination of further diagnostic tests. TTE is frequently used in patients who are in ICU to assess LV function. However, if TTE is not possible (or diagnostic) in these patients a time-consuming and expensive TEE is usually needed. Yong et. al. demonstrated that the use of contrast in technically very difficult studies improves visualisation of the ventricular endocardium and increases the accuracy of interpretation of regional and global LV function. Contrast echo was cost-effective compared to TEE in determining regional and global ventricular function, with a cost saving of 3 per cent and 17 per cent, (US$ 43 and US$ 423) respectively.
Robert Olszewski is a Consultant Cardiologist at Military Medical Instytut Warsaw, and Honorary Trust Doctor at the John Radcliffe Hospital in Oxford. His research has involved the development of echocardiographic phantoms and techniques such as Doppler Tissue Imaging, stress and contrast echocardiography and tissue specle tracking. Harald Becher is Professor of Cardiac Ultrasound at Oxford University and consultant cardiologist at the John Radcliffe Hospital Oxford, UK. He is member of writing committee of the American Society of Echocardiography for “A Consensus Statement on the Use of Ultrasonic Contrast in Echocardiography 2008”.
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Surgical speciality
Heart Valve Surgeries Innovations and new developments
Operation through a smaller incision makes valve surgery easier on the patient. Because of improved durability, more tissue valves are implanted compared to mechanical valves. The latest development is percutaneous replacement of aortic valves and repair of mitral valves. Timothy J Gardner Medical Director Christiana Care’s Center for Heart & Vascular Health, USA
S
urgery directed at valvular heart conditions dates back almost 80 years when the first efforts were made to relieve mitral valve stenosis. Rheumatic fever was a common disease worldwide and frequently resulted in mitral stenosis. The scarred two-leaflet mitral valve appeared to be an easy target for simple division of the fused valve leaflets along the closure plane of the valve. A few daring attempts by brave surgical pioneers to open the obstructed valve while the heart was beating and pumping blood throughout the body almost always ended in failure and the death of the patient. But occasional by such mitral commissurotomy was successful and, as predicted, when the obstruction to blood flow through the valve was relieved, heart function improved considerably. Arrival of the heart-lung machine
Despite those rare attempts at direct valve repair, it was not until the heart-lung
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pump with a blood oxygenator became available that heart valve surgery became widely practised. In the early 1960s, ‘open heart’ surgery became feasible and relatively safe with the development of cardiopulmonary bypass. Surgeons continued to treat the still common condition of mitral stenosis, including many who persisted in using ‘closed heart’ approaches to performing mitral commissurotomy. The major attention in the early days of open heart surgery, however, was directed to the aortic valve which required that the patient be on full cardiopulmonary bypass support in order to work in a bloodless field. The development of heart valve prostheses
The other requirement for successful treatment of a diseased or deformed aortic valve was a valve substitute, or prosthesis, that could be used to replace the diseased native valve. Heart valve
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prostheses, both mechanical and those fashioned from biological material and usually derived from pig or cow heart tissue, have undergone multiple iterations over the 50 years of heart valve replacement. Currently available heart valve prostheses represent excellent refinements of earlier devices, but there have been few major innovations in design or manufacture of heart valve prostheses over the past 20 years. Current innovations in heart valve surgery have been directed more toward refinements to the operative approaches and technical aspects of valve surgery itself. Repair, don’t replace, a leaking mitral valve
Today’s heart valve surgical innovators are a relatively small group of heart surgeons, representing, perhaps, fewer than 20 per cent of practising cardiac surgeons. Although heart valve surgery and surgery for the treatment of congenital
Surgical speciality
heart defects were the most commonly performed procedures during the first two decades of open heart surgery, coronary artery bypass surgery has dominated the field since the late 1970s. Most currently practising heart surgeons are expert coronary bypass surgeons, but their experience with heart valve surgery may be quite limited. This is an especially important consideration today since the most important ‘innovation’ in heart valve surgery over the past two decades has been the successful evolution of mitral valve repair surgery for the treatment of mitral valve insufficiency. In the Western world, with the dramatic decline in rheumatic fever, mitral stenosis is much less common. At the same time, mitral insufficiency, due either to structural deterioration of the valve or secondary to changes in left ventricular geometry from chronic ischemic heart disease, has become a common indication for heart valve surgery. Structural repair of the leaking mitral valve whenever possible, rather than replacement of the valve with an artificial prosthesis, has been shown to be decidedly better in virtually all important respects, with fewer perioperative deaths and better late outcomes. Some estimate that as many as 80 per cent of leaking mitral valves are amenable to successful repair. Despite compelling outcomes, and data favouring repair rather than replacement, fewer than 50 per cent of patients with mitral valve insufficiency undergo valve repair, but have mitral valve replacement instead. This disappointing statistic has resulted from the fact that many cardiac surgeons have not mastered the technical challenges of valve repair. The clear advantage of mitral repair over replacement with either a mechanical or biological prosthesis has been established by multiple surgical series, making repair rather than replacement mandatory whenever feasible. Since many practising cardiac surgeons are not comfortable attempting mitral valve repair, the referring physician should select for referral of a patient with mitral valve insufficiency only to a
surgeon who is capable of and willing to repair the incompetent mitral valve whenever anatomically feasible. Minimally invasive or limited incision heart operations
The other important innovation in heart valve surgery over the past decade has been the successful development of alternate, and often less invasive, surgical incisions for valve repair or replacement surgery. The standard and most common incisional approach used by heart surgeons over many years is the median sternotomy incision. This operative approach entails a midline incision from the base of the neck to the upper abdominal wall, exposing the sternum which is then completely divided using a bone saw. For most cardiac surgical procedures performed on cardiopulmonary bypass, full exposure of the heart and great vessels within the pericardium and adjacent mediastinum facilitates the necessary operative manoeuvres, provides the surgeon with full exposure of the heart to deal with any unexpected problems, and is in fact necessary to allow for full exposure of the posterior or inferior aspects of the heart. Some negative physiological consequences of a full sternotomy incision, especially when combined with entry into one or both pleural spaces, include respiratory insufficiency, increased post-
Technical innovations in handling diseased valves Preferential repair of a leaking mitral valve instead of replacement with a prosthesis Valve-sparing replacement of a dilated or dissecting aneurysm of the ascending aorta instead of replacement Routine repair of a leaking tricuspid valve rather than valve replacement with a prosthesis Repair of selected leaking tricuspid and bicuspid aortic valves instead of replacement with a prosthesis Direct-vision commissurotomy of stenotic mitral valves
surgery wound inflammation and greater blood loss. Patients with these extensive surgical incisions experience slow recovery and long convalescence. While many surgeons have eschewed the challenge of minimally invasive approaches, complaining that smaller incisions restrict their procedural options and add unnecessary risk for the patient, operations performed through smaller incisions generally result in less discomfort, less blood loss and corresponding reduction in the need for transfusion, more rapid recovery and few wound complications. The hemi-sternotomy incision
The partial sternotomy approach, sometimes referred to as a hemi-sternotomy incision, represents an important innovation for heart valve surgery. The most common application of a hemi-sternotomy incision in heart valve surgery has been the upper partial sternotomy approach for aortic valve repair or replacement. The sternum is divided from the suprasternal notch and may be carried laterally for a short distance into the 3rd or 4th intercostal space. For an aortic valve procedure, this ‘J’ incision, as it is often referred to, may be directed medially to the left or laterally to the right, depending upon the patient’s unique anatomy. If the mitral valve is the target of procedure, the partial upper sternotomy is generally carried laterally into the 3rd intercostal space. Less commonly used is the lower partial sternotomy incision that some surgeons have employed for mitral valve procedures. The primary disadvantage of the lower partial sternotomy is poor exposure of and access to the ascending aorta for cannulation and cross clamping. If the lower sternotomy approach is used for a mitral valve procedure, arterial access for cardiopulmonary bypass is usually obtained via the femoral artery and the aorta is not cross-clamped. An additional disadvantage of any hemi-sternotomy incision that is carried medially or laterally into an intercostal space is the need to sacrifice the internal mammary artery on that side.
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Surgical speciality
Mitral valve surgery through a right chest wall incision
Although some have used a partial lower sternotomy incision to expose the mitral valve for repair or replacement, the more commonly used ‘less invasive’ incisional approach for a mitral valve procedure is a right lateral thoracotomy incision via the 4th intercostal space. Chest wall muscle sparing and careful rib spreading will minimise chest wall trauma and generally will provide for excellent exposure of the left atrium and mitral valve along with adequate exposure of the ascending aorta. Depending on individual anatomic variations, however, the ascending aorta
Innovative operative approaches in heart valve surgery • Greater use of smaller incisions to expose the valve (“limited incision” or “minimally invasive” heart valve surgery) • Upper or lower “hemi-sternotomy” approaches for isolated aortic or mitral valve procedures instead the traditional full median sternotomy incision • Right lateral thoracotomy approach to the mitral valve • Increasing use of peripheral cannulation (femoral or iliac artery, internal jugular and/or femoral vein) for cardiopulmonary support when using a very small chest incision to expose the targeted area of the heart • Use of full Port Access approach for mitral valve repair via a 10cm or smaller right thoracotomy incision, including femoral or iliac artery cannulation and internal jugular and/or femoral vein cannulation to establish cardiopulmonary bypass support, use of a percutaneous endo-clamp catheter to arrest the heart, remote and magnified visualisation of the surgical site, and use of elongated surgical instruments including scalpel, scissors, suture needle driver and knot tying tools, all of which allow for extra-thoracic instrumentation of the valve repair.
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may not be accessible for cannulation or even cross-clamping from right chest incision. Despite the procedural challenges, the right thoracotomy approach through a small incision has been mastered by many skilled cardiac surgeons and has been shown to be well tolerated by patients as well as hastening postoperative convalescence and full recovery. Another incisional approach that has been used by some is the right parasternal incision, made over the 2nd to 4th intercostal spaces. It is necessary to incise the corresponding costal cartilage tissue that often resulted in a chest wall defect and lung herniation. For this reason, the right parasternal approach has been largely abandoned. While the upper partial sternotomy can be reliably used for exposure of the aortic or mitral valves, this incision is not suitable if the patient requires concomitant coronary artery bypass grafting. As is the case with mitral valve repair versus the technically easier mitral valve replacement option, undertaking an aortic or mitral valve procedure through a smaller surgical incision is generally more technically challenging and may, in fact, be riskier. When working on the aortic valve through a partial upper sternotomy, deairing of the left heart chambers may be more difficult, and accessing a tear or disruption on the posterior or lateral aspects of the aorta or adjacent pulmonary artery may be very difficult. Conversion to a full sternotomy incision under such circumstances may be necessary. The dilemma that the surgeon faces when pondering a smaller incision is whether to perform a procedure that will be easier on the patient but technically more challenging for the surgeon. The other important consideration is whether any added risk related to limited surgical field exposure is worth the benefit of the smaller incision and reduced surgical trauma. The referring physician bears some responsibility for determining the appropriateness of the procedure: is surgery indicated and is this the right time for the patient to undergo the operation. The referring doctor must
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Trends and improvements in heart valve prostheses • Improved durability of bioprostheses (tissue valve substitutes), resulting from improvements in harvest, preservation and production techniques • With improved durability of bioprostheses, the proportion of mechanical valve prostheses implanted is declining compared to use of bioprostheses • Availability of multiple mitral valve annuloplasty rings for varied anatomical conditions for use in mitral valve repair • Recent availability of self-monitoring devices for prothrombin time calculation greatly facilitates daily warfarin dosing for patients with mechanical heart valve prostheses.
also take into consideration the capability of the surgical team, especially when the procedure involves additional technical challenges related to valve-sparing repairs and smaller incisions. Heart valve repair and replacement performed without surgery
The most important current innovation in heart valve surgery has been the development of transcatheter techniques for repair or replacement of heart valves. Just as has been the case with percutaneous transcatheter treatment of coronary artery disease, catheter delivery of valve prostheses for valve replacement is now a reality. In addition, percutaneous catheter techniques have been developed to reduce mitral valve insufficiency. To treat aortic valve stenosis, two transcatheter devices have been implanted successfully in hundreds of patients with excellent results in terms of safety and efficacy. Both are bioprostheses mounted on a balloon catheter. In the more common approach, the catheter is threaded into place in the aortic root retrograde through the aorta via a trans-femoral or iliac artery insertion site. Alternately, the catheter with
Surgical speciality
clip is deployed in such a way as to attach the central leading edges of both mitral leaflets. With this technique, a billowing and incompetent mitral valve is converted from a single leaking orifice to a more effectively closing double-orifice valve. While many patients have been successfully treated with transcatheter mitral repair devices or have had transcatheter aortic valve replacement, the longterm durability, especially of the mitral repairs, remains to be demonstrated. Regardless, these innovations have been transforming. In the case of transcatheter aortic valve replacement, many people in need
A u t h o r
the collapsed valve prosthesis is inserted through the left ventricular apex into the aortic root. The balloon is then inflated, compressing the native aortic valve, followed by deployment and expansion of the valve prosthesis snugly into place in the aortic annulus. For transcatheter mitral valve repair, two options have been used successfully over the past several years. The technique referred to as transcatheter mitral annuloplasty involves insertion of a semi-rigid device into the coronary sinus directly adjacent to the posterior aspect of the mitral valve. With successful sizing of this annuloplasty device, the dilated posterior mitral annulus is compressed or shortened by the device, reducing the dilation of the annulus and rendering the valve more functional and less insufficient. The other technique involves apical septal puncture and placement of a catheter into the left atrium. Using fluoroscopic and echocardiographic imaging of the valve leaflets, a
of relief from progressive aortic stenosis who may not have tolerated surgical valve replacement have, and will be, successfully treated. As we have experienced with percutaneous stent therapy for obstructive coronary artery disease, the availability of percutaneous techniques for heart valve disease will greatly increase the number of those benefitting for heart valve therapy. It is remarkable to reflect on the progress in heart valve surgery over the past 80 years. Who could have predicted the success of heart valve surgery or the development of transcatheter heart valve repair and replacement!
Timothy J Gardner is a noted heart surgeon and leader in cardiovascular medicine in the US. He is Medical Director of Christiana Careâ&#x20AC;&#x2122;s Center for Heart & Vascular Health. He was chief of the Division of Cardiothoracic Surgery for the University of Pennsylvania Health System from 1993-2003. He has lectured extensively both nationally and abroad and he is the author of nearly 200 scientific papers and has edited or contributed to many texts on cardiac surgery.
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Diagnostics
MR Diffusion and Perfusion Can they replace PET? Functional Magnetic resonance imaging tools have now become widely available and allow viewing beyond the morphology of physiologic and pathologic tissue. Using innovative sequence design and modern MR contrast media, most methods can be easily integrated into the standard #MRI protocols and make a combined assessment in one single exam possible. Although MR is still less sensitive than PET imaging, functional MRI tools end up as a comparator using to some of the assessments, e.g. perfusion imaging or diffusion MRI, even the same modelling strategies of the imaging data are used. Marco Essig Professor Radiology, Department of Radiology German Cancer Research Center Germany
W
hile in the past, MRI was praised mainly for its superb anatomic display and tissue contrast, a number of advanced, nonenhanced and contrast-enhanced MR imaging techniques have been devel-
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oped in the past years that provide new insights into the physiology of tissues and the pathophysiology, for example, of tumours. These techniques include MRspectroscopy, perfusion MR imaging, dynamic contrast-enhanced MRI and diffusion tensor MR. The provocative question, if these methods may one day replace PET in oncological imaging, needs to be discussed. Today, the combined PET-CT acquisition is becoming the standard in the assessment of focal and systemic cancer. PET-CT provides a n excellent combination of morphological and metabolic imaging and identifies tumorous lesions that are at least 5mm in diameter with the uptake of e.g. fluorine-18 FDG. With the use of a combined system one has the possibility to locate those lesions with a high precision. PET-CT, however with its limited spatial resolution, fails to detect lesions smaller than 5mm reliably. Therefore, MRI could perhaps aim to compete by realising its high-resolution potential. Whilst FDG-PET is the standard tracer method in most cancer types, alternative tracer methods with a more specific uptake are investigated and may allow for a better imaging of anti-tumour effects involving angiogenesis, apoptosis and reporter gene expression. But if the advocates of both of these modalities view each other as rivals, how can they help each other? Instead they should answer following questions: What can functional MRI learn from PET and vice versa? How and when can MRI be used instead of PET? These questions can form key for panel discussions for the radiological community. Proton magnetic resonance spectroscopy of Chemical Shift Imaging (CSI) is becom-
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ing a common clinical tool because it can add to the diagnostic accuracy of MR imaging. In neurooncology it has been shown that MRS, especially if combined with the later described MR perfusion, is able to increase the sensitivity and positive predictive value in the determination of the glioma grade when compared with conventional MR imaging. The use of modern scanner technology further allows to measure spectroscopic data from a single voxel. Two or three dimensional MR spectroscopy (2D or 3D CSI) help to acquire multiple small voxels which give better information about the heterogeneity of a lesion. The voxel information can be used to calculate metabolite ratios which can be colour-coded and overlayed on the anatomic images to better visualise, for example, hot spots within the tumour. Follow-up assessment of tumours is another promising field for MR spectroscopy. Increase in size and contrast enhancement are typical findings in tumour progression but they also reflect therapy-induced changes. The same is true for postoperative changes. Magnetic Resonance Spectroscopy (MRS) provides, beside the definition of extent of changes, the metabolic fingerprint of a lesion which can be further enhanced by the analysis of the quantitative ratio of tissue metabolites such as N-acetylaspartate (NAA), creatine, choline and lactate. Perfusion-weighted imaging (PWI) is a new tool which provides information about the hemodynamics of anatomic tissue or lesions and is mainly used in the assessment of disturbed cerebral hemodynamics, e.g. in stroke MRI. In brain tumours, the method showed benefits for three major fields: differential diagnosis, biopsy planning, and treatment monitoring. MRI can now provide quantitative
Diagnostics
diffusion weighted and Diffusion Tensor Imaging (DTI) also play an important role in the diagnostic workup and monitoring of patients with cerebral tumours. Another promising field is diffusion weighted imaging in the assessment of lymph node metastases. DTI is a promising new methodology which allows insight into the integrity of tissue of the brain. Lymph node imaging and prostate cancer DSC (A) MRI
DCE (B) MRI
DSC acquires a series of EPI images after a bolus injection ofcontrast media and using the indicator dilution theory for quantification of blood flowand volume. DCE MRI acquires a series of GRE images after slow contrast mediainfusion for quantification of tumor vascularity and vessel permeability. Histology proved the presence of low grade and high grade areas with different vascularity and molecular vascular profiling within the same tumor and in good correlation to the imaging findings. Figure 1
are good examples in the description of tumour infiltration potentiality by this method. All methods can be integrated in the treatment monitoring in anti-cancer therapy. As at initiation, tumours in a pre-vascular phase are supplied by oxygen and nutrients that diffuse from pre-existing normal vessels, ischemia leads to the secretion of angiogenic factors when the tumour reaches a critical size. Angiogenic markers, such as VEGF, are responsible for the recruitment and maintenance of
A u t h o r
information of the underlying pathological tissue with the help of PWI. It can also provide better metabolic information about brain tumour biology with the help of MRS. PWI in neurooncology is mostly performed on the basis of T2+ weighted dynamic susceptibility contrastenhanced (DSC) MR echo-planar imaging approaches. Newer perfusion imaging approaches, which do not need extrinsic contrast media application, use the blood as intrinsic contrast media. Dynamic Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI) describes the acquisition of serial T1 weighted images before, during and after the appearance of extracellular low-molecular weighted MR contrast media in the tissue. The resulting signal intensity measurements of the tumour reflect a composite of tumour perfusion, vessel permeability, and the extravascular-extracellular space. DCE-MRI has been used in quite a large variety of clinical oncologic applications including body cancer detection (e.g. The DCE-MRI). It allows to measure the vascular permeability and its aberrations, while the microvascular density (MVD) describes the histopathologically partial picture of the tissue microvasculature. Furthermore, MVD is also a heterogeneous property of tumours and is limited by histopathologic sampling and are generally hotspot values. The measurement of the tumour microvascularity using the DCE-MRI method has found to be well correlated with prognostic factors such as tumour grading, angiogenic factors, e.g the vascular endothelial growth factor expression (VEGF) and with the risk of recurrence or simple survival outcome measurements. Dealing with modern chemotherapeutic approaches, the use of DCE-MRI in follow-up studies is becoming more and more important. Since the anti-angiogenic therapies focus on the measured DCE parameters, the method may play an important role as a predictive marker. Diffusion weighted MRI is used routinely in the assessment of cerebral infarction and infectious diseases. Both
tumour vessels, which exhibit increased blood volume and permeability compared with normal vessels. MR-based techniques like dynamic susceptibility weighted (DSC) MRI or dynamic contrast enhanced (DCE) MRI can be used to measure the blood volume, the vascularity, the size of the vascular space within designated areas, and the behaviour of contrast within those vessels. DCE-MRI has been used in a variety of tumour entities and oncological applications including cancer detection, diagnosis, staging and assessment of treatment response. Tumour microvascular measurements by DCE and DSC-MRI have been found to correlate with prognostic factors such as tumour grade, microvessel density (MVD), and vascular endothelial growth factor expression (VEGF) and with recurrence and survival outcomes (Figure 1). A group of researchers from the University in Munich are evaluating the role of perfusion MRI to monitor the efficacy of anti-angiogenic treatment in kidney cancer. This type of cancer has been shown to respond well to anti-angiogenic drugs. Functional measurements related to the tumour blood supply should provide a surrogate marker of whether the treatment strategy is working. This may not be obvious from measurements of the tumour size or morphology. Work to standardise and to quantify diffusion and perfusion MRI procedures is just beginning. This will be most essential if multi-centric trials are to be conducted to be used for follow-up assessments and in clinical trials. However, it should be taken into account that for absolute quantification both diffusion and perfusion MRI require specifically tuned sequences and an extensive and time-consuming post-processing.
Marco Essig is a Professor of Radiology in Heidelberg Medical School and Assistant Medical Director in Department of Radiology, Head of MRI and Neuroradiology, German Cancer Research Center, Heidelberg, Germany. He was Professor of Radiology, Heidelberg Medical School.
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Diagnostics
Cardiac Computed Tomography
Emerging cardiac devices and technologies Recent studies have confirmed that non-invasive coronary imaging using Computed Tomographic Coronary Angiography (CTCA) is exceptionally accurate and at the same time, compared with its invasive counterpart, is faster, cheaper and safer. Jeffrey M Schussler Medical Director Cardiac Intensive Care Unit Baylor University Medical Center, USA
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O
ver the last five years, the speed and resolution of mutislice Computed Tomography (CT) has advanced to the point where it can now be used for accurate cardiac evaluation. Calcium scoring, a popular method of cardiac evaluation using Electron Beam CT technology (EBCT), has been re-evaluated using spiral CT technology, and has been validated for risk assessment of patientsâ&#x20AC;&#x2122; long-term cardiovascular outcomes and in varied patient ethnicities. Calcium scoring, a gated non-contrast examination of the heart using cardiac CT, is a quick and safe way of evaluating for the presence of calcified atherosclerotic coronary plaque. The largest drawback of calcium score is that while a positive test confirms the process of atherosclerosis, a negative score does not completely rule out the disease. While high calcium scores can assess general risk of coronary events, they cannot accurately predict individual coronary stenosis (Figure 1). Multislice Computed Tomographic Coronary Angiography (CTCA), unlike calcium scoring, allows for the evaluation of the soft as well as the calcific plaque within the coronaries. The technique is similar, but the addition of iodinated contrast during the scan, and higher resolution imaging allows for more anatomic evaluation of the coronary structures and the surrounding cardiac anatomy (Figure 2).
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Prior to the advent of 16 slice scanners, it was difficult to evaluate the heart, much less the coronary arteries, due to the constant motion of the beating heart. With a 16-slice scan, patients would typically have to hold their breath for 25 to 30 seconds for the entire heart to be imaged. This was difficult for some patients to do, and there was acceleration of heart rates towards the end of the scan. In addition, it was difficult for
LAD
Calcium score of a 45 year old asymptomatic man with strong family history of coronary disease. Calcified plaque (arrow) is demonstrated in the proximal left anterior descending (LAD). This amount of plaque in a young man places him in the highest per centile risk for future cardiac events compared to men of the same age without detectable plaque. Figure 1
Diagnostics
the patient to remain movement free for such a long time. Sixty-four slice scanners, which were largely available starting in 2006, allowed for acquisition of heart scans in only few seconds, and at higher heart rates than were previously possible. With the larger (approximately 4 cm) arrays in 64-slice scanners, the heart could typically be scanned in its entirety within five or six heart beats. This eliminated almost all of the problems with breath holding, and there was a much shorter time that patients needed to remain motionless. The additional benefit was that a wider range of heart rates were acceptable for scanning. There has been a great deal of publication on 64-slice scanners with regards to accuracy of the evaluation of coronary disease, as well as its utility in evaluating the larger structures of the heart. The majority of recent evaluations suggest that the sensitivity and specificity for 64-slice scanners is exceptionally high, typically in the 90-95% range. Currently, most research and clinical trials are being performed on 64-slice technology, and the majority of scans being performed clinically are using this technology. From a patientâ&#x20AC;&#x2122;s perspective, having a CTCA or calcium score is a relatively simple and painless process. Calcium scoring is slightly less involved than a CTCA, since no contrast is used, and no intravenous access is necessary. ECG leads are placed on the patientâ&#x20AC;&#x2122;s chest, and a 2.5 to 3mm thickness scan is performed through the level of the heart, gated to the patientâ&#x20AC;&#x2122;s heart beat. There is no post-imaging recovery time, and the patients are able to leave immediately. A preliminary report is often given to the patients before they are discharged. The final report is generated only after the review of the final images by the reading physician. Images are sent to a workstation for initial processing by the imaging technologist and then reviewed by the reading cardiologist or radiologist. For patients, the total time this process takes, including paperwork, is less than 30 minutes.
For patients receiving a CTCA, the process is similar. Outpatients are typically given oral beta blockers two to three days prior to and on the day of the scan. They are asked not to eat six hours prior to scan. Once in the imaging suite, an intravenous line is placed in an antecubital vein. Telemetry is connected to ECG leads which are placed on the chest, but as lateral as possible to avoid interference with the scan. Patients who have significant renal insufficiency are typically not candidates for this test, although a mild amount of renal insufficiency is not enough to disqualify them. With 64-slice scanners, there is less of an issue related to heart rate, and patients with heart rates up to 80 bpm are still able to be imaged with excellent image quality. Patients with irregular heart rates (e.g. atrial fibrillation or a large amount of ectopy) are not good candidates for coronary imaging, although it is still feasible to evaluate the larger structures of the heart. The CTCA scan itself consists of a series of pictures including an optional initial calcium score. A scout scan it used to localise the borders of the heart, and then a test bolus (typically 20 cc of contrast material) is used to localise the left main coronary and estimate the transit time of the contrast from the IV to the coronary arteries. The full bolus (typically 80 cc of contrast material) is injected at a rate of 3 to 5 cc / second. The patient is asked to hold their breath for the duration of the scan, which lasts 5 to 10 seconds, depending of the area of the scan. Once the scan is complete, the patient is allowed to leave. Images are sent to the reading workstation, and the reading physician evaluates the raw data, reconstructed images, and generates a final report. For patients, the process (including paperwork) takes less than one hour. In comparison with its invasive counterpart, CTCA is much safer. The only risks are related to the contrast dye, which is potentially toxic to the kidneys, and the theoretical risk of the
A 64-slice computed tomographic cardiac scan in a 50 year old woman with chest pain and risk factors for coronary disease. A A 3D reconstruction (panel A) demonstrates the coronary arteries and the larger structures of the heart.
B A maximum intensity pixel projection (panel B) highlights areas of calcific plaque.
C The left anterior descending (panel C) is free of disease.
D A close-up of the left main and proximal left-sided arteries (panel D) highlights a small area of non-obstructive calcification in the ostium of the left main (arrow).
Aa
E The left circumflex (panel E, arrow) is free of disease, as is the right coronary artery (panel F).
F Curved reformatted images (panels C-F) allow the visualisation of the lumen of individual arteries.
This patient was treated with aggressive medical therapy, as no flow limiting disease was seen. No invasive angiogram was indicated. Figure 2 www.asianhhm.com
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Diagnostics
A
B
C
Invasive cardiac catheterisation (panel A), 3D reconstruction (Panel B) and axial image (Panel C) of a patient with a single coronary artery arising from the right coronary cusp. The left main (arrow) is noted to be traversing between the aorta and pulmonary artery, which has been associated with sudden cardiac death. Figure 3
dose of ionising radiation. For patients with normal renal function, the contrast load is very safe. Only about 100 to 120 cc of contrast is given during a typical cardiac CT. The radiation is variable, but typically ranges from 10 to 16 mSv for a gated study. The application for multislice cardiac CT generally falls into two categories: Evaluation of the coronaries and evaluation of the non-coronary cardiac
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structures (Table 1). The evaluation of coronaries is mostly done to the patients who suffer from chest pain and have a low to moderate risk of flow limiting coronary disease. It is always better to send patient for an invasive angiogram if there is a very high pre-test probability of significant coronary disease. Many patients sent for CTCA have had a prior stress test which was thought equivocal or negative, but in patients who had an invasive angiogram it is deemed overly aggressive. In this subset of patients, CTCA can define those patients in whom it is unnecessary to proceed with further testing. In high-risk asymptomatic patients, there is still potential use for CT to identify patients who have very premature or sub-clinical atherosclerosis. This type of evaluation is currently not being reimbursed by insurance companies, and is often paid for by patients outof-pocket. Coronary anomalies, while uncommon, are potentially lethal. Certain subsets of these patients are at high risk for sudden cardiac death, and so it is helpful to evaluate the course of the anomalous arteries (image-anomaly Figure 3) CTCA is considered the gold standard for the evaluation of the coronary tree for the presence of anomalous coronaries. While this is its strongest indication, these patients represent a much smaller group than the patients who are suspected of having flow-limiting coronary disease. A large group of patients are now receiving cardiac scans as part of the preoperative evaluation for electrophysiology procedures such as pulmonary vein ablations for atrial fibrillation (Figure 4). In our centre, as with many others, this is becoming the standard of care prior to this type of invasive treatment. A growing number of patients in whom re-operative coronary artery bypass is being contemplated are receiving CTCA to evaluate patency and location of grafts (both readily determined utilising CT) prior to repeat median sternotomy. Some
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patients are now receiving CTCA instead of invasive angiography prior to noncoronary cardiac surgery in whom the pre-test probability of disease is relatively low. The most significant change from 16 to 64-slice scanners was the reduction of acquisition time, while the resolution of the scans was essentially unchanged. Beta blockers, which are less necessary with 64-slice scanners, are still typically used as they improve the overall image quality and allow for larger radiation dose modulation. Recently, there has been an increase in the awareness of the potential dangers of radiation, and in particular those theoretical dangers associated with ionising radiation from the increase in utilisation of computed tomography. While the dosage of CTCA is higher than that of a typical invasive angiogram, the onetime dosage of a CTCA is negligible in the total impact of clinical incidence of cancer. Current Indications for Cardiac Computed Tomography • Chest pain in patients with moderate risk for flow limiting coronary disease • Chest pain in patients with equivocal stress testing • Coronary anomalies • Cardiac evaluation prior to pulmonary vein ablation • Post coronary bypass evaluation of graft patency
Possible Future Indications for Cardiac Computed Tomography • Screening for early presence of asymptomatic coronary disease • Pre-operative coronary evaluation for non-coronary cardiac surgery • Pre-operative coronary evaluation for coronary bypass • Pre-operative coronary evaluation for non-cardiac surgery • Post-PCI evaluation of coronary stent patency Table 1
Diagnostics
A
LPV
B
LSPV
C
RSPV
LAA RPV
LIPV
RIPV
LAA
Internal view (panel A) and external views (panels B and C) of the left atrium of a patient prior to pulmonary vein ablation for atrial fibrillation. The ostiae of the left sided pulmonary veins (LPV) as well as the left atrial appendage (LAA) and right sided pulmonary veins (RPV) are clearly seen (panel A). This type of imaging facilitates the operator’s choice of catheters, as well as allows planning for ablative procedures. External views allow for the determination of the number and location of the pulmonary veins. LSPV – left superior pulmonary vein. LIPV – left inferior pulmonary vein. RIPV – right inferior pulmonary vein. RSPV – right superior pulmonary vein. LAA – left atrial appendage.
Figure 4
Calcium scoring may be supplanted by CTCA once technology to reduce overall radiation dosage is adopted. It is not too farfetched to foresee a time when an ‘at-risk’ individual will receive a screening CTCA at age 40, much in the way that certain individuals receive a screening colonoscopy. Once the resolution of CTCA approaches that of invasive heart catheterisation (approximately 0.2 mm), there may be far fewer diagnostic procedures performed. Besides preoperative scans performed in patients with low-risk for flow limiting coronary disease, it may become feasible to scan individuals who are high-risk for left main and multivessel disease, sending them to coronary bypass without having an invasive catheterisation. It will also be more feasible to visualise post-stent patients to evaluate for in-stent restenosis. If this becomes the norm, there may be shift in training programmes away from producing ‘inva-
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There have been advances in reducing the amount of radiation by reducing the amount of peak radiation during those parts of the cardiac cycle which is less useful to image (e.g. systole). Dose modulation has been available for several years, but the most recent generation of software and hardware allows a significant dosage reduction. New hardwares have focussed on two areas: array size and spatial resolution. Several companies have produced scanners with larger physical arrays, which can theoretically image the heart in a single heart beat. Some of the early literature suggests that utilising a higher-slice scanner would allow for faster acquisition and reduction of additional dose and gathering more data in less time. There is almost no clinical data out on the 320-slice version of these scanners and at present, only a handful of clinical sites are in operation. It is likely that with the quicker acquisition times, it will be easier to scan patients whose heart rates are higher, and possible that patients with irregular heart rhythms may be imaged more successfully. Other companies have focussed on improving detector quality and resolution, keeping the physical size of their detectors unchanged. These efforts will further improve the evaluation of plaque distribution, lumen size, and their potential ability to determine ‘at risk’ or ‘unstable’ plaque characteristics. For example, arterial collaterals, which have previously been too small to define, are potentially visible through this technology. With these evolutionary advances in technology, there will be expansion of applications which will be seen in the coming years. One of the areas which may benefit immensely from this technology is the emergency department. Recent studies have shown that chest pain triage is feasible and potentially cost-reducing in the emergency setting. It is notable that several hurdles (including rigorous patient selection) need to be addressed before this technology is utilised in a wider clinical setting.
sive’ cardiologist who do not perform interventions. Resource utilisation may change, with a greater focus on outpatient diagnostic imaging with a larger percentage of patients being referred directly for intervention or surgery. Overall, the future of cardiac computed tomography looks bright. There is a strong advocacy for the adoption of this technology. Active training programmes are being conducted throughout the world, with the first board certification in 2008. The technology is proven even in its infancy, and appears to be here to stay. Cardiac computed tomography, which has advanced quickly in only a few years, stands poised for more evolutionary leaps over the next decade, as it is incorporated into our cardiovascular treatment algorithms. References are available at http://www.asianhhm.com/magazine
Jeffrey M Schussler is the Medical Director of the Cardiovascular ICU, one of the assistant Fellowship Directors for the Cardiovascular Disease Fellowship, and is the Vice-Chair of the Institutional Review Board at Baylor University Medical Center . Schussler’s research and publications have involved both invasive and noninvasive coronary angiography and the use of multi-slice CT for cardiac imaging. He has written chapters for several current textbooks on CT cardiac imaging.
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Diagnostics
The Innovator’s Prescription How Asia can disrupt the global healthcare Asian innovators have the opportunity to design systems and services that are profitable and sustainable, yet affordable and accessible to everyone. As they do so, they can make major contributions to solve the global healthcare crisis by collaborating with colleagues in other regions to adapt and export those new models of care. Alexandra Leichtman Manager Jason Hwang Senior Strategist Healthcare Practice Clayton M Christensen Co-founder Innosight LLC, USA
T
oday’s healthcare systems are in a critical state of distress in nearly every nation around the world. In developing countries, the prevailing model equates to adequate care for the wealthy and little for the masses. Nationalised, single-payer models like the systems in the UK and Canada face long waiting lists and spiralling costs. The notoriously dysfunctional US system combines the follies of each: escalating costs that threaten to swamp public payers and employers, together with impending workforce shortages in critical areas—fostering both inequali-
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ties in access to care and in the ability of patients to afford it. Asian systems are facing similar pressures. As developing nations become more urban and affluent, patients will inevitably transition from sporadic reliance on local healthcare providers to a model of healthcare consumption that attempts to mirror the systems found in developed countries. Industry players will be increasingly tempted to compete by developing cutting-edge, centralised and high-cost infrastructure. However, the outcome of this model in western systems suggests that this impulse should be questioned, and, concerted effort should be made to avoid the traps in which those systems now find themselves. Improved healthcare should not come at the expense of creating innovative, convenient, low-cost models that are accessible to everyone. Based on 20 years of research at the Harvard Business School as well as field work designing and deploying innovations, we have observed the transformation of industry after industry when complicated, expensive products and services are replaced by affordable, accessible alternatives. This agent of transformation, disruptive innovation, has a rich history of success in Asia. Cellular telephony catapulted Southeast Asian countries past stages of expensive infrastructure development. The advent of compact and inexpensive automobiles, first in Japan and more recently in India and China, has upended the global auto industry. Consumer products targeting the bottom of the pyramid have found early traction in Asian markets. Indeed, innovations in Asia have often presaged transformations in the US and Europe. In Asian markets, themes of affordability and accessibility
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are familiar, particularly in developing economies that face the natural challenge of serving low- and rising-income consumers. Healthcare is an industry ripe for disruption worldwide, and it is possible that Asia will lead a wave of disruption there as well. A more comprehensive discussion of disruptive innovation in healthcare can be found in The Innovator’s Prescription: A Disruptive Solution for Health Care (available January 1, 2009) and at the book’s website. Enabling technology
Technological enablers in healthcare often take the form of innovations that precisely diagnose the underlying causes of patients’ conditions. They replace the historical process of trial-and-error treatment of symptoms followed by post-hoc diagnosis. Precision medicine involves applying therapies that are predictably effective for precisely-diagnosed diseases, and this rules-based work can be standardised to facilitate treatment by a wider range of caregivers and in a wider range of settings than previously possible. This transition enables broader access and reduces overall system costs in two ways: Procedures can migrate from specialists to generalist physicians, nurses, family members and patients themselves. Additionally, the site of care can shift to local hospitals, outpatient clinics, offices, and retail locations. Avoiding the use of centralised hospitals populated by highly-trained specialists eliminate major drivers of healthcare costs. Singapore’s Economic Development Board, via its healthcare venture capital arm Bio*One Capital, has a good grasp of the concept of technological enablers,
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Diagnostics
investing in a portfolio of disruptive companies. Building upon the Singapore government’s investments in medical research, Bio*One formed Dx Assays, a joint venture with a European biotech firm. The focus is developing molecular diagnostic assays to facilitate cost-effective drug development by identifying appropriate candidates for trials based on genetic factors and precise disease diagnosis. On the treatment side, Bio*One has also funded ventures aimed at expanding access through accurate, simple to deploy therapies that would preclude intervention by a professional. One portfolio company, ReVance Therapeutics, is exploring novel technologies to deliver large active molecules through the skin. One lead application in clinical trials is delivery of botulinum toxin type A, which, in addition to cosmetic applications, can be used to treat a variety of muscular disorders, regulate certain glandular functions, and possibly treat very common conditions like prostate hyperplasia and migraines. The technology also shows promise for delivering insulin, antibody-derived therapies and non-steroidal anti-inflammatory drugs. Telecommunications, too, has an important role to play in enabling healthcare disruptions. Remote care networks in Asia have been entrusted with outsourced diagnostic work for years. Using state-of-the-art telecommunications technology, Teleradiology Solutions, a Mumbai-based radiology services provider, leverages wage and timezone differentials to allow hospitals in the US and Singapore to better meet growing demand. Though wage disparities may
ultimately shrink in the long run, the same model can be applied to serve remote or sparsely-populated communities. With the advent of simple, low-cost, portable imagers and the increasing video capabilities of general telecommunications tools like mobile phones, the telemedicine model may allow health systems in developing economies to provide widely-accessible quality care without the 30-40 year cycle of infrastructure development. Business model innovations
The US and European healthcare systems have been particularly resistant to business model innovations, with strong inertia due to entrenched fee-for-service accounting and payment models and a century-old focus on hospital- and physician-directed delivery. The result has been a system in which healthcare providers are economically incentivised to create or inflate demand for their services. Generically, there are three distinct business models: solution shops, valueadding process (VAP) businesses and facilitated networks. In healthcare, these are often conflated in a single organisation, creating a complex, confused institution that is unable to accurately allocate costs and drive efficiency and productivity. Segregating these business models through the creation of single-purpose institutions is the most promising avenue to increased access and affordability. Solution shops, like the general hospitals that excel at diagnosing and solving unstructured problems, will necessarily have high-cost business models, and the payment systems they employ should compensate them sufficiently for their
The mechanism of disruptive innovation • Enabling technologies that simplify and routinise formerly complex and unstructured processes (e.g. precise diagnostic technologies, telecommunications) • Business model innovations that allow companies to profitably deliver affordable, accessible solutions to consumers (e.g. targeted and efficient providers, facilitated user networks) • Value networks of companies that have mutually compatible economic models which together provide the underlying commercial infrastructure (e.g. drug and device suppliers aligned with integrated payer-providers and a health information system).
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specialised services. The fee-for-service model is appropriate for these problems and is likely to persist in dedicated solution shops. VAP businesses, by contrast, focus on transforming incomplete or broken things into higher-value outputs. For unrefined crude oil, the treatment process to transform it into petrol is consistent and known. Therefore, the petroleum refining business conforms to the VAP model. Many medical procedures are likewise suitable for VAP hospitals and clinics, which take a narrowly-defined slice of customers with similar needs and apply standardised, efficient care—often at a fraction of the cost of a solution shop or conflated model. Aravind Eye Hospital in India, a pioneer in the VAP hospital movement, is now the world’s largest and most productive eye care facility. From the outset, Aravind’s founders were committed to providing free eye care for the poor, creating a powerful incentive to develop innovative low-cost treatment models. By some measures, Aravind is more than five times as productive as the average ophthalmologic hospital in India. Expanding their reach beyond their local markets, VAP hospitals like Aravind can serve as models for the emerging trend of medical tourism. While some early entrants in medical tourism have simply re-created the high-cost model of solution shop general hospitals, the savings based on wage and cost differentials alone are not a durable advantage. Innovative business models like Aravind have a greater chance of remaining relevant even as wages rise, because unlike solution shops, VAP businesses present a more attractive value proposition by charging fixed prices for their outcomes—often guaranteeing the results. Because of this output orientation, VAP hospitals can significantly reduce the total system costs. A final model, facilitated networks, holds promise for treating chronic illnesses requiring behaviour changes, coordinating the response of caregivers and patients to disease outbreaks, and filling persistent infrastructure and logistical gaps in the
Diagnostics
Value networks The final element of disruptive innovation, value networks, is often the most difficult in industries like healthcare in which system participants have evolved to develop mutually-incompatible economic incentives. As a result, the commercial infrastructure is resistant to change, even when it optimises overall outcomes, and the system remains deadlocked. One model for untying this Gordian Knot is integrating the payer, provider, and physician models as some nationalised systems have done. Though Singapore has focussed considerable effort in this direction, the model may not be widely replicable as it requires significant control and alignment of multiple stakeholders. In the absence of government-controlled reform, innovative businesses should explore models for creating integrated systems of their own. In the US, Kaiser Permanente created a system in which it owns hospitals, employs doctors, and provides services to consumers for a fixed annual fee. Aravind, the Indian eye hospital, has also had success integrating critical parts of its commercial infrastructure. Given its volume of eye patients, Aravind was able to set up a manufacturing facility to produce intraocular lenses of comparable quality to imports at less than 15 per cent of the cost. Its value network has also evolved to include facilities to train and house doctors and nurses, ensuring a supply of quality practitioners.
SMS messaging to sign up donors, post requests, and coordinate donations. Using Rs 2 lakh of his own money and without the assistance of the government or NGOs, Kushroo Pocha has created the largest blood donor database in India. Networks like these can help accomplish the same individual and public health outcomes that formerly required constant reliance on skilled health workers or the building of high-cost infrastructure and organisational capacity. Conclusion: The last shall be first?
Asian systems at every stage of development are being confronted by the
Alexandra Leichtman is a Manager at Innosight LLC, an innovation and strategy consulting firm in Watertown, Massachusetts, USA.
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medical landscape. Examples of facilitated networks in healthcare include communities targeted to specific chronic conditions like dLife.com, which focusses on Type 1 and 2 diabetics, whose daily healthcare questions and needs cannot be conveniently, efficiently, and profitably served by traditional healthcare providers. Facilitated networks played an important role in containing the 2003 SARS outbreak in China. ESRI China, a geographical information software firm, created the SARS Mapping Website that used data from government health authorities to produce accurate maps of affected areas that even included details about specific buildings. Public health officials, health workers, the media and individual citizens could get up-to-date reports on suspected, actual, and recovered cases to inform their activities. The same model could easily be adapted to create an effective H5N1 influenza surveillance and response network. Facilitated networks have also helped coordinate blood donations in India, which faces chronic blood shortages. In the absence of comprehensive municipal or national blood banks, the burden of finding lifesaving units of blood often falls to the patient or his family. Indianblooddonors.com is a network that connects patients and potential blood donors using the Internet and
challenges of delivering comprehensive, accessible and affordable healthcare. However, many are not yet encumbered by the legacy cost structures and patient expectations that impede innovation elsewhere. The patterns we have seen in healthcare and other industries suggest that innovation paths need not be linear or predetermined. Emulating the established healthcare models already found elsewhere will guarantee that Asian systems will always remain behind. But the central message of disruption is that innovations can come from unexpected and counterintuitive sources. By experimenting with new healthcare models, Asian innovators have the opportunity to design systems and services that are profitable and sustainable, yet affordable and accessible to everyone. As they do so, they can make major contributions to solve the global healthcare crisis by collaborating with colleagues in other regions to adapt and export those new models of care. Meanwhile, developed economies in Asia can foster innovation by funding and facilitating technologies and business models that enable the rehabilitation of their healthcare systems. With deliberate management and foresight, Asian healthcare systems can pioneer innovations that not only serve their populations, but also provide the models the rest of the world is so desperately seeking.
Jason Hwang is Senior Strategist for the Healthcare Practice at Innosight LLC; Executive Director of Healthcare at Innosight Institute, a non-profit social innovation think tank in Watertown, Massachusetts, USA; and the author of The Innovatorâ&#x20AC;&#x2122;s Prescription: A Disruptive Solution for Healthcare.
Clayton M Christensen is the Robert and Jane Cizik Professor of Business Administration at Harvard Business School and co-founder of Innosight LLC and Innosight Institute. He is the bestselling author of six books, including The Innovatorâ&#x20AC;&#x2122;s Prescription: A Disruptive Solution for Healthcare.
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Technology, Equipment & Devices
Industry report
Orthopedic Medical Devices Emerging technologies and trends Scope and Segmentation
Research is looking beyond using implants, screws, metallic cages, to incorporating biologic bone substitutes with regenerative potential to address orthopedic conditions. For example, Medtronic Sofamor Danek of Memphis licensed the growth factor rhBMP-2 developed by Wyeth and this powerful bone stimulant has been coupled with their LTCAGE Lumbar Tapered Fusion Device.
However, A biologic substitute can be any material that dynamically alters and affects the surrounding environment to proceed in an active biological manner, which manifests as cellular activity, growth, and differentiation. For instance, orthopedic surgery required surgeons to use biocompatible specifically designed metal implants to structurally support a fractured bone or in some cases to fuse bones in spinal conditions. Now surgeons are looking towards a biologic component incorporated with the metal implant so that the latter serves to regenerate living bone tissue while the metal implant functions in a structural manner. Definitely, the next stages of technology development would reduce the amount of metal in implants and use biodegradable scaffolds for the structural function. An ideal biologic bone substitute is required to have either or all of the following--osteogenic, osteoconductive, and osteoinductive properties. Steady progress in biologic material sciences assures that the future treatment of injury and tissue loss will be altered and more biologically correct. The objective of this research service is to analyse and report new and emerging orthopedic biologic substitutes; advances in research and development (R&D) and product development in the orthopedics arena. The research service plans to identify key players (with contact information)--those in the forefront of technology development and commercialisation pertinent to this market and end-user information. The scope has been sketched to include bone substitutes or biologics that fill voids, support and enhance the repair of biological defects.
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The first chapter gives an introduction to orthopedics, followed by an overview of the technology developments observed in orthopedics till date. The scope and segmentation of the study and the methodology adopted for it are also discussed here. A technology primer of the different kind of biologic substitutes--allografts, demineralized bone matrix (DBM), synthetics, factors and stem cells are discussed in the second chapter. A heads-up of the trends in the orthopedics industry and important clinical trials has also been included under relevant headings. Developments in technology, products, and research studies in orthopedic biologic substitutes that have osteogenic, osteoconductive and osteoinductive potential constitute the third chapter. Challenges faced by the industry participants, and the drivers to the biologics industry are discussed under relevant heads in the fourth chapter. This chapter also comprises an analysis of the impact of the biologic substitutes (allografts/ DBM, synthetics and factors/cells) on different orthopedic applications. The factors include funding, partnerships, intellectual property (IP) portfolio, regulatory impact, biocompatibility, and scalability. Patents and the contact details of company officials and university faculty members who have participated in the study are listed in the fifth chapter. (Patents are listed by area and contacts are listed separately for companies and universities). Decision support database tables form the sixth chapter of this study. Frost & Sullivanâ&#x20AC;&#x2122;s healthcare decision support database service offers a valuable collection of tables that provide historic and forecast data for medical devices. Methodology To provide a thorough analysis of each topic, Technical Insightsâ&#x20AC;&#x2122; analysts perform a review of patents to become familiar with the major developers and commercial players and their processes. Building on the patent search, the analysts review abstracts to identify key
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Frost & Sullivan scientific and technical papers that provide insights into key industry participants and the technical processes on which they work. The analysts then create a detailed questionnaire with content created to address the research objectives of the study, which functions as a guide during the interview process. While the analysts use structured questionnaires to guarantee coverage of all the desired issues, they also conduct interviews in a conversational style. This approach results in a more thorough exchange of views with the respondents, and offers greater insight into the relevant issues than more structured interviews may provide. The analysts conduct primary research with the key industry participants and technology developers to obtain the required content. Interviews are completed with sources located throughout the world, in universities, national laboratories, governmental and regulatory bodies, trade associations, and enduser companies, among other key organisations. Our analysts contact the major commercial players to find out about the advantages and disadvantages of processes, and the drivers and challenges behind technologies and applications. Our analysts talk to the principal developers, researchers, engineers, business developers, analysts, strategic planners, and marketing experts, among other professionals. The project management and research team reviews and analyses the research data that are gathered and adds its recommendations to the draft of the final study. Having conducted both published studies and custom proprietary research covering many types of new and emerging technology activities as well as worldwide industry analysis, the management and research team adds its perspective and experience to provide an accurate, timely analysis. The analysts then prepare written final reports for each project and sometimes present key findings in analyst briefings to clients.
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In and Out of the
Emergency Room Streamlined design of patient flow Many factors influence the patient throughput in and out of the Emergency Department. Clarity in layout and simplicity in operations are keys to streamlined flow. James W Harrell Design Leader Healthcare Group GBBN Architects, USA
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T
he Emergency Department (ED) has become the ‘Front Door’ to the hospital. Many institutions report that 50 per cent or more of their admissions come through the ED. Yet in many hospitals the flow to and through the ED is fraught with bottlenecks, with confusing and conflicting messages circulating to and within the ED. Hospitals with only one or poorly placed dual entrances experience the chaos of comingling of self-arriving patients with those coming in emergency vehicles. Many EDs have poorly conceived first encounter systems. For instance, triage stations that are too small or too few result in patients lining up to be seen, in effect, diluting or even negating the concept of priority screening. Or, queuing can also build up if distinct patient registration stations are adjacent to the waiting room. Poorly designed treatment areas inhibit efficient clinical operations.
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There are many examples of layouts that require excessive walking to fetch supplies, to get patients to an x-ray room, or to simply manage the patient record. These conditions lead to delays in treatment and increased length of stay within the department, which in turn lead to the buildup of stress in patients and staff alike. Poor and inefficient patient throughput results in costly, error-prone operations and patient dissatisfaction. Arrival
There are two ways to come to the ED. Most of us envision going to the ‘Emergency Room (ER)’ as that dramatic, frenetic trip we see depicted in movies and on television in an ambulance with the siren blaring. The by far more common occurrence is to be brought by family, friends or come alone. We distinguish these two arrivals as ambulance and ambulatory or self-arrival.
Facilities & operations management
Department should point only to the Ambulatory Entrance—ambulance drivers and emergency medical technicians are familiar with the route and don’t require such directions. This arrangement eliminates the need for the selfarriving patient to make choices regarding which entry may be correct. The Ambulatory Entrance should be unmistakably obvious and have a system to shelter arriving patients from the elements. Doorways should have hands-free operation and a supply of wheelchairs should be readily accessible. There should be someone from the hospital available at this point to assist the patient into the hospital. This is often done by security personnel. Electronic health record
Initially, the ‘ER’ had but one entry. The ambulance arrivals and the ambulatory patients alike came in this way. Of course, as the hospital’s emergency services grew, more and more people began to access the service and this entry became highly congested, chaotic and, quite simply, unsafe. Fundamental change in the layout of the ED began to manifest separate entrances for the two types of traffic. These entrances were generally side-by-side, and indeed, many instances of this arrangement are in use today. Having these in close proximity, however, still creates an opportunity for confusion and uncertainty for the self-arrival patient as to which is the correct place. The optimal layout is to have distinct pathways for the ambulance apart from the ambulatory. This separation should begin at the arrival to the campus and continue to each entry. Ideally, the ambulance entrance should be located so as not to be in sight from those coming to the ambulatory entry. Signage and directions to the Emergency
The advent and utilisation of the electronic health record brings a significant opportunity to streamline and improve patient flow. When a ‘paper’ chart is used, the patient record must remain in close proximity to the unit clerk, who manages the upkeep of the record. Since doctors, nurses and ancillary caregivers must access this same, unique, singular set of documents, there are frequent occasions when the location of the chart is difficult to determine and much time is wasted by care-givers looking for it. The electronic record allows data to be entered anywhere within the unit, especially at the patient bedside. Multiple, simultaneous access permits faster entry and retrieval of data from within the unit and from remote diagnostic services such as the lab. Strategic supply placement
An axiom of the workplace holds that worker efficiency has direct relationship with the placement and availability of supplies. The same holds true in the healthcare environment, especially in the ED, where patient throughput is impacted by the nurses’ ability to get needed supplies at the bedside. It is clear that if much walking is required to fetch supplies from centralised
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Facilities & operations management
Traditional intake flow
First encounter Patient
Triage
Bed
Patient
Registrar
Patient
Greeter
Patient
High impact intake flow Patient
But, what to do when the beds are all full? After the quick reg, the patient is given an initial assessment by a clinician—generally a nurse in a triage station. This triage will determine the severity of the patient’s condition and allow the emergency personnel to establish the priority to provide care. The patient, and in many cases with family members or escorts, is then shown to an ‘inner waiting area’ in the treatment zone. The patients can be watched and reprioritised, thereby getting the right patients into a bed more quickly. The traditional concept of a main waiting room is altered. Since patients and some family members are waiting within the treatment areas, the main waiting room can be much smaller, as it will be serving family and visitors who shouldn’t be or prefer not to be accompanying the patient.
Registrar
Bed
Quick reg
Patient
Contemporary emergency department Ambulatory Entrance Distributed Imaging Ambulance Entrance
Low acuity "fast track"
Inner waiting
Acute care Critcal care Inner waiting
Swing spaces
Distributed Imaging
Inner waiting
Acute care
Immediately upon arrival, the ambulatory patient must be acknowledged and given the opportunity to state his problem. This is done by a non-clinical “greeter” who conducts ‘quick reg’ (registration)—a basic set of identifiers to register the patient into the hospital’s record system. This should take but a few minutes. When beds are available, the patient is placed immediately therein. The registration process can be completed at the bedside.
Distributed Imaging
To improve patient flow, a scheme for treating patients with low-risk problems such as sprains and lacerations should be developed. This notion of a ‘fast-track’ should be incorporated within the context of the total treatment area. All beds should be capable of severing any acuity level. The fast track patients can be clustered in one area of the overall department not isolated in a discreet or separate unit. This will permit flexibility in assigning patients to rooms based upon the variation in volumes throughout the day. Ambulance patients have a different track into the ED. The condition of these patients is generally communicated to the ED by the ambulance personnel—paramedics or emergency medicine technicians. Their arrival is then anticipated and care protocol can be promptly implemented. However, there are occasions when multiple arrivals occur at essentially the same time. When this happens, a triage of these incoming patients becomes necessary. In high-volume EDs, especially trauma centres, planning for an ambulance triage station will afford appropriate space to handle this traffic. Figure 1
clean supply and utility rooms, more time will elapse in the patient visit. Moreover, evidence now shows that when nurses spend a lot of time walking, this can result in increased stress and concomitantly decreased effectiveness in direct patient care. When supplies are decentralised and evenly distributed throughout the department, walking distances are reduced and access time is improved. A three-tier supply system has proven to be highly successful in supporting improved throughput. The first tier system includes items common to each bedside, alcohol wipes, blood draw tubes etc. The second tier system,
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which includes items like procedure trays, IV fluids, assorted catheters etc., is essential to this concept. These items must be located within just a few steps from the patient bedside. An often used configuration is to have the second tier supply in carts or cabinets at the perimeter of the nurse and doctor work area that is in the centre of an array of exam rooms or patient care stations. A central storage room, the third tier supply system, is located on the unit out of the area of direct care. This is where infrequently used items and backup supplies for Tier 1 and Tier 2 are kept.
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Diagnostics
Getting diagnostic information in a timely manner has significant impact upon patient flow through the ED. A high per centage of patients require xrays. Sending the patient to the Radiology Department has become too onerous in terms of time—transport time, queuing in the department, waiting for a radiologist’s reading and so on. The quest to improve patient throughput has resulted in placing medical imaging within the ED. The volume of patients seen in the department will, of course, determine the number of radiographic devices required, but in high volume EDs, multiple devices can be
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Facilities & operations management
Supply system configuration
expected. As in the case of decentralised supplies, the same benefit of improved throughput will accrue from decentralisation of diagnostic tools, especially if digital radiographic devices are used. Since digital medical imaging is filmless, multiple devices need not be clustered for operational efficiency. Placing a DR in proximity to the ‘fast-track’ zone will greatly increase turnaround time for image acquisition and result in quicker diagnoses. A second DR can then be placed conveniently to serve the more acute patient. Placing a CT scanner adjacent to trauma bays saves critical time in dealing with life-threatening situations.
Tier 1 Supplies @ bedside
Tier 2 Supplies in close proximity
Discharge process
After medical clearance by the emergency medicine physician, the patient and his family / escort is either given discharge instructions and is released to leave the hospital or is admitted to the hospital. If the patient is admitted, several steps must be taken to place the patient in a bed. The timeliness of moving the patient out of the ED and into this bed will greatly affect the overall patient flow in the department. If location and assignment of beds is slowed or beds can’t be found, these admitted patients become ‘boarders’ in the ED. Boarded patients then
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occupy space that could be used to treat the next incoming patient and in effect reduce the number of beds available to do so. Just a few unexpected ‘boarders’ can choke an organised flow through the ED.
Nurse / Physician work area
Figure 1
The disposition of inpatient beds is a complex issue, but it is imperative that the hospital be committed to a policy of timely bed availability for those in need.
James W Harrell has over 40 years of experience in planning, design and construction of healthcare facilities. His interest in improving the environments in which healthcare is provided has led him to be involved at the national level in the development of design standards for adult critical care units, newborn intensive care units and women’s healthcare environments.
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IT continues to evolve in an industry characterised by slow adaptation and other challenges that vary from country to another. Asian countries would have to transform their systems so as to integrate with the rest of the world. In this scenario, e-Health and the Internet seem to be the way forward.
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c) Establishment of e-library where all the articles can be accessed through Internet. Considering that a majority of Asian countries are still developing, do you think Asia is ready for the rapid technological changes shaping healthcare globally? In my opinion Asia is ready for rapid technological changes happening in health care globally. More over, in country like India with such a vast population it might benefit the most.
Pradeep chowbey Chairman Minimal Access, Metabolic and Bariatric Surgery Centre, Sir Ganga Ram Hospital India
In your experience, how has IT helped improve patient care, what are your expectations from it in the coming years? Yes, healthcare IT has definitely helped us in improving patient care. It provides us with complete and accurate history, timely alert, medical knowledge to patient and doctors, communications with other points of care, greater ease and speed of recovery of patient data. In future there might be: a) More training provided to health care providers b) Development in the field of telemedicine and telesurgery
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How do you see the adoption of PHRs and EMRs in Asia? Do you think Asian hospitals are prepared to shift toward the trend? Electronic Medical Records (EMR) is being utilised in various hospitals in Asia but Personal Health Record (PHR) system has to go a long way before its implementation due to its vast population size, cost and limited knowledge in this field to health care provider. What are the areas of Healthcare IT that you think need to be further developed? Areas in which I think healthcare IT can be further developed: a) Personnel heath record system b) Centralised e-library c) Better training to healthcare providers d)Development of improved and specialty software for medical data archiving and retrieval. e) Uniformity of data recorder to improve data analysis
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What are your views on Asian healthcare IT sector? The most important issue facing the healthcare IT sector in Asia is to ensure that quality of care is achieved through effective diagnosis, patient compliance and avoiding medical errors. In addition, the Asian healthcare IT sector must improve access to care in remote communities, or emerging and underdeveloped economies, with enough hospitals and care professionals to meet healthcare demands. With an ageing population across the globe and especially in the Asia Pacific region, the healthcare sector will need to focus on reducing patient care and administrative costs for the healthcare system. Thus, it is imperative that healthcare organisations recognise these issues and respond with effective processes and technologies for delivering superior care. This includes the widespread adoption of healthcare IT systems to deliver improvements in the quality and accessibility of care, while also lowering costs. As the region is home to more than half of the world’s population, and with the Age Wave, (fast forward into the next 15 to 20 years)—there are 3 distinct markets for Health IT to address: • The first is Chronic Diseases / Ageing management (Personal Health Records / PHR • The second is Modernizing the Point of Care (Electronic Medical Records / EMR) • And the third is Population Health and Bio Surveillance (Electronic Health Recrods / EHR). These pose the following threats as well as opportunities: • Incredible healthcare demand is certain • Healthcare Infrastructure cannot be built fast enough
Learning from the
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Global Experience • The only way out of system failure is increased efficiency—this can be achieved through the growth of the Healthcare Information Technology adoption. Do you think Asia is ready to accept the changes in technology? Developed countries in Asia are undertaking national initiatives to develop national EHR policies, with hospitals focussing on digital integration and operational efficiency. These initiatives are being undertaken with the ultimate goal of improving productivity and quality of care, while also helping to reduce overall healthcare costs. As for the developing economies in Asia, they are also working on healthcare reform and are building their infrastructure to meet the needs of the new demands in healthcare. Some of these economies, such as China, may eventually leap-frog the rest of the world through the adoption of new technologies. What is the scenario in Asia? Different countries in Asia are facing different challenges and will need to respond accordingly. For example, due to their rapidly ageing populations, countries such as Australia, Japan and Singapore are already placing a focus on the ‘silver industry’, which is potentially one of the fastest growing markets. In such countries, PHRs and home-care initiatives are part of the national focus to empower patients to have the same level of care at home, while bringing down costs and improving the quality of care beyond the hospital itself.
The scenario for China is slightly different. The country is likely to leapfrog the rest of the world in healthcare IT adoption if they are able to do the following: • Learning quickly from the international / global experience • Overcoming the resistance to change • Knowing how to manage change • Developing more expertise in these areas of need. Other countries like Malaysia and Thailand are focussing on Telehealth and improving primary care by providing accessibility to remote communities and building healthcare infrastructure. How do you see the adoption of PHRs and EMRs in Asia? Do you think Asian hospitals are self sufficient to shift toward the trend? EMRs and PHRs are still at a very early stage of adoption both globally as well as in Asia. Asian hospitals can learn from international HCO experiences through successful EMR implementation. They will also need to work with national health authorities on policies and EHR /EMR plans pertaining to legal, standards and infrastructure matters. What are the areas of Healthcare IT in which do you think improvement is required? It depends to a great extent on the goal and plan of each hospital. Having said that, hospitals should focus on managing change, and measure the business value that Healthcare IT brings to its operations. Developing KPI(s)
Steven Yeo Vice President and Executive Director HIMSS Asia Pacific, Singapore
to measure Access to Care, Workflow Optimisation, Employee Productivity and Patient Satisfaction are also important contributing factors to the success of Healthcare IT adoption in a hospital environment. Events such as HIMSS AsiaPac09, happening from 24–27 February 09 in Kuala Lumpur, provides health IT stakeholders with a platform to connect and exchange ideas in order to help advance quality healthcare delivery through the use of IT. It is a place for intensive learning and knowledge exchange and networking with leaders from healthcare, government and IT.
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Peter Gross Senior Vice President and Chief Medical Officer Hackensack University Medical Center, USA
Start with the Basics In your experience, how has IT helped improve patient care, what are your expectations from it in the coming years? IT when properly implemented in an orderly fashion should improve patient safety, facilitate compliance with performance measures, reduce costs, and improve physician and nurse satisfaction with their jobs and their health care institution. Considering that a majority of Asian countries are still developing, do you think Asia is ready for the rapid technological changes shaping healthcare globally? I think you need to start with the basics. Automate laboratory and
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radiology results reporting, then follow up with a pharmacy system that helps manage physician orders. Build in some clinical decision support to help reduce errors from medication ordering. Putting transcripts of history and physical dictations and those of operative notes online could come next. Add electronic signatures. Nursing documentation and the electronic medical administration record can follow. This approach is reviewed in Gross and Bates. JAMIA 2007;14:25-28. How do you see the adoption of PHRs and EMRs in Asia? Do you think Asian hospitals are prepared to shift toward the trend? PHRs and EMRs are inevitable to
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accomplish what was described in the first question. They also will be the basis for a country wide RHIO (Regional Health Information Organization) or HIE (Health Information Exchange) which will permit doctors and patients wherever they are in that country to access there medical information. What are the areas of Healthcare IT that you think need to be further developed? Virtually all areas of Healthcare IT need further development. In fact, they will be in a state of evolution for a long time.
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Driven by e-Health Sisira Edirippulige Coordinator e-Healthcare Programme Centre for Online Health University of Queensland Australia
In your experience, how has IT helped improve patient care, what are your expectations from it in the coming years? It is not an overstatement that new information and communication technologies (ICT) have revolutionised the way people access information and communicate with each other. All spheres of human society have impacted by these developments. Undoubtedly, the impact of ICT developments on health sector and medicine has been significant. However, the changes prompted by ICT in health care are limited compared to other areas such as trade, banking or media. The influence of ICT can be seen in clinical practice, administration, education and research. The use of the Internet by patients and practitioners to access health information has tremendously increased in recent years. The Internet also has become a powerful media of
public health and education. Disciplines such as teleradiology and telepsychiatry have proven being efficient and cost effective in delivering care. In general, a large number of research studies have shown the effectiveness of telehealth / telemedicine applications in providing improved care, particularly to communities otherwise are deprived of such services. These include rural and remote communities and populations in developing countries. Evidence suggests that the use of ICT in health, i.e. e-health / telehealth / telemedicine has a potential to address critical problems in the health sector. There is a growing awareness in health professionals, policy makers and business communities that ICT has a major role to play in health sector. These factors will facilitate the use of e-health in the future. Considering that a majority of Asian countries are still developing, do you think Asia is ready for the rapid technological changes shaping healthcare globally? The irony is that despite its limited use, e-health is better suited to address critical problems in developing countries. e-Health can be helpful to support limited (and often isolated) health professionals by providing better education, information and
peer-support. E-health can also provide alternative ways of care delivery to meet needs of patients. But the main problem in developing countries has been the lack necessary infrastructure, funding and expertise to establish and sustain e-health. This is true with a substantial number of countries in Asia which fall into the category of developing countries. The level of ICT use in the health sector of these countries is limited. The barriers mentioned above will prevent these countries benefiting from this new tool. Another reason for slow progress in e-health in Asia can be the magnitude of health problems themselves. Countries like India and Chinaâ&#x20AC;&#x201D;worldâ&#x20AC;&#x2122;s most populous countriesâ&#x20AC;&#x201D;have enormous challenges in terms of health care provision. Restructuring health systems in these countries is an enormous task. However, the good news is that the rapid economic growth and the technological development have already begun to re-shape the health sector in these countries. Meanwhile, it is worth mentioning that there are some good examples in Asia where progress in e-health has been substantial. South Korea, Singapore, and Taiwan, for example, have been able to use modern technological developments to advance their health systems.
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scenario in australia The level of success in e-health in Australia, like in many other countries has been mixed. There have been some success stories in implementation and sustained use of e-health while others have shown disappointing results. In general, there is a rapid increase in the use of computers and the Internet within health care sector. A recent survey revealed that 94 per cent of GPs nationwide are computerised, 90 per cent GPs use clinical software packages and nearly 80 per cent use broadband connection. The growth of ICT use can be seen in both public and private health sectors. As mentioned, the use of e-health in Australia is patchy. There are number of different research projects underway to investigate the effectiveness of ICT use in improving health care provision. Some e-health projects are initiated and funded by federal and state governments while others by business partners. However, the majority of these initiatives are run as research projects, but few have been integrated to mainstream care provision. One key feature of the current state of e-health in Australia is a clear lack of coordination. This is probably due to the absence of an authorised body to oversee and coordinate e-health activities. It is
How do you see the adoption of PHRs and EMRs in Asia? Do you think Asian hospitals are prepared to shift toward the trend? Electronic storage and access of patients’ data has been a topic of the day in many parts of the world. Progress in electronic health records in Asia has been slow due to understandable reasons, such as lack of funding, infrastructure and expertise. Unlike European Union (EU) or some other industrialised nations, Asian countries have not been able to invest heavily into electronic health records. However, there are some impressive examples in Asia; for example to certain extent, Singapore, Taiwan and South Korea have made headway in implementing electronic health records. These examples show the trend in Asia. The transition from paper based patient records to electronic health records has not been an easy and smooth process even in industrialised countries. Continuing economic and social progress along with the technological advancement are the key for Asia to achieve this goal.
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expected that the National e-Helath Transition Authority (NEHTA)— nation’s peak e-health body—is to play a key role in Australia’s fragmented e-health fabric. Having said that, a number of e-health projects have shown the potential to be feasible, cost- effective and sustainable. One good example is the telepaediatric service managed through the Centre for Online Health (website http://www.uq.edu.au/coh/) at the Royal Children’s Hospital in Brisbane which provides services to rural and remote communities in Queensland. It is estimated that some 15 per cent of all burns consultations are now done via telehealth. Attempts are being made to use telehealth applications to improve the health services in the indigenous communities in Australia. If successful, these models can be used to in similar contexts in other parts of the world, particularly in developing countries. Australian government’s emphasis on expanding broadband coverage and funding IT education will have an impact on the growth of e-health. At the same time, Federal Government has also shown interest in supporting e-health.
What are the areas of Healthcare IT that you think need to be further developed? When you look at the global scenario, you can see that the key emphasis in ICT use in health has been on administration and education. A limited attention has been put on the use of ICT in clinical practice. I think it is vital to explore new ways of using technology for clinical practice and for better clinical outcomes. It is also important to explore ways to use low cost technology as opposed to expensive technologies. There is some good evidence that simple and inexpensive technologies can be effectively used in providing quality health care. One such example can be email. I strongly believe that technology must NOT be the focus of e-health / telehealth. While technology is important, the primary focus of e-health must be on the clinical need. Evidence shows that technology driven practices are doomed to fail. Technology must be a tool to address the need. Therefore, e-health practitioners must
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adopt a ‘techno-skeptical approach’ to treat technology as a tool to serve the purpose. Any other comments? I think there is a critical need for a global governing body for e-health. Setting up such an organisation with appropriate legal and regulatory rights should be a priority. While this peak body would have authority relating to e-health across the world, it should also have the necessary financial capability to fund its activities. The importance of e-health education has so far been overlooked. Evidence shows that access to systematic education in e-health is limited in both industrialised and developing countries. Systematic education in e-health for health professionals must be at the heart of the strategy to promote e-health. It is important to increase funding for post-graduate studies in e-health/health informatics. The accreditation of e-health qualifications is another way to attract health professionals and help address the critical skills shortage.
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Wipro Healthcare Offers Hospital Information System in the “Pay Per Use” Mode
Offering the Software as a Service(SaaS)
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atients’ data in hospitals must be timely, accurate and reliable as it could make the difference between life and death. The benefits of Information Technology can effectively address the challenges faced by healthcare providers. Wipro HealthCare IT (Wipro HCIT) is a dedicated Health Informatics Company and is part of Wipro Ltd ,which is the World’s first CMMi Level 5 certified software services company and the first outside USA to receive the IEEE Software Process Award.Wipro HCIT has a talent pool of over one hundred professionals with healthcare domain, Information Technology and management expertise. There are more than 50 satisfied global healthcare customers who have successfully implemented the healthcare information systems in private and government hospitals, clinics, pharmacies and diagnostic centres. Wipro has recently launched SaaS model called as “Pay per use” or the “Utility Computing Model” of Hospital Information System in India. Especially designed for medium and small sized hospitals and clinics who work on very low IT maturity and shy away from automation. Software as a service (SaaS, typically pronounced ‘sass’) is a model of software deployment where an application is hosted as a service provided to customers across the Internet. By eliminating the need to install and run the application on the customer’s own computer, SaaS alleviates the customer’s burden of software maintenance, ongoing operation, and support. SaaS has the potential to transform the way informationtechnology (IT) departments relate to and even think about their role as providers of computing services to the rest of the enterprise. Simply put, SaaS can be defined as “software deployed as a hosted service and accessed over the Internet.” Today, SaaS applications are expected to take advantage of the benefits of centralisation through a single-instance, multi-tenant architecture, and to provide a feature-rich experience competitive with comparable on-premise applications.
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Key characteristics…
The key characteristics of SaaS software, includes: • network-based access to, and management of, commercially available software • activities that are managed from central locations rather than at each customer’s site, enabling customers to access applications remotely via the web • application delivery that typically is closer to a one-tomany model (single instance, multi-tenant architecture) than to a one-to-one model, including architecture, pricing, partnering, and management characteristics • centralised feature updating, which obviates the need for downloadable patches and upgrades SaaS applications are generally priced on a peruser basis, sometimes with a relatively small minimum number of users and often with additional fees for extra band width and storage. Managing the Risks of Software Acquisition
In a small hospital or nursing home setup it may-not be viable to install, run and maintain an application and the hardware infrastructure by the hospital team. Not only does it require a substantial commitment of financial resources , it also requires space , manpower, power, air-conditioning etc. With this there is always the fear of the initiative not being successful and hence the risk of failure. Hence in a smaller setup the management is looking for a risk free software acquisition where the cost of sunk investment is low. SaaS is a perfect solution for this since it is on a monthly rental model with no upfront investment in either the software or hardware or AMC. SaaS model of hospital information system doesn’t require the deployment of a large infrastructure at the hospital location, which eliminates or drastically reduces the upfront commitment of resources. Managing IT Focus
With SaaS, the job of deploying the hospital information system and keeping it running from day to day—testing and installing patches, managing upgrades, monitoring performance, ensuring high availability, and so forth—is handled by the provider ie Wipro.
By transferring the responsibility for these ‘overhead’ activities to a third party, the hospital management can focus more on high-value activities that align with and support the business goals of the hospital.
Front Office
Considerations for Embracing SaaS
OP Billing
However there are certain considerations when adopting the SaaS model. Having a strong internet connectivity is an essential as all transactions will happen over the internet. Also here the server and data is residing at a third party through it is essential that all data has to be secure and safe with the provider and for that the vendor has to sign all legal non disclosure agreements with the hospital. The datacenter has to follow all norms of physical and virtual security to ensure that the data is secure and non accessible by anybody other than the hospital itself. Thirdly SaaS model proposes standardization of solution for all hospitals. Hence the software is fairly standard across all hospitals who use the hospital information system and individualization or customization of processes and workflows is not encouraged in this model. What is WIPRO offering in SaaS
A secured datacenter which will host and run your software • Complete maintenance and running of the software on Wipro’s infrastructure • Customer access the software over a remote broadband online real-time 24x7 • Wipro experts will train clients people in using the software. This will be done onsite. • Maintenance of hardware, backups, security, bug fixing, database maintenance and application maintenance is Wipro’s responsibility • There is no capital expenditure from Customers side, apart from a monthly fee based on usage. The advantages of offering SaaS to the customers are:
1.No upfront investment in hardware or software 2.Only monthly rental fee plus one time setup and training fee 3.No investment in IT staff and manpower. No headache of retaining them and looking for replacement once they leave 4.No fear of virus or any other form of security attack 5.No challenges of server downtime or breakdowns 6.No worries on data backups 7.No space cost for setting up a server room 9.Monthly recurring cost of air-conditioning the server room. The Product–Modules offered are
The modules and functionality are as foll.
• Registration • Patient search and information • Doctors information • Package and tariff information • Appointment scheduling • OPD Consultation billing • Pathology/Laboratory billing • Radiology and other services billing Admission,Discharge and IP Billing
• IP admissions • Bed availability information • Locate patient- bedwise- wardwise • Collection of advances • IP bill on discharge • Discharge summary • Cancel discharge Consumption Module
• Service consumption by patients during inpatient stay • OT and all procedures tracking • Equipment utilisation • Medicines • Automatic updation of bill Laboratory and Pathology and Radiology
• Billing • Result printing • Result dispatch tracking Contract Management and TPAs
• Package deal designer • TPA data management • Insurance claim and handling TPA patients • Tracking payables from TPAs • Outstandings Reports and MIS
• Analysis on new patient registrations • Collection summary daily, department wise, doctor wise • Profitability of each department • Outstanding position and ageing analysis • Admissions analysis • Clinical data analysis Wipro aims to provide software solutions that are well thought-out, heavily tested and reasonably priced and, ensures reliability and consistency in the performace of the hospital information system by furnishing it with a comfortable and user-friendly interface, elaborate documentation, and technical support. Bottom Line… You concentrate on running the hospital efficiently Wipro will be your partner and take care of your IT and automation needs.
Advertorial
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An Optimistic Outlook
IN D IA
Krishna Ganapathy Co-founder Telemedicine Society of India, India
In your experience, how has IT helped improve patient care, what are your expectations from it in the coming years? It was Rudyard Kipling who once remarked “What do they know of England, who only England know”. In the 21st century this aphorism could be replaced thus “What do they know of healthcare who only medicine know”. 21st Century is the age of informatics. Today’s doctor needs to be as well versed in the basics of Information Technology as he/she is in anatomy, physiology and pharmacology No man is an island unto himself. In the 21st century the physician or surgeon is only a member of a multi disciplinary healthcare team which necessarily must include experts from various domains. Information Technology should necessarily be an integral part of any modern healthcare system. Having been trained in the BC era (before Computers and Before Christ are essentially one and the same!!). It has been my good fortune, to have witnessed the growth and development of medical care in the last 35 years in India including the gradually increasing use of HIT. It would be no exaggeration to state that IT has made, is making and will
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continue to make a significant difference in patient care. Whether it be in the field of diagnosis, investigations, treatment, documentation, retrieval of information, access to state of the art knowledge, medical instrumentation, teaching, research etc IT has made a major difference. IT in healthcare will level the playing field. It will bridge the gap between the haves and the have nots. In spite of the obvious short term and long term benefits it is a matter of deep concern that the use of IT in the healthcare industry is far less than its use in banking, commerce, travel, automobile or almost any other industry. Less than 2 per cent of gross revenues are set apart for deployment of ICT, compared to 5 to 8 per cent in most other industries. IT improves patient care, by enabling processes and systems to be introduced and repeatedly monitored. Standard operating procedures and audit processes can be introduced in almost every aspect of healthcare. Viewing healthcare as an industry and attempting to achieve a sigma six though improbable is not impossible. Using ICT should not be viewed as a dehumanising process. IT should be viewed as a tool to achieve an end. Not
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an end by itself. IT has improved patient care in many, many ways. Providing real time appropriate relevant information to every stakeholder in the healthcare industry makes all the difference. Well informed patients and doctors can make a significant differences in the standard of healthcare. Rapid increase in computing power is accompanied by exponential reduction in costs. Though the healthcare IT market in India has grown 200—300 per cent in the last 10 years, it is accepted that the healthcare sector has to be more IT-oriented. Studies indicate that the use of IT in healthcare has enormous benefits—short term and long term for all stake holders, for e.g. a patient’s hospital stay could be reduced by up to 39 per cent with improved use of IT. Considering that a majority of Asian countries are still developing, do you think Asia is ready for the rapid technological changes shaping healthcare globally? A major advantage that developing countries in Asia have, with regards to being ready for the rapid technological changes shaping healthcare globally, is the fact that they have no colonial legacy to ‘disinherit’ in the field
scenario in India India is indeed a paradox. While we have world-class hospitals of excellence, these are few and far between. They are like oasis in a desert, confined to the urban elite and the well to do. We are in a position to offer state of the art healthcare, to those who come to us from other countries but are unable to do so for the 700 million Indians living in suburban and rural India. The picture, however, is not totally bleak. It is reassuring to see that the central government and several state governments have accepted Telemedicine as a means to provide healthcare. We are optimistic that the present digital divide in healthcare, existing between the haves and the have nots, will gradually shrink. The formation of the Telemedicine Society of India, the Medical Informatics Society of India, the publishing of several journals dedicated to e-Health etc. all augur well for the future though we have a long way to go, but then so do scores of other countries. The Government of India has launched the Health Management Information System (HMIS) portal to convert local health data into real time useful information, management indicators and trends which could be displayed graphically in reports. Real time data provided by web-enabled technologies will strengthen monitoring, enabling policy makers, to make better decisions for public health delivery. Enhancing the information flow at various levels and providing useful and timely inputs for programme development and monitoring. And midcourse interventions in policies would be a direct spin-off. Several multinational companies like GE Healthcare, Intel, Hewlett Packard, Cisco Systems, Qualcomm,
of modern healthcare; for example, they do not have to ‘unwire’ to introduce mHealth. One does not have to undo to keep up with technology simply because e-Health is still not a reality. We do not have to follow the advanced countries. We do not have to piggy back. We can leap frog. The apparent lack of progress in the field of healthcare during the last few decades is not a deterrent. It can actually be viewed as an incentive so far as introduction of e-Health is concerned. We may not have achieved ‘health for all by 2000’ but the target e-health for all by 2020 is not impossible. The exponential growth in mobile telephony and in ICT in India clearly shows that we are more than ready to embrace technology. While it is a matter of justifiable pride that eGovernance is slowly being introduced and that mBanking and mCommerce has also commenced it is a matter of deep concern that the use of ICT in
Microsoft, Google, IBM, Computer Sciences Corporation (CSC), Perot Systems, TCS, HCL and Satyam, to name a few, have all entered the health space. These new healthcare models initiated by the IT companies, while delivering quality care will explore the possibility of innovative new technology that are simple to use, cost effective, portable and power independent. Challenges in integrating IT into the healthcare system in India are many. They include lack of Standards, lack of in-house IT expertise, reluctance of medical, nursing and other staff to change, fear of technology failing (paper systems appeared more reliable), poor support from vendors, reluctance of vendor to make changes in software when requested. These can be addressed by leadership and strong message from the top , ownership by the departments and long term vision, Health Administration acting as facilitator and recognising IT as a felt need in health, recognising champions among the health personnel, customising IT solution to needs of the users, confidence building, good co-ordination and communication between vendors and users. Reasons for relative failure in IT implementation initiatives in Indian hospitals are many. They include customisation of software used to computerise manual processes without proper refinement in policies and procedures; lack of proper implementation methodologies (detailed process study and refinement strategy). To make the management aware about time and efforts required for successful computerisation and not using standard inter operable, scalable software.
the healthcare industry is considerably lagging behind. How do you see the adoption of PHRs and EMRs in Asia? Do you think Asian hospitals are prepared to shift toward the trend? Universal adoption of Personal Health Records (PHRs) and Electronic Medical Records (EMRs) is a challenging and daunting task even in the most advanced countries. The very fact that we have started talking about it in India is itself a good sign. It was Confucius who once remarked “a journey of a thousand miles begins with the first step”. The concept of Personal Health Records (PHR) continues to gather steam as several healthcare and insurance providers established connectivity with PHR platforms like Google Health and Microsoft HealthVault, which allows their members to access and store personal
health information online. Microsoft also continued with its strong strategic alliance plans to promote several of its healthcare offerings. The development of a common strategy and roadmap for e-health standards development, to support interoperability and the adoption of electronic patient records is crucial. One of the barriers in the adoption of international e-health standards in hospitals, is the priority given to internal process functionality. Standardisation of data and processes across hospitals will go a long way in enforcing the use of PHR, EMR etc. A Hospital Information Management System (HIMS) should essentially interconnect all departments of the hospital seamlessly and attempt to minimise operations on paper. No doubt it will take a long, long time before PHRs and EMRs become a reality in India, but it will certainly happen.
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IT Sp eci al What are the areas of Healthcare IT that you think need to be further developed? With the exponential increase in mobile telephony and the imminent deployment of 3G, it is imperative that broad band wireless technology be exploited and used to develop mHealth. While mBanking, mCommerce, mEntertainment is becoming a reality we need to develop mHealth. Pilot studies carried out by Apollo Telemedicine Networking Foundation in conjunction with Erricson in Tamil Nadu, Bhutan and Bangladesh have shown that mHealth can be a reality in India. The number of ‘Hospital on Wheels’ are very few. This needs to be considerably increased, with facilities for real time
UAE
two way audio video contact with a tertiary center. Virtual skills laboratories where a large number of medical and surgical procedures are simulated on virtual patients are now a reality in advanced countries. We need to have such learning centres. To achieve all this, IT should be a part of the medical curriculum. Similarly, Applications of IT in Healthcare should be taught to all IT students. Any other comments? HIT strategy should be driven broadly by business, clinical and societal requirements. Business needs are around administrative work, financial and procurement. Clinical and social needs are quite specific. For
example, patients need to access their health records, get reminders and be advised by doctors even when mobile. Data needs to be captured at source, whether from doctor’s written/spoken word or from equipment or even at patients’ home. On the output end, portable health information should be disseminated to patients’ families and their general physicians. Many hospitals are committed to the use of innovative technology. Apollo Hospitals is working on a project with Tata Consultancy Services that would give each of its patients a Universal Hospital Identification Number (UHIN), thereby providing access to the entire medical records of the patient. The medical data will
An Innovative Transformation John R Hawkins Director Information and Technology Services Abu Dhabi Health Service Company (SEHA), UAE
In your experience, how has IT helped improve patient care, what are your expectations from it in the coming years? Health Information Technologies are streamlining patient care and providing data to foster improved and faster clinical decision making. The SEHA ecosystem is implementing an Electronic Medical Record which will be seamless across 14 hospitals and 65 clinics. Patient Data will be accessible throughout our ecosystem which will drive efficiencies and reduce duplicate procedures. I expect that HIT will continue to drive efficiencies at the clinical level, and that researchers will
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begin to drive population based disease management initiatives which will drive continuous healthcare improvements for the citizens of Abu Dhabi. Last, I expect that social networking tools like Facebook will flourish to launch online communities focused around diseases or conditions to improve patient awareness and information sharing. Considering that a majority of Asian countries are still developing, do you think Asia is ready for the rapid technological changes shaping healthcare globally? Asia and the Middle East are uniquely positioned to harness and implement
be stored for life. Any doctor anywhere in the world will be able to access the patient’s medical history using the number. Apollo has been at the forefront of technology adoption for healthcare in India. The complex issues in healthcare arising due to non-adoption of technology, in managing data, burgeoning manpower cost, quality costs etc. and its impact has been understood. HealthHiway is an Apollo Hospitals and industry initiative to build and provide a comprehensive National Health Data Network ensuring global best practices in healthcare processes and solutions HealthHiway will ensure efficiency in day to day processes in a healthcare system, thereby impacting the key
performance indicators—patient services, clinical outcome and financial health of user companies. This will help the companies in creating satisfied patients and create knowledge for the community. Reduced process and process time will deliver enhanced patient care, lowering operational costs. In the long term, HealthHiway will deliver a National Health Data Network which will create an interoperable, standards based healthcare network that will enable the healthcare community to interact and share data in an efficient and secure environment, with the patient in the center of the universe. According to Ashvani who spearheads the HealthHiway initiative, “Easy to
deploy, Easy to use and Easy to pay” best describes the project. Revenue Management, Learning Management and CME, Performance Management, including Decision Support and Knowledge Management, and Clinical Information Systems form the core of the system While several pilot projects and proof of concept validation studies have been carried out, confirming how IT in healthcare can make a significant difference, these need to be scaled up. A solution is not a solution unless it is universally available. The time is now ripe to go all out and make sure that in the next decade India will be in the forefront of e-Health. Improbable? Perhaps. Imposible? No.
new technologies during this period of rapid growth and development. In addition, these emerging markets can learn from legacy markets to harvest the best of bread for hardware, software, and communication tools.
initiatives are transforming healthcare in the UAE.
EMR. Asian hospitals, and the community are well prepared to shift towards this trend.
What is the scenario in United Arab Emirates (UAE)? Healthcare in the UAE is undergoing innovative transformation to better meet the needs of the current as well as the anticipated population growth. Brand new state-of-the-art hospitals are being designed and built. Insurance reforms are shifting the healthcare economic risk from a government funded model to a more traditional managed care model. The UAE Health Authority (HAAD) is defining health data standards to ensure that providers and insurers are reporting data consistently; HAAD is leveraging this empirical data to drive population based healthcare reforms and healthy lifestyle initiatives. Hospitals are investing in new healthcare technologies, albeit, Software Based, or Therapeutic based. These innovative
How do you see the adoption of PHRs and EMRs in Asia? Do you think Asian hospitals are prepared to shift toward the trend? There is a convergence of consumers, technologies, and providers that are driving the adoption of PHRs and EMRs. Consumers are demanding PHRs to facilitate ownership of their healthcare, to become smarter consumers, and live healthier lives. Technology companies are providing the hardware, software, security, and communication tools to integrate disparate data elements to create the PHRs and EMRs. Providers, regardless of structure: government funded, for-profit, or non-profit, are driving the deployment of EMR to foster improved and more efficient clinical decision making. The convergence of these three vectors—the consumers who are demanding it, technology companies who are supplying it, and the providers who are leveraging it are all driving the adoption of the PHR and
What are the areas of Healthcare IT (HIT) that you think need to be further developed? I am excited about extending the HIT footprint beyond the clinical walls and into the patients home. This extension will be fueled by the development of integrated technologies traditionally found in the clinic, e.g. blood pressure, blood sugar or wound management tools that are connected electronically to the PHR or EMR. Imagine a patient living in a digital home, where the blood sugar is measured and tracked electronically which is correlated to the diet and the exercise program all connected electronically through components like the smart refrigerator and work-out equipment. Extending the HIT footprint into the home will foster patients owning their own healthcare, to allow patients to see the benefits of healthier lifestyle choices, and to avoid costly hospitalisations.
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David W Bates Chief Division of General Internal Medicine, Brigham and Women’s Hospital, USA
What is your take on the issue of interoperability in healthcare IT? The inability to move clinical data from place to place—that is to say, the lack of interoperability—clearly hinders delivery of good care around the world. It also imposes barriers to move between healthcare systems. Work done by our group at the Center for Information Technology Leadership has estimated that the US could save US$ 77.8 billion annually if interoperability were in place. Another key finding that emerged from this analysis
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was the importance of standards for addressing this issue—if standards are not in place, and data are exchanged for example in PDF format, most of the savings would not be realised. We did a further evaluation for Australia, and found that Australia could save approximately $ 4 billion (AU) annually, if interoperability can be implemented there. What is currently being done to overcome this issue? Relatively little is being done with
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respect to regulation in the US to promote clinical data exchange. Most of the emphasis has been placed on what we call regional health information organisations, or RHIOs. In early 2007 we surveyed 145 regional health information organisations (RHIOs), and published the results in Health Affairs in 2008. The key findings were that nearly one in four was defunct, and only twenty were of at least modest size and exchanging clinical data. With respect to what was being exchanged, most successes related to exchange of test results, and few prescriptions or referrals or notes were exchanged. The RHIOs are expected to support themselves, but struggled to do so: thirteen RHIOs received regular fees from participating organisations, but eight were heavily dependent on grants. These data suggest that the business model for clinical data exchange may be problematic, and federal support may be needed. Other countries are using a much more centralised approach. For example, Australia has implemented data exchange in several regions. The UK has a national approach, and “the spine” will eventually allow exchange of a core of clinical data for all citizens in England. Clearly standards play a key role in facilitating this. In the US, the federal government and quasi-governmental entities have established standards for most of the key types of clinical data, but the problem has been that there
Healthcare IT’s Big Challenge are costs to convert, and few users have demanded conversion, so that even though they exist they aren’t yet widely implemented. Other countries like the UK are much further along in this regard. Much more work needs to be done internationally so that standards become accepted. In the far east, Singapore has been a leader in this area, as has Australia and Hong Kong for example has established data exchange within the Health Authority. Issues with privacy and security also represent an important concern, and a small but vocal minority in many countries has substantial concerns. One way of dealing with this is to use an ‘opt-in’ as opposed to an ‘opt-out’ or mandatory approach toward having one’s data included in the clinical data exchange.
date have used some sort of central repository structure. The alternative approach has been to use a federated approach, and only to extract data on a ‘need-to-know’ basis. One of the biggest issues with the latter approach has been speed, which is central in clinical care.
What, according to you, could be the panacea for interoperability? I think that panacea is too strong a word, but one key will be to represent data in standard format and then actually to implement data exchange. Any time you start with data exchange, you identify issues which need to be worked out. Many of the key standards are not fully mature—for example, just because a message is represented as HL7 version 3 doesn’t mean that it will be possible to read it on the other side. Another key issue is the architecture of the data exchange. All the exchanges that have worked well to
How is interoperability affecting patient care? Many predictions have been made about how interoperability will affect patient care, but relatively few empiric data are available regarding this. But it can be expected that patient safety will improve, that it will be possible to decrease redundancy for example with respect to tests, and that the quality of care will improve. We are evaluating the impact of clinical data exchange that has been established in three communities in Massachusetts, and will be looking at these and other issues.
How are vendors responding towards this trend? Vendors are clearly interested and paying close attention, but they are also waiting to be pushed by their clients to be asked to use key standards and to set up the portals to facilitate data exchange. This makes good business sense, as being a ‘first mover’ in this area carries significant risk, but on the other hand will be very problematic for vendors to be laggards in this area.
In our own network, we have achieved interoperability, and it has been very helpful clinically in my own practice to be able to look at lab results from anywhere in the network. Before this, it would often take a long time to get results from some other site by lab or fax, and this often represented a big enough barrier that it was easier to just repeat the test. Furthermore, another effect has been that the pool of specialists I am comfortable working with is much larger, as I can now see data from several thousand specialists. What could be the role of Internet in overcoming interoperability? Clearly, the Internet provides a platform that makes it easy to exchange information at low cost. There are issues at the same time with security, but these should be manageable with techniques like the use of virtual private networks. Any other comments? Overall, clinical data exchange has the potential to dramatically improve care, and reduce costs. That being said, there are many practical hurdles to be overcome. Some of the biggest are better defining the business case, actually using key standards so that they become more mature and the kinks get worked out, and then dealing with the inevitable privacy and security concerns that will arise.
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Banking on Market Demand Gerard Anthony Dass Leader Healthcare Solutions, Nortel Asia, Australia
What is your take on the issue of interoperability in healthcare IT? I believe there is still a lot of room for improvement for interoperability in healthcare. We still see issues in solutions that are not able to be integrated, which costs healthcare institutions a lot of money to fix and causes delays to the implementation of critical solutions. What is currently being done (in terms of regulations and standards) to overcome this issue? User groups have been formed around the region to look into this issue, but with so many vendors providing solutions to the healthcare market, it will take some time to see any change. The main driver for change would be the cost of customizing the solutions. What is the interoperability scenario with respect to Asia? In Asia, the problem with interoperability is the same as in North America and Europe. Healthcare institutions are still faced with the challenges of integrating solutions. Hospitals are currently spending a lot of money to fix issues as we see with the NHS project in the UK. What, according to you, could be the panacea to health IT systems interoperability? I think if key stakeholders in the healthcare market demand something to be done, then the interoperability issue will
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see a significant change. While we don’t see this happening in the next one to two years, there are already forums and user groups that come together to work out a common ground for all solutions to co-exist and operate in an eco-system. How are vendors responding towards this trend? The key challenge is cost. Vendors are taking steps to address this issue but it’s moving at a slow pace. How is it affecting patient care? As hospitals spend more money to fix the issues of interoperability, the cost is passed to the patients. We also see delays with patients being discharged from a hospital or for a patient to get his/her medical records. Once there is a
seamless flow between all the solutions, we will see a significant time savings in patient care. What could be the role of Internet in overcoming interoperability? More industry players are starting to adopt web 2.0 in the healthcare industry. With Web 2.0 technology, the belief is that we will fix some of the issues that are creating the current bottle neck with healthcare applications. Are the existing standards enough to support healthcare data exchange? I think the current standards need to be reevaluated to take into account the current technology trends in the healthcare market. This is already being looked at and we hope to see some changes in the next 12 to 24 months.
New technologies, powered by unified communications, are also now being implemented within healthcare, ensuring the right information is available at the right time, regardless of location. A range of wireless communications are in already in use, such as mobile PDAs or tablets that allow practitioners to make bedside care decisions more quickly. When equipped with mobile devices, they can connect with doctors or specialists at other locations for an immediate consultation or quickly access information from a facility’s digital files without losing valuable time running back to the central nursing station on the floor. Doctors can also now share medical imaging files with distant colleagues for an immediate second opinion and can receive real-time alerts wherever they are, from the moment a patient’s condition worsens and needs attention. For example, Kyushu University Hospital in Japan upgraded its current IT system to a new medical service infrastructure to enable information to be more efficiently stored, managed, retrieved and shared amongst physicians and medical staff. Built on the hospital’s vision to offer patient-oriented, one-stop medical services, the new clinical grade next-generation network provides anywhere, anytime, quick access to information such as diagnosis data, X-ray and ultrasound imaging - and real-time readings of patient vital signs and operating theater monitoring. Real-time access to this important information creates an environment for primary physicians, specialists and medical staff to collaborate more efficiently for remote consultations, diagnosis and patient care. The network from Nortel is an example of how technology can improve quality healthcare services and patients’ quality of life by simplifying the complexity for medical providers to access and share information.
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Adoption in Asia Pacific Challenges such as rising healthcare costs, demand for better quality of healthcare, increasing labour shortage and fragmented healthcare system are making it imperative for healthcare organisation to integrate IT solutions in their administrative and clinical workflow. Sourabh Kankhar Consulting Analyst Frost & Sullivan, Singapore
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e have seen the influence of Information Technology (IT) in many different sectors such as banking, finance and education but healthcare is one sector where the impact of IT has not been so conspicuous. Healthcare organisations have been slow adopters of IT solutions in the past. However, they presently aggressive in adopting IT solutions due to various challenges to healthcare delivery. In Asia Pacific (APAC), Singapore, Japan, South Korea and Australia have been at the forefront of technology adoption in the healthcare sector whereas China, India, Malaysia and Thailand are the emerging markets. Factors driving the adoption of HIT in Asia Pacific Strong government support for HIT initiatives
In Australia, the state and federal government are supporting state-wide and country-wide HIT initiatives. A few examples of such initiatives in the past are HealthSmart, a four-year technology programme in the state of Victoria and HealthConnect, the nationwide electronic health records programme
by the federal government. At present, the State of South Australia is developing Australia’s first fully integrated state-wide electronic health record system through its careconnect.sa programme. In Western Australia, eHealthWA is a major reform programme designed to provide a modern and integrated platform of Information and Communications Technology (ICT) for public health care services in the state. Globally, countries are trying to achieve an integrated healthcare delivery structure in their quest to improve the quality of patient care. Singapore has been successful in its progress towards a well-integrated quality healthcare service. This success can be attributed to the country’s focus on achieving immediate HIT goals rather than holistic ones along with the recognition of the importance of integrating IT into health system by the hospital administrators and clinicians. In 2003, the country’s health minister identified the use of information technology as one of his priorities with the aim of ‘One Singaporean, One EMR.’ With the announcement of the Intelligent Nation
Impact of clinical IT solutions on the challenges to healthcare delivery Challenges Medication errors
e-Prescribing
Fragmented healthcare delivery
EHR, Telehealth
Rising cost of healthcare
PACS, EMR
Increasing labour shortage
Workflow management solutions
Source: Frost & Sullivan
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Clinical IT solution
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Outcome Better access to information Integration of agencies Improved efficiency
Staff retention Figure 2
Roadmap to integrated healthcare delivery in Singapore
• Acute care hospitals, speciality centres and primary care polyclinics restructured into two vertically integrated clusters: the National Healthcare Group (NHG) and Singapore Health Services (SingHealth)
• Harmonisation of the financial, materials and patient management processes across all the NHG institutions by an integrated information system.
• Exensive implementation of administrative and clinical IT systems by the NHG and SingHealth clusters.
1999 - Restructuring of healthcare facilities into two clusters
By2003 - Single EMR system in SingHealth
2003 - NHG's project Naut1cus
• One EMR for every patient • Electronic personal health records • Clinical decision support systems • Home monitoring systems • Clinical databases to support research
2004 - EMRX program
• SingHealth had a single EMR system for the entire cluster.
Future - iN2015 plan
• Government rolls out the EMR Exchange (EMRX) initiative to share electronic medical records across all the public hospitals and polyclinics.
• NHG institutions had different EMR systems linked through a Cluster Patient Record Sharing system.
• Plan to extend EMRX initiative to the private sector healthcare agencies in the future
Source: NBR Center for Health and Aging / NHG Annual reports
Challenges to healthcare delivery drives investment in HIT
Healthcare facilities are facing daunting challenges such as rising healthcare costs, demand for better quality of healthcare, increasing labour shortage and fragmented healthcare system. There will be a huge rise in demand for healthcare services in the future due to ageing of population, lifestyle changes and increasing incidence of chronic diseases. For example, Japan has the fastest ageing population in the world. Today, one in five Japanese people are over the age of 60. The population aged 60 years and above is estimated to be around 28 per cent in 2025. From around 13 per cent of the total population in 2006, the population aged 65 years and over in Australia is projected to be around 28 per cent in 2056. Today, one out of every 12 Singaporeans is aged 65 or above. By 2030, this ratio will become one out of five. These challenges are making it imperative for healthcare providers to integrate IT solutions in their administrative and clinical workflow to bridge the gap between the demand and supply for health services.
Challenges to adoption in APAC Under-investment in healthcare IT
In many APAC countries, there has been an under-investment in healthcare IT in the past. Even now, healthcare agencies in APAC are spending considerably lower on IT initiatives as compared to their counterparts in Europe and North America. In countries such as India and China, the government funding for healthcare IT initiatives is limited and there has not been a strong push from the government regarding HIT initiatives. Economic slowdown
The present economic slowdown is bound to have an impact on the IT budgets of healthcare agencies in APAC. The Chief Information Officers (CIO) in majority of the hospitals will react to the economic slowdown by cutting down on their overall IT budgets. Legacy systems
The lack of awareness of the right systems and limited budgets has led to the installation of legacy systems in many healthcare facilities in APAC, A u t h o r
2015 (iN2015) plan, the government has accentuated that HIT will always be a priority for them.
Figure 1
especially in countries such as India, China and Australia. These systems lack industry standards as well as pose a big challenge in the integration with new modules. In Australia, the state health departments are currently spending millions of dollars in replacing these legacy systems with solutions that are based on industry standards. Conclusion
There has been a successful implementation and wide use of IT solutions in administrative workflow of healthcare organisations in Japan, Singapore, Australia and South. The focus in these countries will now be on clinical IT solutions such as Electronic Medical Records (EMR), Electronic Health Records (EHR) and decision supports systems. Countries such as India and China will concentrate on the implementation of administrative solutions. Clinical IT solutions will play a major role in developing an efficient and patient-centric healthcare delivery structure in the future.
Sourabh Kankhar is a Consulting Analyst with the Frost & Sullivan Asia Pacific Healthcare Practice. He focusses on monitoring and analysing emerging trends, technologies and market dynamics in the Medical Technologies Group in Australia.
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t the start of 2009, it is interesting to look further forward and see just what may be coming in the next 10 years. Many of the people alive today are going to live longer than their ancestors and as medical technologies and our understanding improve, there are more things we can fix. This adds up to a lot of problems for health services around the world; there are not enough doctors, surgeons, nurses and healthcare is getting increasingly expensive. Medical tourism will increasingly drive patients around the world but ultimately there will always be a shortage. Can machine intelligence, sensors and robotics offer some of the services we get from doctors, dentists and surgeons? Can we do this in the home?
The ‘Hippocratic Oath’ mentions the teaching of knowledge and leaving jobs to professionals; in the future, the professional may be a robot. Historically, technological changes have come at a manageable pace; today, the potential danger is that a lot of new technologies are emerging very quickly. We, therefore, need to look forward to what may happen in order to be better prepared for the future.
Chips that are good for you
We are already starting to see the promise of ‘lab on chip’ sensors (or Micro Total Analysis Systems (µTAS)), where a single drop of blood can be scanned for a whole range of problems. Though still in development, the promise of a reduction in the time and cost to do pointof-presence tests has many advantages (rapid results, smaller samples required and no supply chain required for sending samples, though aerial delivery (discussed later) offers an alternative for this). If ‘lab on chip’ sensors are proven successful, it will have a big impact on the way healthcare is provided; near constant monitoring would become cost-effective.
Smart toilets have been touted as the obvious place to do testing, and the toilet does have a provenance in spotting early signs of parasitic infection. More modern variants could soon be analysing what we flush for more subtle indications of changes to our bodies before they become apparent to us and, with diabetes on the increase, it may be crucial in allowing us the chance to change our lifestyle before we need medicine. This, however, raises issues. If a smart toilet can detect traces of drugs, alcohol, sexually transmitted diseases or pregnancy then who should be allowed to see the information, just the person who flushes the toilet, or the owner of the toilet?
A look into the
Future
Ian Neild, Disruptive Futurist, BT, UK
w ww ww w .. aa ss ii aa nn hh hh m m .. cc oo m m
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Have a heart, or at least print me one
shot A snap sim io of per Figure
Figure 1
The doctor can see more now
Augmented reality (mixing computer generated images with real life) and haptic interfaces (controls which give feedback) could aid in the training of medical professionals. ‘Periosim’ from the University of Illinois is a training tool for dentists. Students see a computer-generated view of a mouth from any angle (see Figure 1) and then, using haptic controls, are able to practice many procedures without going near a patient. This has lots of benefits as machines can monitor the students’ progress to ensure that future tooth work is as pain-free as possible and require less return visits. The students can be set dentistry homework and can also watch how procedures should be done. The haptics allow the students to judge just how deep those instruments have to be and how much pressure is needed. If the machine can recognise what would cause pain, then each procedure could score like a computer game. This is starting to become much more feasible as graphics, processing and networking costs have plummeted, while the sending and viewing of extremely large medical files such as DICOM allows for better
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2
ting anipulaclass m s t n Stude OM files in DIC
Research is underway to print replacement body parts and whilst the whole femur may not be replaced it may be possible to create replacement bone, which can be grafted onto existing bone. This rapid prototyping is already available for objects and will have many uses in the medical world, where accurate scans are readily available. Artificial organs are also a possibility, with modified printers already able to print human cells in precise patterns. Rat hearts have also been rebuilt using donor hearts; the donor heart is first partly ‘dissolved’, which eaves a ‘skeleton’ framework and then a DNA soup from the host is used to rebuild the heart using the existing framework. This method creates an organ that the body does not reject since it is made from its own DNA.
teaching and consultation. Disect systems have already performed trials of this with 2D and 3D images being viewed remotely. Students in the class (see Figure 2) access radiology files and annotate the images. A mentor can also work on the same files looking over their ‘virtual’ shoulder. As this is network-based, the students do not have to be in the same classroom and the best teachers / mentors can influence students around the world and expert assistance can be found during normal working hours somewhere on the planet. If operations are recorded along with the haptic data, the computer-generated images used in applications like Periosim can be replaced with real images and a large database of previous procedures stored for future training. We may even see a league table of medical professionals / hospitals and patients may get to know just how good the surgeon or dentist really is. As these leagues would be global, the idea of ‘tele-doctoring’ gets even more promising. If such a league existed, it may be tempting to only carry out certain
procedures, in order to do well in the league. So, would such a league influence the procedures that were carried out? This is entirely feasible but it would be very visible; if each procedure was ranked in terms of complexity by the profession, then any professional or institution that only carried out low-risk or simple procedures may find themselves performing these simple procedures. In the future, as robot surgeons such as the Da Vinci improve. Those who limit their work to simple procedures will find themselves replaced by machines, like modern day luddites. So, soon patients could upload Xrays of their teeth and body scans onto a medical YouTube (it really would be you) and ask the medical professionals to show how they would operate and how this compares to a robotic system. With robots doing the simple surgery, the highly skilled people are able to focus on more complex procedures, though they may be programming the robot to do the task rather than holding the tools
United States flu activity 2008-2009
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Robotic pigeon post delivery
Robots may also help in drug delivery; visiting a pharmacy for drugs is commonplace in the developed world but are we ready for drugs delivered by air autonomously? Unmanned aerial vehicles (UAV) have already been shown as capable of travelling between distant points, therefore, they could be used to deliver drugs and transport blood samples. Flight times would be short and so problems with temperature control would be reduced. A central refrigerated drug store could deliver drugs over a very wide area and blood samples could be flown to central labs efficiently for testing. Let’s play your notes
Multimedia patient records would be a useful addition to patients’ notes as cameras and microphones could record how visual and audible conditions have changed over time. Instead of subjective measurements, it would be possible to see (or hear) how a treatment is actually working.
There is no argument that self-help forums are extremely important but with increasing access to information on disease, a growing number of people are suffering from Cyberchondria.
Improving the patient awareness
As health authorities shift the first line of care to web and telephone-based systems, an increasing number of people have already turned to the Internet and self-help groups for information on their condition. In the past, the medical profession had access to all the knowledge and the patient had none. Today, that balance is shifting as patients have access to a wide range of information. A medical professional has to know a lot about many things whereas a patient wants to know everything about the specific ailment or condition they may have. So today, when a patient meets a health professional, they may be in the strange situation of having spent more time reading about a condition than the professional. But where is this information coming from, is the information correct and well balanced or biased and based on some other unknown factors? There is no argument that self-help forums are extremely important but with increasing access to information on disease, a growing number of people are suffering from Cyberchondria. Cyberchondria is a recognised phenomenon based on hypochondria, when people read about symptoms they think they have the same condition; with so much access to information on ailments, these people are going to be able to pseudo-suffer with a new condition every hour. As users search Internt to know what their ailments are, the search engines could be used for the first sign
A u t h o r
directly. To many medical professionals, this may seem an abomination of their skills, but is it really so when you consider that they are just linking their eyes, brain and hands to a different tool? Would you be happy letting a machine operate on you? Machines make cars more efficiently than humans do as the parts are all the same, whereas the human body is built to the same specification, every one is unique. With the right scanners, does a machine have better vision than a human? Surgeons performing close-up work wear ‘microscopes’ to let them see in finer detail; they may use micro manipulators to allow them to do finer movements. So, in one way, the machines are already operating on us; they just have a human at the wheel. Just 10-20 years ago, this was science fiction and absurd; today, machines have started to carry out the operations, these machines won’t grow old and as they perform more operations, their cumulative knowledge will exceed that of a human.
of pandemics etc. In an attempt to selfdiagnose, the population is flagging up potential health problems (see Figure 3). If enough people enter the same symptoms, it may be the first sign of a problem that needs to be acted upon. As the Internet address has a fixed location, this may even be broken down into areas. This is also the case if a supermarket or pharmacy notices a sudden increase in the sale of certain medicines, which may indicate a problem. If these sales could be tied to a user’s location or previous sales then it may even be able to pinpoint that a certain restaurant may need a visit from the health inspector. Flu like search terms used in Google show a rise in searches around February. Wrap up
The ‘Hippocratic Oath’ mentions the teaching of knowledge and leaving jobs to professionals; new technology will play an important part of this in the future as the world changes. Historically, these changes have come at a manageable pace; today, the potential danger is that a lot of new technologies are emerging very quickly. We, therefore, need to look forward to what may happen in order to be better prepared for the future. I work in BT Innovate; it is the future looking part of BT; my company’s strategy is to enable our customers to thrive in an ever changing world. http://www.btplc.com/
References are available at http://www.asianhhm.com/magazine
Ian Neild is a disruptive futurist who presents on technology trends and social / business impacts. He writes the BT technology timeline, which lists possible technology changes and their impact. Currently he is working on an area dubbed the ‘Internet of Things’ within BTs foresight team and working on his doctorate.
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Enhancing self-management of
chronic
low back pain
Role of a patient-centred website
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hronic pain can have a profound impact on sufferers’ lives, and it is often associated with a loss of confidence and self-esteem. While the majority of cases of low back pain is self-limiting and resolve on their own, the risk of recurrence and development of chronic disease is significant. The Internet is praised in the literature for its potential of enhancing patients’ coping with conditions. Yet online websites on back pain are for the most part affected by a main limitation: Due to their mainly informative nature, websites provide generic advice that often does not spark users’ interest and does not meet their expectations. The comprehensiveness of generic material is based on the assumption that, as people have different informational needs, individuals will select the content that is relevant to them and sift out what does not apply to them. Despite the avalanche of advice on how to prevent or manage low back pain, there exists an information gap between
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general knowledge of back pain and the application of this knowledge to ameliorate the individual’s condition. Between June 2006 and October 2008 the Institute of Communication and Health of the University of Lugano conducted a project to explore to what extent an interactive website, that provides tailored information to patients affected by chronic low back pain, is a proper response to enhance their selfmanagement of this condition. The conceptual framework behind ONESELF is based on the notion of health literacy. Most recently health literacy—as the cognitive and social skills which determine the ability of individuals to gain access to, understand and use information in ways which promote and maintain good health—has been given increasing attention in attempts to understand people’s health promoting capacities. Patients’ health literacy is a competence that integrates factors working at three main levels. On the first level, health literacy is made up of the
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kind of knowledge technically labelled declarative. This is the ‘knowledge of the what’ that patients have or develop when they hear / read and understand certain medical-related statements, e.g. diagnoses, explanations of what certain conditions are and of what the benefits / side effects of treatments and drugs are. On the second level, another type of knowledge plays a key role in the development of health literacy, namely procedural knowledge. This term refers to the ‘knowledge of the how’. Procedural knowledge is knowledge directly applied to a task, e.g. to treat a certain disease. It tends to be less general than declarative knowledge and results in the ability of doing specific activities, e.g. to follow a certain treatment, to take a certain drug or to do a specific exercise. Above these two types of knowledge, health literacy includes, on a third level, a set of skills derived from patients’ ability to integrate their knowledge and all sorts of information received in the context of their own existence and goals.
There exists, from the patientsâ&#x20AC;&#x2122; point-of-view, an information gap between general knowledge about treatment and prevention, and capacities to change behaviours. Often, delivered information does not address specific difficulties of the patients. Sara Rubinelli Senior Researcher Maria Caiata Zufferey Senior Researcher Peter J Schulz Director Institute of Communication and Health University of Lugano, Switzerland
In the outcome, the website includes the Library and the Gym, where users can find texts and videos of exercises to increase their declarative and procedural knowledge, as well as a Forum and a Chat-room where they can meet and interact with both other patients and a group of health professionals that are part of the project team. These are the sections where patients can ask for a contextualisation of their knowledge towards the development of more critical skills to manage their disease. ONESELF is currently used by approximately 900 patients who live in Ticino (the Italian speaking part of Switzerland) and who have been recruited by health professionals and mass-media channels. Among them, 112 patients agreed on taking part in the study, where they were asked to navigate on the website for 12 months. The patients filled an online questionnaire at the beginning of navigation, and responded in a post questionnaire distributed at the end of the interven-
tion. Qualitative interviews were also conducted with a sample of 18 patients selected depending on the total time they spent online. Generally, many users reported benefits of using ONESELF in their answers to five different questions
asked in the post-use survey. More specifically, 25 per cent reported that ONESELF contributed much to increasing their knowledge about back pain, and an additional 58 per cent said ONESELF had contributed sufficiently to knowledge. Users also acknowledge
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Development of self-confidence: ONESELF helped people to acquire confidence in their ability to manage cLBP. Some users felt reassured because they had a trustworthy place where they could address concerns. From the point of view of the health professionals’ daily practice, the project ONESELF appeared to be succesful in the creation of a bridge between clinic-based methods for treating back pain and the humanistic approach from communication sciences. There were several difficulties linked to the amount of time that health professionals can devote to projects of medical websites. ONESELF has minimised the risk of overloading health professionals by sub-dividing their tasks and scheduling exactly when each of them had to enter the website and answer patients’ requests. Despite their initial concerns, the health professionals involved in this project became more and more interested in conducting online interactions with users. From the point of view of their daily practice, ONESELF has helped them in at least two ways: First, by referring patients to ONESELF for general background, health professionals could focus the time at disposal
for the consultation on more urgent matters; second, ONESELF could help screening requests from patients that do not need face-to-face encounters to be answered. Overall, the conceptual model of ONESELF proves its potential in improving techniques of self-care through new technologies. Effective self-management of chronic low back pain can reduce healthcare costs and increase worker productivity because of fewer work-related absences. Beyond the simple financial savings, ONESELF has the potential of improving substantially the quality of life of patients who suffer from back pain and from chronic conditions that require similar management. The authors wish to thank the National Research Programme NRP 53 ‘Musculoskeletal Health – Chronic Pain’ of the Swiss National Science Foundation for the financial support of this study (project 405340–104841/1), as well as the Lega Ticinese per la Lotta contro il Reumatismo, which has enabled its feasibility. References are available at http://www.asianhhm.com/magazine
Sara Rubinelli holds a PhD from the University of Leeds (UK) in the areas of ancient logic, argumentation theory and rhetoric. She is a Senior Researcher at the Institute of Communication and Health of the University of Lugano (CH), where she collaborates in national and international research projects in the field of health.
A u t h o r
in majority ONESELF’s contribution to managing their back pain: 12 per cent said the site had contributed much, and 57 per cent said it had contributed sufficiently to managing pain. The next most frequently acknowledged benefits were improvement of communication with doctors (56 per cent) and family and colleagues (55 per cent). A majority of users (55 per cent) also reported that their search for information had decreased (including decidedly decreased) as far as other websites are concerned, and 45 per cent reported the same of other sources of information. Roughly one in three users reported they exercised more (including decidedly more) since starting to use ONESELF, while just 2 per cent said they exercised less since then. Results from the qualitative study highlight additional information on the way patients used the website. The participants mentioned several positive effects of the use of the website on attitudes and behaviours related to self-management. In the following section we reported the main effects recorded, namely: Self-comprehension: The interviewed sample considered ONESELF very useful to build an individualised understanding of their situation: the richness and trustworthiness of the information, the possibility to interact with health professionals to obtain specific answers and the stability of the material helped them to construct their personal frame of reference about the nature and the course of their cLBP. Improvement of argumentative abilities: ONESELF helped people in learning how to speak about their health condition. Users could improve their capacity to frame and explain their situation in a way that people—and especially health professionals—could comprehend and assess correctly. Orientation: ONESELF provided users with basic information on how to behave towards cLBP. For example, people could learn new exercises or brush up on old ones.
Maria Caiata Zufferey holds a PhD in social science from the University of Friburg (CH). She is currently Senior Researcher at the Institute of Communication and Health of the University of Lugano (CH). She currently works, on a qualitative basis, on doctor-patient communication in the information era.
Peter J Schulz is a Professor of Semiotics and Health Communication at the School of Communication Sciences and Director of the Institute of Communication and Health of the University of Lugano (CH). He currently holds several project grants from the Swiss National Science Foundation in the area of health communication.
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Healthcare Information Exchange On the Internet
I
n a nation like India, where population multiplies in leaps and bounds, delivery of healthcare involves numerous challenges and barriers. This is not just because of the lack of infrastructure and skilled resources but also because of the unavailability of the patient’s medical records to provide the right treatment at the right time. Though, India being a strong and preferred destination in Information Technology, the penetration of IT into healthcare sector is much below the supposed mark. Whereas in countries like Australia, Canada, US and many European countries, most of the hospitals and group-practitioners are using integrated healthcare solutions like Hospital Information Systems (HIS), Electronic Medical Records (EMR), Electronic Health Records (EHR) etc. to substantially reduce medical errors and treatment costs besides focusing on the quality of healthcare delivered to the patients.
Need for a unique solution
eMedReport has launched an integrated web based solution eMedReport.com. This cost effective and feature-rich solution ensures flawless communication among all the healthcare providers and patients for exchange of health information. The solution ensures unlimited and secured storage of patient’s health records, along with other benefits such as sending prescriptions to pharmacies and test requests to pathological labs and diagnostic centers. Patients can create a free health account which would help them access their health records, prescriptions, test reports and radiological images “Anywhere-Anytime”. Patients can also search for doctors in a specific area and request appointments which would save time and money to a large extent. All the above features ensure that the patient gets the right treatment at the right timeAll this happens with a single click at eMedReport.com Doctors can manage their calendar, view patient appointments, previous health records, review notes, prescriptions and test reports which would help them in providing a better patient care. In addition, doctors can also refer a patient to other doctor for a second opinion with all the previous health records of the patient. All this critical information is stored in a secured doctor’s account that no one else has access to. eMedReport also offers SMS alerts and system reminders to patients, doctors and other healthcare providers about appointments, prescriptions, test requests and test reports. eMedReport offers inexpensive subscriptions for the web solution for a period of 3 months, 6 months and 1 year.
Realizing the fact that Internet along with recent innovations in open source technologies can be combined to deliver a cost effective comprehensive healthcare solution, the Hyderabad based company
For more information Please logon to www.emedreport.com or send an email to info@emedireport.com
Reasons for lagging behind
Although there are numerous benefits associated when adopted to healthcare IT systems, the acceptance rate is not high in the Indian healthcare sector both in the public and private sectors. There are many reasons for slow adoption rates, but the major reasons include, the bare minimum spending by hospitals, lack of technical expertise and lack of common standards. Apart from the above, the lack of awareness about the benefits associated in adapting to these systems both among the healthcare providers and people is also one of the important reasons.
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Benchmarking and Accrediting in Health Informatics
Driving up quality and reducing risk Quality assurance and continuous development of health information and IT services in healthcare is a key patient safety and business issue. A part of this is the need to assure the professionalism of individual practitioners as well as the services themselves. Di Millen Head Informatics Development NHS Connecting for Health, UK
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nformation has always been at the heart of healthcare delivery. Today, new information systems and technologies are becoming ubiquitous in health and give rise to new opportunities and challenges to the ways care is delivered and the way professionals work. Information sharing between professionals, care providers and sectors; and patient access to and management of their own records are driving changes in inter-professional relationships and care delivery processes. So, information and information systems underpinned by technology are increasingly impacting directly on patient experiences of healthcare delivery and on their treatment and on the outcomes of their care. There is, as a result, an increasingly vocal group of professionals in health who would argue that if information, information systems and IT can positively impact upon patient care, then the converse must also be true. The UK Council for Health Informatics Professions (UKCHIP) has collected a catalogue of examples of healthcare delivery failures where information and IT systems are implicated in errors and even loss of life. Our information and IT systems, therefore, need to be safe; and the professionals—individuals and teams, who design, implement, support, manage and develop these systems must also be assured, as far as possible, as safe to practice.
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In an increasingly litigious world, is this an issue healthcare delivery organisations can continue to ignore?
Further, commercial pressures, whether in State—funded healthcare services which exists in the UK or private or insurance-based services (or indeed a mixed health economy)—have an obligation to deliver best value, high quality services that demonstrably use accepted standards and be committed to the principles of continuous improvement. Commissioners of services want to know they are buying a quality, value for money service; and service deliverers want a competitive edge in an increasingly pressured free market. In England, a further driver in the push for benchmarking and accreditation of both informatics practitioners and services and teams has been a continuing concern that recruitment and retention in informatics in health is problematic and that we just don’t have access to the right people with the right skills. When we find and appoint staff, the employment package is not sufficiently attractive to retain the best. Whilst there is a perception that pay is not as high in the public sector as it might be in the private sector, it is actually lack of status and lack of opportunities for career progression that drive staff out into the more lucrative private sector. The adoption of standards and the accreditation of people and
services / teams are seen to be at the heart of all of addressing these issues—at national and local levels. In the UK, UKCHIP now holds a professional register of some 700+ individuals and is in the process of applying for accreditation by the UK Accreditation Service which will authorise it to certify professional status. This will require a revision of existing standards for and levels of registration and further contribute to driving up quality and providing assurance to employers that staff are safe to practice having not only met the requisite standards but agreed to abide by a code of professional conduct and created a planned programme of continuous professional development. IT and informatics are relatively young professions and are in the formative stages of development. They are sometimes criticised for not making faster progress but recent developments in English national informatics strategy indicate that the tide may be changing. There are a number of actions that could speed up progress, foremost of which are: 1. Giving informatics a place on Executive boards with a CIO type post reporting directly to the CEO 2. Organisations should expect professional accreditation/registration and include this in job descriptions and person specification Developing an approach to benchmarking and accreditation of health informatics services
Let us move away from discussing the accreditation of informatics practitioners as individuals, to consider a range of issues associated with the benchmarking of health informatics services and teams. Benchmarking or accreditation?
The nature of the political environment and the strategic drivers for a scheme will influence decisions about whether either benchmarking or accreditation, or both, are required. Benchmarking may well be the first stage of a process
Benefit recipient Health Informatics Service Provider
Description of benefit • Reputation enhancement • Competitive edge • Marketing tool • Staff morale • Recruitment and retention • Reduced risk of litigation
Purchasers / Commissioners • Assurance through third party attestation • Increased confidence in supplier’s ability to deliver to agreed plan and to agreed standards • Opportunity to influence nature and quality of service • Aid to procurement • Know what to expect Table 1
of accreditation, enabling teams and services to assess themselves against a set of measures and metrics in a nonthreatening environment; and to share the outcomes only with selected peers and colleagues; or more widely in an anonymised or pseunomynised form. This implies that outcomes may not routinely be shared with commissioners and purchasers of services and may arguably have limited value from these perspectives.
The nature of the political environment and the strategic drivers for a scheme will influence decisions about whether either benchmarking or accreditation, or both, are required.
With benchmarking there is generally no ‘pass or fail’ and the process may, therefore, be seen more developmental and less threatening than a formal accreditation scheme. Table 1 summarises the high level business benefits of an accreditation scheme to both providers and commissioners / purchasers of services. Voluntary or mandatory?
Whether an accreditation scheme should be mandatory or voluntary is
again a potentially contentious issue for some of the reasons set out above. It may well be the case however from the perspectives of both commissioners / purchasers of services and service providers themselves that a requirement to go through a process of assessment is desirable in the interests of patient safety and continuous improvement; but this is not the same as saying that a scheme should be mandatory and that services will be classified according to an agreed scoring system. The implication of the latter is that a service or team might be deemed unfit for purpose or ‘unsafe’ and accordingly lose its ‘licence to trade’. Again, the political and commercial drivers for the scheme will dictate the preferred approach. Experience from other UK public sector approaches to accreditation in healthcare undertaken by organisations such as the English NHS’ Healthcare Commission suggests that an incremental approach to scheme implementation and development are more likely to receive the support of participating organisations and, therefore, more likely to achieve scheme objectives. A generally well-respected and well received scheme in England has been the Pathology Accreditation Scheme which combines an accreditation scheme with integral peer review and support for improvement through a programme of action learning to support service modernisation and continuous improvement, and the establishment of pathology (people) networks.
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Balanced scorecard for effective informatics services Delivery of services Meeting user expectations Benefitting care delivery Positive effect on informatics staff
Functional descriptions for each IM&T service component Best practice service delivery models Options for deployment and management Potential for standardisation and critical mass Benchmarks and success criteria
al tion ts era in Op eckpo ch
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Four critical success factors •Leadership •Governance •Strategic development plan •Long term resource framework
n atio alu s l ev itie tica rior Tac of p
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or ts f ien s red ces ing suc gic rm at e t e Str long Figure 1
information management and training and development) to those delivering just some of the possible elements of service. Conclusion
Quality improvement and value for money, together with large scale investment in health informatics systems, are at the heart of the need to ensure effective, efficient and safe health informatics services available to support clinical professionals twenty-four hours a day, seven days a week, 52 weeks of the year. The accreditation of individual practitioners, teams and services to agreed national / international standards are themselves at the core of service improvement goals. A u t h o r
Researching existing approaches to benchmarking and accreditation in the chosen domain is essential in the interests of time and resources. Avoiding duplication is essential. Checking out what standards, measures and metrics already exist will not only save time and ensure appropriate links and connections are made with other complementary schemes; but will make the task of scheme members less burdensome. If an organisation already has been through a process of accreditation to, for example, ISO 9000, any accreditation scheme comprising a comparable standard should accept a statement of compliance (to be supported by evidence if required) as sufficient for its purpose. Reference to existing standards either as guides to good practice or as required evidence of quality should be built into a scheme and references to sources of information and support be made available within the scheme. Measures and metrics should also be both clearly defined and meaningful to stakeholders. In designing any assessment tool, stakeholders—service providers and service purchasers / commissioners—should be involved and the tool tested in a robust way to ensure sense, appropriate use of language and ease of use. A simple glossary to help define terms might help avoid misunderstandings and a loss of credibility for the scheme and its content further down the line; as will testing and piloting in a cross section of organisation types and environments. A high level description of the tool developed in England is provided below. Behind the framework is an online tool comprising 300+ measures and metrics. It started life as a complex and macrorich MS Excel spreadsheet and is in the final stages (early 2009) of conversion into a web-based tool flexible enough to support the assessment of services and teams, from those delivering the full range of informatics services (including
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In the English NHS, a Health Informatics Service Benchmarking Club has been established with support from NHS Connecting for Health but owned and managed by the constituent members (over 100 services have joined the Club at the time of writing). The next phase of the development, during early 2009 will be to appraise a number of modes and models of accreditation already in existence and to consult service commissioners and providers on the business benefits and merits of a national accreditation scheme. If such scheme is supported and there is optimism that this will be the case a service provider will be procured during 2009 with a view to the scheme becoming live in 2010.
Di Millen has worked in the area of informatics education, training and development and workforce and service development for more that fifteen years at local, regional and national levels.
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Patient Proxies in Decision-Making
What computers can't capture Healthcare policy makers face the challenging task of balancing managements’ requirements for quantified information with the often unmeasurable realities of clinical decisionmaking. Decision-making and healthcare policies need to be responsive to biomedical, personal, cultural, as well as economic needs. Anne Croker Research Associate Franziska Trede Senior Lecturer Joy Higgs Director The Education for Practice Institute Charles Sturt University, Australia
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any technological, human, economic and knowledge accessibility factors are making healthcare increasingly complex for providers and consumers alike. This complexity requires a form of decision-making that balances the collection and use of technical, rational information for cost-effective evidence-based care and accountability, and consideration of patients’ interests and their wish to participate in clinical decision-making. Alongside these changing patient attitudes, health professionals are increasingly taking on the roles of patient advocate and proxy through patient-centred inter-professional decision-making. Different worlds and competing interests
The worlds of health management and patients collide on many accounts. Policy makers and managers may look at patients from the-point-of-view of a diagnosis that needs to fit into particular groupings, a body occupying bed days and a number that needs to meet benchmarking targets. However, there is a risk that care plans that are developed without fully understanding the patient’s situation are ineffective and inefficient. Patients bring hopes, fears and at times unreflected expectations to their hospital stays. Health management interests may concentrate on measurable data and efficient patient flow, whereas patients want to be respected, listened to and well cared for. A one-sided focus on electronic, codified information may impede and marginalise the complexity of professional practice as well as silence the voices of
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patients. The challenge for stakeholders of hospitals and other healthcare services lies in providing balanced policies that enable both worlds to blend to achieve acceptable processes and outcomes for all. Complexity of professional practice
There is a solid body of evidence-based knowledge that guides best clinical practice of decision-making from biomedical perspectives; however, this perspective is only one amongst many. Other perspectives include professional values and ethics of healthcare professionals, cultural beliefs of patients and their carers, staffing levels, and economic perspectives of hospital management. For example, we can understand a young doctor’s recommendation to a geriatric patient to start living in institutionalised care in order to be safe. We can also understand the reluctance and resistance of patients to comply with such a recommendation because they want to remain in their home environment. Delaying such a patient’s discharge can be seen as an uneconomical approach to hospital bed occupancy once all biomedical aspects of the patient’s care needs have been addressed. Instead, providing opportunities for adequate discussions with patients and their families, responding to their concerns and searching for the most suitable accommodation for individual patients can be seen as a duty-of-care approach to hospital bed occupancy. Valuing patients’ voices and proxies in team decision-making
Sharing patient stories may not fit comfortably with the ‘body focus’ biomedical
model and procedural concepts of efficient team meetings. While many team members interviewed in the research valued the role of storytelling for developing shared understandings of patients and their rehabilitation directions, some were significantly time pressured and preferred quicker meetings. However, if teams routinely shorten their case conferences there is a risk of marginalising patients’ voices and proxies. Health professionals’ contributions could be reduced to discipline-centred reports of progress, and teams’ foci could be narrowed to collecting and recording information for procedural purposes. In short, such an approach to case conferencing would thwart the incorporation of patient proxies in shared decision-making. Critical opportunities for building networks of understandings about patients would be missed. Can we value what computers can’t capture and policy makers don’t see?
Accountability and reporting to other team members are important aspects of being a professional. However, accountability extends to patients and also to self, not just the technical tasks of healthcare. Deficiencies in procedural accountability are often obvious, for example inadequate documentation can be identified through monitoring of adverse events. The situation is different for patients’ voices and proxies at team meetings. While audible during meetings, these voices then merge into decisions and rehabilitation directions, and often disappear. Once they become part of teams’ decisions there may be no evidence that they were ever there. Valuing what cannot be seen and counted can be difficult. While policy makers’ requirements for quantified information from clinicians are not disputed, the value of the often invisible informal sharing at case conferences should not be discounted. An unequal focus on technical rational information over patientcentred narratives relies on the caring attitudes of health professionals and the
Hearing patients’ voices and proxies in team decision-making One area where complexities of professional practice are evident is the inter-professional discussions that occur at case conferences or team meetings about patient care. These meetings provide regular forums for doctors, nurses and allied health staff to discuss patients. Members of the different professional disciplines bring their own perspectives and understandings of their patients’ problems, abilities and contexts. As patients may not be present during these discussions, there could be a risk that their perspectives and wishes are obscured or sidelined within the milieu of health professionals’ contributions. However, a recent qualitative research project exploring the experiences of collaboration in rehabilitation teams found that patients’ voices and proxies were brought informally to case conferences through the stories and anecdotes that health professionals shared with each other (Croker, Higgs and Trede 2008). These overlapping conversationalstyle interactions were interspersed between the formal sequences of contributions in case conferences observed in this research. Team members shared stories describing patients’ conditions and situations, gave examples of insights and concerns, and relayed extracts of their conversations with patients and families. These contributions often stimulated responses from others and triggered recall of other incidents. The patient’s voice became evident in these overlapping discussions, particularly when team members repeated verbatim patients’ words in ‘she said’ or ‘he said’ types of contributions. From these spontaneous and seemingly disordered interactions, shared understandings of patients’ situations, aspirations and directions emerged. These shared understandings often influenced team decisions. The following scenario gives an example of how team decisions can be influenced by a patient’s proxy. “He said he wants to go home on the weekend”: Following a stroke, Duncan was admitted to a rehabilitation unit 250 kilometres from home. His wife Peg was torn between spending time with Duncan and returning home to be with her elderly mother. Duncan still required extensive assistance with everyday activities. When he initially expressed a wish to return home with his wife for a weekend visit, the team were sceptical about the feasibility of this. However, when they heard about how keen he was to see his friends, sleep in his own bed for a weekend and take the pressure off his wife’s concerns about her mother, they decided to work with his local health service, family and friends to ensure that his visit would be adequately supported. His local health department provided a shower chair, his builder friend put in a toilet rail, and his neighbours ensured that someone was with him when his wife was visiting her mother. The visit went well and Duncan returned to the unit with a new understanding about the progress required to regain independence at home and renewed enthusiasm for rehabilitation. Opportunities to relay patients’ hopes, fears, perspectives and aspirations through the sharing of stories and anecdotes provided informal ways of bring their proxies to meetings. However, in highlighting the contributions patient proxies make to patientcentred clinical decision-making, this research also raises an important question: How can a balance be achieved between the time taken to incorporate patients’ voices and the need for team members to be responsive to work time pressures?
professional culture they create with each other to bring patients’ voices and proxies to team decision-making. Adequate time for case conferences, stability of team membership, team social events and sharing food during meetings are some ways of creating suitable atmospheres in which team members in this research feel encouraged to contribute their stories
and anecdotes. While this may sound obvious and mundane, there is a danger of overlooking such basic concepts when team meetings are rushed or common practice removes the patient’s voice from the debate. If patients’ needs and expectations are to be valued alongside hospital procedures and documentation structures, policy
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A patient-centred orientation to clinical decision-making that includes patients’ hopes and fears can assist interprofessional teams in making relevant and meaningful decisions. Management can play a role in supporting this by appreciating and actively supporting a professional practice that is responsive to the complex and human world of people in search of improved health.
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References Croker A, Higgs J, Trede F, (2008) Shared decision making in rehabilitation teams: the role of patient-directed proxy. International Conference on Communication in Healthcare, 2-5 September, Oslo, Norway.
Anne Croker initially worked as a physiotherapist in the area of rehabilitation, and then subsequently worked with teams of individuals from different professional and consumer groups in an area of public health. These experiences led to her current PhD research interest in how members of rehabilitation teams collaborate with each other.
A u t h o r
makers need to not only appreciate but actively support the notion that there is more to healthcare than what can be captured by computers and quantified reports. With this awareness and leadership, health managers can play a key role in enabling and nurturing complex professional practice. Key questions that should be posed to scrutinise all policies are: “Does this policy impede patientcentred practice?” and “Where is the patient in this policy?”
Franziska Trede has extensive experience as a, university lecturer, clinical physiotherapist, health communication researcher and hospital policy adviser. She researches in the area of complexity, cultural diversity, uncertainty and communication in clinical practice. She is interested in exploring values, bias and practice philosophies that shape the way clinician practise. Joy Higgs is the Strategic Research Professor in Professional Practice at Charles Sturt University. She has published widely, including 14 books, in her fields of expertise in professional practice, knowledge and education. In 2008 she published the third edition of Clinical Reasoning in the Health Professions with Mark Jones and colleagues.
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it bookshelf
Understanding Healthcare Information
Author: Lyn Robinson Pages: 256 Year of Publication: 2009
Product Description In an age of internet resource guides, which suffer from the malaise of being outdated before they are published, this book addresses the information chain in its entirety, providing a timeless way of understanding healthcare information resources. The book takes a holistic approach in its consideration of healthcare information with the aim of building an overall understanding of healthcare information within the information society. The contents cover the domain of healthcare information; its organisational structures and history, and the nature of its resources and the factors affecting them. It looks at examples of healthcare information resources from the perspective
of different user groups, including healthcare professionals and consumers and goes on to highlight areas of research into healthcare information, including evaluation studies, user studies, impact, bibliometrics, metadata and web 2.0. This title features themes such as: healthcare information background, nature and drivers for change; healthcare information resources, users and services; and, healthcare information research. This book would be of interest to anyone working in the field of library and information science wishing to understand healthcare information, especially public librarians, who are increasingly called on to advise on health resources, as well as anyone interested in ‘healthcare literacy’.
e-Business in Healthcare From eProcurement to Supply Chain Management
Authors: D Karagiannis N LeMaster Ursula Hübner Marc A Elmhorst Pages: 328 pages Year of Publication: 2007
Product Description eProcurement in Healthcare is a book that aggregates 5 years of experience of three successive R and D projects (ELCH, GetTogether, GROPIS) covering technical and organizational issues of eProcurement. The projects, which were funded partly by the government and partly by industry and hospitals, looked at the characteristics of procurement processes and at standard technologies. Two of the projects included case studies (ELCH, GROPIS), the third project focused on the development of standard business objects for eProcurement in healthcare (GetTogether). Together they form a rich source of information worth communicating to a large audience of experts and newcomers alike. Results from the projects are supplemented
by the contributions of international experts and their particular views on eProcurement, which gives the book a global perspective and hence allows its readers to learn from a variety of different approaches. Each chapter of the book is structured in a way that satisfies the needs of executives as well as academics. A management summary, tables and graphics together with key statements of experts allow the quick reader to capture the main message of each chapter, whereas background information and reference to the literature address readers who wish to gain a deeper and more comprehensive insight into the field. The management summary and the expert statements will appear in boxes separated from the main text by visual cues, e.g. background color, font size, font type.
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Advances in Telemedicine Systems Frost & Sullivan
Synchronous telemedicine is an industry, which though a part of the medical and healthcare industry vertical, is more affected by the developments and changes in the communication industry. The technology belonging to telemedicine, which is basically remote data communication system cardinally belongs to the information communication technology (ICT) industry. The data that these commu-
nication systems dynamically acquire, process, and communicate in either half duplex or full duplex manner is medical or rather clinical data acquired through the biosensing modes. Hence, the telemedicine industry is a fusion of the ICT and healthcare Industry. This research explores the overall technologies in the market and R&D. It focuses on examining the telemedicine
systems industry and applications that drive the larger markets. Frost & Sullivan provides an integrated focus by ferreting out the trends and opinions of the vendor community and the opinions of the ICT experts at Frost & Sullivan, the opinions of the academic community, and the needs of the user community. The research service not only reports the opinions and views of the entire global community linked with the telemedicine industry, but also further analyzes the impact of these opinions and trends. This sort of analysis has facilitated the portrayal of a constructive future for this industry. There are two types of technology forecasts done here. First, the research service gives a roadmap of the technological developments occurring over time and forecasts the developments in the industry. Second, this research also talks at length at the developments in the individual technologies (comprising the telemedicine industry) and charts out the mechanism in which developments will occur.
Advances in Clinical Information Systems An Impact Analysis Frost & Sullivan Clinical Information Systems (CIS) is an industry, which though a part of the medical and healthcare industry vertical, is more affected by the developments and changes in the IT industry. The technology belonging to CIS is basically information system, which is IT in nature. The data that these information systems acquire, process, and archive is medical or rather clinical data. Hence, the CIS industry is a fusion of the IT and healthcare Industry. This research explores the overall technologies in the market and R&D.
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It focuses on examining the clinical information systems industry and applications that drive the larger markets. Frost & Sullivan provides an integrated focus by ferreting out the trends of the vendor community, the opinions of the IT community, and the needs of the user community. The research service not only reports the opinions and views of the entire global community linked with the CIS industry, but also further analyzes the impact of these opinions and trends. This sort of analysis has facilitated the portrayal of a constructive future
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for this industry. There are two types of technology forecasts done here. First, the research service gives a roadmap of the technological developments occurring over time and forecasts the developments in the industry. Second, this research also talks at length at the developments in the individual technologies (comprising the CIS industry) and charts out the mechanism in which developments will occur. Further to it, based on the future forecast, this research service also identifies a new type of service business model that will easily branch out CIS.
Industry reports
Healthcare Technology – Opportunities in the Electronic Health Record Market Datamonitor EHRs will help change the healthcare industry from today’s reactive, frenetic environment to one that is more proactive, informed and leverages planned workflows. The majority of players in healthcare realize this, but reaching a consensus on how to make this transition has been difficult to say the least. This report will explore the EHR market and its technologies in four different ways. The Market Focus section establishes the context for the report, focusing on key drivers and inhibitors in the EHR market. The Strategy Focus section offers insight into the evolving EHR market and analyzes different approaches to increasing EHR adoption. EHR technology trends are discussed and parallels between EHRs and technology solutions in other industries are drawn in the Technology Focus section. Finally, the Databook sections provide a five-year forecast on EHR spending segmented by geography, technology and application. Examining the Global Market for Electronic Health Records (Market Focus)
The Market Focus section discusses the main factors affecting the EHR market, specifically those driving and inhibiting the adoption of technology. EHRs are a major breakthrough in healthcare. They will change the ways in which healthcare is delivered and medicine is practiced, improving care and creating a more efficient system. However, the obstacles organizations face implementing these solutions will be anything but small. Datamonitor will discuss the following issues influencing the uptake of EHRs in the global healthcare market: • Electronic health records will become a “must-have” for healthcare organizations;
• EHR adoption will be inevitable due to internal as well as external factors; and • Cost is the most significant, but not the only, barrier to adoption. Using a Multi-faceted Approach to Increasing EHR Adoption (Strategy Focus)
The Strategy Focus section forecasts the size of the global EHR market through 2012 in addition to providing an overview of strategies to increase EHR adoption. The potential for EHRs is not difficult to comprehend, but the adoption of the technology has been painfully slow. Though the barriers to EHRs are significant, Datamonitor believes the market will grow rapidly during the next five years and the rate of adoption will increase through multiple strategies. This brief will explore the following statements about EHRs in more depth: • Worldwide interest in EHRs will continue as the market evolves; and • No one-size-fits-all, but EHR adoption will increase if approached from many angles. Leveraging Existing Technologies for Electronic Health Records (Technology Focus)
The Technology Focus section provides an analysis of technology-specific trends in the EHR market and a framework for prioritizing EHR investment. EHR technologies have improved immensely over the last few years but are still far from perfect. Vendors, however, do not need to design every new feature of EHRs from scratch. Datamonitor believes the following ideas will help further advance EHR technologies and aid end-user implementation: • No need to reinvent the wheel: EHR
technologies are already available in other industries; and • As EHRs become more advanced, they will require solutions from multiple vendors. North American Spending on Electronic Health Records Through 2012 (Databook)
This Databook section provides datasets relating to EHR spending in North America. Key information provided in this Databook section includes: • Spending by country as well as technology segment; and • Comparisons between hospital and ambulatory care markets. European Spending on Electronic Health Records Through 2012 (Databook)
This Databook section provides datasets relating to EHR spending in Europe. Key information provided in this Databook section includes: • Spending by country as well as technology segment; and • Comparisons between hospital and ambulatory care markets.
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European Healthcare IT Outsourcing Market Frost & Sullivan Objectives
Scope
The objective of the research is to present a comprehensive analysis of the European healthcare IT outsourcing market. The analysis includes the factors driving growth, challenges, revenue forecasts through 2010 and opportunities within the market. Detailed financial analysis of European healthcare IT outsourcing market is presented. The analysis is based on four key factors. • Forecasted market dynamics • Market shares • Segment revenues • Regional trends
The market for healthcare IT Outsourcing systems is witnessing increasing activity across Europe. The market can be broken down into three segments that are examined in the report: • Applications Management Outsourcing • Infrastructure Management Outsourcing • Integration Services Outsourcing The geographical regions analysed include: Germany, United Kingdom, France, Italy, Spain, Benelux and Scandinavia.
Segments
Regional Analysis Applications/ Infrastructure/ Integration Services
Germany, France, Uk, Italy
Emerging Markets
Segment Trends
Market Engineering Measurements
$ 396.4 million (2005)
Growth Rates
$697.71 Million (2010)
Market Metrics
2008 Highlights
Featured Healthcare IT articles
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
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Patient Records Online Shared access for quality care
Online Personal Health Records signal a aradigm shift in the management of a atient data. By allowing easy access to patient nformation, online health records can enhance patient care and create a healthy doctor-patient relationship. Prasanthi Potluri, Editor Asian Hospital & Healthcare Management Akhil Tandulwadikar, Editor Asian Hospital & Healthcare Management
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Emerging Scenario for Vendors in Europe
The Current Scenario Wherein Customers are Adopting Technology to Boost Productivity and User Confidence Will Change in the Coming Years With More Stress on Competitive Pricing and Solutions Capabilities as a Whole. Services Will Have the Power to Tilt the Scales. Competitive Structure in Europe – Healthcare IT Outsourcing Vendors Types of Competitors
• Pure IT Solution Vendors Offering Outsourcing Services • Healthcare IT Vendors Able to Offer Outsourced Applications • IT Consulting and Services Firms • Infrastructure/Technology Outsourcing Vendors Distribution Structure
• Sales Subsidiaries and Independent Distributors, Partnerships
Applying Path Innovation Seeking revolutionary HIT
Healthcare requires a revolution in the way we deliver care by utilising IT in new and innovative ways. Path innovation allows experts to work together in the development of workflows that best leverage HIT. Barry P Chaiken, Fellow of HIMSS, USA
Healthcare IT
Innovations for better care Innovations will move to areas of consumer empowerment by providing greater access to services and information including personal health applications populated with data. Thomas M Eberle, Senior Clinical Architect, Digital Health Group Intel Corporation, USA
Industry reports European healthcare IT outsourcing and Drivers ASP market-key drivers and restraints, 2006-2010
Increasing Emphasis on Post-Clinical Care
Increasing focus on Core-Competancies And Advantages Associated with The ASP Model
European Healthcare IT Outsourcing and ASP Market: Conclusions
IT Modernization Initiatives
Impact Low
Medium
Issues Related to Patient-Data Ownership
High Lock of Quality in-house Management inputs
Fragmented Nature of the Industry
Improper Identification of Strategic Sourcing Needs
Restraints Competitive factors
• Ability to offer flexible scalable solutions • Integration of new systems with existing HIS platforms • Services support during implementation and beyond • Ability to maintain a diverse and satisfied client portfolio From Outsourcing to ASP- The Next Step? Utilities of ASP in Healthcare
• Provide outsourced management of
application software via the Internet • Widen business opportunities, save time and money • Access to high-end software applications Who is Providing ASP in Europe
• Independent Software Vendors • System Integrators • Telecom Companies What Does the Future Look Like for ASP in Healthcare
• Increase in delivery of new applications by this model • ASP enabling of old complex healthcare IT applications
• The European healthcare IT market is set to experience steady growth riding on the initiatives shown by regional and national health authorities • State of the art information technology solutions adoption is inevitable. Some regions will move swiftly to capitalise on the benefits to the healthcare industry. These markets represent the biggest potential for Outsourcing. • Three main segments identified in the healthcare IT outsourcing market. Several sub-systems likely to gain importance in the market. The specifications of Integrated Care will drive the outsourcing markets. • European technology vendors in a strong position to consolidate market share. Global players will not give up the fight to attain respectable market share. Fair amount of consolidation / joint ventures expected in the industry. For more reports, visit knowledge bank section of www.asianhhm.com
Commoditising Healthcare IT The next wave
With the costs of healthcare rapidly increasing, the monolithic model of HIT is no longer sustainable. HIT commodity capability that provides a new level of convenience and serviceability to the healthcare environment while being cost-effective. Werner van Huffel, Health and Social Services, Industry Strategist Regional Public Sector Group, Microsoft Asia Pacific, Singapore
Medical Banking
Information Technology in Healthcare
As the management of healthcare data progressively moves to an electronic platform, banks are realising that their technical systems, privacy and security frameworks, identity management engines and marketing channels can be leveraged to fast forward e-Health.
While improving computer systems would not eliminate all medical errors, researchers believe it will reduce the errors dramatically. Now is the time to share progress, challenges and best practices to enable interoperability and link the ecosystem in the delivery of better quality care.
John Casillas, Founder The Medical Banking Project, USA
Madhav Ragam, Director Healthcare & Life Sciences, IBM Asia Pacific, Singapore
A new stakeholder
Creating a stronger healthcare system
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Microsoft and HIMSS launch Health Users Group HL7 publishes PHR standards draft
The Health Level Seven (HL7) Personal Health Record System Functional Model (PHR-S FM) is available as a draft standard. It has been made available for download as a trial use. The PHR-S FM allows global users to work with a stable standard for up to two years while it is being refined into an American National Standards Institute-accredited version. The PHR-S FM defines the set of functions that may be present in PHR systems to create and manage an effective PHR. It also offers guidelines that facilitate health information exchange among different PHR systems and between PHR and EHR systems.
The Microsoft Corp. and the Healthcare Information and Management Systems Society (HIMSS) launched the Microsoft Health Users Group (Microsoft HUG) across Europe, the Middle East and Africa (EMEA). The launch was announced at the World of Health IT Conference and Exhibition in Copenhagen, Denmark. Microsoft HUG comprises more than 5,000 members and 31 corporate supporters across North America.
Intel introduces Health Guide Intel introduced a new device, Intel Health Guide in a series of health monitoring devices aimed at tracking chronic and age-related conditions. The technology offers interactive tools for personalised care management and includes vital sign collection, patient reminders, surveys, multimedia educational content and feedback and communications tools such as video conferencing and alerts. The Intel Health Guide combines an in-home patient device with an online interface—the Intel Health Care Management Suite—making it possible for clinicians to monitor patients in their homes and manage care remotely.
Europe launches its health data exchange pilot With the support of European Commission, involving 12 European countries, a project titled European Patient Smart Open Services (epSOS) ‘large scale pilot’ has been undertaken for ensuring healthcare interoperability of national e-health systems in Europe. The countries involved in the epSOS project are Austria, the Czech Republic, Denmark, France, Germany, Greece, Italy, the Netherlands, Slovakia, Spain, Sweden and the UK. The project plans to connect what already exists. Through this large pilot, the countries will look at all of their systems for electronic health records and see what can be shared and every member country has its own system of storing healthcare information, yet these systems often can’t ‘talk’ to each other.
SRISHTI SOFTWARE APPLICATIONS PVT LTD profiles of it companies
PARAS, HMIS, PACS, INTEGRATED EHR SYSTEM AND TELE-HEALTHCARE SYSTEM Srishti Software Applications Pvt. Ltd. is a specialized software engineering and business solutions company. Established in 1997, Srishti now serves global clients across various sectors. Among the notable clients of the company are healthcare institutions, big corporates, financial service companies, and media companies. Srishti, with headquarters located in Bangalore, has offices in Delhi, Mumbai and London. Its wholly owned subsidiary IntelliApp is a UK based services provider. Key markets served by Srishti are UK, USA and India. Presently strong efforts are being made by the company to enter new markets like Middle East, Africa and East Asia. The company broadly offers • A one stop HMIS for a wide variety of healthcare service providers
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• Offers integrated electronic patient records across entities in the healthcare universe • Best in close image recording and communications platform to exchange critical components of patient records (PACS) • Offers powerful assisted diagnostics and prescription to support healthcare delivery • Guarantees clinical pathways following accepted global standards • Features powerful tele-healthcare functionalities to adapt to a geographically dispersed healthcare delivery organization. PARAS-The Healthcare Suite from Srishti.
happenings in 2008
Google Health introduces application to help patients with prescriptions Google Health added a new application to help users find assistance programs for their prescription medications online using PatientAssistance.com. This new application allows users to automatically search for patient assistance drug programmes they are eligible for on the basis of medications included in their Google Health profile. Rex Bowden, President, PatienceAssistance.com said, “our new integrated service on the Google Health platform is designed to make that process much easier by allowing users to search for programs on multiple medications at once, while using existing information to save time in searching for eligible programs that meet all, or most, of the patient’s needs.”
PHRs emerge as the biggest trend
Robotic technology boosts stroke recovery
2008 was the year for more opportunities and challenges in Healthcare industry. Personal Health Records (PHR) emerged as the biggest trend all set to change healthcare. Entry of Google (Google Health) and Microsoft (HealthVault) and many other online PHR services marked this trend. PHRs will help patients to get connected to numerous data sources and manage their own health records. With the increasing focus on the patients, PHRs are likely to evolve in the future in a big way and adopted by consumers. The prevalence of PHRs will create many challenges for healthcare institutions, payers and employers.
Scientists have performed first study using a new, hand-operated robotic device and functional MRI to map the brain in order to track stroke rehabilitation. Functional MRI measures the tiny changes in blood oxygenation level that occur when a part of the brain is active. From this study, scientists have found that chronic stroke patients can be rehabilitated. And the results showed that rehabilitation using hand training significantly increased activation in the cortex, which is the area in the brain that corresponds to hand use. Furthermore, the increased cortical activation persisted in the stroke patients who had exercised during the training period but then stopped for several months. For more happenings, visit www.asianhhm.com
PHENIXVISION PhenixVision is a company with a conscience and a soul. Our existence is governed by our belief in these core values. PhenixVision provides the software solution like the lifeblood of digital radiography system. Its products and services have always been designed to meet the needs of enterprises and consumers alike. PhenixVision has been focused like a laser on high quality, high speed, high costefficiency of Digital Radiography system. PhenixVision established FUMA as an image processing tool and DXView as an operating workstation for various kinds of digital radiography systems based upon amorphous-silicon, amorphousselenium, and CCD, and linear scan detector, etc. PhenixVision is composed of experts with many experiences in medical imaging field. Since its inception in 2001, as a global digital radiography solution provider, PhenixVision has provided the products and services of unparalleled quality which can accommodate a wide variety of needs in a dynamic environment. FUMA is the PhenixVision’s unique software technique which incorporates the fuzzy concept into the image enhancement method: • It creates homogeneous image (pre-processing) • It provides an important step to aid a physician in visualizing detail and structure of the lesions
• It improves diagnostic utility as well as the properties of soft and hard tissues • It provides the ability to reduce noise and unwanted background that may affect the visualization quality of digital radiograph. DXView, an optimized and easy-to-use operating workstation, fully conforms to international standard protocols, and the acquired digital images are immediately sent to PACS network, or laser camera for film printing: • Its workflow, in conjunction with digital x-ray control interface and elegant graphical-user-interface, assures maximum diagnostic flexibility and increased patient throughput • It supports full integration of digital radiography system • Synchronization of the timing between the detector and x-ray equipment • Digital control interface of various x-ray generator. PhenixVision’s customers are now satisfying their customers completely. It is very encouraging for all of us.
For more companies, visit www.hospitals-management.com
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2008 Highlights
featured non-healthcare it articles
Echocardiography
Globalised Healthcare
New and evolving roles
What lies ahead
With the increasing complexity of globalisation, escalating cost of healthcare and rapid advances in technology—both equipment and IT—the challenges and choices facing the practising physician, managers and leaders are daunting. The effects of these changes on patient care may be even more difficult to discern. Basri JJ Abdullah, Professor Department of Biomedical Imaging, Faculty of Medicine University of Malaya, Malaysia Ranjit Kaur, Lecturer Department of Biomedical Imaging, Faculty of Medicine University of Malaya, Malaysia
Care Pathway for Total Hip Replacement An innovative approach
Using clinical pathways to standardise care across the continuum—from the physicians’ office to the O.R., recovery post operation—improves communication among the care-giving team. The pathways are also a tool to educate and involve patients in their care, as they identify variation from expected outcomes and goals. Pathways improve the delivery of care to patients through encouraging early ambulation for those patients who undergo total hip replacement surgery while increasing clinical and organisational efficiency and revenue. Yosef D Dlugacz, Senior Vice President and Chief Clinical Quality Education and Research, Krasnoff Quality Management Institute, USA Carolyn Sweetapple, Vice President Finance and Business Operations, Krasnoff Quality Management Institute, USA
Techno trends Posture device featuring Nanosensor Technology
Echocardiography plays a key role in the diagnosis of many cardiac conditions and in the assessment of response to therapies. Despite the emergence of new, advanced diagnostic tools such as cardiac computer tomography and cardiac magnetic resonance, echocardiography still plays an important role in patient care because of its unique capabilities. Michael H Picard, Director Echocardiography, Massachusetts General Hospital, USA
Patient-Centred Healthcare
Moving beyond ailment An involved patient is a blessing for healthcare organisations, provided they are able to facilitate comprehensive communication between the staff, physicians and the patient. To enable this, providers would need to put in place an appropriate channel of communication. Unless healthcare establishments take it upon themselves to introduce a patient-centred approach organisation-wide, a change of this proportion can never be positive in the long run. Akhil Tandulwadikar, Editor Asian Hospital & Healthcare Management
ACuRay™ chip, a new technology for cancer screening Researchers from the Georgia Institute of Technology have launched ACuRayTM (which stands for ACoustic micro-arRay) a acoustic sensor that can detect, treat and monitor cancer in patients. It can report the presence of small amounts of mesothelin, a molecule associated with a number of cancers including mesothelioma, as they attach to the sensor’s surface. The findings of the research were reported at the American Association for Cancer Research’s second International Conference on Molecular Diagnostics in Cancer Therapeutic Development.
Moacir Schnapp, a Memphisbased neurologist has launched a posture correction device. His innovation, called ‘the iPosture’, is intended to aid men and women in improving their posture that benefits their health in the long run. The iPosture is to be worn for approximately four hours each day for the initial two to four weeks in order to correct posture by establishing a habit in the user.
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Luminex launches xTAG™ Respiratory Viral Panel Luminex Molecular Diagnostics, a division of Luminex Corporation, has launched xTAG Respiratory Viral Panel (RVP), an assay for the detection of multiple viral types and subtypes, including influenza, metapneumovirus and adenovirus. xTAG has been developed in association with a team of leading virologists and infectious disease specialists. The test can assess 12 viral targets at once and provide qualitative results in just few hours. The test has received 510(k) clearance from the US Food and Drug Administration (FDA) and CE mark for sale in Europe.
Global Health Landscape
Healthcare “beyond borders” At a time when the global citizen is transforming how healthcare is delivered worldwide, there’s a need for a vision for delivering coordinated, high-quality and affordable care “beyond borders.” Ori Karev, CEO, UnitedHealth International, USA
Digital Ward
Hospital of the future Imagine a future where hospital wards have no paper case notes or files. Information on a Patient’s medical condition is automatically captured via intelligent context-aware devices and sent directly to the central computer systems.
Telemonitoring in Cardiac Device Therapy
Enabling optimal management of patients The vastly increased complexity of cardiac rhythm therapy over the past several years, demands commensurate improvements in overall device monitoring and telecommunication technology. Auricchio Angelo, Professor Division of Cardiology, University Hospital, Germany
Devices Containing Membranes
Better membrane, improved outcomes
Noah Tay Chin Seng, Manager Fong Choon Khin, Group Chief Technology Officer Grace Ng Yi Lin, IT Specialist Yvonne Eng, Systems Specialist InfoTech department Singapore, Health Services Pte Ltd (SingHealth), Singapore
Medical Devices Meet Consumer Electronics
Revolution in healthcare delivery
Devices containing artificial membranes for the treatment of kidney disease lack the ability to replace or augment metabolic and endocrine functions, which are non-selective and biologically reactive.
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.
Nicholas Hoenich, Clinical Scientist Medical School, Newcastle University, UK
Alison Burdett, Director Technology, Toumaz Technology, UK
Queen’s University introduces innovative antennas
Stanford researchers develop new Spectroscopy technique
Experts at Queen’s University, Belfast, UK have introduced a new type of antenna that is up to 50 times better and efficient than the existing designs. The new design is capable of utilising ‘wireless body area network’ (WBAN) technology to full potential. A WBAN is a network of biosensors attached to different parts of a patient’s body.
A team of researchers from Stanford University School of Medicine has developed a new type of imaging system that can depict tumours in living subjects with a precision of around one-trillionth of a meter. The technique is called Raman Spectroscopy. This is the first time the technology is being used to see deep within the body.
World’s first Bluetooth(R)-Enabled, Wireless Fingertip Pulse Oximeter The US-based Nonin Medical, Inc. has introduced a wireless fingertip oximeter with Bluetooth wireless technology for the first time. The fingertip oximeter assists patients who suffer from diseases such as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) by allowing vital signs to be easily monitored and sent wirelessly through communication devices (cell phones, PDAs, PCs, etc.). Patients can also take readings outside of the home and transmit the time-stamped data after their return using the device’s Store and Forward facility.
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HEALTHcare projects Apollo to set up a medicity focussing on Ayurveda
Macquarie University to set up new Private Hospital in Australia
Apollo Hospitals has revealed its plans to set up a medicity in the state of aharashtra in India. The new construction will take place in collaboration with Hindustan Construction Co (HCC), a real estate firm. A total of US$ 47 million will be invested for the project. It will offer ‘first rate ayurveda treatment’. There would be facilities for ayurvedic healing of various diseases and complete rejuvenation. The effort will boost the medical tourism scenario in the country. Apart from all his, Medicity will be involved in extensive research on cancer and heart related issues. To begin with the hospital will have 50 beds and will be upgraded to a 150-bed hospital by 2012.
Macquarie University and Dalcross Private Hospital based in North Ryde New South Wales in Australia have announced plans for a joint venture to build a private hospital with an investment of US$ 80 million. The new Macquarie University Private Hospital will deliver medicine involving training, medical research and high quality patient care.
Balco to build US$ 75 million cancer hospital in Chhattisgarh, India
Apollo to set up a medicity India to build a new Cancer Institute
Panacea Biotec plans to set up a multispeciality hospital
The Government of India is going to build a National Institute for Cancer in the South Indian city of Chennai. The institute will have research, service and education activities and will be the first-of-its-kind in India. The institute will be built on 10 acres of land in Vepery, Chennai. This will be the second Cancer institute to open in Chennai. The institute is expected to be operational by mid 2011. The government of India is ready to make an investment of US$ 125.2 million.
Panacea Biotec, a health management firm has revealed its plans to set up a multispeciality hospital with Gurgaon-based Umkal Medicals. Panacea Biotec has 75 per cent stake in Umkal’s project at Gurgaon. A total of US$ 200 million will be invested for the project. Upcoming hospital will have overseas patients and affluent Indians as its target making 25-30per cent of the market.
The Bharat Aluminium Company Ltd (Balco), a part of the India-based Vedanta Group, has announced its plans to build a new cancer hospital and research centre in north Indian state of Chhattisgarh with an investment of US$ 75 million (Rs 300 crore). The project is expected to be completed in the mid of 2010. This new hospital will be the first of its kind in the state. Apart from regular health services, Balco plans to provide free healthcare to the poor people of the region. The Chhattisgarh state government has allocatd a 41 acre plot of land free of cost to Balco for the new hospital.
events
KPC to build a Healthcare City in West Bengal, India KPC Healthcare Services, a part of US-based KPC Group has revealed its plans to build an integrated healthcare city in West Bengal, India. The company has acquired around 300 acres of land for the healthcare city. KPC Healthcare Services is investing around US$ 325 million in the project. The Healthcare City will include a 750-bed medical college, a 260-bed multi-speciality hospital, a 400-bed super speciality hospital, an infectious disease hospital, medical information technology centre and a medical store that will sell medicines and healthcare consumables.
February
February 24, 2009 Reducing Medication Errors 2009 Venue: Manchester Conference Centre, Manchester, UK Organiser: Healthcare Events Email: matt@healthcare-events.co.uk www.healthcare-events.co.uk/conf/ booking.php?action=home&id=240
February 12- 13, 2009 Chronic Heart Failure and Hypertension Venue: Institute of Physics, London London, United Kingdom Organiser: MA Healthcare Ltd Email: lisa.f@markallengroup.com www.mahealthcareevents.co.uk
February 26 – 27, 2009 Hospital Management Sydney Harbour Marriott Sydney, NSW, Australia Organiser: Informa Email: info@iir.com.au www.iir.com.au/bedmanagement
February 21 - 23, 2009 Meditec-Clinika 2009 Venue: Hitex Convention Centre, Hyderabad, Andhra Pradesh, India Organisers: Orbitz Exhibitions Pvt. Ltd. Email: sksingh@meditec-clinika.com www.meditec-clinika.com
For more projects, Visit Knowledge Bank section of www.asianhhm.com
March March 10 - 12, 2009 The 5th Annual World Health Care Congress - Europe Venue: Berlin, Germany Organiser: World Congress Email: indsay.pater@worldcongress.com www.worldcongress.com March 11-13, 2009 5th Health Asia 2009 Venue: Karachi Expo Centre, Pakistan Organiser: Ecommerce Gateway Pakistan (Pvt.) Ltd Email: info@health-asia.com www.health-asia.com
March 14-16, 2009 HOSPIMedica India 2009 Venue: Bombay Exhibition Center Goregaon, New Delhi, India Organiser: Messe Dusseldorf India Email: UllalS@md-india.com www.hospimedica-india.com
April April 1-3, 2009 13th Southeast Asian Healthcare & Pharma Show 2009 Venue: Kuala Lumpur, Malaysia Organiser: ABC Exhibitions Email: sales@abcex.com www.abcex.com April 16 - 19 The 6th Annual World Health Care Congress Venue: Washington DC, USA Organisers: World Health Congress Email: amy.wilder@worldcongress.com www.worldcongress.com/events/ HR09000/index.cfm?confCode=HR09000
For more events, visit www.hospitals-management.com and www.asianhhm.com www.asianhhm.com
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Hitachi Medical Systems (S) Pte Ltd . .................................... IBC www.hitachi-medical.com.sg International Business Conferences .........................................15 www.ibcinfo.com Inverness Medical .....................................................................5 www.determinetest.com/print Plus ninety one .......................................................................19 www.plus91.in Ratcliff Architects . ..................................................................47 www.ratcliffarch.com Robinsons Global Logistics .....................................................49 www.rglindia.com Shimadzu Asia Pacific Pte Ltd ................................................ 45 www.shimadzu.com.sg Wipro HealthCare IT Limited ....................................................57 www.healthcareit.wipro.com/aboutus.htm 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