Asian Hospital & Healthcare Management - Issue 23

Healthcare Management | Medical sciences | Diagnostics | information technology | TECHNOLOGY, EQUIPMENT & DEVICES

I s s u e 23

2011

w w w.asianhhm.com

mHealth healthcare on the go

Patient-Provider Communication Peer-to-Peer Communication Disease Management Track Clinical Trials Patient Monitoring Ambulance-based Tracking

Emerging Healthcare Delivery Models in India

PET-CT - Towards personalised cancer treatment

Quality Management Systems inw wTelemedicine w.asianhhm.com

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Foreword

The mHealth Revolution Mobile technology has created a whole new paradigm for healthcare delivery and practice. Mobile Healthcare – also known as mHealth – enables providers, practitioners, patients, payers and pharma to connect in a never before way. The ubiquity of the mobile phone is being aptly exploited to bridge the communication divide that has plagued the healthcare landscape.

This shift is being driven by the combination of greater smartphone adoption, mobile internet penetration and a spurt in healthcare applications There has been a dramatic growth in the use of mobile applications for healthcare, the market for which is estimated to reach US$1.7 billion by the end of 2014. Also 500 million of a total 1.4 billion people with smartphones are expected to use health applications by 2015. mHealth connects patients and doctors and provides peer-to-peer communication. Applications exist for needs such as access to medical content to more sophisticated ones those aide providers and patients in disease management, tracking clinical trials, patient monitoring, ambulance-based tracking and many other services. One such application is Medscape, a free application which provides more than 7,000 drug references, 3,500 clinical references for diseases, 2,500 clinical images and procedure videos, CME activities and much more. This list is only likely to grow as the concept evolves. Creativity of application developers, mainly third-parties, could spawn a range of applications that could make the lives of patients and doctors easier than ever before.

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According to astudy by PricewaterhouseCoopers’ Health Research Institute, mobile technology holds great promise for keeping people healthy, managing diseases and lowering healthcare costs. It helps doctors take decisions faster based on complete and more accurate data in real-time provided by mobile devices. Different types of applications like remote monitoring, prescribing medication wirelessly, accessing electronic medical records (EMRs) wirelessly and many more also help both providers and consumers. mHealth will play a key role in improving healthcare outcomes while cutting costs, with well-integrated partnerships among technology developers, device makers, policy makers, academic institutions and NGOs. However, providing mHealth in low and middle income countries may not be as easy as compared with developed countries due to small scale implementations and pilot projects with limited reach.

The cover story in this issue of Asian Hospital & Healthcare Management provides experts’ insights on the impact of mobile devices on healthcare and also discusses applications of mhealth to demonstrate the change in healthcare landscape.

Prasanthi Potluri Editor

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Contents

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mHealth New opportunities for healthcare improvement Claudia Tessier RHIA, President, mHealth Initiative C Peter Waegemann, Vice President, mHealth Initiative President, Waegemann Associates LLC, USA

31 mHealth Poised for growth in India K Ganapathy, President, Apollo Telemedicine Networking Foundation President, Telemedicine Society of India

mHealth healthcare

WHEN BUSINESS IS SLOW

DON'T SPEND...

on the go

Healthcare Management

Diagnostics

06 Reforming Claims Processing with Real Time Adjudication

22 PET-CT Towards personalised cancer treatment

Apoorv Surkunte, Lead Business Analyst, USA

Wai Lup Wong, Consultant Radiologist, Mount-Vernon Hospital, UK

08 The Role of Quality and Quality Management Systems in Telemedicine Markus Lindlar, M German Aerospace Center, Institute of Aerospace Medicine

information technology

Harald Korb, Chief Medical Officer, Vitaphone GmbH, Mannheim, Germany

36 An Integral Solution for Hospital Information System

12 Emerging Healthcare Delivery Models in India

Ivan Evgeniev Ivanov, Vice-Head, Department of Systems and Control, Head , Advanced Control Systems Laboratory, Technical University of Sofia, Bulgaria

Ratan Jalan, Founder & Principal Consultant, Medium Healthcare Consulting, India

Medical sciences 16 Telemedicine Using the example of practical models of healthcare with cardiovascular disease Heinrich Körtke, Tanja Feige, Songül Secer, Sabine Frisch, Annette Hoffmann-Koch, Britta Gräfe, Otto Wagner, Institute for Applied Telemedicine, Heart and Diabetes Center NRWA

Vesselin Gueorguiev, Assistant professor, Department of Computer Systems and Control, Technical University of Sofia, Bulgaria

special features 35 Events 42 Books 44 Research Insights 50 News

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Advisory Board

Editors Akhil Prasanthi Potluri Art Director M A Hannan Copy Editors Sri Lakshmi Kolla Hemanth Reddy Sankepally Jenny Jones John Milton

John E Adler Professor Neurosurgery and Director Radiosurgery and Stereotactic Suregery Stanford University School of Medicine, USA

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

Peter Gross Senior Vice President and Chief Medical Officer Hackensack University Medical Center, USA

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

Vivek Desai Managing Director HOSMAC INDIA PVT. LTD., India

Sales Team Khaja Ameeruddin Aravind Maroju Jeff Kenny Ben Johnson Compliance Team P Bhavani Prasad Srikanth Katragadda Sam Smith CRM Yahiya Sultan Radha Krishna Kottakki Subscriptions incharge Vijay Kumar Gaddam IT Team Ifthakhar Mohammed Azeemuddin Mohammed Krishna Deepak Head - Operations S V Nageswara Rao

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A member of Confederation of Indian Industry

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Healthcare Management

Healthcare Management

U

nlike sectors such as banking and retail where business transactions with consumers take place over few minutes, US healthcare still lags behind on efficient transactions processing front. After patient visits provider and receives the services, it takes days to settle the claim for various reasons. This scenario however could be reformed with implementation of real time claims processing.

The American Medical Association in its National Health Insurer Report Card 2010 has stated that seven major payers which received claims submitted electronically took 5 to 13 median number of days to respond with claim processing details. There are delays in provider’s office as well while submitting the claim owing to various activities such as documentation, medical coding and billing.

As a result of the rising healthcare costs, patients are paying more out of their pocket for their healthcare which

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puts increased burden on providers to seek collections from patients. It may take days to know amount payable by members, after which members would initiate payment settling process with providers. This factor is even more prominent in Consumer driven Health plans where members pay larger amount out of pocket. A Report by AHIP shows that the number of people covered by highdeductible health plans (HDHPs) totaled 10 million in January 2010. With growing number of CDHP members, account receivables due from patients are going up and increase the risk of bad debt and reduce the cash flow for providers.

As CDHP enrollment grows, medical offices that experience growing receivables have a promising option in real-time claims adjudication. With the Real-Time Claims Adjudication system, provider may collect the member payable amounts at the time of member office visit after services have been provided and

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Real Time Claims Processing significantly reforms how healthcare claims are submitted, adjudicated, remitted and paid and helps make the process far more efficient.

Adopting real-time adjudication may result in administrative simplification mandates driving real time claim processing.

Apoorv Surkunte Lead Business Analyst, USA

the claim has been processed real time.

Providers would be able to bill for service and receive an explanation of benefits (EOB) at the point of service before the patient leaves the office premises.

Here is an example as to how it would work. Member Greg goes to see the physician Dr Derek and seeks healthcare services. Dr Derek examines and renders the services to Greg. Right after services are provided, Dr Derek / his support staff verifies that Greg belongs to plan which supports real time claim processing. Staff member then files the claim with help of EHRs or payer website. Payer's system processes the claim real time and sends the details of payable amount to the provider and the amount owed by patient. Greg could make the payments while he is in hospital and discuss with the staff about any queries he may have pertaining to bill. Dr Derek would receive amount payable by payer within a day or two

The Real-Time Claim Adjudication process provides the capability to submit and receive ASC X-12N transactions in a real-time mode. Payers need to implement functionalities that will have members’ benefit details and provider’s contracted rates and can accurately process submitted claims in a matter of seconds.

Providers need to set up IT infrastructure and communication channels with specific payers which are offering this service. RTCA uses the electronic data interchange (EDI) channels for communication with payers. Communication can be performed through web link, a B2B software setup or third party vendor.

Providers could deploy Electronic health record systems to enter claims, submit the claim to the Payer with a click of a button and within seconds have a response back about adjudicated claims.

Usage of smart cards for patients would help providers to collect member information related to eligibility and personal health record instantly and eliminate manual information keying in part.

with Electronic fund transfer (EFT).

The whole process could be as quick and simple as this, from the present scenario where it takes days to settle a claim.

of providers and members would go up due to efficient claims processing systems and payers would be able to use this as a differentiating factor.

Benefits with RTCA implementation RTCA implementation helps reduce administrative burden and excess paperwork which eventually helps to cut down the costs related to administration.

Members need not spend time and energy to follow up and resolve their health care billing issues. They need not wait for weeks to receive statement in the mail. Members also can discuss the EOB with hospital staff while they are in hospital.

Provider staff would spend less time on administrative activities such as following up with payer on overdue claims. The risk of bad debts associated with patients receivables would go down as providers would be able to collect these while patient is in hospital.

Providers would receive the payment from member right after the encounter and the remaining payment from payer over Electronic Fund Transfer in few days. Quick turnaround in reimbursement improves the cash flow of providers / hospitals.

Payers would have fewer people working the telephones to answer claim and benefit inquiries. The satisfaction levels

Challenges RTCA implementation substantially alters the existing workflow of providers.

Claims need to be keyed in while patient is in hospital. When patients get their bill in real time, they would have questions about bill and would expect the answers from the staff in hospitals which mean hospitals will have to invest on personnel and infrastructure to support real time processing.

Many providers are not able to prepare bills for claims submission for at least few days owing to various activities involved. The hospital staff needs to navigate through thousands of diagnostic and procedure codes while generating the claim. This activity gets even more complicated when the provider is a generalist and deals with large number of medical conditions.

Author BIO

Reforming Claims Processing with Real Time Adjudication

Implementation Provider offices have been keying in the claims in a batch mode system for long time. Change in mindset would be required to implement RTCA, it also would have financial and administrative implications for provider.

Providers need to have proper practice management setup to submit real time claims. This could be accomplished by implementing Electronic Health record systems. However, EHR implementation could be financially burdensome and impact productivity of provider and staff by about 30% over first year of implementation.

Along with providers, payers also need to upgrade their systems to support RTCA. However, not all payers offer this option of RTCA to providers.

Payers' claims processing for long have relied on batch processing. Migration to real time processing would be costly and complex.

Road ahead RTCA significantly reforms how healthcare claims are submitted, adjudicated, remitted and paid today and helps make the process far more efficient. In future, we may see administrative simplification mandates driving real time claim processing.

While it may still seem far off, progress is being made towards the adoption of real-time adjudication with payers like Humana, BCBS FL, BCBS Highmark, and BCBS WV implementing and pushing RTCA usage. There is also increasing interest among providers about usage of RTCA systems. With EHRs being implemented as part of HITECH act across USA, we may expect significant growth on RTCA implementation front.

Apoorv Surkunte works as Lead Business Analyst in Healthcare IT area with one of leading Health insurance companies in USA. His areas of interest include health reforms, healthcare innovations and insurer side applications such as provider networks and claims.

Apoorv is certified Fellow, Academy of Healthcare Management (FAHM) and project management professional (PMP).

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Healthcare Management

Healthcare Management

The Role of Quality and Quality Management Systems in Telemedicine

In particular, EN ISO 9001:2008 certified QMS are widespread in hospitals, doctor's practices or in companies producing medical devices. In Germany, providers of medical care are committed to implement QMS and to improve them continuously starting 2010.

Regarding the evolving role of telemedicine in the healthcare system worldwide and its claim to deliver at least equivalent or better quality than the standard non-telemedical services, it should be expected that quality and quality management systems are already considered when developing products or services.

The Institute of Aerospace Medicine of the German Aerospace Center addressed this topic in 2008 conducting a survey searching the databases of PubMed and the Telemedicine Information Exchange (TIE) to gain an overview of the role of quality in general

To secure and demonstrate quality of their processes a growing number of providers of medical care establish quality management systems (QMS) following international quality standards like e.g. EN ISO 9001:2008. Telemedical services following these quality standards are rare as results of a literature research showed in 2009. The article demonstrates study results and first promising activities on the field.

Search criteria Studies Services Quality aspects all Quality aspects Services QMS

T

he proof of quality very often is a precondition requested by principals prior to concluding a contract or to place an order. Quality of services and or products gains in importance not only in the medical sector; this applies to products, services produced or provided by companies or service providers as well. Quality is defined as the conformance with requirements usually defined by the customers themselves. In the healthcare sector, products include medical devices or pharmaceutical drugs. Medical services include medical examinations or (tele)-medical applications. The main services or core processes of hospitals which in general are medical service providers are diagnostics, treatment and rehabilitation. The level of quality of these services corresponds to the grade of customer retention. The better the service quality more the patients return to the hospital the next time medical support is needed.

To provide objective evidence of product or service quality more and more health care providers on various medical fields have established Quality Management Systems (QMS).

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and especially of quality management systems in the field of telemedicine with focus on telemonitoring. Catchwords in this research were "Telemedicine or Telehealth or E-Health or Telemonitoring" in combination with "Quality" and "Certification or Guidelines or Pathways or Management or ISO 9001" Only 202 publications matched the search criteria; 141 were found on the PubMed portal of the U.S. National Library of Medicine. In the database of the Telemedicine Information Exchange; 61 publications matched the query.

Among these, 108 publications described studies about new applications or limited projects; 72 publications analysed established services in the field of patient care. The topics of 22 papers were neither studies nor running services; 35 publications dealt with quality aspects of telemedical applications. The papers of 20 telemedical services reported to be integrated in patient care discussed quality aspects.

But only two different publications described a teleradiological application certified as EN ISO 9001:2000. Unfortunately, these publications belonged to one and the same application. One publication described a QMS following the Six Sigma standard which is however focusing more on quality management systems on the manufacturing than on the service field.

Markus Lindlar is a physician who studied medicine in Italy and Germany and specialised in medical informatics in 2001.

Focus of his work at the German Aerospace Center is telemedicine and e-health with focus on health economics and service quality. He is board member of the German Society of Health Telematics – DGG

Professor Harald Korb is one of the leading experts in the field of telemedicine providing of more than 10 years in experience in the monitoring of patients with cardiac disorders. Prof. Korb is vice president of the German Society of Health Telematics – DGG and member and speaker in numerous medical associations, advisory boards and executive committees.

PubMed

TIE

Total

141 47 52 23 13 1

61 61 20 12 7 1

202 108 72 35 20 2

These results were unexpected and a first superficial analysis of the results could lead to the assumption that QMS do not play a significant role for telemedicine service providers.

But that interpretation could miss some facts. QMS cover companies, not services. Thus, telemedical services could be just one part of a complex product portfolio offered by a company which could run a QMS including all the telemedical and non-telemedical processes. But keeping in mind the spread of QMS not just in the medical sector, a few references to QMS of the publishing institutions would be present in the corresponding papers. It has been very surprising that only two publications of established telemedical services describe the embedding in a QMS. Yet a distortion of results could be caused by the study's design. In fact, several scientific publications are published in an early stage of development of a telemedical application. QMS very often are established when services are already operational. For this reason the study focused on well established telemedical applications. But an additional

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Healthcare Management

random research in the Worldwide Web delivered a trend similar to PubMed and TIE research. Summing up the results of the study, quality management systems did not play a similar role in telemedicine as they did in other sectors of medical care or medical business in general at the time of study performance.

But the demographic development in Europe with the growing number of elderly, and very often chronically ill people, and the lack of resources for medical care, especially in the outpatient sector, have created a growing need for telemedical services to deliver medical care. Thus in 2008 Germany and Europe initiated research programmes to support the development of Ambient Assisted Living (AAL) services for senior and/or chronically ill citizens.

AAL is the support for people in their personal environment by technologies and services in the fields of medical care, safety, social integration and supply with convenience goods. The majority of AAL-conceptions or of telemonitoring supported programmes for the chronically ill are based on the collection and transmission of biological signals from the domotic, medical and social field, whereby the focus is mainly set on the technical implementation with all inherent problems. Due to the fixation on technical details, a decisive aspect is largely ignored: where is the obtained information collected, concentrated and interpreted, and who triggers after this initial analysis which reactions based on clear juridical backgrounds and responsibilities? A putative solution is provided by a centralised Telemedical Service Center (TSC), which must, however, fulfill all prerequisites of a quality-assured information and service platform as part of the interconnected network of customer / patient, healthcare partner, care and medical technology.

Many planners and operators of TSCs are sometimes overstrained with the complexity of their IT systems.

Therefore, it seemed necessary to set up a Quality Management System

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Healthcare Management

framework dedicated to the needs of a TSC. The Working Group “Quality Management”, commissioned by the VDE-Initiative MicroMedicine committee “Telemedicine / Disease Management” in VDE / DGBMT has defined standards derived from DIN EN ISO 9000:2000, DIN EN ISO 9001 and DIN EN ISO 13485 and other relevant legislations for the application of telemonitoring systems and implemented a quality management system for telemedical service centers. The result was the VDE application "Telemonitoring", which is a practical reference work of high quality.

In addition to the comprehensive definition of terms and detailed description of telemedical resources, requirements for personnel qualifications, structures and processes, it provides a complete overview of the relevant legal standards. The new VDE application defines the quality requirements for the provision of telemedical services and internal processes, but also the necessary hardware and the secure transfer of data from the domestic area of the patient to the TSC, clinic or doctor's office. Thus patient data cannot be disclosed to any third party. Given a consistent application a misuse of sensitive personal data and findings is virtually impossible. The VDE Test and Certification Institute successfully used it as a reference for the certification of TSCs. Under the background of growing internet connectivity in private homes and ubiquitous cost pressure in healthcare, TSCs offer an efficient complement to established services in chronic disease management. The TSC acts as the general contractor of an extremely complex structure. Apart from the provision of hard- and software for the home environment, installation of data communication between patient, TSC and specialist, efficient organisational set-up, the management of sensitive patient data and the related data safety aspects are the major challenges. Due to the high level of complexity, TSCs are looking for independent third party assistance to get confirmation of their legal

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QMS still do not but start to play an important role in telemedicine, especially with focus on telemonitoring and AAL to guarantee quality of services on one hand. compliance and fulfillment of customer needs. Besides these aspects, third party evaluation has several benefits. One is assistance to involve employees from all hierarchical levels and functions in order to install a process of continuous improvement as the vital part of the QMS. Another is supporting the top management in the penetration of the concept by regularly reviewing its effectiveness and helping to adopt the quality strategy accordingly. Furthermore, the QMS sets the framework for auditing and certification, which adds two more aspects: enlargement of scope and formal acceptance. Scope enlargement comes from the interaction and discussions with the auditors, having a fundamental background from the industry and, therefore, efficiently guiding the organisation towards reasonable modifications and optimisations of their QMS. Finally, formal acceptance by certification gives credit to all people involved and motivates for continued commitment of resources.

The review looks to safeguard confidential patient data is one of the most relevant topics during the audits. In addition to hierarchically restricted access for patients, doctors and administrative staff, the software structure is in focus. Data safety handling of external subcontractors, either for health & care, outsourced IT or any other services will be included as well as review of intermediate storage

or long-term in archives in juke boxes, on tape or WORM. Whether data safety is an integral and essential part of the risk management scheme, and whether the risk levels are properly addressed and corrective action plans are in place will be monitored. Scenarios of data loss, data recovery or data fraud are covered as well.

Nevertheless, the focal point is always the patient. Comprehensive information about the content of the services provided, formal authorisation before any transfer of confidential patient data to third party and regular customer satisfaction surveys are key requirements of a QMS. Third party auditing and certification of the system, give a measurable value added to the performance of TSC.

Safeguarding legal compliance with priority on data safety, cost effectiveness, involvement of employees and customer satisfaction will be key ingredients to fulfill the needs of all stakeholders in telemonitoring applications. Adequate management of these topics will foster both public acceptance and penetration of these services and – in consequence – making life of chronic disease patients a little bit easier.

Finally, it must be stated that QMS still do not but start to play an important role in telemedicine, especially with focus on telemonitoring and AAL to guarantee quality of services on one hand. On the other hand QMS at present are a unique selling point for healthcare providers to convince contractors of the quality of their telemedical services.

[1] http://www.pressebox.de/pressemeldungen/tuevsued-ag/boxid-190748.html [2] European Foundation for Quality Management, www.efqm.org [3] Motorola University, What is Six Sigma, http:// www.motorola.com/content.jsp?globalObjectId=3088 [4] Kooperation für Transparenz und Qualität im Gesundheitswesen, www.ktq.de [5] The Joint Commission, www.jointcommission.org [6] VDE Initiative MikroMedizin, VDE-Anwendungsregeln für TeleMonitoring Qualitätsmanagement ISO 9001:2000 - Aufbau | Ablauf | Fallbeispiele, Frankfurt/Main, 2007, ISBN 978-3-00-022879-7 [7] VDE Anwendungsregeln für TeleMonitoring – Qualitätsmanagement DIN EN ISO 9001:2000, Aufbau | Ablauf | Fallbeispiele. Arbeitskreis „TeleMedizin/Disease Management“ – Projektgruppe „Qualitätsmanagement“. VDE Initiative MikroMedizin, Projektleitung: Prof.Dr.med.

Harald Korb, Vorsitzender der Projektgruppe „Qualitätsmanagement“ (Hrsg.), Frankfurt, 2007 [8] Korb, H et al: Grundsätzliche Überlegungen zum Anforderungsprofil und zu Qualitätsstandards eines Telemedizinischen Zentrums. In: „Telemedizinführer Deutschland 2007.“ A Jäckel (Hrsg.), Minerva Verlag, Darmstadt, S. 92 – 9, 7 2007

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Healthcare Management

Emerging Healthcare Delivery Models in India

The current restricted healthcare delivery models need to focus on preventive aspects in healthcare and create functional progressivereferral systems managing bulk of healthcare at the ‘front’ or the primary healthcare level, for better healthcare delivery models.

Ratan Jalan Founder & Principal Consultant Medium Healthcare Consulting, India

1. What are the trends driving the shift in healthcare delivery models in India?

Various attributes associated with ‘shining India’ work for healthcare as well. Rapidly increasing disposable income, growing urbanisation and higher levels of literacy are known to have significant impact in contributing to higher healthcare spending. A vast majority of Indians, particularly in urban India, are experiencing a transformation in service sector such as banking, entertainment, telecoms, education and aviation, which is comparable to anywhere else in the world. Such exposure results in a more demanding and discerning consumer. Increasing penetration of health insurance, both private and government-funded, helps in improving the overall affordability, and hence spend and the ability to choose.

Interestingly, migration to different urban centres and emergence of nuclear families has resulted in great belief in institutional brands, since there is no carryover of earlier bonds and relationships with the physician or the local drug store in such situations. The family physician of yesteryears is fast fading into oblivion. Also, high acceptance amongst the vast populace in the country of even the newer providers such as Fortis is a strong indication of this shift.

2. What are the sectors that are converging with healthcare to create new models?

Healthcare, as a sector, even globally suffers from incurable insularity. And it is no different in India. Real estate firms seem to have taken greater interest in healthcare and offer newer models to

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Ratan Jalan founded Medium Healthcare Consulting in 2009. He was the CEO of Apollo Health and Lifestyle Limited for the last eight years. He created some of the most successful and innovative healthcare formats in the country such as a nationwide network of The Apollo Clinic and The Cradle, South Asia’s first boutique birthing centres. He also championed some of the strategic marketing initiatives for the group.

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Healthcare Management

A greater shift towards outpatient services shall certainly help in correcting some inherent imbalances in healthcare delivery and should help improve both quality and affordability.

work together, which, in some cases, has greatly reduced the capital outlays in the initial phase. Similarly, the PE firms, given their varying background in terms of ‘ticket size’ and investment horizon have helped in energising some of the innovative, even if less proven, models.

Such firms, fortunately so, also tend to be guided by their global experience.

Other than large hospital chains, globally renowned PE firms have chosen to invest in diagnostic services, pharmacy chains, ambulatory surgery and facilities, which focus on single specialty such as eye-care, dental services or even beauty. Some of these firms have even invested in firms which provide a variety of healthcare services through web relying on existing Brick and Mortar network rather than create their own.

3. What are the new models emerging?

So far, it has essentially been large multi-specialty hospitals in big cities, which has managed to become the most visible face of healthcare delivery in the Indian context. Their ‘glamour’

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quotient may have helped them attract some overseas patients, but have also adversely impacted their image with the local patients, as they tend to believe that such places are prohibitively priced.

One welcome trend has been the spate of initiatives in the recent past in terms of smaller hospitals, which tend to focus on single specialty, be it eye care, dental services, obstetrics, or ENT. There have also been hospitals focusing on children or just secondary care services for the community. Quite a few of such initiatives have been immensely successful and in a shorter time frame in relation to some of the larger hospitals.

It is widely known that hospitals account for only about 35 per cent of the overall healthcare expenditure in the country. Outpatient services account for a much larger share and also happened to be extremely fragmented. Fortunately, there have been quite a few experiments in outpatient services as well. We come across different types of clinics ranging from a simple family physician clinic (as in the case of Razi Clinics in Andhra Pradesh) or those offering more comprehensive services, such as in The Apollo Clinics. We also have facilities focusing on chronic ailments, such as diabetes, offering diagnostic services.

Stand-alone dialysis centres such as Nephroplus or Sparsh and ambulatory surgery and minimal access surgery centres like Nova or BEAMs have also started getting some attention. However, such initiatives are far too few given the vast potential to innovate and create more focused facilities.

4. Is there a scope for public private partnerships in creating new models?

There is immense scope to create win-win relationship amongst various stakeholders given the enormity of the challenges involved. Various governmental agencies can bring in their focus on certain basic and core areas critically important in their context – for example, maternal health, nutrition, or immunisation. Such

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agencies also focus on less advantaged sections of the society, be it poor or rural patients, who suffer from inaccessibility to quality healthcare services. They can also provide financial resources and distribution network through existing infrastructure. Private sector, on the other hand, can deliver a certain sense of accountability, quality and performance.

Ironically, it is often the land – and just the land – which is expected or asked for by the private player from the government.

Government, on its part, firmly believes that the private sector’s sole motive is to make profits. As a result of this mutual ‘trust deficit’, there is not enough happening on ground. Certain states such as Gujarat, Karnataka, Maharashtra and Andhra Pradesh have succeeded in creating enormously successful experiments at a large scale through innovative PPP models in healthcare.

One notable achievement has been Rashtriya Swasthya Bima Yojana (RSBY). This programme has managed to leverage partnerships amongst various stakeholders ranging from governmental agencies, technology solution providers, private healthcare services providers and also people at large. It has also adopted unique technology solutions to address the pitfalls of corruption. It has already managed to reach over 23 million Indians and is widely recognised as one of the most successful initiatives globally.

5. Who are likely to be the biggest beneficiaries of this shift?

There have been huge gaps in healthcare delivery in the country on various fronts. Physical access for the masses, more so in the rural context, has been a challenge with various research studies pointing to the need to travel more than 200KM for a simple secondary care procedure. Lack of regulatory framework for quality has ensured that poor quality in the larger context continues to be the norm. Similarly, affordability of quality healthcare services for the masses has been an elusive goal. Innovative attempts as outlined above create more evolved

platforms for delivery, which are patientfocused and efficient. Such initiatives tend to benefit different cross-section of patient population. We have witnessed such a transformation in many other sectors in India such as banking and telecom, where a combination of quality, affordability and reach have managed to achieve really high levels of penetration and help transform people’s lives. Given the vast gap, enormous disease burden and a sizable population below poverty line, it is such innovative measures, which shall help us all achieve the global health indicators, which have so far managed to remain just the goals!

6. What are the deficiencies in the current healthcare delivery models in India?

The current healthcare delivery models, particularly amongst the large organised players, have been unfortunately restricted to creation of more and more large ‘world-class’ multi-specialty hospitals. Such models, at best, can address a certain client segment and also tend to be expensive in view of their higher overheads. Larger players have rarely gone beyond the big cities to the smaller towns and villages, although almost 90 per cent of the country lives there.

Moreover, in their overall approach, they continue to be excessively providercentric and rarely address the needs of the patient beyond the clinical perspective. And that’s precisely the reason most of them score quite poorly on critical issues such as transparency, trust and patient communication. There is a great need to create functional progressive referral systems as is found in countries like the UK, where bulk of healthcare is managed at the ‘front’ or the primary healthcare level. There is a great need to focus on preventive aspects in healthcare. In view of the likely impact on costs of lifestyle diseases so prevalent amongst the masses in India, as a country we can’t even afford treatment.

As they say, if the disease doesn’t kill you, the treatment will. It is extremely

unfortunate that even the government does not seem to care enough about this aspect. I find it an alarming signal that the finance minister in the recent budget has proposed tax on preventive health checks.

We also need to promote aggressively the wealth of traditional medicine, be it Ayurveda or Yoga. While the West seems to be adopting these with an unprecedented fervor, we are not making any attempt to even catch up. A system as potent as Ayurveda has been reduced, in people’s minds, to spas and massages, while rightly speaking, it has the potential to provide effective and inexpensive cure for so many chronic conditions.

7. Is this trend, in your opinion, going to improve the quality of care?

A greater shift towards outpatient services shall certainly help in correcting some inherent imbalances in healthcare delivery and should help improve both quality and affordability. However, at a macro level, the increasing competition amongst like-minded players so far has focused more on price and at times, the power of a celebrity physician to attract patients. Healthcare sector has to realise the potential of creating the right patient experience as a differentiator. It takes a certain mindset and a non-negotiable

Migration to different urban centres and emergence of nuclear families has resulted in great belief in institutional brands, since there is no carryover of earlier bonds and relationships with the physician or the local drug store in such situations.

attitude to create an institution, which is ethical, transparent and trust-worthy.

8. Any other comments?

In times to come, the healthcare sector needs to focus on some of the basic issues, be it drinking water, sanitation or nutrition. It also has to look beyond the traditional model, which is focused on cure and treatment. Equally importantly, a strong foundation in terms of affordable and quality primary healthcare provider network can be the real boon. Given the alarming levels of penetration of different lifestyle diseases – India has already emerged as capital of many such conditions ranging from diabetes to hypertension - the role of preventioncan no longer be ignored.

In view of our vast geographical landscape and scarcity of qualified manpower, adopting solutions, which leverage technology to provide reach and quality in an affordable manner, is yet another direction, which has barely been explored.

People, who focus on social ventures and an inclusive approach, have achieved impressive performance by using telemedicine or mobile and internet-driven solutions to provide access and information. Moreover, supportive framework to encourage local manufacturing of medical equipment and greater emphasis on generics shall help in reducing the overall cost of healthcare.

Lastly, there is a lot that needs to be done in the area of medical education.

Our archaic laws and rampant corruption have managed to perpetuate inadequacies and inefficiencies. We need more medical colleges, which can deliver quality education and are affordable.

And we need them across the length and breadth of the country rather than have them dominate the South and the West. Similarly, huge efforts need to be made to address the gaps in educating nurses and technicians.

I am quite optimistic about the future in healthcare, as long as we can resist the temptation of aping the USA and leverage some of our inherent strengths.

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Medical sciences

Medical sciences

Telemedicine

Technical progress, statistical evidence of significant increases in therapeutic success, as well as the participation of an increasing number of ambulatory physicians has made telemedicine successful.

Heinrich Körtke, Tanja Feige, Songül Secer, Sabine Frisch, Annette Hoffmann-Koch, Britta Gräfe, Otto Wagner Institute for Applied Telemedicine, Heart and Diabetes Center NRW Germany

Using the Example of Practical Models of Healthcare with Cardiovascular Disease

H

ealth is one of the most important human commodities. However, in times of economic shortage, it is not only crucial that a healthcare system is fair and effective, but also that it is efficient. Protagonists and institutions within the German healthcare system are increasingly having to base their actions on the imperative of efficiency. But this necessity for efficiency is not the only thing changing the situation in the care system. The simultaneous occurrence of erroneous care, overcare and undercare, as well as increasing patient contributions to the costs and, especially, medical progress and the resulting increase in chronic diseases are all playing their part. This increase is also due to the demographic development, which is leading to an ever larger morbidity in the field of chronic diseases, in particular as a result of a

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steadily aging population. The growing shortage of physicians is also taking more and more of an effect, exposing the limitations of medical care and necessitating the creation of new care structures.

The Institute for Applied Telemedicine (IFAT) The cardiologists at the Heart and Diabetes Center North Rhine-Westphalia (HDZ NRW) in Bad Oeynhausen, University Hospital of the Ruhr-University of Bochum, are among the pioneers of telemedicine and have been working successfully on this project since 1998.

The Institute for Applied Telemedicine (IFAT) was founded at the HDZ NRW in late 2003. It plays an integral part in various medical quality studies and also conducts its own. With due respect to data protection and medical secrecy laws, patient data are collected at IFAT and statistically evaluated. The patients, as well as all treating hospitals and physicians, are informed of this procedure in detail. The result is a multitude of services which IFAT is able to provide in the areas of prevention, diagnostics and treatment.

To date, more than 7500 patients with cardiological diseases have been monitored and treated by IFAT. Chronically diseased patients are able to be treated in accordance with the guidelines as a result of their own collaboration in a kind of cross-sector telemonitoring. Its goal is the treatment at home of patients with chronic diseases such as cardiac insufficiency, diabetes mellitus, impaired coagulation, increased risk of heart attack, chronic arterial hypertension or cardiac dysrhythmia. Patients are looked after by the telemonitoring team at IFAT and appropriately trained physicians at the HDZ NRW. The aim of this undertaking is to improve both the quality of life and the safety of patients in the light of cost reductions in the healthcare system. Should IFAT observe any changes in the health of its patients requiring more intensive supervision

by a family practitioner or even inpatient treatment, then the institute will initiate this step. IFAT is striving to introduce blanket coverage of telemedicine, primarily through integrated care contracts and in particular with AOK NordWest. This is taking place in close cooperation with family practitioners, ambulatory physicians, other specialists and clinical contact partners. Qualified evaluation of data, supervised by a physician, is guaranteed around the clock, 365 days a year. The medical expertise of the IFAT team is continually being expanded by networking and integrating telemedicine in other fields of medicine. The comprehensively trained physicians and specialists on call rotate after four months of telemedical work to perioperative cardiology or outpatient care, where they gain practical experience in ambulatory and diagnostic medicine. This guarantees a high level of training and further training for IFAT staff, reduces staff fluctuation and increases motivation.

IFAT’s chief cooperation partners are ambulatory physicians and hospitals.

IFAT thus functions as complementary support to the conventional treatment of patients. The indication for telemedical supervision by IFAT is pronounced by the cooperating physicians. They also select the diagnostic equipment required, such as a blood pressure measuring device, a set of scales or a portable ECG device, and decide the duration of telemedical monitoring.

From March 2011, patient telemonitoring at IFAT will undergo technical reorganization. A special telemedical software platform is being created using the medPower power solution from IBM premier business partner SVA and IBM technology, with support from EU and regional funding for its development and implementation at IFAT. This new platform will provide a higher quality of treatment, easier access to affiliated physicians and hospitals, lower costs, less complicated processes and higher safety levels.

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Medical sciences

Models of care for home monitoring Anticoagulation management (ESCAT/TELEQIN studies) Preparatory work for IFAT began as early as 1994. Clinical studies on anticoagulation self-management following mechanical heart valve replacement were performed at the ESCAT (Early Self-Controlled Anticoagulation Trial) headquarters. Patients in a study group were each given a CoaguChek measuring device from Roche Diagnostics Deutschland GmbH, enabling them to measure their INR values at home. The ESCAT I and subsequent ESCAT II studies were able to show that self-management and an INR adjustment within the low-dose range are significantly able to reduce the complication rate, as well as patient mortality and morbidity, compared to conventional treatment by family practitioners.

The current ESCAT III study has reduced the INR target ranges of 1.8-2.8 for patients with aortic valve replacement and 2.5-3.5 for patients with mitral valve replacement to 1.6-2.1 (aortic valve replacement) and 2.0-2.5 (mitral valve replacement) after seven months in order to examine whether in this study group, with very low adjustments, significantly fewer complications (e.g. hemorrhaging, thrombosis) occur. Such a tendency could already be ascertained in the interim analysis. Patients performing coagulation therapy self-management display a scientifically proven loss of expertise over the course, which reduces the quality of their INR adjustment. For this reason, in 2003, the TELEQIN study (Telemedical quality assurance in INR self-monitoring versus INR self-management after a mechanical heart valve replacement) was initiated. TELEQIN is a prospective study for evaluating INR quality following mechanical heart valve replacement.

It aims to register the frequency of under and overadministration of marcumar, as well as to draw up a mid- to longer term quality control evaluation. This study is examining whether the loss of expertise in

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Medical sciences

patients can be compensated by continually monitoring them with telemedicine, in order to guarantee optimum safety in the long term.

Since IFAT was founded, more than 3000 marcumar patients have joined the network and received telemedical care.

On the basis of more than ten years’ experience with anticoagulation following heart valve replacement, a system has been developed for the telemedical quality assurance of INR management.

The telemedical thrombosis service reliably helps patients to ascertain their INR values and promptly recognizes any fluctuations in coagulation status.

Patients with the appropriate indication are equipped by their health insurance companies with a CoaguChek XS coagulation measuring device for autonomous ascertainment of INR values. In addition, IFAT provides patients with an electronic data transfer module. Patients are instructed in INR self-management or INR self-control 7-10 days after the heart valve operation. How to use the devices, the anticoagulation treatment, how to use the test strips and the telemedical data transfer are all explained to the patients. Immediately after an INR

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value has been measured, patients use the module to transmit it to IFAT automatically. There the new data are added to the corresponding patient file and looked at by physicians and trained staff.

If the values are outside the therapeutic range, a physician contacts the patient to discuss what action is to be taken.

Ambulatory rehabilitation (NOPT / AUTARK) Inpatient rehabilitation measures after surgery are conducive to the healing process, but contribute to financial pressure on the healthcare system. Politicians are therefore now concentrating on establishing a care system which prioritizes ambulatory over inpatient care. With this in mind, ambulatory rehabilitation with telemedical support for patients after a heart attack or cardiac surgery was tested as a pilot project in the NOPT

The growing shortage of physicians is also taking more and more of an effect, exposing the limitations of medical care and necessitating the creation of new care structures.

study – New OWL Postoperative Therapeutic concept – from 1998 to 2002.

In 2005, following positive experience with the NOPT study regarding physical performance and quality of life in patients undergoing ambulatory rehabilitation with telemedical support, the AUTARK program was developed – ambulatory follow-up rehabilitation following coronary or valvular surgery on the basis of telemedicine. With AUTARK, patients are spared tiring journeys to outpatient clinics, while their autonomy at home improves their quality of life. Participation in the program does require the continual support at home of next-of-kin or other carers, however.

Patients are supervised over a period of three months. They are equipped with a portable ECG device and a bicycle ergometer. Following a thorough postoperative cardiological examination, patients are prepared for ambulatory rehabilitation, including individually adapted instruction and consultation on their particular cardiovascular risk factors (arterial hypertension, nicotine abuse, hypercholesterolemia, diabetes mellitus, lack of exercise, diet). Training also includes practical instruction on operating the portable ECG device, which can be used in an emergency to record and send an ECG by telephone to the medical team at IFAT. On the basis of their postoperative ergometric values, patients are given an exercise plan for closely supervised implementation at home using the bicycle ergometer provided. The exercising program should be completed daily, but can be adjusted to suit the individual routine of the patient in question and is thus very flexible. Every three weeks, the treating family practitioner and cardiologist perform ambulatory checkups. After each check-up, the exercising program is adjusted to suit the updated condition of the patient. The portable ECG device also helps patients to estimate their physical tolerance levels more accurately, providing a high degree of safety. The treatment plan for the rehabilitation period has an interdisciplinary

HerzAs Telemedical care of patients with a structural cardiac disease including symptoms of cardiac insufficiency Chronic cardiac insufficiency is one of the most common internal diseases and can lead to cardiac decompensation on the basis of different mechanisms.

A new concept for treating chronic cardiac insufficiency within the framework of integrated care has been in place at IFAT since January 2008. Patients with chronic cardiac insufficiency of degree NYHA II or higher are cared for jointly and in accordance with § 140a SGB V by IFAT, AOK NordWest, the German association of ambulatory cardiologists in the SHI region Westphalia-Lippe, the regional association of medical practice networks Westphalia-Lippe, the association of SHI physicians Westphalia-Lippe, as well as KVWL-Consult. Patients join the program on the basis of an assessment by their local cardiologist. The latter then also instructs them in the telemedical procedure.

Home monitoring, with its combined modular structure, facilitates early detection of signs of cardiac decompensation and thus immediate therapeutic intervention. Patients are equipped with a set of scales and, if appropriate, a blood pressure measuring device and an ECG device (Holterphon/ Cardiophon).

Regular back-up examinations are performed by the treating cardiologist after three, six and twelve months, and by the family practitioner after three, six, nine and twelve months. During the IFAT program, initially spanning twelve months, patients are supervised in telephone consultations. They are instructed in how to deal with their disease in prevention talks which take place in the first six weeks. In these talks, patients receive comprehensive information about their disease, use of medication, diet and lifestyle.

The vital parameters recorded using the scales and blood pressure measuring device are transmitted to IFAT by text message automatically, where they are collected in a database. Recorded ECGs are transmitted to IFAT as an acoustic signal via an open telephone line. Patients can thus ascertain their values with these devices independently and autonomously, sending them to the telemedical service center at any time they choose around the clock. At IFAT the data are checked by experts and compared with previous values logged in an electronic patient file. If the new values indicate any deterioration (cardiac decompensation), the physician then telephones the patient in order to take early measures and prevent repeat inpatient treatment. Four times a year, a complete set of pathological data is sent to the physicians working within the program. In an emergency this happens immediately.

framework and includes different levels of patient care, but the overall coordination of everybody involved is managed

by IFAT. SMART – Slim with Applied Telemedicine Over the past few decades, the number of overweight and obese people has increased dramatically. Obesity is one of the most significant risk factors for cardiovascular diseases. There are many

programs which target weight loss, all with different aims, and yet participant compliance in such measures is often insufficient. Since October 2006, patients have been able to participate in the SMART program. Based on experience gained in the initial SMART study, IFAT offers overweight patients who would like to be slimmer, as well as patients who would like to keep their weight down after successful slimming,

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Medical sciences

Ambulatory rhythm diagnosis/ ischemia detection In addition to the abovementioned programs and telemedical studies, IFAT also attempts to reach all cardiovascular risk groups by offering programs for patients who suffer from cardiac dysrhythmia or have problems breathing. In clinical practice it is often difficult to record cardiac dysrhythmia because it occurs so irregularly. It is often the case that during an outpatients consultation or a 24-hour, even a 72-hour Holter ECG no dysrhythmia is recorded.

Patients with difficulties breathing often do not know the cause. This is the basis for telemedical rhythm diagnosis and ischemia detection. For their telemedical supervision, patients are given a portable ECG device which guarantees transmission of an ECG in the highest quality with maximum safety. Two device types are available to patients. The Cardiophon with twelve leads is for patients with apnea (breathing difficulties) and an unclear cause (ischemia detection).

The Holterphon with one lead controls heart rate in conjunction with dysrhythmia, atrial fibrillation or tachycardia

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With AUTARK, patients are spared tiring journeys to outpatient clinics, while their autonomy at home improves their quality of life. (palpitations). This portable ECG device can be used by patients after a very short instruction period. Transmission of an ECG recording is possible with immediate effect. When the symptoms in question are experienced, a recording can be made at the press of a button.

The recorded ECGs are transmitted to IFAT as an acoustic signal via an open telephone line, where they are evaluated

by IFAT experts. The results are then sent straight to the treating cardiologists.

In an emergency, the physicians at IFAT can give patients immediate advice or, if necessary, send for an ambulance.

Telemedical blood pressure management Telemedical supervision is also suitable for patients with hypertension or hypotension. The telemedical controls give chronically sick and high-risk patients an elevated degree of safety and a better quality of life. Dangerous fluctuations in blood pressure can be detected early on, enabling physicians to intervene straightaway. Patients receive blood pressure management instruction in a special training session which includes operation of the telemedical device. They then transmit their blood pressure and pulse values to IFAT at regular intervals. This

Author BIO

the chance to participate in the telemedically supervised SMART program for 12 months. The aim of this weight management program is to achieve a long-term adjustment of diet and lifestyle in participants, while reducing body weight and improving cardiovascular risk factors.

Following an initial examination, participants are individually supervised and counselled by specialists at IFAT. Here, too, patients are equipped with a special set of scales and a Bluetooth mobile phone for transmitting their values.

Instruction in the program takes place at the HDZ NRW. Following an interim examination after six months, the second half of the program is then continued autonomously by patients at home (telemedical supervision and transmission of recorded weight). At the end of the twelve-month period, a final examination is performed.

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regular transmission of data by patients means that all values can be precisely monitored. In an emergency, necessary measures can be taken immediately.

Conclusion IFAT links patients, ambulatory physicians and hospitals. An electronic patient file means faster and better access to information for all physicians involved in the treatment of a patient under telemedical supervision. In addition, the physicians themselves pronounce the indication for telemedical supervision.

For each of the diseases mentioned, a modular concept is in place so that the clinical picture can be monitored telemedically. All care programs were developed with the additional goal of investigating the medical and economic benefits of telemedicine. The success of telemedicine is now scientifically proven. This success is based on technical progress, statistical evidence of significant increases in therapeutic success, as well as the participation of an increasing number of ambulatory physicians. In addition, savings of 30-40% have been realized for the cost bearers.

By closely linking clinical research and scientific practice, and through the variety of programs available, the comprehensive range of preventive, diagnostic and therapeutic services is continually improving. Patient satisfaction with the system, which has also been scientifically proven, plays a particularly important role alongside the medical aspects.

The greatest problem which still needs to be solved is how to increase acceptance of this new type of care in the medical colleagues working in inpatient and outpatient care.

Heinrich Körtke is the Medical Director of the Institute of Applied Telemedicine (IFAT). He is a member of the working group “INR Self-Management“ of the German Society of Cardiology; member of the Association of German internists; and Member of the Medical Board of the German patients’ magazine “Die Gerinnung”.

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Diagnostics

Diagnostics

PET-CT Towards personalised cancer treatment In 2011, it is impossible to consider the modern management of cancer without including PET-CT. The article reviews the up-to date role of PET-CT in oncology practice and considers current areas of PET-CT research that will directly impact on care of cancer patients.

Wai Lup Wong Consultant Radiologist, Mount-Vernon Hospital, London

I

n 1898, Roentgen discovered X-rays. It gave birth to medical imaging which has revolutionised the care of cancer patients. In 2011, it is impossible to imagine delivery of cancer care without medical imaging.

A direct and advanced application of the Nobel Prize laureate’s discovery is Positron Emission-Computed Tomography (PET-CT). Hailed as invention of the year by Time magazine in 2000, it is one of the main tools of contemporary cancer imaging.

Derangement in chemical processes is the first indicator of cancer and it precedes changes in cellular structure. PET-CT provides unique information about metabolic or chemical processes within cells and precisely identifies where these malign processes are occurring within in the body.

Cancers have increased glucose metabolism compared with normal

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tissue. 18F-fluro deoxyglucose (FDG) PET-CT demonstrates this difference between normal and cancer cells and is the most sensitive test for diagnosing cancer.

FDG PET-CT impacts on all steps of a patient’s cancer journey. Appropriate initial treatment of cancer hinges on accurate diagnosis of where the cancer originates from in the body, or in other words determination of the primary site of the malignant tumour, and precise delineation of extent of spread of cancer or establishment of stage of disease.

The primary site is normally confirmed by clinical assessment complimented by usual imaging and biopsy.

There are occasions when the primary site is not apparent on usual assessment and in these cases, FDG PET-CT is contributory. The typical clinical scenario is the patient who presents with cancerous nodes in the neck and no primary site of disease found on

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usual evaluation. FDG PET-CT reveals the primary site in up to 30 per cent of patients.

In cancer staging, FDG PET-CT is of particular value in patients with a high risk of widespread disease; in lung cancer, the commonest cancer in the western world, FDG PET-CT prevented futile surgery in up to 21 per cent of patients and influenced treatment plan in 17 per cent of patients with oesophageal cancer. Colorectal cancer patients with disease localised to the liver only or lungs only are usually considered for surgical removal of the disease in lungs and liver. In a comprehensive and objective survey of published data, Dr Strasberg and Dr Dehdashti found FDG PET as the most accurate test for diagnosing spread of disease beyond the liver and altered management in 25 per cent of patients including reduction of futile laparotomies and hepatectomies. A study of 75 patients found that

additional cost of including FDG-PET in the diagnostic work-up of patients with potentially resectable colorectal liver metastases was compensated by a reduction in futile laparotomies.

Net monetary benefit (NMB) analysis showed savings over a relevant range of willingness to pay for Quality-adjusted life years (QALY).

Accurate diagnosis of residual disease following treatment is important for planning further appropriate management. The ability of FDG PET-CT to accurately detect residual disease within scar tissue has changed the management of Hodgkin’s and non Hodgkin’s lymphoma. Use of FDG PET-CT in lymphoma has been shown to cost effective and could contribute to savings in public health care programmes.

Early detection of recurrence of cancer offers the best chance of cure.

Delay in diagnosis is often due to difficulty in distinguishing between

treatment sequelae and recurrent disease. In a survey of 19 published studies designed to evaluate the use of FDG-PET in the detection of recurrent neck cancer, overall sensitivity and specificity for FDG PET 86 per cent and 73 per cent respectively, compared with CT/MR, 56 per cent and 59 per cent respectively.

Blood tests for detecting proteins in the serum secreted by tumours, such as carcino-embryonic Antigen (CEA)

Empowering patients so that they are at the driving seat to model developments in health care may lead to as yet unseen and unexpectedly positive effects on our healthcare.

by colon cancer and thyroglobulin by thyroid cancer is routinely used in follow- up as elevation and raising levels of these serum proteins often heralds recurrence of cancer. In cases where usual assessment cannot identify recurrent disease, FDG PET-CT will reveal previously unknown disease.

The increasing popularity of well person health screening programmes in the UK, brings with it rising number of clients with incidental lesions that need investigation. FDG PET-CT provides an accurate and non-invasive way of characterising these lesions. Dr Chang and his colleagues found that FDG PET-CT correctly identified 89 per cent of such lesions in the lungs.

FDG PET-CT improves care of patients and results in more effective use of scarce health resources. Appropriate use of PET-CT reduces investigations including invasive procedures and helps clinicians make the optimal

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Diagnostics

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FDG PET-CT improves care of patients and results in more effective use of scarce health resources.

select appropriate patients into clinical trials. It potentially allows for early identification of the effectiveness of the drug studied. Labelling drugs with PET radiotracers will enable scientists to confirm that the drug is reaching the places where they are supposed to and in sufficient quantities to be potentially effective. It is easy to see that such applications of PET-CT can lead to a reduction of the duration of clinical trials and the number of unsuccessful clinical trials, and hence reduce unnecessary financial costs.

By way of example, Vascular Endothelial Growth Factor (VEGF) is a protein that stimulates the growth of new blood vessels. In malignant tumours over production of VEGF promotes growth and spread of cancers. New drugs that hinder production and action of VEGF provide promising new avenues for treating cancer. Using VEGF-PET tracer (89)Zr-ranibizumab in a mouse model of human cancer dynamic changes were demonstrated during sunitinib treatment within the tumour with a strong decline in signal in the tumor center and only minimal reduction in tumor rim, with a pronounced rebound after sunitinib discontinuation; the first positive step for a possible new anti-cancer drug.

PET-CT in tandem with advances in treatment and refinements in CT and MR will undoubtedly change care of cancer patients beyond its present

Author BIO

treatment decision. The strongest case can be made for FDG PET-CT as a cost-effective tool in the initial management of non-small cell lung cancer by contributing to improved care and less exposure to ineffective treatment.

Research should be focused on providing similar confirmatory evidence in other cancers.

We are just at the beginning.

A landmark publication by Professor Florian Lordick and colleagues compellingly showed that in oesophageal cancer patients who are treated with chemotherapy prior to surgery, FDG PET-CT scanning at 14 days after the starting chemotherapy predicted whether the patient has active cancer at surgery. Similar promising results have been demonstrated with other cancers.

FDG PET-CT potentially allows for early changes in treatment plan by identifying poor response and spares patients from unnecessary treatment which would not be of likely benefit.

This is another example of where FDG PET-CT can improve patient care and result in financial savings.

PET-CT is expected to contribute to important advances in radiotherapy treatment. An ever-increasing body of scientific evidence shows that radiotherapy is more accurately targeted and leads to fewer side effects, when FDG PET-CT is included in planning radiotherapy delivery. Studies confirming that this approach improves patient longevity are awaited. There is ground breaking research on using PET-CT to direct radiotherapy to areas in a tumour most resistant to radiotherapy, including areas starved of oxygen, hypoxic areas, by using radiotracers selectively metabolised by hypoxic cells such as [18]F-fluoroMIZO, copper-ATSM and areas of high cellular turn-over using fluoro-thymidine. PET-CT will also find new applications with the advent of novel radiotherapy techniques including proton therapy and cyber-knife therapy.

PET-CT is being employed to evaluate new cancer drugs. PET-CT is used to

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recognition. In our life times we will see individualised treatment at all stages of the cancer journey in our cancer patients.

Individualised treatment is often viewed from the standpoint of healthcare professionals as I have done in this essay but it important that it should also be considered from the standpoint of the patient and with a broad interpretation.

Patients provide us with a yet unutilised powerhouse of energy to improve healthcare. Currently, it is healthcare professionals in the main that shape current and future health care programmes.

Empowering patients so that they are at the driving seat to model developments in health care may lead to as yet unseen and unexpectedly positive effects on our healthcare.

Ground-breaking modern medical discoveries are made not by one individual but by successful collaboration and cross fertilisation of ideas. In an age of increasing specialisation and sub-specialisation, all stakeholders including scientists, engineers, medical professionals, patients and commissioners who fund healthcare need to take every opportunity to meet to exchange ideas and develop a broad understanding of each others disciplines. This is going to be of significant importance in the advancement of areas of medical science and including cancer diagnostic imaging.

Expanding connections between Patients, Practitioners, Providers, Payers and Pharma are greeting greater access to care, resources, information and experts.

Wai Lup Wong is a Clinical Director London PET-CT centre Harley street. He is also a Clinical Guardian (PET-CT) Department of Health UK. Past President Royal Society of Medicine (Radiology).

At St Thomas’ hospital, he took the radiological lead in the team that pioneered computer combination of PET to CT in the head and neck and demonstrated the advantage of PET-CT in the assessment of head and neck cancer. He grew up in Malaysia and continues to spend time in the country of his birth.

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Technology, Equipment & Devices

Technology, Equipment & Devices

mHealth application clusters

mHealth

While mDevices are an essential component of the mHealth Revolution, their impact is exponentially increased by the mobile applications (apps) that are enabled on them. It is these apps that are facilitating communication-enabled healthcare. mHealth Initiative (www.mobih.org), an organisation based in Boston Massachusetts USA, has identified 12 categories into which the more than 5000 healthcare-related apps can be distributed. (Figure 1.)

A review of these 12 categories of mHealth applications readily demonstrates the degree to which mobility is becoming an integral part of healthcare and how it is changing how healthcare is accessed, delivered, monitored, adapted, evaluated, documented, managed, taught, paid for, etc. These categories are not mutually exclusive, and, therefore, any single healthcare app may fit into one or more of these categories. Very likely, however, there is a primary category in which it best fits. Also of note is that the sequence in which the categories are discussed is not intended to reflect a hierarchy among them.

New opportunities for healthcare improvement

Adoption of mDevices (cell phones, smartphones, tablets, and more) and their numerous healthcare applications (more than 5000 and growing) is expanding as the opportunities they present for improved quality of care, enhanced efficiency, and lower costs are increasingly recognized.

This paper will explore the practical applications of mHealth and their impact on how health information is recorded, collected, accessed, and transmitted.

Claudia Tessier RHIA President, mHealth Initiative, USA C Peter Waegemann Vice President, mHealth Initiative President, Waegemann Associates LLC USA

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mHealth encompasses healthcare and wellness/fitness endeavors that are supported by mobile technologies. As it creates new communication patterns, mHealth represents truly revolutionary communication-enhanced healthcare and wellness. This mHealth revolution is advancing rapidly, facilitated by such factors as easy and simple access to the Internet and the healthcare community through mobile devices (mDevices) that are changing communication patterns.

An increasingly trusted Internet has democratised access to healthcare information, as evidenced by the Pew Internet & American Life Project report in early 2011 that healthcare research is now ranked the third most popular web activity online, after email and using a search engine. Similarly, just as the public is increasingly turning to online peer reviews of movies, books, restaurants, products, and other items before purchasing them and no longer limiting themselves to “professional” reviews, consumers/patients are also seeking out opinions through public online discussions with their peers about healthcare providers, disease conditions, treatments, and medications. Of course, one does not need an mDevice to access

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information or participate in online public discussions, but what mDevices add to the formula is anywhere, anytime access for anyone with such a device and connectivity. No longer are consumers or patients limited to desktop PCs. With devices such as smartphones and tablets, they can respond immediately to a need or impulse to seek information, whether at the end of an encounter with the doctor, at home, when traveling, or wherever they are.

Such access expands the meaning of connectivity. While the power of making and maintaining a connection between two or more points in a telecommunications system is essential, the real power of such connectivity in healthcare means that patients, practitioners, providers, payers, and pharma can be connected and can communicate directly in real-time, at the point of care or remotely. This has never been possible before.

In turn, these expanding connections are expanding access – to care, to resources, to information, to experts.

Through new voice, text, and image capabilities, such access is creating the path to a new style of communicationbased healthcare.

Cluster #1: Patient Communication Patient communication applications are used by the patient before, during, and following visits to their clinician, as well as for purposes unrelated to such visits. They assist patients, for example, in locating and selecting caregivers, in making and changing appointments, in accessing insurance information, in upgrading demographic data, in doing advance check-in, and in creating a PHR (personal health record) or CCR (continuity of care record).

Through email, text messages, and instant messaging, patients can provide their caregiver with advance information regarding their visit and potentially be advised to have lab tests done prior to the visit. During visits, these apps facilitate patient education and financial and administrative transactions. Separate and apart from visits, they assist in disease management, including recording ODLs, observations of daily living.

ODLs help the patient and the caregiver identify trends and influencers related to their condition, for example, circumstances under which certain disease symptoms are relieved or exacerbated.

This cluster also includes applications that give patients direct access to information about their medications, their lab data, their diagnoses, second opinions, etc. Smartphones with cameras allow patients to communicate visually, for example, by sending photos of skin conditions, for example, or videos that demonstrate their gait. Additionally, these apps assist patients/consumers in monitoring their wellness and fitness activities. Other apps facilitate emergency communication, vital sign monitoring, and safety “fencing”, for example, for seniors.

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Technology, Equipment & Devices

Cluster #2: Access to Resources Resources are readily available through smartphones or other mDevices, not just through direct access to the Internet, but also through apps that provide customized access. For clinicians, these include formularies, guidelines and protocols, decision support tools, telemedicine guidelines, medical journals and texts, access to patients’ PHRs and patient directives, and information about patient eligibility. They can also be used as personal assistants.

From the patient perspective, web resources facilitate their researching symptoms, diseases, and treatment, as well as medications and lab data. These apps give them access to sites where they can communicate with other patients who have similar diseases, surgery, and other experiences. And increasingly, they provide second opinions, as more and more patients turn to the web in order to compare and confirm information that their physician provided. The most researched health topics online in the US are specific diseases or problems, specific medical treatments or procedures, exercise and treatment, doctors and other health professionals, and prescriptions as well as over-the-counter medications.

Furthermore, patients incorporate web-accessed information into their office visits with caregivers, as well as through eCommunications between visits. To what degree clinicians respond to this information and to what degree they document the data in patient’s records is, for the most part and at present, left to their discretion, but it is expected that increasing attention will be given to incorporating web-based and app-based information into a patient’s record, particularly if it is utilised in offering the patient options or in making treatment decisions. Indeed, some clinicians are beginning to “prescribe” Internet searches and specific mobile apps, and certainly such “prescriptions” should be documented in the patient’s record.

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A si a n H o s p i t a l & H ea lt hcar e M an age me n t

Technology, Equipment & Devices

Impact of mHealth As evidenced above, mHealth is not just changing the delivery of healthcare but also the management of health information and records. Management and policy guidelines must be revised or newly developed that address their wide variations in content, relevance, and immediacy. Further, authorized apps and device-captured information must be integrated into the health information system without distortion or loss of data. Good and secure identification systems must be linked to and integrated into the patient’s record, whether it is electronic or paper-based.

The volume of communications through such applications requires determining just which are administrative and which are clinical. Furthermore, systems must be developed that determine how and when and by whom such data are reviewed and acted on. A healthcare institution could potentially receive hundreds or thousands of text messages and emails from patients.

These require sorting into those that can be handled by canned, standard responses, those that require timely and customised but non-urgent responses by a health professional, those that allow time-flexible responses, and those that require immediate attention because they represent urgent and emergency communications. Additionally, issues, such as patient consent and patient preference, must be taken into consideration when using these apps, as well as when using text messaging and email in patient communications. Strict regulations that apply to all personnel and associates, not just employees but also volunteers and contractors, must assure that there will be no unauthorised use of camera or video capabilities of mDevices. Clinicians and others may need tutoring regarding the professional and safe use of smartphones, tablets, and other mDevices.

Wireless communication security must be implemented and connectivity must be guaranteed. The security and privacy of patients’ personally identifiable information must be assured, whether the information is accessed on, entered into, or transmitted from mDevices. That is, the information must be protected whether it is stored on such devices or transmitted to and from them, and access to such devices as well as such data must be restricted to those authorised for same.

Clearly, design and management of all these systems will require, as noted above, coordination and cooperation among a variety of personnel – from C-level executives to clinicians to legal counsel to health information managers to health IT specialists to quality assurance personnel and more.

It is also essential that patients’ rights and preferences be taken into account.

ISSUe - 23 2011

Cluster #3: Point-of-Care Documentation Point-of-care (PoC) documentation apps allow clinicians to access, document, transmit, and navigate patientspecific information in real-time, whether at the PoC or remotely. This means clinicians no longer need make treatment decisions blindly, without access to the most current and relevant information about a patient’s condition and treatment. It also means that patient documentation entered on the mobile device must be communicated to and integrated into the patient’s electronic or paper-based record.

Real-time documentation requires particular attention to accuracy, authentication, interoperability, and security.

Managing this requires cooperation among the clinicians, the health information services personnel, and the health record managers. It also requires timely attention in order to assure that the information being accessed is indeed the most current information. Furthermore, health IT personnel must assure that any protected health information (PHI) stored on and transmitted through such devices assures privacy and security.

Cluster #4: Disease Management The current focus of disease management apps for clinicians and patients is on diabetes, asthma, dermatology, preventive care in pregnancy, smoking cessation, and hypertension. Patient data, such as ODLs mentioned earlier, are sent directly to the caregiver, thus providing continuous rather than periodic monitoring and stimulating more timely intervention. This requires that systems must screen incoming information along the spectrum of routine to emergent and direct messages accordingly. Some apps provide diaries and opportunities for self-observations, which may or may not be shared with the caregiver. Other apps provide prompts when lifestyle changes result in improved readings. Such data collected over time must be aggregated

in order to monitor and manage the patient’s signs, symptoms, care, and treatment.

The clinicians, HIT, and health information team must work together to design ways by which patient information derived from disease management applications is integrated into the patient’s record and to assure that privacy and security of PHI are adequately addressed. Also relevant here is the attention that the FDA is giving to mDevices to determine if they are also medical devices. Indeed, an important question yet to be answered is: when does a mobile device become a medical device?

Cluster #5: Education Programmes Education apps support professional teaching, monitoring, coaching and on the job training, as well as teaching patients self-care, self-monitoring, and about diseases, conditions, medications, etc. Some medical and nursing schools offer student evaluations and reviews of instructors and texts, as well as course content, through such apps. Other apps offer education and training, along with self-assessment tools. Still others enable participants in widely scattered locations to share educational activities and data and to view videos and have discussions in real-time. As noted above, those apps

that involve patient education should likely be referenced in the patient’s record if they are '“'prescribed' or recommended by the clinician.

Cluster #6: Professional Communication Professional communication apps provide preferred communication channels for healthcare professionals, lab, pharmacy, internal departments, etc. They connect colleagues for team conferences and create specialty specific communities and professional networks, where experiences can be shared and expertise tapped. Some of these enable a clinician to contact a specialist “on the fly” i.e. in real-time as they are assessing a patient with an unusual complex of symptoms or in emergency situations.

Cluster #7: Administrative Applications Administrative applications include provider-payer applications related to financial, demographic, and nonclinical data. Also included are apps for appointment scheduling, self check-in, and reminders regarding appointments, medication refills, and lab reports. Other such apps facilitate both internal and external staff communications. There are also third party applications that connect healthcare facilities with payers, labs, and

mHealth opportunities It is especially important that all stakeholders involved be prepared to address these issues openly and with a willingness to be innovative. The appropriate starting point is not asking “how can we fit these new technologies into our existing systems,” but rather asking “how can we use these new technologies to improve or replace our existing systems and make them less burdensome for clinicians and patients, as well as more efficient and effective and less costly in delivering care.” The fact that these questions have not been widely asked in reference to electronic medical record (EMR) systems has contributed to both their deficiencies and their limited adoption. mHealth , as a disruptive technology, provides new and important opportunities to improve the management and delivery of healthcare, as well as the management of health information and medical records.

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Technology, Equipment & Devices

other providers. Also here are asset-tracking apps, for example, barcode scanning and RFID systems that facilitate inventory control for surgical instruments and equipment, even for mDevices themselves. Similar apps track paper medical records and facilitate patient flow management, for example, scheduling, admissions and discharges, and bed management.

Cluster #8: Financial Applications Financial applications enable real-time charge capture, as well as access to eligibility, coverage, and co-pay information. Some check ICD and other codes and send electronic bills. Through these apps, payers can actively communicate with patients and providers and perform online real-time adjudication.

Some also process payments by phone.

To assure proper management of financial data and transactions, these must be linked to in-house financial systems.

Cluster #9: Ambulance/EMS With ambulance and emergency medical services apps, emergency service providers are collecting patient information while en route to the emergency department and communicating such information in advance of arrival, thus facilitating faster, more informed triage and treatment. Some apps enable the emergency service providers to access a patient’s PHR or CCR and to identify and contact the patient’s primary care provider. Utilisation of these apps requires design and implementation of a system that assures that patient information so collected and communicated is incorporated into the patient’s record.

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A si a n H o s p i t a l & H ea lt hcar e M an age me n t

Cluster #10: Public Health Public Health apps facilitate reporting and managing disease outbreaks, disasters, and bioterrorism. These can send alerts to providers and notify populations of pending or occurring public health incidents. They facilitate surveillance and reporting and enable instructing the public at large. Public health apps are seeing increasing adoption, especially in developing countries where communication channels are otherwise not easily accessible, if at all.

Cluster #11: Pharma/Clinical Trials Pharma/clinical trial apps facilitate through automatic, scheduled, and ad hoc information transmission of data.

By relying on the mDevice rather than the patient for data collection, they improve its quality and timeliness.

Also of relevance are spontaneous or organized exchanges of information among patients. Those conducting clinical trials initially dismissed these anecdotal discussions, but their poten-

Author BIO

mHealth is all about changing the delivery of healthcare and also the management of health information and records.

Technology, Equipment & Devices

ISSUe - 23 2011

tial value is gaining increasing attention within pharma. Of course, data collected through formal trials must be accurately identified, aggregated, and integrated into clinical trial records and, where appropriate, into patient records.

Cluster #12: Body Area Network (BAN) BANs are mobile wearable or implanted sensors that monitor vital body parameters and movements and wirelessly transmit data from the body to the provider or elsewhere via a home base. Examples include heart monitors to identify a potentially pending heart attack and BANs that auto-inject insulin for diabetes patients. Also represented here are sports activity apps for monitoring speed, distance, heart rate, blood pressure etc. A big issue with BANs is security, and of course data transmitted to a patient’s healthcare provider through BANs requires both interpretation and integration into the patient’s medical record.

mHealth Poised for growth in India Bridging the health divide, mHealth can go a long way in providing equitable, sustainable healthcare for the have nots.

Claudia Tessier is an internationally recognised expert on mHealth, healthcare documentation, PHRs and the CCR (continuity of care record), is founder and president of mHealth Initiative, a membership organization based in Boston Massachusetts, which promotes adoption of mobile technologies in healthcare as the catalyst toward participatory health. Her previous positions include vice president of Medical Records Institute, executive director of MoHCA (Mobile Healthcare Alliance), and CEO of American Association for Medical Transcription (AAMT). She is the author of The Surgical Word Book (Elsevier 2005), The AAMT Book of Style for Medical Transcription (AAMT 1995) and most recently, Management and Security of Health Information on Medical Devices (AHIMA 2010).

C Peter Waegemann is President of Waegemann Associates, LLC and Vice President of mHealth Initiative Inc., a Bostonbased membership organization promoting mHealth applications nationally and internationally. Previously, he was CEO of the Medical Records Institute, a Boston-based organization involved in applied research and functioning as an educational clearinghouse. Since the 1980s, he has been a visionary and promoter of electronic medical record systems (EMRs). Twenty-five years ago, he started the annual conference Toward an Electronic Patient Record (TEPR) that draws each year several thousand attendees. Waegemann defined EMRs, PHRs, and EHRs. He is the former chair of MoHCA, the Mobile Healthcare Alliance. In 2007, Waegemann was cited.

K Ganapathy President, Apollo Telemedicine Networking Foundation President, Telemedicine Society of India

I

ncreasing usage of mobile phones has invaded our lives and changing an urban teledensity to 103% and a rural teledensity to 19%. The introduction of mEntertainment and mBanking; with a scope for mCommerce and mGovernance; India is certainly poised to incorporate mHealth into the very fabric of healthcare delivery system.

Deploying mHealth, that is relatively absent worldwide, is today obvious in India for 750 million, living in suburban and rural India, who have direct access to only 20% of India’s depleted healthcare personnel. mHealth is more relevant in the Global South than conventional eHealth.

There are at least 15 active mHealth pilot projects in India carried out by some state governments and NGOs as part of an mGovernance initiative and a few sporadic projects have been carried out by others as well.

Projects include use of mobile games to enhance HIV/AIDS awareness, use of handheld devices to collect raw health data which were transmitted in real time to the Health Information System Database. Mobile phones are also used to send daily health alerts and to track Disease and Epidemic Outbreaks.

Key applications of mHealth include education and creating awareness, remote data collection, communication and training for healthcare workers, disease and epidemic outbreak tracking, diagnostic and treatment support and remote monitoring, access to technology, end user and health care provider acceptance, lack of regulatory issues,

logistics and availability of appropriate, need-based, customised solutions are some of the other challenges.

Challenges in deploying mHealth include changing the mind set of the people, convincing them with large success stories, providing education, training, providing solar units for power to charge their mobiles and making available appropriate, cost effective, need based, Value Added Services.

Mobile phones—can check refractive errors, used as a microscope, used to manipulate DICOM images, used to see ECG, used to hear heart sounds and used to connect blue tooth enabled sensors and a Body Area Network to a physician remotely. Mobile phones can also store mPHR and enable access to drug interactions. However, there is a long way to go before a mobile phone becomes a hand-held hospital. mHealth should be delivered in combination with other mServices including mCare, mServices, mSurveillance and mLearning. The fruitful result from mHealth will depend on creating the right ‘fit’ between mHealth applications and healthcare needs; in other words mHealth should be need-driven not technology-driven.

As Walter Hugo once remarked “Nothing can stop an idea, whose time has come”, the time has come in India, that in spite of all the challenges, mHealth can and should be part of the healthcare delivery system. mHealth, bridging the health divide, can go a long way in providing equitable, sustainable healthcare for the have nots.

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The Floor is Yours

Carpeting in Hospitals Design from the floor upwards

Good hospital design is therefore about such nonclinical issues as building in ambient light and colour, giving patients privacy – and all aimed at reducing patient stress and improving outcomes, not least by reducing the incidence of medical error. The New York Times last year reported that more than 1500 studies have been carried out into how good design can achieve those objectives.

Good design is more than providing a softer floor for healthcare workers or using different carpet colours to help patients find their way around what can be a bewildering place.

Air quality & noise At Desso, one of the world’s leading carpet manufacturers, we also believe in evidence-based design, because there is now overwhelming evidence that good design can start from the floor upwards. It’s more than providing a softer floor for healthcare workers or using different carpet colours to help patients find their way around what can be a bewildering place.

Primarily, in terms of patient outcomes, it’s about air and noise.

area of a hospital took 22% less analgesic medicine than patients with the same medical condition on the dark side of the hospital. Apart from the human cost, that equated to a 21% cost differential.

Patient experience Good healthcare design, based on empirical evidence, aims not only to make the patient experience better but to improve patient outcomes. For architects and interior designers, it’s about building complex and expensive facilities that are designed to work to best effect, and then testing every aspect of their design.

In recent years, the medical profession has been adopting “evidence-based medicine” that uses research finding to guide best practice, rather than simply accept expert opinion, the traditional and the age-old route towards clinical decisions.

The same is true in hospital design, where architects and interior designers have come to recognise that a healthcare facility is more than just its component parts. It should be a place that goes beyond mere functionality to create an environment that actually aids patient recovery.

Evidence-based design can be about recognising the importance of something as simple as natural light. For example, it’s long been known that we are all influenced by circadian rhythms that govern our performance in numerous ways – including sensitivity to drugs, hormone secretion, sleep patterns and immune responses.

Knowing that is one thing, but making natural light a key part of the architectural brief requires good medical evidence – and there is now plenty. For example, a 2005 study (1) that showed that patients in a brighter

Taking air quality first, the air that we breathe indoors has been named and shamed as one of the top ten health risks of the modern world, and that’s especially true in a healthcare environment dealing with the vulnerable and sick.

A 2009 study in the USA (2) exemplifies how basic yet how profound evidence-based research can be and how, once bad design is built into the fabric of a building, undesigning it can be difficult if not impossible. In the study, fifty-two physicians were asked to examine a standardised patient in two hospital room settings using a replica of the proposed architectural plan. The settings differed only by the placement of the alcohol-based hand-rub dispenser.

The World Health Organization (WHO) estimates that indoor air pollution is the 8th most important risk factor to health and is responsible for 2.7 per cent of the global burden of disease. Asthma, in the developed and developing world, is the largest culprit.

The result was that when the dispenser was in clear view of the physicians as they observed the patient, 53.8 per cent washed their hands. When the dispenser was not in their line of sight (as it had been in the original architectural plan), only 11.5 per cent washed their hands. Based on these results, the final architectural plans were adjusted accordingly. Obvious, perhaps: but it took research.

The philosophy of patient-centric care is, of course, not a new one. It’s what hospitals are there to do: care for the sick. However, traditional hospital design has been largely about functionality. Compare that with a new private hospital opening this year in the UK. Their view is that a night in hospital costs more than a night in a 5-star hotel. So why not make the experience similar? Compellingly, the hospital aims to “give people good health, not an experience of illness.”

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In 1993, a study titled "Global Strategy for Asthma Management and Prevention" was published collaboratively by the US National Heart, Lung, and Blood Institute and the World Health Organization. The 2007 update to the original report states that there is no evidence that replacing carpet with hard surface flooring has a health benefit.

At Desso, recognising those potential health benefits, we’ve gone a significant step further by launching a next-generation carpet with a unique yarn structure that captures even more harmful fine dust from the air – specifically designed to meet the requirements of the health sector, and address the very real problems posed by poor indoor air quality.

Independent tests have confirmed that AirMaster® is eight times more effective in capturing and retaining fine dust than hard flooring – and four times more effective than standard carpeting (3) - and therefore able to make a very real difference, particularly in high-traffic areas where lots of feet would otherwise churn up dust and fine material from the floor.

The WHO also estimates that, in 2005 alone, some 250,000 people died from asthma worldwide. It remains the most common chronic disease in children, and its incidence is increasing. Worldwide, there are some 300 million sufferers.

Acoustics

As a carpet manufacturer, we’ve long recognised that carpeting can improve indoor air quality by capturing and holding allergen-causing substances tightly and, as a result, keeping them from becoming airborne, and therefore minimizing their circulation in the breathing zone.

The importance of sound in healthcare is much better understood now, although research continues to demonstrate that sound levels remain stubbornly high in many healthcare environments. A study for the Centre for Health Design (4), found that there were two primary reasons.

Indoor air quality

First, hospitals and healthcare facilities generate a range of background noises – from telephones and trolleys to staff conversations and bleepers, making sound reducing strategies inevitably complex. However, and second, the study also found that the surfaces in hospitals – floors, walls and ceilings – are usually hard and reflect sound rather than absorb it.

In 2001, Dr Michael Berry wrote a report entitled Assessment of Carpet in Sensitive Environments. In it he examined the findings from a number of studies that looked at the relationship between carpet and indoor air quality (IAQ) in settings that directly affect the very young, the very old and those who are ill.

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His research found that “carpet is a preferred and widely used floor covering associated with minimal complaint. Previous claims [that carpets contribute to IAQ] are not supported in the scientific literature.

Research to date, some going back over 30 years, consistently shows carpet to be a safe and healthy product

A s i a n H os p i t a l & H ea lt h c a r e Ma na g em ent

ISSU e - 2 3 2 0 1 1

That, however, was only half the challenge that we gave ourselves, because the other problem in a busy hospital or healthcare facility is acoustics, and noise can be distracting, intrusive – and detrimental to health.

Events

thirty years – and that carpets do not influence hospital acquired infection rates.

For many health professionals, the everyday sounds of a hospital are entirely normal. However, the experience of patients is quite different, finding themselves in unfamiliar and stressful surroundings. For patients, the evidence is that reducing sound in a healthcare environment can have significant benefits.

That conclusion is backed by recent US research

by John Hopkins University and the Georgia Institute of Technology (5). They found that noise in hospitals is a significant problem that is generally getting worse, even in new construction – and that high noise levels in hospitals can potentially contribute to stress and burnout in hospital staff, reduced speed of patient wound healing. The research also found that there is legitimate concern that hospital noise can negatively affect speech communication and cause an increased number of medical errors.

The authors state that: “Conventional acoustical treatments are used sparingly in hospitals because it is believed that sound absorbing materials with pores harbour bacteria. Instead, smooth, hard, flat surfaces are used because they are easy to clean. Consequently, these surfaces are acoustically reflective and serve to aggravate existing noise problems.”

Of course, noise can be reduced in a number of ways. A recent report in the Wall Street Journal says that, at least in the USA, there is a trend towards private patient rooms, social spaces for family members, decentralised nurses’ stations, acoustical tiles – and carpet to reduce equipment noise.

Health benefits That trend is, of course, based on evidence-based research. For example, the Karmanos Cancer Institute in Detroit, Michigan, saw a 30 per cent reduction in medical errors on one unit after it installed acoustical panels and introduced decentralised nursing stations.

Additionally, the Methodist Hospital in Indianapolis, Indiana, USA, attributes its lowered medical error rate on a redesign of its coronary care unit, decentralised nursing, and carpet in the hallways.

Reviewing carpet use in the US healthcare sector, the Centre for Disease Control found that carpets have been used in both public and patient areas for over

For example, and taking one study from many, research carried out in Stockholm (6) among coronary intensive care patients found that, when sound-reducing strategies were introduced, patients slept better, were less stressed and reported that nurses gave them better care.

13 - 15 Jul 2011

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Standard carpet gives impact sound reduction properties of between 20 and 30 decibels. We’ve developed a new carpet backing, specifically for environments such as healthcare facilities, that gives a further reduction, depending on the carpet type, of 10 dB or more, making it the most sound absorbent option on the market – and in many cases rendering it unnecessary to install other sound reducing strategies such as ceiling tiles.

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We live in an age that has seen, and will see, huge strides forwards in healthcare, from new drug types to new treatments. Unravelling the genone and the development of stem cell research hold out the promise of medical miracles on the near horizon. But we shouldn’t forget that medicine is also holistic, and that other factors such as natural light, quietness, and air quality also have a part to play.

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After all, the evidence is now there.

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Reference

Sep 21 - Sep 24, 2011

Hospital

International Heathcare Exhibition St. Petersburg, Russia

1. Walch JM et al 2. David J Birnbach, University of Miami Miller School of Medicine, University of Miami-Jackson Memorial Hospital Center for Patient Safety.

3. Independent tests were carried out by GUI, the German test institute, and based on AirMaster® performance against standard PVC hard flooring and standard structured loop pile carpet. GUI specialises in assessing air quality, dampness and dust particle count.

4. Ulrich and Zimring, Centre for Health Design, 2004.

5. Noise in Hospitals: Effects and Cures, 2008.

6. Blomkvist et al

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Information Technology

Information Technology

General structure of hospital information system

An Integral Solution for Hospital Information System

The joint research with Medical University Sofia in the area of e-Health and Telehealth is oriented to complex investigation of new concepts and methods for continuous acquisition of patient’s vital data, transmission, collection and binding of that data for diagnostic and disease tracking purposes as well as investigations on relevance of life quality and healthcare based on the e-Health technologies.

Ivan Evgeniev Ivanov Vice-Head, Department of Systems and Control, Head , Advanced Control Systems Laboratory, Technical University of Sofia, Bulgarian Vesselin Gueorguiev Assistant professor, Department of Computer Systems and Control, Technical University of Sofia, Bulgarian

The Intelligent Hospital Information System structure and subsystems are shown on Figure 1. It offers the following features: • Unified environment for data exchange between installed apparatus and systems in the hospital • Tracking the full process of hospitalisation of every single patient • Data collection and storage for every medication and procedure • Offers Remote Medical WWW Services for out-of-hospital health tracking and care • Management of all procedures and medications • Administrative tracking of all patients • Remote messaging of medical personnel about health status of selected patients based on remote vital data acquisition and control • Extension background for expert medical systems for analysis and control of health status for every single patient The future target of this work is to establish an environment for transformation of the treatment data to knowledge system which will improve the following elements: • To increase the quality of the healthcare and services

• To offer to medical personnel access to the information resources via a heterogeneous communication environment (mesh) • To offer structured information for increasing diagnosis quality • In-and out-of hospital life-long patients’ tracking

Doctors’ network This network has to provide doctors access to huge data sources (e.g. pictures, video films, etc.) in the hospital. It is useful for accessing data bigger than 50MB via fixed network resources. Now bandwidth of 1GB is possible and this guarantees on-line diagnostics and data exchange between sources, doctors’ terminals and storage servers.

Clinic’s server It controls access over the local network, database consistency and tracks patients at home care.

Fixed hospital network Fixed clinical network provides connectivity for all machines and apparatus in the hospital from one side and servers and personnel’s terminals from the other side.

Additionally it guarantees better redundancy and offers possibility to control internal clinical networks loading.

Data analyses sever Clinic’s server

T

he aim of this paper is to present results obtained in the context of the “Medical data acquisition, processing and collection for e health solutions” joint research project for investigation, design, organisation and future expansion of a hospital information system.

The research started with deep investigation of current status of hospital information systems on the territory of the Medical University Sofia and implementation of pilot version of integrated solution. Elimination of the usual paper-based information exchange to e-health and IT-based one is one of the major project topics.

Medical University Sofia is a huge hospital complex distributed on a large territory and has tens of different clinics, laboratories and buildings.

Results of this investigation and some of implemented solutions are discussed hereafter. We focused on the following main problems:

Wireless medical sensor network This network enables access for the medical personnel to data servers. Additionally, sensors and apparatus generating small amount of data can be mobile on hospital territory. This guarantees unbroken control when patients can carry their vital data acquisition sensors or simply to move patients over clinics without loss of connectivity.

Management server It controls all administrative processes, hosts all records about manipulations (total and associated to every patient), personnel and patients archive, etc. Based on this, doctors can do different analyses and increase quality of medication.

Main database server This is SAN network offering: on-line information for all patients; fast access to disease history and hospital archive.

Data analyses server This is the core for future advances. Data mining services will be positioned there.

A hospital grid with specialised servers will be built on this basis.

Certificate sever

Main database server

Public key sever

Hospital network border

Hospital public WWW server

MAN network

Hospital gateway

Management server Fixed network

Doctor network

Wireless medical sensor network General structure of IHIS

Figure 1 36

A si a n H o s p i t a l & H ea lt hcar e M an age me n t

ISSUe - 23 2011

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Information Technology

• Interface incompatibility between different medical systems and apparatus - Medical systems from different vendors are incompatible. Most of them are designed to transfer data directly to computer application with HMI. • “Data are distributed, heterogeneous and changeable“- Hospital medical systems collect a diverse variety of patient information represented in many digitized or hard-written types.

Creation and support of patient’s analyses library is a problem solved under presented project.

• Data validity, security and protection Data validity is very important to make decision-making process stable and safe. This includes time validity and safety and security of delivery. Data access and privacy are very important and have to provide end-to-end security and validation in the system.

• Tracking patients when they are out of the hospital – technical, medical and economical aspect.

• IT problems of a) archiving and b) digitalisation of paper-based video-images.

• Improvement of analyses of medical video-images.

Of course, this list cannot pretend to cover all possible aspect of hospital information systems, solutions, problems and similar. At the end of this material is presented briefly the structure of implemented intelligent hospital information system.

Integration of available medical apparatus and software systems in new system Starting with the investigation of how to integrate available equipment in one system we contacted directly vendors’ representatives for detailed technical data.

Equipment includes from very modern

to 10-15 years old machines. Interfaces to humans and to other computers vary much. Computer interfaces include RS232 / RS485 and Ethernet wired connections, floppy-disk data exchange and on-screen or printed output. Protocols are very different, too. All of this stands as big challenge to the integration team. We contacted technical groups supporting other hospitals and found that even products from one and the same vendor are not fully compatible on interface and protocol levels. As an example can be shown DICOM-based image systems. DICOM has variety of dialects and needs additional processing to make all sources fully compatible with all visualisation systems.

Data integration A hospital medical system collects a variety of patient information represented in many digital or hand-written types.

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ISSUe - 23 2011

w w w . a s i a nin h h mthe . c o m World 39 The Highest Performance, Best Made Laser Systems

Information Technology

Tracking patients when they are out of the hospital One big objective of the presented project was to implement tracking patients when they finish the hospital phase of medication. Experimentation field was clinic of pulmonary diseases. Technological idea was to equip patients with mobile sensors controllable via smart phones and to collect and transmit data using SMS and/or data channels. Currently in the non-military areas of application the most common mobile/wearable biosensors available on the market are 1 or 3 lead ECG sensors, spirometers, pulse and blood pressure meters, thermometers, SPO2 meters and glucometers.

All of these sensors were investigated.

These are our conclusions about technical aspects: • Many providers offer closed multilayer systems which does not allow

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Well structured Intelligent Hospital Information System (IHIS) based on e-Health technologies will provide quality healthcare by transforming the treatment data to knowledge system. their sensors to be used with other systems and also excludes the possibility to extend the system with other sensors. When such providers do not offer a full list of sensors, remote patient support becomes limited to the available peripherals.

• Another problem is that some data acquisition software for smartphones is very aggressive and starts to connect and transmit acquired data to the upper system levels without user permission.

This increases the exploitation price and lowers battery life.

• Uninterrupted usage of any type of sensor is impossible. Phone’s battery cannot last more than 6 hour on intensive Bluethoot or WiFi communication. Investigation oriented to sports control envisaged that this technology can be used only for approximately short training processes.

Conclusions about medical and economical aspects • From the very beginning of experiments, supervising medical doctors concluded that this remote control over their patients’ data helped them to prevent possible dangerous situations but this needs a lot of human effort. A system to control vital parameters is needed. It cannot be simple “in/out of boundary” control but complicated multi-variable decisionmaking system. Presently, some work is in progress but it still needs a lot of investigations.

ISSUe - 23 2011

• Instructions to patients about interpreting very simple raw data from sensors decreased number of hospital visits based on apprehensions. Psychologically, patients felt much comfortable when they knew somebody keeps an eye on them. Thus hospital expenses were decreased.

One important remark is that because of financial limitations, number of obtained sensors is relatively low and the investigation was useful for experimental conclusions and future directions but is not enough representative for statistical purposes.

Data validity, security and protection Developing and implementing hospital information systems including remote data acquisition requires strong data protection. But before this, some other problems important for the patients have to be resolved. First is data validity. Investigating paper-based process we found that in many cases information is wrong or interpreted inadequately or simply lost somewhere in document paths. This is a well-known administrative problem but here it is important because human health depends on it.

Where the biggest problems are s: • Remote data acquisitions via smartphones need data validation and time stampings. Because sensors are worn by patients and acquisition and communication software is run by them too, improper measurements and operations are common.

• Inter-hospital data exchange is not always marked properly. Results for one patient can be assigned to other.

This is a usual human error – to mark a box near the exact one or to change some letter or digit.

On the one hand, medical doctors are overloaded and normally hate to go trough deep and strong security system. From patients’ side, data protection and security are very important. These opposite restrictions make solutions hard to design. Currently, we

think that only hardware identification systems fast enough and easy to use can solve identification problems and access rights, but even this opens a new domain of problems.

Digitalisation of paper archives Designing the solution for integrated hospital information system required us to think how to transfer current archives in digital form. Of course, the problem for archive digitalisation has existed for more than 20 years.

The main problem we had to solve was digitalisation of video imaging library.

Investigation about possibilities to digitise images of different types envisaged that the on-hand solution to use flatbed scanners is not applicable. Available scanners for large X-ray pictures start from US$15000. Services for film scanning are from US$2 to 10 depending on picture and requirements. Financial

limitations directed us to design lowcost scanners for all kinds of films and pictures. It is presented in. Its price is much lower and resolution is better than film grain. This system is equipped with software for images post-processing. Some results are presented in.

A very important additional problem is the size of digital archive. For medium level Bulgarian hospital (covering 30000-

Author BIO

All over the world, a huge number of standards of organisation and representation of the Electronic Health Record exist(HER). Unfortunately, many of them depend on local law regulations and even in European Community they are not synchronised. Hospital data (not originally included in HER) are harder to track they include information from many sources – diagnoses, many types of laboratory results, imaging results – X-ray / ultrasound / scanners / Doppler, medications, consultations. These data are very distributed. In a large hospital like the Medical University Sofia original data are held on the laboratories and clinics servers. They have to be exchanged and bound in patients’ records. Such a data base did not exist before the beginning of this project. One of the biggest problems was the fact that data are very changeable, the amount increased all the time and the structure depends on uncontrollable variety of external (mostly human) factors. Today, an information system based on unified generalised structure which covers all types of available is implemented in the MU Sofia medical information system.

Information Technology

50000 people) only DICOM library is more than 5-6 Tbs/year. Today, disk devices have huge capacities but nevertheless increasing hospital data server with 10TB/year is problematic.

Acknowledgement This work is started and partially funded

by Bulgarian NSF under D002/1132008 project.

Ivan Evgeniev Ivanov is also a member of IEEE and Bulgarian Union of Automatics and Informatics. He has led a number of projects oriented to (embedded) computer control systems, heterogeneous distributed systems.

Vesselin Gueorguiev is also a member of Bulgarian Union of Automatics and Informatics. He has led a number of projects oriented to real-time computer graphics, program code analysis and distributed systems.

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Books

CURRENT Diagnosis and Treatment Surgery Thirteenth Edition Editor: Gerard Doherty No of Pages: 1324 Year of Publishing: 2009 Description: To-the-point information on more than 1000 diseases and disorders surgeons are most likely to encounter The leading single-source surgery book for house-staff, students, practitioners, and surgeons "This is an excellent source of updated, authoritative, and concise information on diseases encountered in general surgery and the surgical subspecialties of otolaryngology, urology, gynecology, orthopedics, plastic and reconstructive surgery, and pediatrics....This is a wonderful resource for all levels of surgical practitioners as well as nonsurgical practitioners. In my experience, it has provided me with a framework to prepare for both oral and written boards. 3 Stars."--Doody's Review Service.

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Blood and Guts: A History of Surgery Editor: Richard Hollingham No of Pages: 320 Year of Publishing: 2009 Description: Today, astonishing surgical breakthroughs are making limb transplants, face transplants, and a host of other previously un dreamed of operations possible. But getting here has not been a simple story of medical progress. In Blood and Guts, veteran science writer Richard Hollingham weaves a compelling narrative from the key moments in surgical history. We have a ringside seat in the operating theater of University College Hospital in London as world-renowned Victorian surgeon Robert Liston performs a remarkable amputation in thirty seconds—from first cut to final stitch.

Innovations such as Joseph Lister’s antiseptic technique, the first openheart surgery, and Walter Freeman’s lobotomy operations, among other breakthroughs, are brought to life in these pages in vivid detail. This is popular science writing at it’s best.

ISSUe - 23 2011

Schein's Common Sense Emergency Abdominal Surgery: An Unconventional Book for Trainees and Thinking Surgeons Editor: Moshe Schein, Paul Rogers, Ahmad Assalia, Robert Lane (Adapter) No of Pages: 673 Year of Publishing: 2010 Description: Emergency Abdominal Surgery is a battleground for the surgeon - providing character-building experiences, and opportunities for triumph and disaster. In the third edition of this 'simple' book, emergency abdominal surgery is discussed in an informal and no nonsense fashion - as practiced in the 'trenches' of the ER and the OR. The preferred approach for a given situation is discussed in context; it has to fulfill certain prerequisites: save lives, decrease morbidity, be cost effective and be performed correctly.

Bariatric Surgery

The Evidence for Neurosurgery

Editor: Nadey S. Hakim, Franco Favretti, Gianni Segato, Bruno Dillemans No of Pages: 300 Year of Publishing: 2011 Description: Over the last two decades, obesity has reached epidemic proportions in the world, resulting in suffering and premature death. Morbid obesity is a chronic medical illness that has longreaching consequences and is caused by multiple factors. Bariatric surgery and other non-invasive procedures in carefully selected patients are effective treatments for obesity. It is the only tool for sustained and effective long-term weight loss.

The field of surgery is developing rapidly -- offering innovative options for patients who have failed to lose weight by diet, exercise and pharmacological methods. The editors review problems that the patients face in the perioperative period and in the long term, as well as their adjustments in lifestyle and healthcare management.

Editor: Edward C. Benzel, Zoher Ghogawala, Ajit A. Krishnaney, Michael P., M.D. Steinmetz, H. Hunt Batjer No of Pages: 350 Year of Publishing: 2011 Description: Neurosurgery represents one of the most specialised arenas in modern medicine. Today, more than ever, patients with neurological disorders seek opinions from a variety of specialists and are often treated by teams of physicians.

While consensus is often reached within institutions, regional variation is found between institutions. The lack of high quality clinical evidence contributes to this problem. This textbook aims to examine some of the most controversial areas of neurological surgery by applying the current evidence to illuminate our understanding of the pathophysiology of each disease and the outcomes from surgical and non-surgical treatments.

Complications in Vascular and Endovascular Surgery: How to Avoid Them and How to Get Out of Trouble Editor: Jonathan J. Earnshaw, Michael G. Wyatt No of Pages: 400 Year of Publishing: 2011 Description: This is the third in a highly successful series of publications from the Joint Vascular Research Group. The title has been inspired by the rapid development in the treatment of patients with vascular disease, which embraces the new endovascular techniques and changes to medical management that are revolutionising our treatment of these patients. Each chapter is written to present up-todate evidence-based information on the prevention and treatment of vascular and endovascular complications. There is a particular emphasis on the tips and tricks of 'how to get out of trouble', and we hope this will help the reader in their practice of vascular and endovascular surgery.

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Research Insights Missing link between HPV infection and cervical cancer development found Researchers at the Georgetown Lombardi Comprehensive Cancer Center, a part of Georgetown University Medical Center, claim that a new mouse model they developed demonstrates that switching the a beta-catenin oncogene on in the cervix of HPV infected mice promoted development of aggressive cervical cancer.

These early findings suggest clinical implications that are both preventive and therapeutic.

The researches say they can potentially develop a screening method to check for HPV and betacatenin activation in pap smears,” that will identify individuals at a higher risk of developing cancer compared to ones who are only HPV positive so that they can be more closely monitored for cancer development.

Cervical cancer is the second leading cause of cancer deaths in women worldwide. “New international approaches to control and treat cervical cancer are desperately needed,” he says.

The mouse model was created by cross-breeding two other strains of transgenic mice A– one that expresses HPV genes in the cervix and the other that forces the beta catenin/Wnt pathway to be constantly activated, also in the cervix. While the HPV infected mice are programmed to develop cervical cancer, the tumors that grew in the double transgenic mice were larger and more aggressive.

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Preliminary human trials show heart damage improves after stem cell injections

In a first of its kind effort, researchers have shown that stem cells injected into enlarged hearts reduced heart size, reduced scar tissue and improved function to injured heart areas. The trial was published in Circulation Research: Journal of the American Heart Association. While they are in early stages, the findings hold promise for five million Americans who have enlarged hearts due to damage sustained from heart attacks.

Options for treatment are limited to lifelong medications and major medical interventions, such as heart transplantation. Researchers injected stem cells derived from the patient’s own bone marrow into the hearts of eight men with chronically enlarged, low-functioning hearts.

The findings suggest that patients’ quality of life could improve as the result of this therapy because the heart is a more normal size and is better functioning.

ISSUe - 23 2011

New squamous cell lung cancer target identified

Umbilical cord blood cells could aid diabetic wound healing

Scientists at the Dana Farber Cancer Institute have identified a mutation in the DDR2 gene that may indicate which patients with squamous cell lung cancer will respond to dasatinib.

Researchers say that there are currently no targeted therapies for squamous cell lung cancer, which affects approximately 50,000 people annually in the USA. Estimates say that DDR2 mutations would be present in lung cancers from about one to two thousand people a year.

Transplanting human umbilical cord blood-derived endothelial progenitor cells (EPCs) has been found to “significantly accelerate” wound closure in diabetic mouse models, according to research published by a team of Korean researchers.

According to the study, diabetes is often associated with impaired wound healing. While the therapeutic potential of transplanted EPCs has been demonstrated in animal models and in humans who have suffered stroke, myocardial infarction and peripheral artery disease, their effect in healing stubborn wounds has not been studied to the same degree.

The researchers, who transplanted EPCs into an experimental group of mice modeled with diabetesassociated wounds, but did not transplant EPCs into a control group, found that the EPCs prompted wound healing and increased neovascularization in the experimental group.

The transplantation of EPCs derived from human umbilical blood cells accelerated wound closure in diabetic mice from the earliest point. Enhanced re-epithelialization made a great contribution in accelerating wound closure rate.

The researchers found that growth factors and cytokines (small proteins secreted by specific cells of the immune system) were massively produced at the wounded skin sites and contributed to the healing process.

Scientists at Johns Hopkins have unlokced the genetic code for a type of pancreatic cancer called neuroendocrine or islet cell tumours.

Using standard genetic sequencing techniques, the researchers identified mutations in the DDR2 kinase gene in about 3 percent of squamous cell lung cancers and cell lines. Furthermore, they found that tumor cells with these DDR2 mutations responded to treatment with dasatinib. A patient whose cancer carried a DDR2 mutation also showed a clinical response to dasatinib.

The researchers claim that wounds associated with diabetes that resist healing are also associated with decreased peripheral blood flow and often resist current therapies. Normal wounds, without underlying pathological defects heal readily, but the healing deficiency of diabetic wounds can be attributed to a number of factors, including decreased production of growth factors and reduced revascularisation.

claim that several of them are difficult to distinguish from other pancreatic cancer types.

The researchers investigated non-hormonal pancreatic neuroendocrine tumors in 68 men and women.

In their first set of experiments, the scientists sequenced nearly all proteinencoding genes in 10 of the 68 samples of pancreatic neuroendocrine tumors and compared these sequences with normal DNA from each patient to identify tumour-specific changes or mutations.

In another set of experiments, they searched through the remaining 58 pancreatic neuroendocrine tumours to determine how often these mutated genes appeared.

The most prevalent mutation, in the MEN-1 gene, occurred in more than 44 percent of all 68 tumours. The researchers also found that 14% of the samples studied contained mutations in a gene family called mTOR, which regulates cell signaling processes.

Pancreatic neuroendocrine cancers account for about five percent of all pancreatic cancers.

Some of these tumours produce hormones that have noticeable effects on the body, including variations in blood sugar levels, weight gain, and skin rashes while others have no such hormone signal.

Hormone-free tumours, however, grow silently in the pancreas, and the researchers

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Get Smarter Transformation in Document Management Access Documents on-demand, improve efficiency • From patient’s admission through diagnosis procedures, medical prescription, every event in a hospital is accounted in forms • Health record management- an administrative task has no direct hands-on patient care • Implies 6% improvement in overall efficiency • Fuji Xerox Healthcare Portal Solution helps streamline clinical workflows, improve forms processing

Health record management being an administrative task has no direct hands-on patient care.

Though, it affects patient care by its time consuming and laborious procedures like form filling, archiving, searching and managing. This time eating process does not let an organisation to effectively extend its resources. Hence, the advent of electronic health records was kindled, way back in late 1960s. Since then there were significant technology developments but with great latency between successive works.

In the year 1999 a study named ‘to Err is Human’ rolled out highlighting a point that, about 44,00098,000 people died in US due to medical errors. The fact that, some of those deaths happened because of ‘unreadable physician handwriting’ is quite ridiculous.

A study estimated about 6% improvement in overall efficiency in an organisation every year upon the implementation of Electronic health records technology. That saves incredibly a lot of resources and avoids any avoidable fatality. And the monthly cost of operating Electronic document management can be offset by a few unnecessary diagnosis tests.

H

ealthcare technology has ascended remarkable heights. It has improved the ability to cure many disorders that affected mankind all along the evolution. Technology development has its effect on every particular aspect in the world, and healthcare is no exception to that. One aspect in healthcare system which is in a gradual process to acquire a technological edge is the healthcare record or document management. Kicking-off from patient’s admission through diagnosis procedures and medical prescription, every event in a hospital is accounted in forms. These forms which correspond to a patient get stacked up reports upon reports ultimately end up with extra large space requirement.

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Though the health document management systems are basically aimed at providing ease of document management, they offer a variety of other benefits and also unwanted challenges. The following can be identified as the multiple benefits offered by a Health document management system:

Improved time efficiency and reduced costs Access to old reports can be easy with digitized files and new records can be updated to the old report file without any heck. The hospital staff probably does not need to use physical document search anymore and could retrieve documents of any patient on the run. Multiple records can be saved at a single place without creating space demand and saving resources by on-demand report printing.

Increased accuracy with low human error factor The human data entry is reduced with digitisation of forms, reports and documents. The data entry into digitized documents will be accurate and appropriate with field by field entry every time.

Enhanced productivity and service quality As the time factor in document search and management is reduced, the quality of patient service and there by productivity of a healthcare organisation is evidently improved. Barcodes can be automatically generated for forms. Storing, sorting and delivery of reports can be instant unlike in traditional paper based document management system.

Increased portability and document access Mobility of documents is another major aspect that will be actively addressed by Electronic document management. However, the increased portability and accessibility of electronic medical records may also increase the ease with which they can be accessed and stolen by unauthorized persons or unscrupulous users. Secured Document Handling is another major concern to be addressed by a qualified Document Management System.

Even when a healthcare organisation has electronic records, document management remains largely a manual process. To deal with the ever growing number of paper documents, a robust solution with efficient use of IT is to be evolved.

Health document management systems development has been targeted by a hand full of technology providers. Each specific design offered a unique service towards document handling. One of the recent developments in this sector is from FujiXerox, a combined development. Designed specifically with Healthcare industry in mind, Fuji Xerox Healthcare Portal solution will help streamline clinical workflows, improve forms processing and help support the importing of patient data/information into EMR systems. In addition to integrating and consolidate the laborious process of forms management the Healthcare Portal Solution is able to realize the above mentioned variety of benefits. With ID and password authentication required for document accessing, the confidentiality and intimateness of the patient documents can be well affirmed by the Healthcare Portal Solution from Fuji Xerox.

An organisation’s ability to process information determines how well its patient’s needs are being met.

In the paper intensive healthcare industry that can be difficult as a ward may typically need to manage 30 to 40 different forms. More than just a document management solution, the Fuji Xerox Healthcare Portal Solution assumes to bridge the gap between paper and electronic records in an organisation. It can be easily implemented into any healthcare organisation and in any stage of IT maturity cycle.

The document management systems are destined to provide a better treatment facility at a healthcare organisation. Every day gets better with a new development opening up in healthcare sector. At the end, better management system implies a better patient care. The world awaits it with an acquisitive insight.

For more information how the Fuji Xerox Healthcare Portal can help your organization please visit: http://www.fxap.com.sg/solution/industry/healthcarepa.jsp The Healtchare portal solution is only available in Singapore/Malaysia/Hong Kong

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News Implantable Cardioverter-Defibrillator can Improve ICM and DCM Patients Survival Rates According to a scientific paper, patients with ischemic cardiomyopathy (ICM) and dilated cardiomyopathy (DCM) who have an implantable cardioverterdefibrillator (ICD) now live more than seven years.

The paper presented at the American College of Cardiology (ACC) Scientific Sessions in New Orleans also presents that ICD patients with hereditary heart disease also can live for decades.

ICDs will improve blood flow in patients with coronary artery disease and prevent sudden cardiac death, researchers at the Minneapolis Heart Institute said.

Statistics showed that between 2000 and 2009, 1,555 patients

UK Researchers Develop New Stroke Rehabilitation Devices

Three 'tactile' devices which generate a realistic 'sense of touch' and sensation - mimicking those involved in everyday activities, have

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(mean age: 64.9 years; gender: 75.2 percent male) received initial single chamber (18.5 percent), dual chamber (42.2 percent) or cardiac resynchronization (39.3 percent) ICDs. Of which, the average survival was seven years, and individuals with hereditary heart disease lived much longer since they were generally younger at the time of implantation.

"Contemporary ICDs need to be flexible and durable enough to adapt to the evolving clinical needs of the patient who is living longer," said the lead author Robert Hauser, MD, a cardiologist at the Minneapolis Heart Institute- at Abbott Northwestern

been developed by researchers at the University of Southampton.

Dr Merrett, Dr Sara Demain, a lecturer in physiotherapy and Dr Cheryl Metcalf, a researcher in electronic systems and devices have developed and tested three technologies which could help people who are affected by stroke to regain movement in their hand and arm.

A 'vibration' tactile device provides a good indication of touch with no feeling like holding anything; a 'motor-driven squeezer' device, which gives a feeling like holding something; and a 'shape memory alloy' device which has thermal properties and creates a sensation like picking up a cup of tea.

ISSUe - 23 2011

Microsoft Concentrates on Identity and Access Management Solutions for Healthcare

Hospital in Minneapolis.

Findings were consistent across all ICD manufacturers and also underscore the need for long-lived ICD pulse generators and leads, concluded the researchers.

Dr Demain says: "Most stroke rehabilitation systems ignore the role of sensation and they only allow people repetitive movement.

Our aim is to develop technology which provides people with a sense of holding something or of feeling something, like, for example, holding a hot cup of tea, and we want to integrate this with improving motor function."

Dr Merrett adds: "We now have a number of technologies, which we can use to develop sensation. This technology can be used on its own as a stand-alone system to help with sensory rehabilitation or it could be used alongside existing health technologies such as rehabilitation robots or gaming technologies which help patient rehabilitation."

Microsoft Corp. has announced rapid growth for the Sentillion family of identity and access management (IAM) solutions for healthcare.

Microsoft has introduced new functionality for Vergence and expreSSO products with the acquisition of Sentillion Inc. Microsoft also continues to see rapid enterprisewide deployment of Sentillion solutions at health organizations in large scale.

With increased demand for Sentillion Vergence, expreSSO and proVision products in 2010, Scottsdale Healthcare, a community-based not-for-profit organization comprising three acute care hospitals, two outpatient surgical centers and a comprehensive cancer center, selected Vergence and proVision to improve the speed

and accuracy with which 8,000 users receive role-based access into clinical and nonclinical systems and to simplify the process for signing in and accessing patient information.

Microsoft has also released Service Pack for Vergence and expreSSO to evolve the functionality of the Sentillion product line.

Vergence 4.5 Service Pack 1 constitutes the first combined release of Vergence Wizard with BridgeWorks.

The Vergence Wizard is used to help customers rapidly create customized Bridges between Vergence and their specific healthcare applications with several other features. Sentillion ExpreSSO 2.5 Service Pack 1 features Windows 7 client support, 64-bit Citrix server support, and expanded card reader support for Citrix.

Non-Tumour Tissue May be an Effective Option for Diagnosis of Prostate Cancer Researchers have analyzed non-tumor tissue and found that it may be an effective option instead looking for tumors directly in patient with prostate cancer, study said.

According to study conducted by researchers at University of California at Irvine, a biopsy needle does not need to hit a tumor to detect the presence of tumor.

"It is reminiscent of the game Battleship; we can detect more cancer cases using 12 shots with a biopsy needle than would otherwise be the case because we have made the ships bigger," said lead researcher Dan Mercola, M.D., Ph.D., professor of pathology and laboratory medicine at the University of California.

The research was conducted on 364 samples from men of all races who had biopsies for possible prostate cancer, or had prostatectomies to remove cancer, as well as control prostates from donors that had died of causes other than prostate cancer.

Changes in the nearby non-tumor tissue have been observed and found that

changes in gene expression in normal tissue could be detected up to a few millimeters from prostate cancer.

"It is hoped that the large sample size and the high statistical significance of this study may help to ensure a better follow-up, and some of the defined stromal markers will eventually be validated with clinical values," said Ruoxiang Wang, M.D., Ph.D., a research scientist and associate professor in the department of medicine at Cedars-Sinai Medical Center, Los Angeles.

Inorder to confirm the findings, further studies will be required and before urologists will likely be able to use a diagnosis based on non-tumor tissue for recommending surgery or other radical treatment, researchers said.

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