Healthcare Management | Medical sciences | Diagnostics | information technology | TECHNOLOGY, EQUIPMENT & DEVICES
I s s u e 24
2011
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g n i y f i t e n s c i u a l m re o u n a o a c c e V h Q t l w a e e n h The of
Transforming Concepts Patient Safety
In Association with
Health in the Green Economy
How Carbon Reduction May Impact Health in Health Sector Services
Strategic Planning of Healthcare Delivery Centres Role of Operations Management www.asianhhm.com
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Foreword
Redefining Care Delivery At a time when healthcare expenditures are on the rise, a new concept for care delivery is taking roots -- value-based healthcare or the patient health outcome per dollar spent. This model of care delivery focuses on the outcome delivered by the care provider rather than just the cost of delivering it or the financial success of the stakeholders.
According to Gloria N Eldridge, Senior Analyst and Project Director, Altarum Institute, after one or two decades, other players will begin to adopt these value-based healthcare strategies as administrative, reporting, and payment systems begin to merge due to the power of Medicare, in particular, to drive market change.
Value-based healthcare determines the value of the procedure based on various parameters. These include quality care, cost containment, patient safety and satisfaction. The focus throughout the treatment cycle is on providing the patient with better health. Under this system poor outcomes waste, reworks, such as re-operations, readmissions are discouraged.
The true value-based healthcare system can be accomplished only when physicians realise that concentrating on patient satisfaction gives more meaning rather concentration on money factors and accept these changes.
According to records, in US, 20-30 per cent of all prescriptions, visits, procedures and hospitalisations are overused, underused (including non-used) and misused. It is also estimated that for every million dollars spent on healthcare more than an estimated US$ 200,000 is likely to be wasted and is potentially causing patient harms. The new service and payment models involved with the value-based healthcare system need to evolve and healthcare organisations are being forced to tag on this. Organisation leadership is the key to migrating to this new form of care. Leaders need to push for a fundamental restructuring of healthcare delivery and put in place systems that measure various processes for the kind of outcomes they provide. Considering the relationship of quality care to cost/expenses and patient/customer satisfaction, the cost of the intervention has to be analysed to determine the value.
The cover story in this issue of Asian Hospital & Healthcare Management, features experts views on quantifying the value of healthcare. Yosef D Dlugacz, Senior Vice President and Chief of Clinical Quality, Education & Research, Krasnoff Quality Management Institute, USA talks about how the traditional and accepted procedures are being reevaluated for value and how the concept of value has changed dramatically during past few years. Gloria N. Eldridge, Senior Analyst and Project Director, Strategic Innovations for Affordable, Sustainable Healthcare: A Model for Health System Reform, Altarum Institute talks about how the value-based healthcare can affect US healthcare.
Prasanthi Potluri Editor
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Contents
Value 10 Quantifying The new economics of healthcare Yosef D Dlugacz, Senior Vice President and Chief of Clinical Quality, Education & Research, Krasnoff Quality Management Institute, USA
14 Value-based Healthcare
Gloria N. Eldridge, Senior Analyst and Project Director, Strategic Innovations for Affordable, Sustainable Healthcare: A Model for Health System Reform, Altarum Institute, US
Healthcare Management 06 The Adoption, Buy In, and Change of Health Information Exchange
TECHNOLOGY, EQUIPMENT AND DEVICEs
Jason Hess, General Manager of Clinical Research, Mark Allphin, Research Director
40 Drivers of HealthCare Industry
KLAS, USA
Sandeep Sinha, Director, Healthcare Practice, Frost & Sullivan, South Asia and Middle East
18 Strategic Planning of Healthcare Delivery Centres Role of operations management Shakti Kumar Gupta, HOD, Hospital Administration & Medical Superintendent, All India Institute of Medical Sciences, Dr. R P Centre for Ophthalamic Sciences, New Delh, India
Medical sciences
FACILITIES & OPERATIONS MANAGEMENT 42 Transforming Concepts Patient safety
22 Back Pain and Treatment options
Diane Pinakiewicz, President, National Patient Safety Foundation, USA
Rasha Snan Jabri, Adjunct Assistant Professor Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, UAE
SURGICAL SPECIALITY 26 Mishaps and Risk Reduction Strategies of Minimal Access Surgery Pradeep Chowbey, Director - Institute of Minimal Access, Metabolic & Bariatric Surgery, Max Healthcare Institute Ltd, India
Diagnostics
46 Health in the Green Economy How carbon reduction may impact health in health sector services Walt Vernon, CEO, Amy Jarvis, Environmental Performance Engineer Mazzetti Nash Lipsey Burch, USA
information technology 50 Identity and Access Management – how does it benefit healthcare providers? Jonathan Leviss, Director, Clinical Solutions for Microsoft Health Solutions Group, USA
32 Advances in Neuroradiology Peter Corr, Department of Radiology, Faculty of Medicine and Health Sciences, UAE University, UAE
36 Planning Secrets For Enhanced CT/ MRI Throughput Robert Junk, President Scott Branton, AIA, Senior Associate RAD-Planning, USA
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special features 31 Events 39 Books
18 32
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Celebrate! Recognize! Inspire!
Congratulation to all the Awards Recipients!
Alexandria - Frost & Sullivan India Healthcare Excellence Awards 2011 22 September 2011
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JW Marriott, Mumbai
{2011}
Alexandria – Frost & Sullivan India Healthcare Excellence Awards recipients in various categories SPECIAL AWARDS Lifetime Achievement Award Healthcare Entrepreneur of the Year
Dr B Soma Raju, Chairman, Care Hospitals Dr Naresh Trehan, Chairman, Medanta - The Medicity
HEALTHCARE IT AWARDS Healthcare IT Application Company of the Year Innovation in Healthcare IT Company of the Year
Napier Healthcare Solutions Pvt Ltd Aircel & HealthNet Global for Aircel Apollo Pocket Health
HEALTHCARE DELIVERY AWARDS Diagnostic Services Provider Company of the Year Emerging Diagnostic Services Provider Company of the Year Wellness Services Provider Company of the Year Healthcare Retail Company of the Year
Super Religare Laboratories MedALL Healthcare Ayurvedagram Heritage Wellness Centre Apollo Pharmacy
MEDICAL TECHNOLOGIES AWARDS Diabetes Detection Company of the Year Diagnostic Imaging Equipment Company of the Year Innovation in Medical Technologies Company of the Year Indian Medical Devices Company of the Year Orthopaedic Implants Company of the Year Cardiology Treatment Company of the Year
Roche Diagnostics India Siemens Healthcare Kimberly Clark Sahjanand Medical Technologies Pvt. Ltd. DePuy Philips Healthcare
HEALTHCARE DELIVERY AWARDS Healthcare Services Provider Company of the Year Emerging Healthcare Service Provider Company of the Year Oncology Care Provider Company of the Year Mother & Child Care Service Provider Company of the Year Eye Care Service Provider Company of the Year
Fortis Healthcare & Hospitals Group Medanta - The Medicity Healthcare Global Enterprises Manipal Hospitals Vasan Healthcare
BIOTECH & PHARMACEUTICALS AWARDS Indian Clinical Research Organisation of the Year Indian Oncology Market Company of the Year MNC Pharmaceutical Company of the Year Indian Vaccine Market Company of the Year Indian Biopharma Company of the Year Indian Contract Research Organisation of the Year Indian Pharmaceutical Company of the Year Gold Partner
Official Channel Partner
Siro Clinpharm Pvt. Ltd Roche India Abbott India Ltd GlaxoSmithKline Pharmaceuticals Ltd Biocon Limited Jubilant Biosys Sun Pharmaceutical Industries Ltd. Media Partners
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Advisory Board
Editor Prasanthi Potluri Art Director M A Hannan Copy Editors Sri Lakshmi Kolla Jenny Jones Sales Team Khaja Ameeruddin Breiti Roger Jeff Kenny John E Adler Professor Neurosurgery and Director Radiosurgery and Stereotactic Suregery Stanford University School of Medicine, USA
Compliance Team P Bhavani Prasad P Shashikanth Sam Smith Steven Banks CRM Yahiya Sultan
Sandy Lutz Director PricewaterhouseCoopers Health Reseach Institute, USA
Subscriptions incharge Vijay Kumar Gaddam IT Team Ifthakhar Mohammed
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
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Azeemuddin Mohammed Krishna Deepak Head - Operations S V Nageswara Rao
Asian Hospital & Healthcare Management is published by
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A member of Confederation of Indian Industry
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Pradeep Chowbey Chairman Minimal Access, Metabolic and Bariatric Surgery Centre Sir Ganga Ram Hospital, India
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Healthcare Management
The Adoption, Buy In, and Change of Health Information Exchange For those who follow news in the healthcare IT world, not too many days pass without some mention of a health information exchange (HIE) being formed, whether through a governmentbacked initiative or a private venture. A lot of attention (and money) is being given to the area, but how much real progress has been made? How far have HIE vendors moved past flashy press releases into actual data exchange? Jason Hess, General Manager of Clinical Research Mark Allphin, Research Director KLAS, USA
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ach year KLAS Enterprises reaches out to healthcare providers in order to collect provider feedback on a variety of healthcare IT vendors and subjects. For the past two years, one of KLAS’s most anticipated reports has been the annual Health Information Exchanges (HIE) report. This year KLAS interviewed 239 providers involved with 228 live HIEs to find out where North America’s HIE market stands today. The below article is an adaptation of the text presented in KLAS’s 2011 HIE report, Health Information Exchanges: Rapid Growth and Evolving Market. For the purposes of this study, KLAS defined an HIE as at least two healthcare provider organisations actively exchanging (unidirectionally or bidirectionally) patient data and other information. Participating organisations can be any combination of acute and ambulatory facilities. Information must be shared between nonowned facilities, meaning the organizations are part of separate organizations. HIEs that are not yet actively exchanging data are
Healthcare Management
not counted as live for the purposes of this study. Sites with point-to-point interfacing within a single IDN or other type of multi-facility system are not included in this study. Still a Mile Wide, But Slowly Getting Deeper... In the 2010 KLAS HIE Performance study, Health Information Exchanges: The Reality of HIE Adoption, KLAS discovered that the HIE market was “a mile wide and an inch deep,” meaning there were too many vendors to count but few actual live exchanges. In this year’s study, KLAS found that the market has matured and a number of vendors are beginning to stand out, but most HIEs still have a long way to go before they start making the positive impact on healthcare that providers and regulators are hoping for. As governments and providers move forward with HIE plans, the number of live HIEs continues to increase. This year KLAS validated 228 live HIEs, up from 89 in last year’s study. The interesting discovery, however, was not the overall growth but where that growth was concentrated. The number of live public HIEs increased from 37 last year to 67 this year, while the number of live private HIEs grew from 52 last year to 161 this year. Why are private HIEs seeing such explosive growth compared to public HIEs? Provider comments point to three main reasons: • Governance—Generally, public HIEs involve a relatively large number of healthcare organisations. Trying to get so many competing organisations on the same page as far as what data to exchange and how to go about it is a laborious process. Add the red tape and complications that always come with government sponsorship, and it is no surprise that public HIEs have a hard time gaining momentum. Private HIEs, in contrast, typically involve a smaller number of organisations (often just one provider organization reaching out to others) and do not have to deal with government oversight. As a result, not only can they
The providers believe that better access to the patient data will allow payers to find ways to improve the quality of care and decrease the cost. reach decisions more quickly, they can also act on those decisions more quickly. • Funding—Financial viability is a concern for any HIE, but it appears to be more of a challenge for public HIEs. Of the providers that KLAS interviewed at public HIEs, 54 per cent said future funding was a legitimate concern. Among providers at private HIEs, that number dropped to 35 per cent. Not only are public HIEs uncertain over where their funding will come from once public grants run out, but they also face limitations on exactly how they can use grant money. One director at a public HIE commented, “The fact that our funding is dependent on political support in difficult economic times is worrisome. With new faces in the federal and state legislatures, there are no guarantees.” Private HIEs, meanwhile, are typically funded by the stakeholder organisations themselves, so future funds are less of a worry, and they are free to do what they please with the money. • Market protection—From a business perspective, many healthcare organisations have an incentive to create private HIEs but not participate in public HIEs. Private HIEs allow them to reach out to community physicians and the patients they treat. Public HIEs, on the other hand, force them to share patient data with competitors, which some organisations are reluctant to do. Providers at both public and private HIEs mentioned that the key to future viability will be creating value for providers. If providers see real value in the services an HIE offers, they will have no problem paying for it. However, if HIEs have no tangible benefits to offer, provider
subscribers will be hard to come by. One executive director described his thinking this way: “We are not charging [providers] right now. I cannot promise it will always be that way. If we need to go ask for funds [from providers], our objective is to make sure that we are demonstrating value at that point, and significant value, at that, so that it becomes kind of a no-brainer.” Getting physicians on board When KLAS asked providers how they measured the success of their HIEs, 37 per cent said they measure it by the number of physicians that actually use the data. Getting physicians to use the data is often easier said than done, especially when it slows them down. One provider related, “The doctors were interested in this to start out, but once they realised that they were going to have to do things in two different places, they lost interest. It is just too cumbersome.” With that challenge in mind, more HIEs are striving for ways to deliver useful data to physicians without requiring them to leave their normal workflow, but so far progress has been slow. In the 2010 study, KLAS found that 37 per cent of live HIEs were delivering data to physicians directly through their EMRs. This year, that number climbed to 43 per cent. If the providers that are running HIEs feel that physician adoption is so critical, why is that number not higher? The chart displays the percentage of data being exchanged by live HIEs in various healthcare areas—listed by the product employed and the type of data that is being exchanged—for example, 41 per cent of live Axolotl customers are exchanging Advance Directive information. (Chart 1) Respondents described a number of barriers standing in the way of more direct interfaces into physicians’ EMRs. The first, and perhaps largest, barrier is the cost of the interfaces. Providers complained that EMR vendors charge an unreasonably high amount for interfaces, leaving both clinics and
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Percent of Live HIEs Surveyed that Are Exchanging Data by Product and Type of Data Being Exchanged
HIEs either unable or unwilling to pay for them. One CIO of a large health system commented, “When I look at the hundreds of providers that are using [our HIE] and the cost of getting those interfaces to their EMRs up, I wonder how we can possibly afford to interface everyone.” Another challenge for HIEs looking to interface into EMRs is that, despite the surge in adoption created by the American Recovery and Reinvestment Act (ARRA) in the US, many clinics have yet to install an EMR, making an interface impossible for the time being.
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In addition, many clinics that have EMRs are hesitant to allow an HIE to push data directly into the EMR because of concerns over data integrity. Some clinics want only certain types of data to be pushed in, while others want to keep HIE data completely separated from their own records. One executive explained, “One interesting thing we are finding is that even though [our HIE] has the capability to move the virtual patient record to populate another system, most of the community physicians are opposed to that. They aren’t opposed to lab results or radiology reports, but they are opposed
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(Chart 1)
to the diagnoses. Their argument is that they are notsure they trust the information coming in, so they don’t want the diagnoses automatically populating their EMRs.” Delivering the data: HL7 is still king Although many of the providers KLAS spoke with plan to eventually exchange data using Continuity of Care Document (CCD) or Continuity of Care Record (CCR) formats, the reality today is that most HIEs have not yet been able to execute those plans. In the 228 HIEs
Healthcare Management
Payers entering the HIE mix: provider thoughts As part of this study, KLAS asked providers for their thoughts on the recent acquisitions of Axolotl and Medicity by UnitedHealth Group and Aetna, respectively. Respondents had mixed feelings on the issue; 33 per cent felt the acquisitions are something to be concerned about, 28 per cent felt the acquisitions are a positive thing for the industry, and 39 per cent either had no opinion or felt the acquisitions will not have a major impact on the market.
The providers who were more optimistic felt that the acquisitions will give the HIE vendors more resources to develop and improve their products. They also believe that better access to the patient data will allow payers to find ways to improve the quality of care and decrease the cost. One CMIO gave the following example: “To me, the purchasing of HIE companies is probably a push for these payers to get patient data so that we can better manage waste. The big problem today is cultural. A patient with a mild head injury gets a CT scan by default that gets paid for by the payer. And yet 90 per cent of CT scans are not turning anything up. So the data would help determine where CT scans are necessary and where they are not.” The providers that were concerned about the acquisitions were mostly worried about how Aetna and UnitedHealth will use the patient data that they will now have access to. These respondents fear the data will be used to deny coverage to patients and to exercise more control over providers. One provider described his reasoning like this: “If payers want to pay for the HIE because they think it will provide better care, I am all for that. However, I don't know how we can ensure that they will not notice that a patient has AIDS, for example, and refuse to cover that patient. If I were [an insurance company’s] customer and I heard [them] say they were going to take my data and throw it into a big database, I
Author BIO
KLAS validated for this study, 81 per cent of the data was still being exchanged through basic HL7 interfaces, while only 12 per cent was being exchanged using CCD/CCR. Providers generally ascribed this to a lag in technology. While some systems can create CCDs or CCRs, many are not equipped to send them, and still more are not equipped to receive them. Even in the organisations that are successfully exchanging CCDs, some providers reported that the CCD is too much information for physicians to search through, indicating that it needs to be further refined so that doctors can quickly find the information they need. One executive said, “I know the CCD is this great document that everyone is expecting to get, but it is very cumbersome for those who have patients who are frequent fliers. In our state, people take recommendations from family and friends and shop around for their care. They may go have a test done at one place, their outpatient service done at another, and their surgery at still another. We want to be able to tie all that information together and see everything the patient wants us to.” The provider continued, “The CCD for that data can be very large. A patient who has diabetes, an orthopaedic issue, and an ophthalmology issue and who has had several surgeries will have a very big CCD. A doctor doesn’t want to see all of that. It is too overwhelming and time consuming.”
would wonder what the heck they plan on doing with it.” Interestingly, Axolotl and Medicity customers were not any more pleased with or concerned about the acquisitions than the rest of the provider population; of those Axolotl and Medicity customers that participated in this study, 47 per cent felt the acquisitions were a positive step and 32 per cent expressed concern. Here to stay While the HIE market has made substantial progress in the past year, it is clearly still in the early stages. The majority of HIEs are still building the foundation for what they hope will become robust and meaningful exchanges in the future. Moving forward, accountable care organisations, other pay-for-performance models, and future government requirements will all continue to increase the pressure on provider organizations to make patient data accessible across the continuum of care. Trial and error among HIEs already in existence, as well as HIE-related initiatives slated for the future will continue to shed light on what works and what doesn’t work when it comes to information exchange. If nothing else, the events and developments of the past year seem to have established one thing: HIEs are not going away. As both the US and international healthcare markets continue to evolve, HIEs will likely only increase in importance.
Jason Hess is responsible for all clinical research collected at KLAS. Jason works with hundreds of CIOs, healthcare providers, and vendor executives in monitoring the performance of Healthcare IT. His expertise include: Health Information Exchanges, Core Clinical, Emergency Department, Pharmacy, Surgery Management, Pharmacy, Lab, Pharmacy Automation, among other research areas. Mark Allphin has spent several years in the software/IT industry both from a sales and a research analyst perspective. He currently works for KLAS Research and oversees several market segments, including HIE, Lab, Surgery, Anesthesia, Critical Care, Medical Device Connectivity and Interactive patient systems.
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Healthcare Management
Quantifying Value The new economics of healthcare Healthcare organisations are redefining value and have been forced to think in new ways about the process of care delivery.
Yosef D Dlugacz Senior Vice President and Chief of Clinical Quality, Education & Research, Krasnoff Quality Management Institute, USA
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CoverStory
D
uring the past few years the concept of value in healthcare has changed dramatically. It has evolved from considerations of profit based on volume of patients and number of procedures to an environment where profit is increasingly connected to quality outcomes. The government is not only increasing reimbursement for good outcomes but refusing to pay for care that is inappropriate or where outcomes fall below established benchmarks. Healthcare organisations have been forced to think in new ways about the process of care delivery; leadership has begun to assess the value of the care delivered, that is, leadership is concerned about the relationship of quality care to cost/expenses and patient/customer satisfaction. Healthcare organisations are redefining value. For example, in their orientation booklet, the CEO of the Mayo Clinic, Denis Cortese, has summarised how senior leadership defines value by an equation (see Figure 1) This premier healthcare institution defines value as more than good outcomes and lowered expenses. Their definition of value also incorporates patient safety and good service, and in Outcome+Safety+Service
Value= Cost Over Time
the June 2011 issue of the Healthcare Financial Association Magazine (http:// www.hfma.org/hfm/) value was said to be “driving a fundamental reorientation of the healthcare system around the quality and cost-effectiveness of care (p.1).” Another article in the New England Journal of Medicine (Swensen, S. et al (2010)) defines value as a function of three elements (see Figure 2): Designing the right treatment for the right patient at the right time and delivering the treatment in the right way represent quality aspects and will increase value and lower cost over time. Shifting the concept of value from volume/utilisation (i.e. how many patients, how many services, case mix index) to outcomes/results that can be documented as effective, safe, and appropriate is a new framework, one which all stakeholders, patients, providers, payers and policymakers embrace. Value has the goal of improving outcomes as efficiently, and as cost effectively as possible. This concept of value can be quantified. Data collected about outcome measures should show the results in comparison to the defined benchmark. Safety can also be quantified. Variables such as infection or nursing sensitive measures, such as decubiti, can be measured as can the morbidity and safety standards formulated by The
Joint Commission. Service can be quantified as well. Government programmes, such as the Hospital Care Assurance Program (HCAP) compensate hospitals that document that they are caring for underserved populations. Therefore, value is no longer a subjective concept but an objectively definable one. This changed concept of value affects every aspect of the hospital organisation. The C-suite (i.e. CEO, COO, CFO, CNO) has become invested in and involved with quality data because that data not only has a relationship to reimbursement but also because quality data is available to the public and influences market share. Healthcare organisations are compared on public websites (e.g. Hospital Compare, Health Grades) that display quality data such as risk-adjusted mortality rates and other variables, enabling the healthcare consumer to make informed choices about where they want their healthcare dollars to be spent. As the availability of data increases, the public concomitantly expects good outcomes, that is, value for their expenditure. This is true for all healthcare organisations globally, not just those in the US. According to Fred Stevens, in The New Blackwell Companion to Medical Sociology (2010) healthcare should be considered a “commodity that can be bought or sold on a free market” (p.447).
Figure 1
doing so integrates concepts that can define the vision of the organization. Value involves quality care, lowered costs, patient safety and satisfaction with the experience. This concept is very different from one stressing volume. Michael Porter, a healthcare economist, in a perspective article in the New England Journal of Medicine (Dec 23, 2010; N Eng J Med 363;26) has defined value as “health outcomes achieved per dollar spent” (p.2477). Value encompasses more than cost reduction; it centers on patient outcomes, that is, the positive results of the care delivered. In
Value of Healthcare Function of three elements
Design
(the right treatment for the right patient at the right time)
Execution
(reliably doing it right every time to achieve the best outcomes)
Cost (over time)
Quality Value = Cost
Source: Swensen , S. et al. (2010). Cottage Industry to Postindustrial Care The Revolution in Healthcare Delivery. The New England Accessed 1/27/10, e12(2).
Figure 2
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Healthcare Management
As reimbursement policy begins to change and as insurance companies demand efficiency, productivity, and optimal results, and as they refuse to pay for poor outcomes or waste, the notion of value in healthcare is measurable through data. In the future, hospital data that reveal rework, such as reoperations, readmissions or never events (i.e. errors, such as wrong-site surgery, which should never occur and are preventable) will not receive payment. Insurance companies will pay more for good results. Administrative leadership, responsible for the budget, is becoming increasingly involved in pursuing good results, the traditional purview of the physician alone. The focus on value is dependent on ongoing cognitive change, improving health not only for individual patients but for specific disease populations. Quality care requires open communication across the continuum, shared goals, teamwork, and increased accountability for performance. Quality data reveal value, from mortality rates to customer satisfaction. In the North Shore – LIJ Health System which is comprised of 15 hospitals and over 200 ambulatory care centers, the CEO, Michael Dowling, encourages all providers to be accountable for outcomes. He knows that the better the results are, the lower the costs and the greater the reimbursement will be.
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His executive leadership monitors value on an ongoing basis through the dashboard that displays clinical and financial indicators in one matrix (See Figure 3). The combined indicators alert the CEO, CFO, CMO, CNO and COO to issues related to value and quality. The valuebased purchasing programme that the Center for Medicare and Medicaid Services (CMS) is promoting will provide incentives to hospitals that exceed certain quality measures relating to clinical care processes and the patient experience. (see Figure 3) The US government is also helping to drive new concepts of value. CMS has defined measures that result in increased reimbursement as well by financially rewarding organisations that are in the top decile of achieving compliance with performance measures, including core measures such as aspirin administration to heart attack patients. In order to reach the top decile and to maximise reimbursement opportunities, healthcare organisations have to establish robust and sophisticated quality management programmes. In the past, even if caregivers did not comply with hand hygiene protocols and patients acquired infections, the hospital still received payment for interventions, such as ICU care or for the increased length of stay (LOS) required to treat those infections. Today, caregivers are
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accountable for hand hygiene compliance and infection rates are monitored to ensure compliance and a short LOS. Current and future reimbursement will be based on patients receiving appropriate treatment and not for the consequences of poor care which endangers patient safety. Financially lucrative transplant programs can be closed down if good outcomes such as survival rates do not meet expected rates. Due to the increased expectation of insurers, the government, and administrative leadership, care providers have become more accountable. It is no longer sufficient for clinicians to argue that their patients are sicker than others or that the excellent education that they have received is sufficient to ensure quality outcomes. In today’s world where value is measured, there has to be data to support such claims. Physicians need to justify variation from the standard of care and are expected to base treatment on evidence and deliver care that exceeds expected benchmarks. Poor outcomes reflect poorly on both the caregiver and the institution. As the computerised medical record becomes integrated into healthcare organisations, leadership will be able to easily monitor the appropriateness and effectiveness of care and services of individual physicians. Therefore, physicians are under pressure to change care processes so that data reveal the value of their care. In addition, the focus on increased accountability and transparency has caused physicians to become more active in managing the specifics of care and responsible for ensuring that that care is cost effective as well as efficient and appropriate. They are using data to ensure that their care is consistent with evidence based medicine and that their patient outcomes can be favorably compared to those of other clinicians. Again, value is definable, measurable, quantifiable, and verifiable Under the previous reimbursement system, hospitals were paid for performing procedures, such as surgery.
CoverStory
Value has the goal of improving outcomes as efficiently, and as cost effectively as possible.
grated across the entire continuum of care, from admission, to pre-operative, post-operative and discharge phases. Multidisciplinary teams examined the medical charts of those hospitalised patients who had died and realised that there were opportunities for improvement. Defined assessment criteria for patient appropriateness were formulated. Consistent variables were defined, databases were developed, which defined expectation and improved communication among the different caregivers. Silos that traditionally separated the continuum were eliminated. All care providers were required to participate in improvement efforts. Because conscious efforts were made, and interventions established based on using the Plan-Do-StudyAct (PDSA) methodology, outcomes improved. With good results, waste is decreased. Therefore, fewer readmissions and reoperations occur, infection and mortality are reduced, and the ICU is more efficiently utilised. Value is generated when results are good and communicated to the public.
Author BIO
The procedure was not evaluated for appropriateness. Today, procedures are evaluated for appropriateness and if it is determined that the procedure was either unnecessary or ineffective, payment will be reduced. In other words, the value of the procedure to the patient has to be proven. For example, patients who experienced back pain were often recommended for surgery. The hospital and the physician received payment for the surgery. Today, payers question whether surgery is the best option for the patient’s condition and whether or not it is effective. Many traditional and accepted procedures are being reevaluated for value.New questions are being asked. Is orthopedic surgery on knees providing patients with the best value? Do heart patients benefit more from medication or stents or open heart surgery? Is new technology necessary and effective? For example, is robotic surgery superior to manual? Is the expense of purchasing and training physicians to use robotics an efficient use of resources? Value takes into account cost factors, effectiveness and appropriateness and these variables have to be argued and proven with data, not subjective experience. Value means that the patient and the healthcare organization get the best return on their investment. Services and procedures should be neither overused nor underused. In the North Shore – LIJ Health System,risk-adjusted mortality rates for cardiac surgery were monitored for over ten years. As new processes were introduced and quality standards integrated into the process of care, mortalities decreased dramatically. The value of having the best results in terms of a physician’s or a service’s performance increases market share. When the public is informed that the volume is high and the mortality rates below the expected benchmark, the organisation maintains a competitive edge and gains in prestige. To achieve good outcomes, improved processes had to be inte-
Value is more complicated a concept than simply lowered cost for services. Leadership has to determine which processes result in good outcomes and then analyse the cost of the intervention to determine its value. Focusing on value rather than volume is forcing medical care to change. Among the challenges healthcare reform faces to ensure superior value for services is changing the current milieu. Practicing physicians are reluctant to change the way they practice medicine and adopt a value-based perspective determined by standardizing care and data regarding outcomes. Of critical importance is that new physicians be educated to meet expectations of a culture focused on delivering value. The Krasnoff Quality Management Institute of the North Shore – LIJ Health System has embarked on curricula development to effectively educate physicians including residents and fellows, as well as healthcare administrators and providers, on improving quality and the efficient use of resources. Patients need to trust their physicians and the healthcare system at large. Until physicians are able to execute these changes, the full achievement of a true value based system cannot be achieved. Increasing value, then, is dependent on the perceptions and behaviors of physicians, insurers, governmental leadership and the general population. If healthcare costs are to be responsibly contained while improving quality, future efforts must support adaptability and the means to meet this challenge and ensure a value driven healthcare system.
Yosef D Dlugacz has decades of experience dealing with process variables and educating professionals and the community about the importance of integrating quality management methods into the delivery of care to improve health outcomes. Dr. Dlugacz has educated thousands of professionals in Quality Management philosophy and techniques nationally and internationally. He is an Adjunct Professor of Quality Management in the Baruch/Mt. Sinai MBA Program in Healthcare Administration, an Adjunct Professor of Information Technology and Quantitative Methods and Professional Faculty Coordinator of the MBA Program in Quality Management at Hofstra University, a Visiting Professor to Beijing University’s MBA Program, and an Adjunct Associate Professor of Medicine at the New York Medical College, Valhalla, NY.
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Healthcare Management
Value-based Healthcare Value-based healthcare is an approach to providing care that aims to restrict the growth in healthcare costs while maintaining or improving quality. The United States Medicare and Medicaid programs, along with a few pioneering employers and private health systems, are testing multiple strategies in this social experiment. Gloria N Eldridge Senior Analyst and Project Director, Strategic Innovations for Affordable, Sustainable Healthcare: A Model for Health System Reform, Altarum Institute, USA
1. What is value-based healthcare and how will it impact healthcare? Value-based healthcare is an approach to providing care that aims to restrict the growth in healthcare costs while maintaining or improving quality. In the US healthcare system, the emphasis
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on paying for units of service through fee-for-service plans has encouraged providers to order many services so they get the highest payment. Value-based healthcare strategies reward providers for improving health outcomes and quality while restricting the growth in costs.
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Value-based healthcare is not a new concept nor is it more popular with one political party than the other. The March 2010 national health reform legislation, the Affordable Care Act (ACA), encourages value-based healthcare in several ways. The ACA calls for implementation of demonstrations, pilots, and programs for accountable care organizations (ACO), patient-centred medical homes (PCMH), payment bundling, and payfor-performance (P4P) initiatives, and it extends a gain-sharing demonstration. The ACA also encourages the development of value-based insurance design, which is discussed in more detail later, and other value-based healthcare techniques. In addition, over at least the past eleven years, many non-partisan laws have furthered value-based healthcare approaches.
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2. What specific impact will value-based healthcare have on American healthcare? Value-based healthcare can affect US healthcare in at least three areas: (1) the organisation of delivery and payment systems, (2) the further integration of provider networks, and (3) a flattening of provider hierarchies in the healthcare system. All three of the trends will be fortified by re-structuring rules that govern relationships between purchasers, consumers, and providers. For example, accountable care organisations (ACOs), patient-centred medical homes (PCMH), and models that integrate primary care and behavioural healthcare will encourage all three of these trends. Value-based healthcare encourages new service delivery and payment models. Accountable care organisations
are networks or groups of providers (for example, primary care physicians, nurses, specialists, and hospitals) that are collectively responsible for healthcare quality and costs for a particular population. The ACOs share in amount saved by reducing growth in healthcare costs while still meeting established quality targets. The ACA legislation lets ACOs use a broad range of organisational forms. These include integrated health systems, physician hospital organisations, and group and independent practices. Patient-centred medical homes assign each patient a primary care provider who leads an interdisciplinary care team. This provider facilitates seamless care across services and settings. The PCMH model exists in diverse settings and evidence is building for improved quality and decreased healthcare costs. The PCMH
complements the ACO models and, in many cases, is expected to reside within ACO frameworks. These new service delivery models will be paired with an increasingly nuanced understanding of payment systems and financial incentives. Bundled payment, pay-for-performance, and gain-sharing (similar to profit sharing) will continue to be revised as value-based healthcare evolves. Value-based healthcare also encourages vertical integration of providers into ACO networks. As ACOs are a relatively new concept, it is not yet known if they will reduce the escalation in cost growth. It is possible that within particular local markets, ACOs will result in a monopoly where they could unilaterally raise prices. There are, however, provisions in the ACA designed to prevent this.
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Healthcare Management
Finally, value-based healthcare encourages delivery of patient care through interdisciplinary patient care teams. In the past, large physician practices, hospitals, and some other settings have used interdisciplinary care teams. However, the ACA calls for significant expansion of these care models in all patient care settings. Interdisciplinary, team-based practices require flatter management structures that encourage collaboration and shared decision making as all team members with function as co-managers of care. This means that there will be a re-definition of traditional roles of specialists, primary care physicians, nurse practitioners, nurses, and other care team members. All team members will share responsibility for the clinical and financial outcomes of patient care. This will result in a flattening of the traditional hierarchical provider roles in American healthcare. 3. What are the key elements of value-based healthcare? With US healthcare expenditures climbing to 18 per cent of GDP, a driving force behind the adoption of value-based healthcare strategies is curbing cost growth. However, the value-based healthcare equation is not one of cost control alone. When evaluating a value-based healthcare initiative, the important dimensions to consider are cost escalation, patient health outcomes, patient satisfaction, and process and other measures of quality of care. The pursuit of value-based healthcare in the US follows a path littered with many barriers. Multiple, fragmented delivery and payment systems and entrenched political interests play a major role in influencing the design of those systems. Medicare and Medicaid are very large and initiatives launched through them are often adopted by private insurance carriers. Through the ACA, and multiple earlier laws, value-based healthcare techniques will be promulgated through Medicare and Medicaid demonstrations, pilots, and programmes. This is sure to have a
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profound effect on the overall structure of the American healthcare system. 4. How does value-based healthcare help in saving cost and promoting healthful practices? Value-based healthcare techniques change incentives to consider the total health of the individual consumer. Patient-focused care reduces hospitalizations, re-hospitalisations, emergency department visits, and other expensive encounters. It also promotes good health. Consider the case of value-based insurance design (VBID), which seeks to increase value in healthcare through insurance design and incentives. One model of VBID reduces or eliminates cost sharing for services that are shown to have strong clinical benefits. VBID uses cost-sharing incentives to encourage consumer behaviour toward actions with clinical benefit. By encouraging patients to adhere to prescription drug regimens through low co-payments, purchasers expect to lower high cost hospitalisation, re-hospitalisation, or emergency department visits. While the cost of prescription drugs may be higher than before the new insurance design, the overall goal is to lower total healthcare costs. VBID takes a broad view of purchaser healthcare costs. If one considers pharmaceutical costs without considering
As the healthcare system adopts value-based healthcare strategies, providers have greater access to a more complete patient health history through electronic medical records, integrated health teams and systems, and innovative communication technologies improving the provider’s ability to oversee prevention, diagnosis, and treatment.
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how adherence affects patient health, then it is possible to miss the opportunity to lower overall healthcare costs. Beyond VBID, pharmaceutical care management plays an important role in disease management, telemedicine, and other value-based strategies. Behind many of these initiatives, strategies that encourage patients’ prescribed drug regimens—or the introduction of preventive drug regimens—plays a vital role in preventing higher-cost medical procedures, visits, or needs. These are just a few examples highlighting VBID and related pharmaceutical care management practices that improve health and encourage prevention of illness while reducing the price tag of a particular condition or set of conditions. This is the general idea behind value-based healthcare—promoting health means less expensive healthcare needs for the individual. 5. How will this benefit providers and patients? As the healthcare system adopts valuebased healthcare strategies, providers have greater access to a more complete patient health history through electronic medical records, integrated health teams and systems, and innovative communication technologies. This improves the provider’s ability to oversee prevention, diagnosis, and treatment. Also, valuebased delivery and payment systems are aligned with the patient’s best interest, so providers have fewer barriers to providing the best possible care. As care teams become more integrated, communication between providers along the care continuum will improve. This will result in fewer communication errors in patient care. As part of the ACA, health insurance exchanges and Medicaid expansions are being implemented to expand access to affordable health insurance for uninsured populations in the US This is intended to align incentives in the healthcare system towards the patient’s highest attainable health status.
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Author BIO
6. How do you see value-based healthcare evolving in the future? In the US, how value-based healthcare evolves will depend on the resolution of three challenges or apparent conflicts. • The first of these is the conversion of the system to electronic medical records (EMR). Electronic medical records are necessary to connect disparate care systems and providers that want
to share patient information across physician offices, ACO networks, or states. In short, for new delivery system models to work, electronic medical systems must be in place. Barriers to EMR adoption include resistance on the part of some providers, the difficulty in implementing EMR systems that work together, and the lack of resources on the part of some stand-alone or small physician practices to invest in this infrastructure.
Gloria N Eldridge has worked extensively in health policy and on the politics of national health reform. She is a Senior Analyst at Altarum Institute, most recently engaged in reviewing the major evidence in the field of value based purchasing. Dr. Eldridge is director of Altarum’s Strategic Innovations for healthcare Reform initiative and senior manager on the Congressionally mandated Centers for Medicare and Medicaid nation-wide review of wellness and prevention programs and their evaluation design. She is also a collaborating member of Altarum’s Center for Policy and Research Translation and Center for Elder Care and Advanced Illness. She holds degrees from the University of Texas at Austin, The London School of Economics, and Yale University.
• A second challenge is the coordination of new telemedicine and remote care technologies with the federal and state healthcare privacy laws. While technology is developing multiple innovative ways to bridge patients’ struggles related to care transitions, remote locations, or lack of shared information among providers, these all must operate in accordance with protecting a patient’s privacy. • Third, encouraging new provider behaviour is difficult in a system of multiple purchasers where incentives are either not recognised by the provider or not large enough for any one provider to reduce escalating costs. So, how is value-based healthcare going to evolve in the US? A few pioneering integrated networks and purchasers are going to continue to lead the way until certain value-based healthcare strategies implemented by Medicare—and, in some cases, Medicaid—take shape. After one or two decades, other players will begin to adopt these value-based healthcare strategies as administrative, reporting, and payment systems begin to merge due to the power of Medicare, in particular, to drive market change. Electronic medical records, harmonisation of telemedicine innovations with privacy laws, and provider behaviour change will continue to be barriers in the short to mid-term. The political and policy negotiations on these three topics will play a vital role in accelerating the direction of the value-based healthcare trajectory. 7. Any other comments? Thank you for the opportunity to share these insights and findings from the work at Altarum Institute’s Systems Research and Initiatives Group. This work focuses on advancing heath system reform by identifying what works and what doesn’t in the value-based healthcare arena: http://www.altarum.org/publicationsresources-health-systems-research/strategic-innovations-healthcare-series.
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Healthcare Management
Strategic Planning of Healthcare Delivery Centres
Role of operations management Operations management is the strategic implementation of programmes, techniques, and tools for reducing costs and improving quality. It focuses on the effective management of the resources and activities that produce and deliver goods and services of a business. In healthcare, effective use of operative management tools outcomes into improved quality of care, reduction in bottlenecks and waiting times, reduction in medical errors, better utilisation of existing beds, reduction in staff overtime and increase in staff satisfaction and finally improves the financial performance of the hospital. Shakti Kumar Gupta HOD, Hospital Administration & Medical Superintendent, All India Institute of Medical Sciences, Dr. R P Centre for Ophthalamic Sciences, New Delh, India
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Healthcare Management
W
ith healthcare costs rising faster than general inflation, cost containment is a theme that resonates throughout the healthcare field today and receives increasing attention of policy makers, academia and industry. The healthcare sector all over the world is experiencing tremendous pressure to not only control the escalating costs but also improve the quality of care it provides to its consumers. The four major areas where principles of operations management are
deployed are facility design and layout, cost analysis, process analysis and information systems development and implementation. Every day, one uses a multitude of physical objects and a variety of services. Most of the physical objects are manufactured and most of the services have been provided by people in organisations. Just as fish are said to be unaware of the water that surrounds them, most of us give little thought to the organisational processes that produce these goods and services for our use. The study of operations deals with how the goods and services that one buys and consumes daily are produced. Operations management is concerned with the design, management, and improvement of the systems that create the organisation's goods or services. The significance of OM principles to organisations outside the manufacturing sector is a conviction shared by OM researchers and practitioners .Generally, hospitals face challenges in healthcare operations management in the absence of a mechanism to capture, analyse and present real-time performance about clinical and financial processes. It is a challenge to improve and integrate the quality of healthcare, for optimal clinical and financial outcomes and real-time performance optimisation. From the view point of operations management (OM) academics, it is evident that there is a strong resonance between the need to deal with the issue of sustainability in hospitals. The Planning for healthcare delivery centers would be incomplete without suitable and sufficient application of the five objectives of Operations Performance objectives: 1. Cost: The ability to produce at low cost 2. Quality: The ability to produce in accordance with specification and without error. 3. Speed: The ability to do things quickly in response to customer
demands and thereby offer short lead times between when ordering a product or service and when they receive it. 4. Dependability: The ability to deliver products and services in accordance with promises made to customers. 5. Flexibility: The ability to change operations. At the core of operations management are the topics of process flow and capacity management, process design and layout, technology choice and management, quality management, lean manufacturing, supply chain management and operations strategy. Operation management is diffusing in healthcare in the following areas:Process reengineering The knowledge of Process design could be greatly used while deploying better process technologies or to use process technologies more accurately. In healthcare, this is directly proportional to Patient Safety. “Patients should experience healthcare processes that are more reliable than manufacturing processes. Regrettably, that is not yet the case� Process design is fundamental rethinking and radical redesign of business processes to bring about dramatic improvements in performance. Fundamental and radical change is not a concept that appeals in the healthcare environment. It emphasises small and measurable refinements to an organisation's current processes and systems have been more widely adopted. Process analysis has been a useful technique for pulling apart the relationships between clinical and managerial tasks. Hospitals could learn how to solve systemic problems systematically, and that to do so will require not the wish lists of strategic planning and structural reorganising, but tangible changes in their collective behaviour. This perhaps explains why less formal methods of process mapping that engage a full range of process participants are more successful, as they create a mandate for change.
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Healthcare Management
Technology management An effective IT infrastructure supporting key operational processes and management reporting is now seen as essential. Hospitals around the world are embracing internet and information technology to improve their client interface, as well as to reduce the overall cost of providing quality care. IT has great potential to improve primary care in many areas including medical records, communication between physicians and patients, information sharing among healthcare providers, and rapid access to reliable information for both physicians and patients.
The Planning for healthcare delivery centers would be incomplete without suitable and sufficient application of Operations Performance objectives-Cost, quality, speed, dependability and flexibility. Operations strategy in healthcare According to Zelman and Parham (1990), there are four strategies for hospitals in defining what business they are in: (i) a generalist strategy (ii) market specialist strategy where the hospital caters a wide range of services to specific markets, (iii) service specialist strategy which relates to a hospital providing specific services to a wide
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range of target groups, and (iv) super specialist strategy that refers to hospitals providing narrow range of services to a limited market. Hospitals would require different operational capabilities to support their mission and positioning in the market. It is important for hospitals to procure and allocate resources for the development of those operational capabilities which are aligned with the corporate mission. The hospital operations strategy should be developed to support the hospital mission and business strategy, and help to gain competitive advantage. Operations strategy in the context of a hospital can be defined as a plan that configures and develops business processes which enable a hospital to serve and deliver quality care to their patients as specified by its business strategy Total quality management (TQM) and six sigma in healthcare Implementation of any quality initiative should embrace a participatory management style; address the issue of changing attitudes and culture, employee involvement and empowerment together with investment in training, development and learning. But these characteristics have not been evident in the quality improvement programmes implemented in the healthcare environment contributing to sustaining the TQM efforts and, thus, to achieving organisational excellence. The system requires the explicit and active involvement of all stakeholders and to certain extent it forces a holistic and integrated approach. Lean production Toyota Production System forms the basis for much of “lean production”. Taiichi Ohno, who has been hailed as the founder of TPS, describes the goal of TPS, “All we are doing is looking at the time line from the moment the customer gives us an order to the point when we collect the cash, and we are reducing that time line by removing the non-value-
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added wastes”. The hospitals can deliver to patients exactly what they need ,when they need it, every time, error-free, in a safe environment, at the lowest cost and without waste by application of lean principles. Supply Chain Management Tremendous opportunities exist for delivering significant improvements in the ability of hospital facilities, networks and other healthcare organizations to optimise the processes and work flows associated with materials management, and reduce the costs related to inventory and supply chain management (SCM). The healthcare value chain is plagued with many problems, including outdated and inaccurate data, laborious manual processes, and lack of visibility into important order information. Rearrangement of storage areas can generate substantial savings Process flow and capacity management The type of resources required for an admission include beds, operating theatre, surgical team, nursing care and potentially an intensive care bed. However ,the need to coordinate resources to manage capacity is not adequately understood in the decision making process of allocating resources to specialties. The result is peaks and troughs in the workloads of departments that are difficult to manage. Hospitals can achieve substantial improvement in patient flow and throughput and reduction in unit costs through the application of techniques such as process mapping and simulation modelling. An important point for understanding and improving patient flow is to look at the whole system of care, rather than the individual units in isolation. Some of the most commonly used tools used in mistake proofing, and performance enhancement in healthcare processes include operations research tools such as queuing theory, quality tools like root cause analysis, failure
Healthcare Management
Measuring demand & capacity while planning for healthcare facilities: The planning for healthcare facilities in a free market is generally decided or rather encouraged by the market size. In healthcare facility designing, this would mean the expected volume of patients, the economic status or the purchasing power of patients and the availability of inputs that enable healthcare delivery. One basic component of social up gradation and disease protection that a healthcare facility could perhaps provide is based on the initial assessment of the burden of disease in the catchment area, where a healthcare facility has been planned for. It is therefore obvious to find starring hospitals in shiny areas of city. However, even while accepting a business model approach, the principles of operations management would justify that a healthcare establishment would flourish quite well, if planned on the outskirts of the city or in lower tier towns. For a health facility planning, which happens to be a small but important element of any health system, the following must be given due consideration: 1. Ageing population 2. Growing demand on health services 3. Chronic disease 4. Mental health 5. Population health 6. Impact of distance
7. Impact of climate change and seasonal and economic changes 8. Community expectations When these aspects are assessed with respect to the population in the catchment area, the outcome leads to strategic and organised planning of the healthcare facilities. It would also be essential for the planners to focus on the needs of patients and their families utilising a holistic care approach. The focus on these would mean: 1. Having the health of patients and communities as the primary objective of all health service planning. 2. Developing models of service delivery that identify and support careers and families. 3. Enabling patients, careers and their families to understand and be partners in the planning and delivery of their healthcare by providing information as to where and how to effectively access required support. 4. Facilitating access to services as close as possible to patients’ support networks (family and friends). 5. Providing culturally sensitive services based on the needs of Aboriginal people. 6. Recognizing the needs of people from culturally and linguistically diverse backgrounds. 7. Encouraging greater self-responsibility for healthcare. 8. Improving the coordination and integration of services so as to present a complete system of healthcare to the patient.
Author BIO
mode & effect analysis, six-sigma and statistical process control. While these tools are quite adaptable to many processes, in healthcare, they are to be deployed after duly assessing the compatibility of the process with the tool. Thus, while statistical process control could be used in logistic errors, six sigma could be used to identify and quantify medication errors, both in dispensing and drug administration. Root cause, FMEA are very well used in medical audits - a specific process to understand the accuracy of patient care processes - an inseparable element of healthcare operations management.
9. Achieving an appropriate balance of in hospital/out of hospital primary and preventive healthcare services. 10. Increasing the focus on well-being and the development of primary healthcare strategies. 11. Improving the level of population health initiatives such as early intervention and illness prevention services. Conclusion The field of application of Operations Management is enormous. The application is dependent on recognition of the fact, that by using the principles of operations management, the outcomes of healthcare delivery can be improved along with its quality and efficiency. These principles need wider understanding among healthcare and hospital administrators. The models which have shown effective implementation, not only during planning stage but also in improving the day to day operations of healthcare activity and service delivery, need to be understood by all. This would enable an institution to demonstrate a greater ability of Enterprise Resource Planning that is a centralized framework for all processes in an organisation, focusing on all aspects of a business. This includes planning to inventory control, finance, manufacturing, sales, marketing and human resources, and last but not the least, a level of patient care with highest level of satisfaction for the patient as well as care givers. Full references are available at www.asianhhm.com/ magazine
Shakti Kumar Gupta is the President of Academy of Hospital Administration, New Delhi. He has been awarded “PRATIBHASHI SAMMAN–2002”, “CHIKITSA RATAN – 2010” and SHRAM SREE2010”. He has been appointed as the expert consultant by Ministry of External Affairs, Govt. of India for establishment of National Referral Hospital at Thimpu & Regional Referral Hospital at Monger, Bhutan. He is the Programme Director of various capacity building programmes notably amongst which are “Healthcare Executive Management Development Programme” (HxMDP) for senior healthcare professionals and “National Initiative for Patient safety” (NIPS).
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MEDICAL SCIENCES
Back Pain and Treatment options LBP is one of the most common pain complaint and usually one of the hardest syndromes to treat. Interventional pain management offers an opportunity to assist in the diagnosis and management of back pain. Rasha Snan Jabri Adjunct Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, UAE
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owbackpain(LBP)isoneofthemost common pain complaints. It is the second most common pain disorder after headache. At least 60-90 per cent of adults will have LBP at some time during their lifetime. Acute low back pain is the fifth most common reason for all physician visits. Although symptoms are usually acute and self-limited, low back pain often recurs. It becomes more difficult to control and treat when it becomes a chronic disease. Low back pain is one of the most commonly cited problems for lost work time in industry and disability in patients of age less than 45 years. Risk factors Studies have generally shown the following factors to be associated with the development of back pain: jobs requiring heavy lifting, use of jackhammers and machine tools, operation of motor vehicles, cigarette smoking, anxiety, depression, stressful occupations, and women with multiple pregnancies, scoliosis and obesity.
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Etiology of LBP Identifying a clear etiology of LBP can be very complicated and challenging. Knowing the complexity of the structure of the spine and biomechanics of the spinal segments is very important in understanding the pain generator in the low back. Multiple studies have shown that causes of LBP correlate with <15 per cent with underlying nerve root compromise, 85 per cent have non-neurogenic back pain and the remainder assumed to have musculoligamental injury or degenerative changes. Some of these pathologies include but not limited to: muscle strain, ligamental injury, facet disease, synovial disease or cyst, compression fracture, pars defect, sacroiliac joint dysfunction, internal disc disruption as well as primary neoplasm or metastatic disease.
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MEDICAL SCIENCES
Medical jargon and LBP Working up of a patient with LBP History and Physical Examination remain the most important initial work up in evaluating LBP. The history should include the patient’s age, past medical and surgical history and any history of trauma. The presence of constitutional symptoms, night pain, bone pain or morning stiffness, claudication, numbness, tingling, weakness, radiculopathy, and bowel or bladder dysfunction should be noted. The onset of pain, its location, radiation, characteristics, and severity should be assessed. A detailed neurologic evaluation should be performed. Patients with low back pain should be screened for the possibility of potentially serious conditions including possible fracture, tumor, infection, or cauda equina syndrome. Frequently, there are well described “red flags” which distinguish these serious conditions from the much more frequent “benign” causes (degenerative disc disease, disc herniation, and spondylolisthesis) of low back pain. Psychosocial Evaluation and Screening for non-physical factors is critical in the management of back pain like any other pain syndrome. Psychological, occupational and socioeconomic factors can complicate both assessment and treatment. Imaging studies: MRI today has become the modality of choice in the evaluation of spinal degenerative disease. MRI is superior even to CT with contrast in the distinction of bone, disc, ligaments, nerves, thecal sac, and spinal cord. It is the test of choice for the diagnostic imaging of neurologic structures related to low back pain. However, MRI can identify abnormalities in asymptomatic persons. Therefore, the correlation between patient symptoms, history and exam findings and the imaging results is very important in targeting the pain generator in the low back and reaching a comprehensive diagnosis and treatment plan. Available treatments Conservative approach Short period of rest, analgesics, retuning
Oftenspecialist in the field use different terminology to describe disc diseases. This can be very confusing to the patients and to some healthcare providers. The North American Spine Society (NASS) recommended detailed definitions of lumbar disc pathology to standardize terminology among experts in the field. Some of the common descriptions of disc diseases are:
Degenerated disc: Changes in a disc characterized by dessication, fibrosis and cleft formation in the nucleus, fissuring and mucinous degeneration of the annulus, defects and sclerosis of the endplates, and/or osteophytes at the vertebral apophysis. Dessicated disc: Disc with reduced water content, usually primarily of nuclear tissues.
Displaced disc: A disc in which disc material is beyond
the outer edges of the vertebral body ring apophysis (exclusive of osteophytes) of the craniad and caudad vertebrae, or as in case of intravertebral herniation, penetrated through the vertebral body endplate. The term includes, but is not limited to, disc herniation and disc migration.
Herniated disc: Localised displacement of disc material beyond the normal margins of the intervertebral disc space. Non-standard definition: any displacement of disc tissue beyond the disc space. Disc material may include nucleus, cartilage, fragmented apophyseal bone, or fragmented anular tissue. Schmorl’s Node: Intravertebral herniation: A disc in which a portion of the disc is displaced through the endplate into the centrum of the vertebral body.
Spondylitis: inflammatory disease of the spine, other than degenerative disease. Spondylitis usually refers to noninfectious inflammatory spondyloarthropathies. Spondylosis: Spondylosis deformans, for which
spondylosis is a shortened form. Non-Standard definition: any degenerative changes of the spine that include osteophytic enlargement of apophyseal bone.
Spondylolisthesis: anterior displacement of one vertebra, typically L5, over the one beneath it.
to function and normal activity as soon as possible and then an exercise program and physical therapy to minimize reoccurrence. In chronic LBP, the multidisciplinary biopsychosocial rehabilitation treatments with functional restoration have been shown to improve pain and function. Nonsteroidal anti-inflammatory drugs (NSAIDs) are moderately effective for the short-term symptomatic relief of patients with low back pain.
There does not seem to be a specific type of nonsteroidal antiinflammatory drug that is clearly more effective than others. If no medical contraindications are present, a two- to four-week course of an anti-inflammatory agent is suggested. Gastrointestinal prophylaxis might be necessary with the older types of NSAIDs for patients who are at risk for peptic ulcer disease. The selective cyclo-oxygenase¬2 inhibitors have fewer
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MEDICAL SCIENCES
Interventional pain management Interventional pain management is defined as the discipline of medicine devoted to the diagnosis and treatment of pain related disorders principally with the application of interventional techniques in managing sub acute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatment. Interventional pain management techniques are defined as minimally invasive procedures including, percutaneous precision needle placement, with placement of drugs in targeted areas as well as nerve block or ablation of targeted nerves; for the diagnosis and management of chronic pain. One of the most common injections used for LBP is Epidural Steroid Injection (ESI). This injection can be performed via an interlaminar or transforaminal approach. The typical patient has degenerative disc disease with or without radiculopathy symptoms. Risks associated with the procedure are minimal if the physician performs adequate screening and follows appropriate selection criteria. Complications include but not limited to bleeding, infection, and possible post dural puncture headache. Multiple studies have shown that the needle can be positioned inappropriately when the procedure is performed without image guidance” blindly”. In 30 to 52% of the cases, the needle misses the epidural space. Using fluoroscopy
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The correlation between patient symptoms, history and exam findings and the imaging results is very important in targeting the pain generator in the low back and reaching a comprehensive diagnosis and treatment plan.
confirms the accurate placement of the needle, the distribution of medication within the epidural space, and minimizes any risk of possible complications. Using epidural steroid injections in appropriate patients is recommended. If they fail to improve after a single injection, a trial of three injections (old practice) is probably not indicated. Reevaluating the LBP etiology, considering different injections approach or a diagnostic nerve block would be more suitable in those cases. Multiple studies have shown that predictors of good result with epidural steroid injection usually correlate with: advanced educational background, primary diagnosis
Author BIO
gastrointestinal side effects, but they still should be used with caution in patients who are at risk for peptic ulcer or kidney disease. The short-term use of a narcotic may be considered for the relief of acute pain. The need for prolonged narcotic therapy should prompt a reevaluation of the etiology of a patient's back pain. The use of muscle relaxants has been shown to have a significant effect in reducing back pain, muscle tension and increased mobility after one and two weeks. All these medication can have significant adverse effects even after a short course and should be used cautiously.
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of radiculopathy and pain duration of < 6 months. Poor results often correlate with: constant pain, sleep disruption and unemployed due to pain. Other injections which are considered diagnostic as well as therapeutic include but not limited to intra-articulr injection of the facet joins or sacroiliac joints as well as selective median branch blocks to those joints. Discography which is intradiscal injection of contrast material is considered when discogenic pain is suspected. This procedure is a diagnostic injection. Recent advanced techniques in interventional approach to LBP introduced minimally invasive intradiscal procedures like Neucleoplasty and Intradiscal Electrothermal Annuloplasty (IDET). Those intervention offer percutaneous procedures to treat disc pathologies and avoid invasive surgical options to treat chronic LBP. Conclusions LBP is one of the most common pain complaint and usually one of the hardest syndromes to treat. Interventional pain management offers an opportunity to assist in the diagnosis and management of back pain. By offering a thorough assessment of the various possible causes of pain, treatment planning can be tailored to patients’ pathophysiology. These procedures also offer the opportunity to manage patients with minimally invasive procedures. Interventional pain treatments are generally better tolerated than surgery, as they are less invasive, less painful and can usually be performed outpatient.
Jabri has a great passion to the field of pain management which is reflected by her eager efforts to increase awareness among healthcare providers about pain medicine, leading and participating in many pain education events like “The 1st international pain conference in UAE: Stop the Suffering! Say No to pain!” in 2009 and the annual multidisciplinary CPMC pain course. Dr. Jabri has published in major pain reference text books like “Essentials of Pain Medicine and Regional Anesthesia” and the “NYSOR Textbook of Regional Anesthesia and Acute Pain Management”. Dr. Jabri is a frequent national.
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SURGICAL SPECIALITY
Mishaps and Risk Reduction Strategies of Minimal Access Surgery
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SURGICAL SPECIALITY
Minimal Access Surgery is gaining widespread acceptance and popularity but there are unexplored areas that remain before the final goal is achieved. Neotechnologies and neocomplications are coexistent. It is important for aspiring laparoscopists to familiarize themselves with these complications before proceeding to practice. Pradeep Chowbey Director - Institute of Minimal Access, Metabolic & Bariatric Surgery, Max Healthcare Institute Ltd, India
Injuries of access: Complications in Laparoscopic Surgery can be related to exposure of operative field, access instruments, video equipment, operative instruments, energy sources and anaesthesia. Needle insertion and gas insuffulation is an important step in Laparoscopic Surgery for the creation of pneumoperitoneum . Injury to gastrointestinal tract with perforation of viscera, gastric injuries (0.027 per cent) and small bowel injuries (0.16 per cent) are more likely when puncture is around umbilicus and can occur even in absence of adhesions (Figure 1). Gastric decompression before trocar insertion is an important step in avoiding colonic perforation as distended stomach pushes transverse colon caudally towards umbilicus. The single most cause of gut injuries is an uncontrolled forced jerky entry. A large vessel within reach of umbilical entry site is at risk in laparoscopic surgery and overall incidence of major vessel injury ranges from 0.03 per cent to 0.09 per cent (Figure 1). The patient should be kept supine with midline entry to avoid injury to iliac and epigastric vessels. A Trendlenberg position with 150 tilt should be the position. The direction of veress needle should be towards sacral hollow.
In a multicentre Dutch study the incidence of injury was 1.13/1000 for epigastric vessel injury and 1.7/1000 for abdominal vessel injury, 57 per cent were attributed to laparoscopic entry. Localised pneumoperitoneum within the mesentery, omentum or retroperitoneum may be a cause of irritation due to compromise of operative field. Gas embolism is a problem when intravenous insufflation takes place. The characteristic sudden drop in cardiac output and mill wheel murmur demand immediate cessation of pneumopritoneum, placing of patient in left lateral position and needle puncture in right side of heart. Other complications are prepritoneal, subcutaneous and scrotal emphysema and pneumomediastinum via retropritoneum. This highlights the importance of checking the correct placement of the Veress needle prior to initiating insufflation. Another condition demanding particular care and attention is a hostile abdomen where multiple scars of previous procedures are visible. Access may be gained in virgin areas either with Veress needle or by use of an open technique. Either of the technique may be chosen depending on the surgeon’s familiarity and comfort as incidence of injuries whether vascular or bowel are similar
with either approach. Intra abdominal adhesions are invariable in such hostile situations and may have to be dealt with before commencing the planned procedure. Careful dissection must be carried out using sharp dissection with minimal use of electrocautery. The severity of such adhesions depends upon : • The nature of previous procedures. • The various pathologies previously dealt with. • Total duration elapsed since the procedure. Use of energy sources should be kept to a minimum. Careful haemostasis should be observed and in case an iatrogenic enterotomy does occur it should be immediately repaired and definitive procedure may have to be deferred, for example, deferring the use of a mesh in a contaminated environment.
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SURGICAL SPECIALITY
Management of these Injuries • In case of suspected bowel perforation the needle is left inserted as such a second needle is inserted, pneumoperitoneum created and the position of the first needle assessed carefully. The injury is subsequently dealt with either laparoscopically or by conversion to an open laparotomy. Any corrective measure should be performed before proceeding with the planned surgery. • Puncture of a major vessel is detected by sudden hypotension and aspiration of blood from the veress needle. The veress needle should be left in position to determine the site of injury. An immediate exploration and repair of the torn vessel can be life saving. • Presence of localized pneumoperitoneum requires no active management as the gas is rapidly absorbed. • Preperitoneal emphysema is usually detected early by increased pressure readings on the insufflator and the needle then repositioned. However, in case a large cavity is created, the peritoneum can be incised under direct vision and trocar inserted intra abdominally. • Pneumomediastinum, subcutaneous and scrotal emphysema do not require active intervention. However, knowledge regarding this entity is important to alleviate patient anxiety. Gas Embolism may be caused by : • Malpositioning of veress needle within a vessel during insufflation or • By gas being trapped within the torn portal venules during dissection. Diagnosis is made on capnometry and capnography and should be suspected when there is absence of abdominal distension, a large volume gas insufflation, aspiration of blood from the veress needle. The treatment consists of: The gas used commonly in Laparoscopic Surgery is carbon dioxide, which has the advantages of being inexpensive, easily available and also suppresses combustion. However, it is rapidly
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Managing Gas Embolism i) Cessation of insufflation ii) Patient placed in the Durrant position i.e. left lateral Trendelenburg iii) Discontinuation of nitrous oxide and ventilation with 100 per cent oxygen iv) Hyperventilation to accelerate carbon dioxide excretion v) Insertion of a central venous line to aspirate gas from the right atrium vi) Cardiopulmonary resuscitation (CPR)
absorbed and creates hypercarbia. Carbon dioxide embolism is, therefore, relatively easy to manage due to its absorbability. Us of nitrous oxide is limited to diagnostic laparoscopy under local anaesthesia as it supports combustion. Oxygen and air is also obsolete as they too support combustion and gas embolism. Injuries from secondary port placement Chances of injury are increased in reusable metal trocars as they are blunt tipped. Vascular injuries in arterior abdominal wall causing haemorrhage can be prevented by abdominal wall trans illumination i.e. utilising the laparoscope within the abdominal
Careful inspection of the entire abdomen should be carried out once the telescope is inserted into the peritoneal cavity. Injuries should be treated immediately.
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cavity as a light source. Injury should be managed by ligation under vision using port closure needle during laparoscopy. Port site herniation may be prevented by closing all ports sized 10mm or more. • In case of cutting trocars the rent in sheath is equal to its diameter. • In case of muscle splitting trocars, the rent is half the diameter of trocar. Also, after completion of the procedure, immediate herniation into the camera port which is usually removed last may occur along with escaping pneumoperitoneum and can be prevented by removing the trocar followed by the laparoscope, viewing the approximating sheath ensuring nothing herniates. Infection at port site may require incision and drainage of the same. Risks due to technology Never before has the surgeon been so completely dependent on the proper functioning of the equipment in use. Difficulties, leading to injuries can be caused by : • Poor image with improper colour balance making tissue differentiation difficult. • Loss of image due to power failure or camera malfunction. This may result in the need to convert to an open procedure if the image is not retrieved. • Thermal burns caused by prolonged contact of the telescope tip to the viscera. This may occur during sudden loss of pneumoperitoneum with failure to withdraw the telescope. • Injury to the viscera due to blind tissue manipulation and dissection. • Loose clip application, clipping of excess tissue if applied without visualization of the tips. • Perforation injury to the diaphragm with tension pneumothorax. All efforts should be made to prevent equipment malfunction. This includes a well-trained staff and a trouble shooting protocol in place. Such mishaps can be prevented by : • Getting good quality video equipment and ensuring its proper functioning
SURGICAL SPECIALITY
before use. • Maintaining an alternate source of power and visual equipment at all times. • Immediate withdrawal of all instruments in the event of sudden loss of pneumoperitoneum. • Keeping the instrument tips under vision during tissue manipulation and dissection • Learning the proper technique of clip application and ensuring proper grip of the clip in the applicator. The tissue to be clipped should be lying in the U of the clip. The ends of the clip are to be kept ender vision during application • Avoiding excessive force during liver retraction Injuries related to energy sources Energy systems are used for purpose of dissection or coagulation. High frequency devices, lasers, ultrasonic waves are being used. They may cause perforation of hollow viscus, injury to diaphragm or perforation of vessel. The high frequency devices may be monopolar or bioplar. The former is more traumatic as current is spread over wider area. These can be avoided by : • Using diathermy in short, frequent brusts. • Ensuring an unimpaired insulation of instruments. • Keeping the entire non insulated tip under vision throughout its use. The various mechanisms of injury are – • Grounding failures • Alternate site injuries • Demodulated currents • Insulation failure • Current Concentration • Sparking and arcing • Direct coupling • Capacitative coupling • Explosion • Toxic aerosols Grounding failures: Lack of uniform contact of return electrode results in significant current concentration and
damage. Return electrode monitoring electrodes help preventing these. Alternate site injuries: If patient comes in contact with metal, which in turn is in contact with the floor and site of contact is small, a burn may result. Demodulated currents: Muscle fasciculation at the site of laparoscopic cannula during the use of electro surgery indicates insulation failure or capacitative coupling. Insulation failure: Magnitude of injury from insulation failure depends on the size of break in the insulation, smaller the break greater the likelihood of injury. Current concentration: While cutting an adhesive band between gallbladder and duodenum with electro surgery, If adhesion is wider near gallbladder than duodenum, current density will be greater on duodenum. If diathermy is applied to the adhesion near gallbladder until tissue desiccates and then reapplied between this area and the duodenum current will travel towards duodenum. These lead to
delayed perforations. Sparking and arcing: Electrical sparks travel greater distance in a gaseous environment, when tissue desiccates and when the environment is moist and smoky. Eschar on electrosurgical instrument promotes arcing to a secondary site and should be avoided. Direct coupling: Direct coupling should be avoided by never activating the electrode outside visual field or near other metal such as a clip, staple, laparoscope or metal instrument. Electro surgery should not be used at staple line
Reason of a complication may be an unoptimised patient, poor image quality, inadequate instruments, improper training or poor technique. A need for conversion should not be considered a failure of the procedure but rather a wise decision on the part of the surgeon.
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• Hypotension related to dysrrhythymias, vasovagal reflex, haemarrohage, gas embolism and inferior vana caval compression. Anaethesia complications The anaesthetist needs to familiarise with the above complications. Presence of a capnometer and pulse oximeter is mandatory for monitoring these patients. Early detection of these
Author BIO
to control bleed as underlying tissue will undergo necrosis leading to anastomotic dehiscence. Capacitative coupling: This is stored electrical charge that occurs when two conductors are separated by an insulator. It is greater through a 5mm cannula compared to 10mm cannula and greater the longer the cannula. The use of a metal cannula with plastic grip should be avoided. Explosion: Hydrogen air mixtures are potentially explosive. Gas mixtures with methane are potentially explosive and hence mannitol should be avoided for bowel preparation as it promotes production of methane. Nitrous oxide is a gas capable of supporting oxidative reaction. Toxic aerosols: These may be biological byproducts as well as chemicals and irritants. Smoke evacuating systems should be available. Ultrasonic devices have definite advantage of minimal tissue trauma during cutting and coagulation and are safer for use in patients with pacemakers. It is important to note that coagulation produced by ultrasonic devices is slower and requires 10 seconds for depth of coagulation compared to what is achieved with in electrosurgery in less than 3 seconds. Anaesthesia complications are related to carbon dioxide insufflation, raised intra abdominal pressure and postural changes. • Decreased venous return due to inferior vena caval compression at pressures higher than 15 mm Hg. • Increased intra thoracic resistance due to diaphragmatic tenting and increased venous resistance causing decrease in cardiac output. • Increased Systemic Vascular Resistance secondary to decreased cardiac output. • Hypercarbia causes reduced contractile force and dilatation of peripheral blood vessels. • Dysrrythmias especially ventricular occur secondary to hypercarbia.
changes gives time for their effective management, which includes: • Detection and control of haemorrhage • Posture reversal to normal • Release of pneumoperitoneum • Cessation of nitrous oxide and controlled ventilation with 100 per cent oxygen • Search for other causes.
Pradeep Chowbey belongs to the cadre of the pioneer laparoscopic surgeons in India. He was one of the first to perform Laparoscopic cholecystectomy in North India and since then, has worked with singular determination to develop, evaluate and propagate Minimal Access, Metabolic & Bariatric Surgery in India. He is Joint Managing Director, Chief – Surgery & Allied Surgical Specialities and Director – Minimal Access, Metabolic and Bariatric Surgery at Max Healthcare Institute Ltd., Saket, New Delhi (India). He is former Chairman of the Minimal Access, Metabolic & Bariatric Surgery Centre, Sir Ganga Ram Hospital, New Delhi, the first of its kind in the Asian subcontinent, established in 1996. He is Founder President of Asia Pacific Hernia Society (APHS). He is President - Asia Pacific Metabolic & Bariatric Surgery Society (APMBSS) and President of Asia Pacific Chapter of International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). He is Honorary Member of German Hernia Society at Germany, Indonesian Hernia Society at Bali, Indonesia & GCC Hernia Society, Dubai, UAE.
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Books
Healthcare Informatics: Improving Efficiency and Productivity
Editor: Stephan P. Kudyba No of Pages: 279 Year of Publishing: 2010 Description: Healthcare Informatics: Improving Efficiency and Productivity examines the complexities involved in managing resources in our healthcare system and explains how management theory and informatics applications can increase efficiencies in various functional areas of healthcare services. Delving into data and project management and advanced analytics, this book details and provides supporting evidence for the strategic concepts that are critical to achieving successful healthcare information technology (HIT), information management, and electronic health record (EHR) applications. This includes the vital importance of involving nursing staff in rollouts, engaging physicians early in any process, and developing a more receptive organizational culture to digital information and systems adoption.
On the Mend:
Revolutionizing Healthcare to Save Lives and Transform the Industry Editor: John Toussaint No of Pages: 181 Year of Publishing: 2010 Description: In On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry John Toussaint, MD, former CEO of ThedaCare, and Roger A. Gerard, PhD, its chief learning officer, candidly describe the triumphs and stumbles of a seven-year journey to lean healthcare, an effort that continues today and that has slashed medical errors, improved patient outcomes, raised staff morale, and saved $27 million dollars in costs without layoffs.
Applying Quality Management in Healthcare Editor: Diane L. Kelly No of Pages: 450 Year of Publishing: 2011 Description: Quality management is a complex process, especially in healthcare. Managers in today's environment need more than just an understanding of the historical concepts of quality. They need to understand how to achieve quality within the structure and relationships of the complex system of a healthcare organization. In this new third edition, Kelly has enhanced the content to promote an understanding of systems thinking in health services organizations. While still providing readers with the foundational concepts of quality management, she instructs readers on the system implications of understanding stakeholders and the role of policy, establishing goals in complex systems, improving and managing process change, performance measurement, and teamwork. Readers learn how to think critically using new frameworks, approaches, and tools and are given real-life examples and case studies to practice these skills.
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Advances in Neuroradiology
Advances in cross sectional imaging using CT and MR have significantly changed the clinical practice of neuroradiology over the last decade. Powerful imaging investigations such as functional MR, MR tractography and PET CT allow detailed functional and morphological analysis of the patientâ&#x20AC;&#x2122;s central nervous system. This article reviews some of these important advances and how they impact on daily clinical practice. Peter Corr, Department of Radiology, Faculty of Medicine and Health Sciences, UAE University, UAE
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Advances in computed tomography (CT) Current state of the art 64 multi-detector CT imaging provides images with a minimum isotropic spatial resolution of 0.6mm. This means that the brain scans can be reconstructed in any plane without significant artifacts. The brain can be scanned in a few seconds and reconstructed in any plane with a slice thickness of less than 1mm if indicated. This excellent spatial and temporal resolution has provided the technology to make CT brain perfusion and CT angiography of the cerebral vessels feasible. CT cerebral perfusion allows the stroke physician the ability to quantify the size and extent of the cerebral infarction at the same time as the initial CT examination is performed. This information is critical if thrombolytic therapy is being considered to identify regions of infarcted brain and surrounding ischaemic but still viable brain that can be rescued. CT angiography of the Circle of Willis provides images of the cerebral arteries of sufficient diagnostic quality to detect small aneurysms above 5mm in diameter and to detect the nidus of cerebral vascular malformations. This provides the interventional neuro-radiologist three-dimensional details of the aneurysm morphology, the size and position of the aneurysm neck and presence of mural thrombus within the aneurysm. These details are important before endovascular occlusion of aneurysms or vascular malformations with coils or occlusive glue is attempted. The main disadvantage of CT perfusion and CT angiography is the much higher radiation dose to the patient, especially to the lens of the eye and the thyroid gland. Despite the recent adverse publicity in the United States concerning CT radiation doses, there is no doubt that the careful use of CT imaging with modern X-ray tube dose modulation techniques is a major advance in neuro-imaging over the last decade.
The most exciting research fields in neuroradiology have been the development of MR tractography of the brain and spinal cord and functional MR imaging (fMRI)
Advances in magnetic resonance imaging The recent trend in using 3 Tesla high field MR systems to image the nervous system has meant that images of the brain and spinal cord have now a significantly improved signal to noise ratio. These images have significantly better contrast resolution when compared to 1.5 Tesla high field MR systems. Three Tesla MR systems appear to be the standard in neuroradiological practice today. Moves to higher field 7 Tesla systems may be some time away given the safety concerns over the higher specific absorption ratio (SAR) and higher and faster changing gradient strengths (faster slew rates) affect on peripheral nerves. Better contrast resolution and the routine use of diffusion-weighted imaging have allowed neuro-radiologists the ability to detect more subtle imaging findings in the brain and spinal cord of patients. Diffusion weighted imaging has become routine in stroke imaging. Diffusion weighted imaging identifies acute cerebral infarcts that require either systemic anticoagulation or thrombolytic therapy. Diffusion weighted imaging is also used to detect focal spinal cord lesions, especially cord infarcts, and vertebral lesions. Cerebrospinal fluid artifacts in diffusion weighted imaging have been significantly reduced with cardiac gated studies of the spine. Diffusion weighted imaging can reli-
ably differentiate between benign vertebral lesions from osteoporotic fractures from malignant metastatic vertebral fractures. The most exciting research fields in neuroradiology have been the development of MR tractography of the brain and spinal cord and functional MR imaging (fMRI). Tractography is based on the imaging of restricted diffusion of water molecules across the myelin sheath cell membranes of axons but unrestricted diffusion within the length of the axons. This has allowed visualisation of white matter fibre tracts in the brain and spinal cord in many different disorders. Abnormal fibre tract connections have been demonstrated in congenital neuronal migrational anomalies of the brain, behavioural disorders such as autism and even psychiatric disorders such as schizophrenia. Tractography of the spinal cord is now possible on 3 Tesla systems with the development of cerebrospinal fluid motion nulling software. Images of fibre tract disorders in white matter disorders such as multiple sclerosis, tumours of the spinal cord and spinal cord trauma are now possible. Functional MR imaging has moved from a research investigation into clinical practice. This technique depends on the principle that neuronal activation of the cerebral cortex increases the regional blood supply within the brain and there is an increase in the percentage of oxygenated haemoglobin (HbO2) in the blood vessels supplying that region of cortex that is activated. This has allowed researchers to investigate many psychiatric and cognitive disorders including Alzheimerâ&#x20AC;&#x2122;s disease and schizophrenia. In clinical practice it is now possible to map out the eloquent motor and sensory cerebral cortex before brain tumour resections are performed. Functional imaging of the spinal cord is now possible on high field 3 Tesla systems. It is used to identify spinal cord motor neuron activation in the corticospinal tracts for pre-surgical studies.
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DIAGNOSTICS
initial stages of the Krebs cycle by hypermetabolic cancer cells where it produces two positrons that can be detected by a gamma camera within a CT gantry. It is particularly useful in differentiating recurrent brain tumour from gliosis. The development of new positron emission isotopes such 18F flutematamol (clinical trial NCT01028053) to detect amyloid deposition in the brain have provided the first diagnostic imaging investigation of early preclinical Alzheimer’s disease. It will soon be possible to detect Alzheimer’s disease before the patient presents with symptoms of cognitive decline, so that patients who have a family history of the disorder will be able to be screened for Alzheimer’s disease in the near future. Glioblastoma multiforme tumours are now being treated with anti-angiogenic drugs such as cilengitide so that there is a need to measure tumour response using imaging. Current research in new molecular markers of neo-angiogenesis has resulted in the first clinical trials of positron producing isotopes that bind to integrin receptors in tumours. These isotopes will be able to document the tumour response to these new anti-angiogenic drugs.
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apy and or radiotherapy for malignant brain tumours such as glioblastoma multiforme. Advances in Positron Emission Tomography Positron Emission Tomography CT using 18F fluoro-deoxyglucose (18F FDG) isotope has advanced the detection and staging of central nervous cancers. 18F FDG is metabolized in the Author BIO
MR spectroscopy measures important metabolites in the brain and their relative quantities as a ratio compared to an internal standard of creatine. The important metabolites of N-acetyl aspartate, choline, creatine, myoinositol and glutamine can be measured noninvasively. This technique is particularly useful in the evaluation of cerebral tumours, cerebral inflammatory lesions such as abscesses and granulomas and metabolic disorders of the brain. With tumours, especially cerebral lymphoma, there is increased turnover of cell membranes in tumour cells so that choline, an essential component of cell membranes, becomes elevated. Spectroscopy is useful with CT-PET scanning in detecting tumour recurrence versus gliosis after surgery, chemother-
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Conclusions Advances in imaging technology have resulted in a better understanding of neurological disorders and have advanced neuro-imaging from a purely anatomical to functional assessment of the nervous system. New PET isotopes hold the promise of molecular imaging of the brain in disorders such as Alzheimer’s disease before the patient presents with symptoms.
Peter Corr is a consultant radiologist at Al Ain and Tawam Hospitals and Chairman of Radiology at the UAE University since 2005. He was trained in Cape Town, S Africa with fellowship training in neuroradiology. His areas of interest are non invasive cardiovascular imaging, neuroimaging of infections, sonography, sports injury imaging and radiology education. He has published 75 peer reviewed articles, 7 book chapters and one textbook.
Exclusive Offer for Asian Hospital & Healthcare Management Readers * SGD 100 off all published rates if you Quote P3EvHC to enjoy this offer Silver Healthcare Market Outlook
14 – 17 Nov 2011, Grand Copthorne Waterfront Hotel, Singapore Rapidly ageing populations present a strain on resources, particularly in healthcare costs. However, this phenomenon also translates to the fact that baby boomers will have their savings and investments, accumulated over their working years, available for their consumption. With that in mind, this Silver Healthcare Market Outlook addresses these pressing issues and more at Asia’s only platform for healthcare providers, policy influencers, health insurance companies and other stakeholders to learn from one another and explore collaboration prospects. Discover strategic case studies; explore the latest trends and opportunities in providing the entire healthcare continuum to rapidly ageing Asia. Gain benefits from industry experts including Kaiser Permanente USA, American Federation for Aging Research (AFAR) USA, International Federation on Ageing Canada, Ministry of Public Health Thailand, Changi General Hospital Singapore and many more. For more information on speakers, agenda and full programme details, visit www.silverhealthcareasia.com
2nd Annual Healthcare & Insurance
14 – 17 Nov 2011, Grand Copthorne Waterfront Hotel, Singapore Healthcare and Insurance Collaboration Forum is Asia’s FIRST and ONLY platform to bring together healthcare providers, medical insurance companies and related stakeholders to discuss win-win partnerships to address questions such as: • How can insurance and hospitals partner more to expand each other’s business? • How can they work better together with the reality of conflicting goals? • How can Asia’s healthcare sector improve and expand to benefit hospitals, insurance and patients? Whether you are from a hospital looking to excel and expand business, from insurance tasked to optimize resources or from a TPA finding the best balance to maximize revenues – the objective of effectively working together is common. Take part in interactive panel discussions, informative talks, thought provoking sharing sessions and the signing of a joint declaration and launch of a dedicated Asian Healthcare & Insurance Alliance. For more information on speakers, agenda and full programme details, visit www.healthcareinsuranceasia.com
3rd Electronic Health Records
29 Nov – 2 Dec 2011, Sheraton Towers Hotel, Singapore Now in its 3rd year, Electronic Health Records is the annual meeting place for Asian countries looking for the latest information in regards to the implementation of seamless patient record management and will bring together senior health IT executives and decision makers from both public and private hospitals and healthcare groups to discuss the progress, challenges and issues in relation to the implementation of EHR across the region. This year’s 3rd Annual Electronic Health Records event will examine the progress of current EHR projects in Asia including Singapore, Hong Kong, Taiwan and Malaysia and feature leading pilots and project case studies profiling issues including interoperability challenges, patient data management and security and the impact of new technologies including cloud and mobile devices. For more information on speakers, agenda and full programme details, visit www.electronichealthasia.com
Produced by: Yes, please send me a brochure on: Q Silver Healthcare Market Outlook • 14 – 17 Nov 2011, Grand Copthorne Waterfront Hotel, Singapore Q 2nd Annual Healthcare & Insurance • 14 – 17 Nov 2011, Grand Copthorne Waterfront Hotel, Singapore Q 3rd Electronic Health Records • 29 Nov – 2 Dec 2011, Sheraton Towers Hotel, Singapore I am unable to attend this time but please put me on your mailing list. Name:
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DIAGNOSTICS
Planning Secrets for Enhanced CT/ MRI Throughput This article will explore ways to maximize MR and CT patient throughput through the use of improved facility layouts, including optimizing the location, number and size of support spaces. Robert Junk, President Scott Branton, Senior Associate RAD-Planning, USA
I
n architecture there is a well known phrase “less is more” which was part of a movement away from overly complex architecture to a more simplified form. This same adage applies equally well to the design and operation of efficient medical imaging centres. In the midst of declining resources and a world-wide recession, imaging providers are struggling to maintain profitability. On the flip side of the coin, driven by population growth and the need to expand services to an ever widening patient base, radiology departments are seeing an increase in patient referrals for MR and CT, which means a higher percentage of patients with higher acuity levels, requiring increased staff interaction and longer scan times. So how can an imaging facility manage these seemingly divergent restraints? In a word: efficiency, and this efficiency needs to be applied across the board, from operations to imaging centre planning and design. For example having just five extra minutes in a centre’s average scan time for MR or CT patients, in a department that does 20 scans per day six days per week, means an additional 520 hours of facility operation annually. Five hundred and twenty hours of additional
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DIAGNOSTICS
staff time, utilities and equipment usage without any additional revenue. Or put another way, working one 10-hour day per week for free! All imaging providers will tell you that working for free is not a good plan for success. Since efficiency needs to be applied across the board in order to be effective the first place to start is to look at the overall layout of the imaging facility. Nothing will kill efficiency faster then a poor facility layout. A poorly planned radiology department can create multiple bottlenecks that slow patient throughput. Admittedly, many radiology administrators in existing centres find this frightening, assuming that the facility layout is something that is a given and not subject to change. Many imaging centre operators are convinced that unless they are planning a move or major expansion they cannot afford to revise the departmentâ&#x20AC;&#x2122;s layout. While this may be true for the large gantry scan rooms, it does not necessarily apply to the many less technical support spaces that many times have a more significant impact on patient throughput than the scan room itself. These days it is very common for a facility to make changes in lighting or mechanical equipment to improve energy efficiency, realizing that the energy savings will pay for the improvements. The same is true for layout improvements. Remember those 520-hours of additional staff and equipment time from just five extra minutes of average scan time? Shaving 520-hours off of a staffing plan can easily pay for layout modifications. The typical response when you ask an Imaging Facility Manger about what areas of the facility layout have the greatest impact on MR and CT patient throughput, the most common answer is the scanner room. The scanner room is a critical component of the patient imaging and throughput process, it is not the bottleneck at most facilities. The bottleneck usually occurs with the interaction with patients before and after the scan and this most often occurs at the dressing
To provide segregated access paths and support spaces for inpatients and outpatients, facilities need to understand their patient demographics and adjust the layout to align with the patient population.
room, a mundane and often overlooked support space that has a huge impact, not only on patient throughput, but also patient satisfaction. So how is it that a non-technical space that is less then 60 square feet in area can bring a 20,000 square foot imaging department to a halt? The answer is as simple as it is frightening: if the patient is not ready to be scanned the scanner sits empty. Far too often imaging centres mistakenly assume that they can â&#x20AC;&#x153;get byâ&#x20AC;? with only one changing room, which usually servers multiple scanners. The thinking is that they can just quickly process patients through the one changing room and then have them wait somewhere else. The most common mistake seen in imaging centres is too few dressing rooms, dressing rooms in the wrong areas and/or dressing areas that are too small. As a general rule of thumb for every large gantry scanner or modality there should be at least two dressing rooms. These dressing rooms also need to be large enough at allow accessibility for patients with mobility restrictions and ideally large enough to accommodate a second person to assist the patient in the gowning process. Having a dressing room large enough for two-persons is most beneficial at imaging centres that serve paediatric or geriatric populations. The goal is to always have one patient gowning-in, one patient in the bore of the scanner and one patient gowning-out to maximise throughput.
In order to do this, each scanner needs to have two changing rooms dedicated to it. Too often, in an attempt to save a few dollars in construction or lease costs, imaging centres will set up two or three dressing rooms to be shared by multiple scanners and typically only one of those is ADA accessible. With the Baby Boomer generation reaching retirement age, the number of people over age 65 will nearly double between 2000 and 2030. This means that more patients will have some type of mobility restriction. Having larger dressing rooms that allow for a second person to assist the patient in the gowning process will speed patient preparation. This combined with upgraded finishes and lighting inside patient dressing rooms has proven to greatly improve a centres overall patient satisfaction rating. Another component of the patient dressing room is where patients store their personal belongings while they are being scanned. It is strongly recommended that imaging centres use personal storage lockers that are located out-side of the dressing room. This gives the patient personal control over their belongings, which helps reduce the liability of the imaging centre from lost item claims. Many times an imaging centre will tell us that they do not use lockers and prefer to allow the patients to lock their belongings in the dressing room. This is less of an issue if each scanner has at least two dedicated changing rooms, but if changing rooms are being shared with other scanners, this can quickly cause a bottleneck as new patients are held up waiting for the previous patient to finish their scan, change and collect their belongings before the next patient can even start to gown-in. Another problem is imaging centres that have the proper number of dressing rooms for their fixed scanners, but fail to take into account the effect of mobile scanners. The common example that we see is a centre that brings in a mobile to help relieve a patient back-log, only to find that the back-log does not
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DIAGNOSTICS
Efficiency needs to be applied across the board, from operations to imaging centre planning and design to manage seemingly divergent restraints.
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to be separated from outpatient traffic. The attached plan is a great example of how to share fixed base scanners with both inpatient and outpatient populations and still maximise patient throughput for each patient group. The added benefit of preventing cross traffic between inpatients and outpatients is avoiding the negative connotations and associated health concerns when healthy outpatients share space with less healthy individuals. Studies have shown that outpatients feel less comfortable in settings when they are aware of sharing
Author BIO
improve, due to the fact that they cannot efficiently process patients through the existing number of dressing rooms. This problem is further compounded when the mobile scanner is a PET or PET / CT. Now the centre has the issue of having to dedicate spaces for radioactive or â&#x20AC;&#x2DC;hotâ&#x20AC;&#x2122; patients only and can no longer share changing rooms or toilets with the non-nuclear scanners. What starts out as a way to increase services and revenue backfires without proper planning and upgrades to support the new services, ultimately negatively affecting patient satisfaction due to increased wait times. Lastly, facilities need to understand their patient demographics and adjust the layout to align with the patient population. The best way to handle this is to provide segregated access paths and support spaces for inpatients and outpatients. This allows the support spaces to be tailored to the unique needs of each patient population. For example, dedicated holding, induction / recovery and screening for inpatients allows patients with higher acuity levels
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space with patients that require a higher level of medical care. So what can a facility due to safeguard against these issues? First, review the existing layout to make sure that the proper patient support spaces exist to support both the fixed and mobile modalities; remember, two changing rooms per scanner. Secondly, the support spaces should be sized to accommodate mobility-restricted patients and located in close proximity to the scanners. Provide patient lockers outside of the changing rooms to allow for the greatest flexibility. Lastly, review the quality level of finishes and lighting within these spaces that patients come in close contact with. A little extra attention to detail in these spaces where patients spend time can reap huge benefits. If upgrades need to be made, usually a medical centre's in-house staff can provide design and construction for minor projects, just keep in mind that as a general rule state health departments require that a licensed architect or engineer be involved in any medical projects that change wall or door locations. If needed, bring in outside professional design assistance, but be sure to use professionals that understand the unique issues related to medical imaging and patient throughput. Remember that layout modifications to improve patient throughput will be a one-time expense compared to the possible perpetual staffing costs and patient dissatisfaction of an inefficient operation.
Robert Junk is President of RADIOLOGY-Planning, a recognised leader in radiology and imaging suite design. He has been involved in healthcare design and medical imaging for over 25 years. He is an expert contributor to the US Department of Veteran Affairsâ&#x20AC;&#x2122; imaging series Design Guides and has served as an expert witness in cases involving imaging suite failures. Scott Branton is a Senior Project Manager for RADIOLOGYPlanning (RAD-Planning) with nearly 20 years of professional experience. He has provided designs and project supervision for healthcare and imaging projects for a breadth of clients from toptier research institutions to municipal health services.
Events Date: Oct 5 - 7, 2011
Asia Medical 2011
Location: Putra World Trade Centre, Kuala Lumpur, Malaysia URL: http://www.asiamedical.org Date: Oct 10 - 11, 2011
MENA Healthcare Infrastructure Finance & Investment Summit 2011
Location: Riyadh Marriott Hotel, Riyadh, Saudi Arabia URL: http://www.euroconvention.com/events. php?action=details&event_id=55 Date: Nov 8 - 10, 2011
37th World Hospital Congress
Date: Nov 17 - 18, 2011
Healthcare Supply Chain Officer 2011
Location: Renaissance Shanghai Pudong Hotel, China URL: http://healthcare.sco-summit.com Date: 19 Nov 2011 - 22 2011
Health Facilities Design and Development Saudi Arabia
Location: Park Hyatt, Jeddah, Saudi Arabia URL: www.healthfacilitiessaudi.com Date: Nov 28 - Nov 30, 2011
Smart Healthcare World Asia 2011
Location: Raffles City Convention Centre, Singapore URL: http://www.terrapinn.com/smarthealthcare
Location: ATLANTIS The Palm, Dubai, United Arab Emirates URL: http://www.ihfdubai.ae
Date: 11 Dec 2011 - 13 2011
Date: Nov 8 - 10, 2011
Location: Abu Dhabi National Exhibition Centre, Abu Dhabi, UAE URL: www.worldcongress.com/me
IHF 37th World Hospital Congress
Location: ATLANTIS The Palm, Dubai , United Arab Emirates URL: http://www.ihfdubai.ae
2nd Annual World Healthcare Congress Middle East
Date: 14 Dec 2011 - 16 2011 Date: 16 Nov 2011 - 17 2011
2nd Annual Hospital Efficiency Asia 2011 Location: Kuala Lumpur, Malaysia URL: www.hospitalefficiency-asia.com
Hospital Infrastructure India 2011 Location: Bombay Exhibition Centre, Goregaon East, Mumbai, India URL: www.hospitalinfra-india.com
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TECHNOLOGY, EQUIPMENT AND DEVICES
Drivers of Healthcare Industry This article speaks about growth in the healthcare delivery industry, medical technology industry growing at a healthy pace of 16-18%, especially in few sectors like cardiology, growing at high pace of 35-40 percent. The author says this growth is happening on account of the growth in advancements in medical technologies. As one reads through the article he can find the Key drivers for growing Healthcare industry. Later in the article the author speaks about convergence, mergers and acquisitions for the growth of Asian medical equipment industry. Finally author speaks about Frost & Sullivan initiative India Healthcare Excellence Awards 2011. Sandeep Sinha, Director, Healthcare Practice, Frost & Sullivan, South Asia and Middle East
What technological developments do you see having the greatest impact on the Industry? Riding on the back of unprecedented growth in the healthcare delivery industry, medical technology industry has been growing at a healthy pace of 16-18 percent Year-on Year and few sectors like cardiology are even growing at very high pace of 35-40 percent. This growth is not only happening on account of the growth in the delivery industry but is also aided by the advancements in medical technologies. Advancement in technology has shortened the adoption curve for new technologies; the benefits of the advancements are clearly visible in terms of smoothening of workflow, ROI, and hospitals ability to treat more patients in the same time span. Some major examples of this phenomenon are • Increase in number of minimally invasive surgeries: With every passing day a higher number of hospitals are shifting towards minimally invasive
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procedures. This concept has been equally appreciated by the patient and provider both, benefits to the patient being early discharge and return to normalcy and for the provider a faster turnaround thus higher profitability. This phenomenon has been helped by advancements in the field of laproscopy, endoscopy, cath labs, etc. • Next generation stents: India has one the highest prevalence of coronary heart diseases, the primary modality of treatment for this disease is either a percutaneous intervention procedure or an open heart bypass. PCI surgeries score over bypass in terms of shorter time of surgery and stay. Advancements in the field of coronary stents have helped the interventional procedures to grow 10 times in the last 10-12 years. This phenomenon is going to get an impetus courtesy the recent developments in the field of coronary stents i.e. absorbable stents. • Home health: With time becoming a precious commodity a significant chunk of population is opting for devices which
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can provide diagnosis, care within the home environment. This phenomenon helps the patients in saving time and utilizes the saved time for other productive activities. The development in the field of blood glucose monitoring, insulin management, sleep apnea, cardiac rhythm management will be the main growth drivers of home health. • Orthopedic surgeries: Joint problems which were regarded earlier as a normal old age phenomenon has started gaining recognition as a disease. Its not only being recognized as a disease but the recognition is also for the fact that it’s curable. This change in the thought process is driving the growth of the joint implant market. The phenomenon gets compounded due to the advancements in the field of implants which are more durable and made of much better material. What kinds of changes are occurring on the demand side? The rise in population, income levels, and awareness have resulted in an
TECHNOLOGY, EQUIPMENT AND DEVICES
respective state governments on board as health is a state subject. However it seems that unanimity has been achieved in terms of proposed content of the bill and itâ&#x20AC;&#x2122;s expected to become a regulation very soon. It will be unfair to pass a judgment on the bill till itâ&#x20AC;&#x2122;s finely implemented; prima facie the legislation seems to be conducive for the growth of the industry.
increase in demand for better healthcare services, adoption of health insurance and increase in personal health expenditure. This rise in income levels along with changing lifestyles and increase in sedentary jobs is transforming the disease profile of India from predominantly communicable diseases to non-communicable diseases such as cancer, diabetes and cardio- vascular diseases. This transition has led to greater interest from foreign sector and is likely to see further activity from Government sector. The 300-million strong middle-class population, in India, with considerable disposable income, is rapidly growing. This highly educated class of individuals is likely to demand better healthcare services and will play an important role in purchasing of healthcare services. Personal healthcare expenditure by households has grown from 4 percent to 7 percent during 1995 to 2005 and is expected to reach 13 percent in 2025. Moreover, as health insurance penetration increases, it will also result in increased discipline and defined standards of care in hospitals. What segments of medical devices are likely to witness growth in the region? Do you see any particular disease type taking precedence? As stated above all segments are expected to witness good growth ,
however as rule of thumb the growth in specialized technology like Cath Labs, CT Scans, High end operating rooms, advanced sterilization services , home health will be significantly higher when compared to medical consumable segment which comprises of products like cannula, catheters, gloves, sutures etc. This differential in growth will be primarily on account of almost no innovation happening in the consumable industry and thus seeing price erosion. Cardiology and Mother & Child Care are two segments which will take precedence both in terms of volumes and values.
What is your take on convergence, mergers and acquisitions for the growth of Asian medical equipment industry? M&As are something that will not be happening very soon in the Indian market. Primary reasons for almost zero activity in M&As are because of the extremely fragmented nature of the medical technology industry in India. This results in multiple companies having very small turnover and the companies being region specific or single product specific. This fragmented nature and small turnovers makes the companies an unattractive target for acquisition. The valuation expected by the Indian promoters is also a bit unrealistic and on a higher side, however in the long run consolidation will be the name of the game.
How do you see the regulatory environment? Is it conducive to its growth? Regulatory environment in the long term will start acting as facilitator than a regulator; however we have a quite distance to cover to achieve that. Current regulatory scenario can be said to be less than optimal, however the government is trying its own bit to improvise the existing scenario. CDA and MDRA bills expected to become regulation in some time, though it was expected to happen long back. Divergent interests of different lobbies i.e. domestic and multinational corporations have resulted in the delay, also the delay can be attributed to the fact that the central government has to take
Please tell us about Frost & Sullivan initiative India Healthcare Excellence Awards 2011.? The Indian healthcare Industry has already clocked in the 55 billion dollar figure and is poised for another fantastic year ahead in 2011. With a 1.2 billion population with 60 percent of the population poised to be in the working class category in the next coming decade, there can be no company whether be MNC or an Indian player, which can afford to neglect the Indian market from their growth plans. We at Frost & Sullivan truly salute the spirit of this growing Industry and support it by recognizing the excellent efforts deployed by a few of them who have the courage to excel in this multi-faceted environment.
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Transforming Concepts
Patient safety
The Institute of Medicineâ&#x20AC;&#x2122;s 1999 report, To Err Is Human, sparked efforts to improve patient safety in the US. Recent data suggest, however, that adverse events persist. The Lucian Leape Institute at NPSF has outlined concepts that have the potential to transform the way healthcare is practised and delivered, and lead to safer care. Diane Pinakiewicz President, National Patient Safety Foundation, USA
F
or the patient safety movement in the US, 2011 has been a year of paradox. Every month brings reports of progress through new tools, methods, or technology. With so many stakeholders working on improvements, we know we must be doing better. Yet recent studies suggest that medical errors continue to be a notable cause of extended hospital stays, preventable readmissions, and even premature deaths.
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How can it be that much is being done, but not much progress is being made? That question was asked earlier this year at the National Patient Safety Foundationâ&#x20AC;&#x2122;s Annual Patient Safety Congress. During one plenary session, members of the Lucian Leape Institute, a think tank based at NPSF, continued ongoing discussions of transforming concepts that have the potential to significantly advance patient safety.
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Most serious discussions of patient safety in the U.S. still cite the groundbreaking Institute of Medicine report, To Err Is Human, which estimated that between 44,000 and 98,000 deaths and more than 1 million injuries are caused each year by medical errors. Experts can point to any number of reasons for the lag in progress, from a dysfunctional healthcare payment system to outdated medical education programs and an agonisingly slow adoption of fully functional electronic health records. The good news is that we know much more today than we did when the initial IOM report was released, and most hospitals and healthcare organizations now view patient safety as a critical competency. More good news is that in April 2011, the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services (the branch of the federal government that provides health insurance coverage for the elderly and the poor) announced the Partnership for Patients, a public-private patient safety initiative that aims to improve the quality of the healthcare system while also reducing costs. Two specific goals are to reduce hospital readmissions and hospital-ac-
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This year’s Patient Safety Congress took place in the wake of new, but similarly disturbing, research: • The Inspector General of the U.S. Department of Health and Human Services estimates that 13.5 percent of Medicare beneficiaries (senior citizens) experience adverse events during their hospitals stays. During the particular month studied, an estimated 1.5 percent experienced an event that contributed to their deaths. Projected nationally, the report estimates that 15,000 deaths per month may be attributed to adverse events. • A study that used the Institute for Healthcare Improvement’s Global Trigger Tool estimates that one-third of U.S. hospital patients experience an adverse event. • A similar study found 25 harms per 100 admissions in a review of 10 hospitals in one state.
quired conditions. But the larger goal is to reduce “all-cause harms.” Rather than focusing on specific actions or outcomes, as many measurement and accrediting bodies do, the initiative seeks to promote fundamental changes to healthcare as practised in the U.S. In 2009, the Lucian Leape Institute published a paper outlining a number of transforming concepts that are necessary to bring significant and lasting improvements in patient safety. Since then, the Institute has organised a series of roundtable discussions with expert panels to map a path to improvement. Following are some of the transforming concepts that have been identified to date: • Medical education reform • Care integration • Transparency • Consumer engagement • Joy and meaning in work and healthcare workforce safety Medical education reform One of the chief recommendations of To Err Is Human was for physicians, nurses and other members of clinical teams to work together in redesigning flawed systems. In the US, however, physicians are primarily schooled in the science of medicine, not in the skills needed to manage and interact in constructive ways with other members of the healthcare team or their patients. Little or no attention is paid by most US medical schools to theories of human factors, safety science, communication
skills, teaming or the other basic tenets of patient safety. Progress in this area has begun, albeit slowly. The Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties have formulated recommendations relative to the acquisition of knowledge, skills and attitudes that support desired behaviours for the delivery of safe care. The IOM has defined a group of “core competencies” that all healthcare professionals—physicians, nurses, and others-should endeavor to achieve in order to practice safe and effective care. In considering medical education reform as a transforming concept, the Lucian Leape Institute also addressed the dysfunctional culture present in many teaching hospitals, noting that when students become physicians, they tend to perpetuate the bad behaviours they experienced during training. In 2010, the Institute published a report, Unmet Needs: Teaching Physicians to Provide Safe Patient Care, which was the result of a series of roundtable discussions by Institute members and a panel of experts with extensive experience in medical education. In the US, we are beginning to see some of these thoughts applied. One recent example is of a medical school that weighs prospective students’ interpersonal and communications skills along with their academic achievements. Such examples represent a positive turn, but much reform is still needed.
Care integration The U.S. healthcare system has been well served by remarkable innovation in medicine and medical technology, but similar innovations have not been brought to bear with respect to its care delivery models. The supporting processes for care delivery have not kept pace with the increasing complexities of clinical care and have evolved without proper aforethought, such that the “system” does not provide an integrated approach to patients. This is due, in part, to lack of appropriate incentives in the payment system and lack of research dollars for delivery system innovation. As a result, the infrastructure of the care system has evolved with a focus on acute care, has been designed to be providercentric rather than patient-centric, and is disjointed in its design and functioning, Handoffs between practitioners and transitions in care have proven to provide significant opportunities for error. Patient safety work requires a system perspective and approach, and this, in combination with growing healthcare consumerism, calls for a complete re-examination of the way care is organised and delivered. Furthermore, the disjointed nature of the system, with independently practicing clinicians and hospitals, has not allowed for a rational and integrated deployment of health information technology, which holds great promise for integrating the care delivered to patients. Much has been written in the US recently about accountable care
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organisations (ACOs), which essentially represent a financial integration strategy. Organisational integration associated with ACO formation would drive realignment of risk, and incentives would be provided for higher quality and safety at lower cost. The Leape Institute, while supportive of payment reform as a key strategy to incent for safe care, believes that the concept of integration as defined organisationally is insufficient and that true integration of care must occur around the patient experience rather than around organisational structures. It is only in this manner that coordination of care across the continuum of a patient’s life can be optimised, as the patient is the only constant in that continuum. This, of course, will call for measurement to assess the effectiveness of new integration models from the perspective of the patient experience. As a transforming concept to improve patient safety, care integration would encompass a reorganisation of care processes around well-defined consumer groups, with clinical resources better matched to care requirements, new and improved delivery components for the non-acute aspects of the care continuum, and a deployment of new technologies to support the care needs and preferences of the involved consumer. This will be critical, among other things, for dealing with the significant challenges of managing chronic illnesses. The system would, ideally, also link patients to community resources, and have an infrastructure robust enough (information technology, medical technology) to manage variations in care. This is a concept that will no doubt be widely discussed in the US over the next few years. Transparency In the US, transparency in healthcare is usually thought of as an organisation’s willingness to participate in public reporting of outcomes. As an example, the Center for Medicare and Medicaid Services collects data from hospitals on
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specific practises (such as giving antibiotics to patients prior to surgery to prevent surgical site infections). At the state level, hospitals are required to report sentinel events. Although these methods can be helpful, they are widely acknowledged to still be flawed in significant ways. Moreover the “public” reports produced from them are extremely difficult for most nonclinical people to interpret. Considering transparency as a transforming concept to promote patient safety requires a much broader focus, as it really lies at the heart of culture change. The Leape Institute defines transparency as a “moral imperative,” a precondition to safe care, and a foundational tenet of a learning culture. It defines full transparency as encompassing transparency among caregivers, between caregivers and patients, between organizations and to the public. Hospital leaders must establish a culture that encourages staff to be open and honest in all of their interactions with patients. It is fundamental to effective provider-patient relationships, to safe care, and is a right that all patients deserve. Significant progress has been made with transparency around error, with “open disclosure” being practised around the country and showing results of decreased malpractice claims, dispelling the initial concerns with this strategy. Perhaps the biggest challenge in this area is internal transparency among the
members of the healthcare team. The U.S. Agency for Healthcare Research and Quality (AHRQ) conducts an annual survey on patient safety culture. The most recent results (2010) revealed that only 44 per cent of respondents felt free to report an error without risking some consequence. If the healthcare staff fears blame or scorn, they are less likely to report errors. If they do not report errors, systems that allow them to happen cannot be corrected. Transparency between organisations is required in order to share learnings from incidents that can prevent their recurrence elsewhere, as well as to share evidence-based best practice to improve care processes. In large part, the ability to practise transparency is dependent upon culture, and in this regard, many organisations still have a long way to go. Patient and consumer engagement In 1998, a Salzburg Global Seminar suggested that patient and consumer engagement could positively alter efforts to improve healthcare, and the phrase “nothing about me, without me,” was first used. Providing patient-centered care is one of the IOM’s recommended core competencies and is closely tied to care integration efforts. Evidence supports the benefit of engaging patients in their own care. When patients self-report their experience of adverse events in the hospital,
The report offers 12 recommendations for reforming medical education, grouped into three main categories:
• Setting the right organisational context: Recommendations in this area address cultural and leadership changes that could help medical schools promote patient safety understanding.
• Creating strategies for teaching patient safety: Recommendations in this area address the need for curricula change to include patient safety competencies. • Leveraging change: This category addresses strategies such as linking accreditation standards to robust patient safety coursework, or applying financial incentives to schools that effectively implement patient safety training.
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Restoration of Joy and Meaning in Work and Ensuring the Safety of the Healthcare Workforce These two concepts go hand-in-hand, as no one could find joy and meaning while also feeling unsafe in the workplace. Like the other transforming concepts, these are complex issues that get to the very culture of the healthcare system. Over the past two decades, healthcare in the US has experienced vast change in the form of medical and technological advances, and the challenges associated with an older and sicker population, and shortages of primary care physicians, experienced nurses, and other healthcare workers. Physicians have also felt the effects of a loss of control, increasing regulation, and a payment structure of vastly varying compensation levels. The healthcare workforce is under a lot of pressure, and there is a growing concern that they have lost touch with why they went into the caring profession in the first place. It is not uncommon for healthcare workers to experience disrespectful, disruptive or even threatening behaviours that prevent people from working effectively in teams. Although many US healthcare organisations espouse the belief that “our workers are our most valuable assets,” too few follow through with tools and leadership to make that belief a reality. We cannot expect our workforce to do the hard work associated with the patient safety if we do not take care of them, support them, and ensure that they are safe as well. The Institute’s recommendation is for leaders to reassess their organizations
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for example, AEs come to light that were not reported by staff and do not appear in the medical record. In many hospitals, patients are serving on advisory committees as well as becoming more engaged as members of their own healthcare teams. Studies support the idea that patientcenteredness and engagement can foster greater patient satisfaction, better health outcomes, and reduced healthcare costs. The Patient and Family Advisory Committee of the National Patient Safety Foundation developed the Universal Patient Compact: Principles for Partnership, to help providers and patients forge relationships that could lead to better, and safer, care. As a transforming concept, patient and consumer engagement requires healthcare organisations to consistently and proactively partner with patients in both their care delivery and planning. Family members need to be considered part of the team as well. Patients and their family caregivers need to be fully informed and able to participate in care decisions and in appropriate self-care. Most research in this area has so far focused on patients’ engagement in their own care. AHRQ has recommended addressing patient and consumer engagement on multiple levels: in their own care; in the design of care processes; and in health policy decision making. This is a broad area, and while anecdotal evidence supports consumer engagement at all levels, future research is needed to document the benefits and demonstrate best practices. The Leape Institute is also considering patient engagement with a continuum perspective, which encompasses consumer education and engagement – educating and supporting consumers on patient safety before, after, and between episodes with the healthcare system when they are not considered “patients.” This calls for addressing patient safety as a public health issue, a daunting challenge but one which part of the dialogue as levers to improve the pace of change are sought.
as dynamic entities composed of skilled and committed people. Everyone working in healthcare should be able to answer “yes” to the following questions: 1. Are you treated with dignity and respect every day by everyone you encounter? 2. Are you given the things you need so that you can make the contribution to the organization that gives meaning to your life? 3. Are you recognized for what you do? In essence, many of these transforming concepts begin with leadership and the successful transformation of culture. They are not easy concepts to pursue, particularly when dealing with the day-to-day requirements of taking care of patients. Taken together, however, they represent a vision for the future as articulated by the Lucian Leape Institute members: “We envision a culture that is open, transparent, supportive and committed to learning; where doctors, nurses and all health workers treat each other and their patients competently and with respect; where the patient’s interest is always paramount; and where patients and families are fully engaged in their care.” Full references are available at www.asianhhm.com/ magazine
Diane Pinakiewicz is a President of The National Patient Safety Foundation, where she has served on the Board of Directors since its inception in 1997, the first five years as an officer. She also serves as President of the Lucian Leape Institute at NPSF. She has an extensive background in the healthcare industry with executive-level experience in hospital administration, healthcare consulting, disease management and pharma. She holds multiple appointments with national patient safety and quality improvement organizations and has served on the faculty of multiple programs, including Harvard’s program for Executives in Managed Care. She has published extensively on the topics of patient safety, value-based partnering and managed care financial strategies.
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Health in the Green Economy How carbon reduction may impact health in health sector services
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he provision of accessible, affordable and quality healthcare is directly dependent on the efficient performance of healthcare facilities. Modern healthcare facilities, and procedures, however, require many costly and energy-intensive processes â&#x20AC;&#x201C; in terms of the use of water, lighting, heating, cooling and ventilation, as well as waste disposal. These are part of the overall cost of healthcare, whose expenditures in 2007 totalled $US 5.3 trillion, or US$ 639 per person per year, roughly 8 to 10 per cent of global GDP. There is also increasing evidence that more climate friendly and energy efficient provision of healthcare services may also improve aspects of healthcare service functioning, safety, and climate change/ emergency resilience. These same strate-
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In 2010, the World Health Organization launched a series of reviews of carbon mitigation strategies in five key economic sectors. The health sector paper focuses on carbon mitigation measures that provide significant carbon reduction benefits as well health benefits for healthcare facilities. This article summarizes key findings from this paper. Walt Vernon CEO Amy Jarvis Environmental Performance Engineer Mazzetti Nash Lipsey Burch, USA
gies may also improve aspects of healthcare access, particularly for the poor and vulnerable. And, there is evidence that some strategies can reduce risks of certain diseases, or otherwise directly improve certain health outcomes. These
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positive impacts are commonly called "co-benefits.â&#x20AC;? In light of this growing body of evidence, more climate-friendly and energy efficient healthcare facilities may yield a double or triple benefit in terms
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of patients, healthcare workers, and the communities served. The work of the United Nations Intergovernmental Panel on Climate Change (IPCC) represents the largest body of global review of climate change mitigation strategies, by sector. Many of the strategies for industry and commercial buildings covered by the most recent IPCC review, the Fourth Assessment Report, Working Group III (IPCC, 2007), are also highly relevant to healthcare facilities. Additionally, the health sector is worthy of special attention insofar as healthcare facilities may also offer some unique opportunities for mitigation overlooked by other mitigation reviews, including the IPCC. And, as perceived leaders in healthpromoting activities and behaviour, health policy decision makers carry a responsibility to assess such evidence systematically, and assume a role in leading initiatives that address global environmental health for the future and present-day generations. For these reasons, the World Health Organization (WHO) is currently undertaking a review of potential health co-benefits of mitigation strategies by healthcare facilities, with reference to mitigation strategies considered by IPCC and, where relevant, other key summaries of evidence. In some cases, health risks are also identified, so that they may, too, be mitigated, in the context of sustainability. The WHO review evaluates IPCCreviewed mitigation strategies for buildings and industry in the healthcare facility context â&#x20AC;&#x201C; with a particular focus on mitigation measures that have direct impacts on the delivery of healthcare services, environmental and occupational health for healthcare workers, patients and the communities; and indirect benefits such as improved resilience of healthcare facilities due to more reliable energy provision. In addition, this review looks at how health equity is impacted by certain mitigation strategies. For instance, in energy-poor settings and off-grid rural
clinics, more use of renewable energy sources, and better management of energy may increase access and reliability of healthcare services. While most of the focus is placed on mitigation strategies considered by the IPCC, some strategies not mentioned by IPCC are also considered, if they take advantage of some of the unique opportunities offered by the healthcare sector to generate health and environment co-benefits. WHO defines the healthcare system as â&#x20AC;&#x153;all organizations, institutions, and resources that are devoted to producing health actions." In reality, the healthcare sector includes such a wide variety of practices and activities that precise definition of the sector boundaries across countries and cultures can probably never be conclusive. Therefore, the WHO review focuses on healthcare sector facilities, including those that provide direct, health treatment procedures to patients. That includes hospitals and healthcare clinics, not health clubs, nor pharmaceutical manufacturing facilities. Home-based healthcare and outreach programmes, such as vaccine and bednet distribution campaigns, are not explicitly considered, except as relevant to facility management, such as vaccine and bednet
distribution campaigns. All the same, healthcare facilities can be considered as comprising a major element of the overall sector's activities and its climate and environment impacts. Health Gains/Risks WHO has identified the following gains and risks in the adoption of more sustainable practices by healthcare organizations: While hospitals and health clinics are not a specific focus of IPCC's mitigation review, adoption of 'green' designs by health facilities may offer more health co-benefit than the same measures applied to other commercial buildings. This is partly due to the large demands for reliable energy, clean water, and
The healthcare sector is well-positioned to "lead by example" in terms of reducing climate change pollutants and also by demonstrating how climate change mitigation can yield tangible, immediate health benefits.
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FACILITIES & OPERATIONS MANAGEMENT
The work of the United Nations Intergovernmental Panel on Climate Change (IPCC) represents the largest body of global review of climate change mitigation strategies, by sector.
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temperature/air flow control in treatment and infection prevention within healthcare facilities. This is also due to significant health gains that can be expected from mitigation interventions, for instance the use of natural ventilation is both an effective energy-saving and infection-control measure. Resilience of healthcare services may be enhanced through use of (clean) onsite energy co-generation that insures more reliable energy supply in areas where frequent energy outages may occur and in emergencies. Access to healthcare can be enhanced and made more reliable through off-grid renewable energy systems coupled with on-site energy storage systems. Particularly in remote, resource-poor settings, renewable energy sources can supply basic electricity for vital life-saving procedures that might otherwise not be feasible. Health risks to health workers, patients and communities will be reduced, from reduced and improved management of healthcare and waste, and so will the carbon footprint. Some 15-25 per cent of healthcare waste is infectious waste, 3 per cent chemical or pharmaceutical waste, and radioactive/ cytotoxic (less than 1 per cent). Scavenged needles and syringes from waste areas and dump sites and reused represent a health threat as do dioxins, furans and other toxic pollutants emitted by poor incineration. Better management of solid, liquid and gaseous healthcare products, and emissions from infectious, chemical, and radioactive agents, can
reduce exposure to risks of hepatitis B/C and HIV infections as well as to asthma, respiratory disease, reproductive problems and cancers. Improved waste treatment measures can reduce the carbon footprint of such treatment and of water extraction. The healthcare sector is well-positioned to "lead by example" in terms of reducing climate change pollutants and also by demonstrating how climate change mitigation can yield tangible, immediate health benefits. The following mitigation measures have particular relevance to the healthcare sector because of its unique needs and features: On-site energy generation and storage On-site rainwater capture and water treatment for re-use and on-site sewage treatment Appropriate use of natural (mixedmode) ventilation and natural daylighting Intensified development and use of low-energy medical devices Expanded use of telemedicine and other home-care strategies Reduction in use of nitrous oxide, and capture/reuse of other inhaled anesthetics Other mitigation measures that can generate significant health and environment co-benefits include Siting of health facilities to improve access to healthcare by mass transport systems, and also minimize fossil-fuel required for transport, e.g. for health workers and visitors. Building-related energy efficiencies Materials procurement and waste reduction/management strategies
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Health co-benefits of specific strategies: The WHO review has also identified a number of opportunities for co-benefit strategies that apply to healthcare facilities, healthcare staff and surrounding communities. A selection of those strategies is detailed below. Water conservation, safe onsite water storage and rainwater harvesting. Large quantities of water and special water treatment procedures are required for many healthcare procedures (e.g. renal dialysis, burns, cleaning of specialized medical devices.) Many rural health facilities lack piped water. Water management is thus important to reduce specialized health risks in healthcare facilities, as well as waterborne-disease more generally. Water efficiencies can help improve water access while reducing carbon-intensive water extraction and ecosystem degradation. Rainwater harvesting is one conservation measure widely promoted in WHO's South-East Asia Region - and also used in large urban hospitals recognized for their 'green' design. Improved recapture and reuse of waste anesthetic gases can provide significant climate and health co-benefits. Waste anesthetic gases are not only powerful global warming pollutants, they are associated with reproductive risks of (spontaneous abortion and congenital abnormalities); and headache, nausea, fatigue, cognitive impairment to exposed health workers. Strategies for reducing impact from these gases widely used in medical procedures requires greater examination. Well designed telehealth schemes may reduce the travel-related carbon footprint of all patients, reduce certain needs for facility space, and improve healthcare access and outcomes, including for vulnerable groups. Simple cell phone applications supporting emergency assistance and long-distance consultation for healthcare workers in remote areas are being used in many developing countries with good results. Systematic review of telehealth, telecare and home monitoring schemes has found evidence
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Health equity Finally, the WHO review has uncovered ways for healthcare facilities to address equity gaps in the provision of healthcare to low-income populations: Location of health-care facilities near major public transport arteries, and safe cycling/pedestrian routes. Siting of health-care facilities is critical to healthy equitable access to healthcare facilities and related employment opportunities. Since hospitals are typically large employers, public transport and active travel routes can also minimize travel-towork emissions, and enhance opportunities for active travel among healthcare workers and visitors. Development and expanded use of low-energy and no-energy medical devices in tandem with expanded use of renewable energy sources (e.g. photovoltaic (PV) solar panels), could further improve access to vital health services in many poorly resourced settings. Inadequate power supply was the single most common cause of medical device failure found by a university training programmes that collected data from 33 hospitals in 10 developing countries: nearly a third of equipment failures were
due to power problems. Examples of devices already in use include solar-powered LED lights; LED microscopes for improved TB diagnosis , ; solar-charged, direct current (DC) refrigerators for vaccine storage , and a wide array of rapid diagnostics that can be used in settings without electricity. The US Department of Energy is currently sponsoring a US$ 1.2 million global survey of use and development of DC-grids and devices for residential and small commercial applications. The WHO review also uncovers a need for healthcare organizations to perform more systematic measuring and benchmarking health sector energy consumption and emissions, as well as address overall environmental perform-
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of effective management for the frail and elderly for diabetes, mental health, highrisk pregnancy monitoring, heart failure and cardiac disease. Meta-analysis also found evidence of health benefits for patients with lung diseases, diabetes and chronic wounds. Procurement of products that subsequently are not used, particularly pharmaceuticals, was estimated to represent 60 per cent of the carbon footprint of the National Health Service-England. Better managed procurement saves healthcare resources as well as reducing unnecessary exposures to chemical and biological agents and their waste products. In the case of NHS-England, it was estimated that a 10 per cent reduction in pharmaceuticals procurement would lead to a 2 per cent reduction in the system's carbon emissions.
ance, in the context of 'greener' facility designs and use of renewable energy sources. In tandem, there needs to be systematic assessment of the actual health impacts and economic impacts of energy-saving technologies, designs, and devices, to identify strategies most cost-effective and practical for scale-up, particularly in poorly resourced settings. Major health organizations in the world, beginning with the WHO, have affirmed that climate change is a public health concern. Given the leadership role of the health sector, it must lead by example and demonstrate to the world that we also can, we must, and we will, do something about it. Full references are available at www.asianhhm.com/ magazine
Walt Vernon is an electrical engineer with over 20 years of experience in the design and construction of healthcare facilities across the country. He is the Vice-Chair for the ASHRAE 189.2 Standard for Green Healthcare Buildings and provided leadership for sustainable healthcare facilities at both the state and national levels serving as one of three Co-Coordinators for the Green Guide for Healthcare (GGHC). Walt serves the World Health Organization as a consultant in helping with greener healthcare buildings around the world and founded the consulting group BLUE. Amy Jarvis has developed an internal sustainability plan to include large-scale sustainable solutions, such as renewable energy installations and the purchase recycled products, as well as metrics to evaluate these solutions. Amyâ&#x20AC;&#x2122;s internal sustainability efforts in the Portland office culminated in earning the first-ever Portland Climate Champion Award awarded by the BEST (Businesses for an Environmentally Sustainable Tomorrow) Business Center.
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INFORMATION TECHNOLOGY
Identity and Access Management – how does it benefit healthcare providers? Many health systems turn to identity and access management technologies (IAM) to better address the workflow needs of providers. An IAM system is only as strong and complete as the processes in place to support the system and the staff who implement the policies. Jonathan Leviss Director, Clinical Solutions for Microsoft Health Solutions Group, USA
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critical challenge to the implementation of health information technology (HIT), including electronic health records, is providing simple, efficient ways for providers to use HIT in the fast-paced workflows of healthcare. As more and more health systems from Australia to Europe implement HIT, projects stall and even fail because physicians, nurses, and other providers demonstrate that certain technologies slow them down or become too distracting for safe and efficient use while treating patients. Many health systems turn to identity and access management technologies (IAM) to better address the workflow needs of providers. The IAM lifecycle The IAM lifecycle is a continuous loop of: identify,provision, authenticate, control, and audit. Identify means to make sure that the individual who presents to a health system is who they say they are. Once identified, the individual is
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provisioned privileges, possibly a role, which typically permits certain functions and restricts others. The individual is then authenticated, through security protocols such as passwords, photo IDs or even fingerprints. Once the individual has been identified, provisioned, and authenticated, his actions within the health system must still be controlled, or limited to a range of actions. Once an individual is properly identified and authenticated, the actions taken within information systems must also be able to be audited. From this lifecycle, we can derive three main components of IAM: • Security—prevent unauthorized people from accessing patient data • Privacy—prevent the use or release of patient data inappropriately • Efficiency—Enable authorized people to appropriately access and use patient data quickly and easily Security and privacy are healthcare IAM requirements by law, but efficiency is a healthcare IAM requirement for busy physicians, nurses, and other providers who care for patients in the fast-paced and high-stress world
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of healthcare. The trained healthcare professional must be able to focus on patient care without the burden of encumbering technologies that introduce confusing or slow workflows, including IAM solutions. The deployment architecture of HIT in most contemporary health systems, involving multiple applications, shared thick and thin client workstations, and taskfocused, short user-sessions, prevents many non-healthcare IAM solutions from meeting these criteria. An IAM system is only as strong and complete as the processes in place to support the system and the staff who implement the policies. Of critical importance is creating IAM policies and processes that support the care of patients by providers; a flexible IAM approach which enables, or enhances, quality healthcare delivery while safeguarding patient information is more important than a foolproof IAM approach that overburdens providers. Healthcare differentiators: patients, staff, workflow, and culture The Patient – A key differentiator in healthcare, unlike other industries, is that the customer really does come first. On a regular basis in all health systems, policies and procedures are broken to address a critical need for patient care—IAM is no exception. If a physician needs emergent access to patient information that would not be available under routine processes (i.e. access to psychiatric notes or medications during treatment in the Emergency Department), there must be a way for the physician to access this information. Effective IAM solutions will, in balance, create an event log for later review. The Staff – Health systems often depend on employed staff, affiliated staff, students, and even volunteers for many tasks. Usually, many different offices maintain different databases to track these varied individuals, which impedes
the monitoring of all persons who deliver care and access patient information. Additionally, some staff may be transient (i.e. students and trainees) and others might start on minimal notice (i.e. new hires and temporary nurses). An IAM system must be flexible enough to support the staffing requirements of health systems, easy enough to be used by transient staff, and robust enough to be effective. The Workflow – Unique workflows are the failure point for many HIT projects. As more HIT projects require providers to enter documentation or orders for a patient, rather than just reviewing results or information about a patient, applications and systems need to link the provider to the work performed. Signing on to multiple applications and searching them all to find information on the same patient slows down a busy provider and can be confusing. Spending 30-60 seconds to sign on to an application is not feasible when the provider only needs to use an application for 1-2 minutes to check a test result or enter an order, before moving on to another computer at another patient bedside. The Culture – The healthcare focus on patients and team care contribute to the shared access to patient information that occurs in many health systems. Providers share access to patient records with colleagues to facilitate care, usually so a colleague can save time and avoid having to sign on to an application. Once providers enter computerised orders or documentation in applications for patients, sharing access creates new problems. Privacy regulations in most countries also prohibit such practices.
Conclusion Implementing IAM in healthcare is similar to implementing change and technology in other environments— the likelihood of success is directly related to how much pain the original problem causes the targeted user as well as to the user’s perception of the value of the new technology and processes being introduced. Technologies that will be used by providers, especially those that change how providers interact with patients or patient information, must be championed by providers for broad adoption. Whether individual providers, Chief Medical or Nursing Officers, or Medical Informatics Officers should lead IAM efforts depends on the health system’s local needs and culture. Effective implementation of IAM will enable better hospital management, improve workflows, and ultimately improve the quality of care provided. Note from the author: The content is based on my chapter in " Medical Informatics: an Executive Primer" and other talks and articles I've authored, with some additional commentary.
Jonathan Leviss is the Director, Clinical Solutions, for Microsoft Health Solutions Group, and an internist at the Thundermist Health Center in Rhode Island. In his current role at Microsoft. Dr. Leviss leads a clinician subject matter expert team to develop and deliver marketing and sales support for technologies and services that are core to the Health Solutions Group.
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Products&Services
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To receive more information on products & services advertised in this issue, please fill up the "Info Request Form" provided with the magazine and fax it, or fill it online at www.asianhhm.com by clicking "Request Client Info" link. 1.IFC: Inside Front Cover 2.IBC: Inside Back Cover 3.OBC: Outside Back Cover
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