Asian Hospital & Healthcare Management - Issue 36

I s s u e 36

2017

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Artificial Intelligence Redesigning Healthcare

Harnessing Big Data Analytics to Deliver Optimal Care

Are We Close to a Global Ban on Powdered Medical Gloves?

Foreword Artificial Intelligence Redesigning healthcare “Healthcare is a prime candidate for technological change. AI is the most advanced and effective option for achieving the reforms.” - Melissa Thompson, Harcourt Health.

Evolving usage of technology in our daily lives is changing the healthcare industry to a great extent.

Machine learning and Artificial Intelligence(AI) are already facilitating significant advancements to drive efficiencies and improve the quality of care.

This transformation is promising to continue its significance in the coming years.

Every day, an enormous amount of data is produced and shared across industries, and healthcare is no different. It is not surprising that experts believe artificial intelligence can play a key role in healthcare advancements. There is an acute shortage of physicians and healthcare professionals the world over with the industry expected to fall short by 12.9 million by 2035 per a WHO report. Training physicians and healthcare providers is a demanding task that requires years of education and hands-on experience.

Technological advancements and AI in particular can help bridge the gap and meet the growing demand. AI-based tools and applications aid healthcare professionals in improving productivity and reducing dependency on skill and energy requirements. This in turn could help expand the service base to attend to the needs of the wider section of population.

AI is gaining ground in healthcare. In 2012, there were fewer than 20 AI startups focused on healthcare but this number rose to 70 last year.

Additionally, AI for healthcare sector is expected to drive overall AI market growth in the next six years, according to a Markets and Markets report. The overall AI market is expected to grow at a compound annual growth rate of 62.9 percent from 2016 to 2022, projected to reach $16.6 billion, and healthcare sector is expected to contribute significantly. “By 2025, AI systems could be involved in everything from population

health management, to digital avatars capable of answering specific patient queries,” says Harpreet Singh Buttar, analyst at Frost & Sullivan.

AI tools can identify patterns in treating diseases thus guiding physicians in providing better care. Machine learning and AI algorithms offer guidance and recommendations based on data and outcomes of past treatments thus increasing survival rates. The solutions offered can be more effective as healthcare companies increase collaboration with technology companies. Be it data analytics or cognitive technologies, technology companies have been working towards transforming the way healthcare is offered. Whether it is IBM’s Watson Analytics or Philips’ Mobile Obstetrics Monitoring (MOM) software, or any other application / solution, AI is sure to disrupt the way healthcare is provided.

Robots can aid in enhancing human efforts thus offering better patient care. AI has thus taken the advisory role offering suggestions to healthcare providers, but is far from replacing human intervention. Recent developments suggest AI may bring in more surprises, but only time will tell if AI can turn to decision making surpassing human brain.

In the cover story, Nicola Pastorello, Lead, Data Science and Analytics Group of Deakin Software and Technology Innovation Lab describes how the vast majority of physicians use AI tools in the future for their clinical and research work.

Prasanthi Sadhu

Editor

Contents Cover Story

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AI in Healthcare

Nicola Pastorello, Lead, Data Science and Analytics Group, Deakin Software and Technology Innovation Lab, Australia

HEALTHCARE MANAGEMENT

INFORMATION TECHNOLOGY

06 Eat or Be Eaten Winning the merger endgame in Asian healthcare

40 Leveraging Information Technology in the Healthcare BPO Industry

Piyumi Kapugeekiyana, Senior Consultant and Relationship Manager, Stax Inc, India

Julius Raj Stephen, Joint Head of Operations, Omega Healthcare Management Services Pvt. Ltd., India

MEDICAL SCIENCES 12 Risk Assessment and Early Detection Key to Timely Treatment of Breast Cancer

Yasmin Jahan, Graduate school of Biomedical and Health Sciences, Hiroshima University, Japan

Aditi Bhatt, Consultant Surgical Oncology Fortis Hospital, India

Md Moshiur Rahman, Institute of Biomedical and Health Sciences, Hiroshima University, Japan

18 New Approaches for the Development of Diagnostic Systems for Prostate Cancer

Pradeep Kumar Ray, Engineering Research Centre on Digital Medicine and Clinical Translation (DMCT), Shanghai Jiao Tong University, China

Julia Zapatero Rodríguez, Postdoctoral Researcher, Dublin City University, Ireland, and Project Manager of AbYBiotech Richard O’Kennedy, Professor of Biological Sciences, Dublin City University, Ireland, and Chief Scientific Officer& Founder of AbYBiotech

Technology, Equipment & Devices 26 Are We Close to a Global Ban on Powdered Medical Gloves?

Patty Taylor, V.P. Professional Education & Clinical Affairs, Ansell, US

FACILITIES & OPERATIONS MANAGEMENT 30 Modelling Facility and Operations in Design of and Transition to a New Healthcare Space Marvina Williams, Senior Healthcare Operations Planner, Perkins+Will, US Amanda Hobbs, Healthcare Operations Planner, Perkins+Will, US

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46 Patient-Physician Communication by Using Mobile Technology in Developing Countries

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Michiko Moriyama, Institute of Biomedical and Health Sciences, Hiroshima University, Japan

52 Harnessing Big Data Analytics to Deliver Optimal Care Suman Bhusan Bhattacharyya, Head, Health Informatics, TCS Member, National EHR Standardisation Committee, MoH&FW, Govt. of India Member, IMA Standing Committee for IT, IMA Headquarters, India

56 Providing High-Quality, Physician-Led Team-based Care Hear from the experts Steve Lieber, President and CEO, HIMSS, Chicago, US

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Advisory Board

Editor Prasanthi Sadhu Editorial Team Grace Jones Vijaya Lakshmi Art Director M Abdul Hannan Product Manager Jeff Kenney Senior Product AssociateS Ben Johnson David Nelson Jennifer Wilson Peter Thomas

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

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Eat or Be Eaten

Winning the merger endgame in Asian healthcare The article asks whether Asian health providers should look at mergers and acquisitions in order to stay competitive and avoid being ‘eaten’ by larger players. This should be a pressing question for the C-suite in healthcare as well as private equity investors interested in buying out healthcare companies. My basic premise is that companies can better strategize their next move if they are closely attuned to their industry’s lifecycle and their position within this industry.

Piyumi Kapugeekiyana, Senior Consultant and Relationship Manager, Stax Inc, India

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bird’s eye view of the global healthcare landscape reveals a market in consolidation and the implications for Asia are well worth considering. In 2016, healthcare M&A activity worldwide topped ~$320B. With 169 deals valued at ~$29B, Asia accounted for 9 per cent of the global pie. For some healthcare players, the endgame might be more apparent than others: If you’re not at the table, you’re on the menu—or worse still, on your way out.

Back in 2008, Chinese medical device manufacturer Shenzhen Goldway Industrial found itself on the menu, when Phillips snapped it up in a bid to solidify its place in the patient monitoring market. Fast forward a couple of years and Asia-based providers are

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increasingly ‘at the table’ making their own cross-border bids. In January 2017, Indian pharmaceutical player Zydus Cadila made inroads into the US specialty pharma market with the acquisition of California-based Sentynl Therapeutics, a company that acquires, develops and commercialises prescription products in the pain management segment. Transactions like these have followed on the heels of similar M&A activity in 2016. Last February, Indian pharmaceutical player Cipla sealed the deal on two US-based companies, InvaGen Pharmaceuticals Inc., and Exelan Pharmaceuticals Inc. Later, in April, Singapore-based Luye Medicals Group acquired Australia’s Healthe Care, vaulting into position as one of the largest private medical groups in the region.

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With an ‘eat or be eaten’ narrative at play, should Asian health providers increasingly look to the acquisitions bandwagon to stay competitive?

Whether through local or crossborder deals, the question is a pressing one—both for the C-suite in healthcare and private equity investors interested in profiting from consolidations and ‘rolling up’ businesses in this space.

The Consolidation Lifecycle

According to the merger endgames theory posited by A.T. Kearney researchers circa 1990, the answer depends on where a particular industry falls in a four-stage consolidation lifecycle. The theory—which is based on an analysis of ~25,000 companies across 24 industries globally—suggests that all indus-

tries will journey through the same four stages over a ~25 year period. The companies that fare well in the longterm are reportedly the ones that take a proactive role in driving their industry’s consolidation—the so-called endgame.

The idea is simple. If it is possible to understand the defining traits of each stage in the consolidation lifecycle, a business should undertake every major strategic and operational move in line with their place in a particular industry and the industry’s stage in the overall consolidation trajectory.

This sounds promising in theory, but what does it mean?

Stage 1: An industry is said to ‘open’ with a single start-up or a monopoly resulting from deregulation or privatisation. Initially, industry concentration

stands at 100 per cent but as competitors make swift inroads, the market quickly becomes fragmented and the combined share of the three largest players drops to between 10–30 per cent.

Players at this initial stage are focused on making inroads, with no real rationale for consolidation.

Stage 2: With the passage of time, players in the industry switch towards building scale and the Top Three come to hold 15–45 per cent of the market.

This is a stage of rapid consolidation as larger players absorb smaller targets in their effort to create ‘empires’.

Stage 3: By this stage, players in the industry are focused on developing their core business and outpacing the competition, with the Top Three claiming 35 per cent–70 per cent of the market. Unlike the previous phase when larger companies acquired weaker targets, Stage 3 is all about mega deals and large-scale consolidation plays—in

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Industry concentration (CR3)

parameters that safeguard proprietary technology. Healios is an example of a Japanese company that seems to be doing this right. In January 2016, the company announced a partnership with US-based Athersys, aimed at the development and commercialisation of novel cell therapy treatments. The partnership includes MultiStem, a proprietary, patented off-the-shelf stem cell therapy developed by Athersys for multiple disease indications. If the consolidation lifecycle is to be believed, it is still too early for players in this stage to consider acquisitive activity as a viable strategic move.

Time C3 = The combined market share of the three largest companies in an industry Recreated from Winning the Merger Endgame by Graeme Deans, Fritz Kroeger, and Stefan Zeisel

Figure 1

essence, the emphasis is on the merger of equals.

Stage 4: During the balance and alliance stage, the Top Three companies control 70 per cent–90 per cent of the market. This is a stage when further consolidation is either limited or non-existent, whether due to antitrust concerns or industry complexity.

Instead, companies operating in these industries must defend their leading positions.

Application of the Consolidation Lifecycle Within the global healthcare landscape, many providers are focused on a medley of consolidation, convergence and connectivity. The concern is that consolidation decisions don’t always pan out as planned, partly due to poor timing. For Asian healthcare providers, the need of the hour is to build strategy around the stage of the industry in which they operate. What might it look like if the consolidation lifecycle was applied to some of these players?

Stage 1: Regenerative Medicine in Japan

In Japan, regenerative therapies are a

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good example of a Stage 1 industry, owing to a new legal framework for cell-based and tissue-based therapies that went into effect in November 2014—expediting the development and conditional approval of products that demonstrate safety and probable efficacy. Japanese corporations such as Cyberdyne and Healios K.K. are increasingly investigating opportunities to bring regenerative therapies to market, even as foreign companies— like Australian regenerative medicine business Mesoblast—look at more partnership deals in Japan.

According to the consolidation lifecycle, the right move for companies in Stage 1 industries is to aggressively defend their first-mover advantage by building scale, developing a global footprint and protecting proprietary technology and ideas. The recommendation for Stage 1 companies is to focus more on earning revenue and amassing market share, particularly before competitors encroach upon the opportunity. In a space soon to be flooded by CMOs, CROs, biotech and pharma companies, the need of the hour is for Japanese businesses to grow within

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Stage 2: Pharmaceuticals Sector in Japan, China and India

A sampling of recent deal activity in Asia suggests that the pharmaceuticals sector is a good example of a Stage 2 industry where players have been focused on building scale. In the three years leading up to 30 June 2016, ~388 healthcare deals transpired in Asia.

Amongst these, ~125 deals were in the pharmaceuticals and biotechnology space—with ~70 per cent of acquisitive activity involving companies based in Japan, China and India.

Mergers and acquisitions have long been underway in Japan’s Big Pharma market; with much large-scale domestic consolidation having already taken place in the past decade involving companies like Astellas and Takeda.

Despite this wave of M&A, Japan’s pharma sector is still largely fragmented and there remain further opportunities for deal-making to expand both R&D investments and end-market reach.

Aside from overseas deals, large Indian pharma companies like Torrent Pharmaceuticals have been busy swallowing up smaller players. In Torrent’s case, these acquisitions have been a means of quickly enhancing their standing as a manufacturer of Active Pharmaceutical Ingredients (APIs) for regulated markets.

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In China, most of the deal activity over the past three years has involved domestic players around Chinese herbals and natural medicine, biopharmaceuticals and other manufacturers of capsules/tablets. In May 2016, vitamin-maker Blackmores acquired Global Therapeutics, Australia’s top Chinese herbal medicine retailer, in a bid to enhance its product push into Asia and deepen its understanding of the Chinese market.

In this sense, a Stage 2 industry is one that has found its bearings—frontrunners in such industries typically enjoy a stable income stream, diverse end-markets, entrenched customer relationships and a clear value proposition. At this point, it makes sense to build scale. As such, Stage 2 is typically characterised by larger players regularly absorbing smaller targets in an effort to create empires. On the flip side, companies that opt to sit out the M&A wave can grow increasingly vulnerable to ‘being eaten’. Achieving a finely calibrated fit in terms of acquisitions may well be pivotal for businesses that do not wish to be overtaken in a Stage 2 industry.

Stage 3: In-Vitro Diagnostics (IVD) Market in China

Globally, the IVD industry has been rather deal-oriented with ~240 acquisitions between 2012 and October 2015.

With in-vitro diagnostics influencing over 60 per cent of clinical decisionmaking, this is a market that appears to be switching from Stage 2 to Stage 3 in China—with foreign players driving the endgame rather than homegrown companies. International companies currently account for ~75 per cent of the Chinese market; with giants like Roche (~20 per cent), Abbott (~12 per cent) and Siemens (~10 per cent) dominating the space. Homegrown players like Mindray Medical, DaAn Gene, Fosun Diagnostics and Shanghai Kehua Bio-Engineering comprise the rest of the market.

With an ‘eat or be eaten’ narrative at play, should Asian health providers increasingly look to the acquisitions bandwagon to stay competitive?

For players entering Stage 3, the strategic priority is to enhance their core business and outpace the competition via large-scale consolidation plays. The goal is no longer the acquisition of smaller targets but mergers of equals. Over the past 2 years, Roche in particular has embarked on a string of acquisitions in order to ensure that the company has an end-to-end value proposition that meets the needs of customers in the clinical sequencing arena. To improve sample preparation, Roche acquired Kapa Biosystems, Lumora, AbVitro, and MilliSect. It also acquired nanopore sequencing firm Genia and launched collaborations with sequenc-

ing tech firms like Stratos. Roche also took on Bina Technologies for its informatics, to generate actionable data. In China itself, Roche invested in a new diagnostics equipment manufacturing facility in 2014 to respond better to the local market. In future, Roche is an example of a company that is likely to shift from the acquisition of smaller targets towards large-scale consolidation plays. By comparison, it would appear that homegrown Chinese players in the IVD space have already lost the merger endgame.

Stage 4: Private Hospitals in Singapore

Singapore’s private hospital space is on the cusp of transition from Stage 3 to Stage 4. While large companies operating in Stage 3 of the industry lifecycle tend to focus on outpacing the competition via large-scale consolidation plays, such players eventually transition into Stage 4 ‘Grandmasters’ whose priority it is to defend their leading positions.

IHH Healthcare Berhad—the 2012 IPO-ed offspring of Singapore’s Parkway and Malaysia’s Pantai—is a solid example of a merger of equals that is pushing Singapore’s private hospital market towards Stage 4. In 2012, IHH alone commanded ~44 per cent of licensed

Figure 2: Word Cloud of themes across 388 healthcare M&A deals in Asia, 30 June 2013–2016 (Source: Pitchbook)

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So What?

Ultimately, the merger endgames theory or consolidation lifecycle has its limitations in terms of the precision with which it can explain an industry’s trajectory over time and the behaviour of companies within these industries. The real value of the consolidation lifecycle, however, is as one of several frameworks for strategic thinking. By studying the cycles through which industries pass, learning to identify where in the cycle their industry currently stands, and understanding the anticipated evolution of consolidation moving forward, Asian healthcare players can better determine which organisational changes to make, when to make them and how to develop and deploy the most feasible acquisition strategies. Health conglomerates can also leverage this knowledge in order to optimise their aggregate portfolio of subsidiaries and business units across the different endgame stages. Not every player can lead the consolidation endgame but there is much to be learned by tracking the progress of Endgame winners, like Roche and IHH Healthcare.

References are available at www.asianhhm.com Author BIO

beds and ~70 per cent of revenues across Singapore. With ~10,000 licensed beds in 52 hospitals across 10 countries and a market value of ~$14.2B in 2016, IHH also tops the region’s healthcare providers in market value.

IHH still appears focused on acquisitions in the medium term. In 2015, the company picked up two hospitals in India—Continental and Global.

However, in future, it is likely that such acquisitive activity will fast become untenable due to antitrust concerns. In 2015, The Competition Commission of Singapore blocked IHH’s proposed acquisition of RadLink-Asia, a provider of diagnostic imaging and radiography services in Singapore. Consequently, during this stage, alliances and spinoffs may become more attractive strategies. Ultimately, companies that lead in Stage 4 industries have the potential to be successful for a long time depending on how they handle their position.

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Piyumi Kapugeekiyana is a Senior Consultant and Relationship Manager for Stax Inc., a 20-year old global strategy consulting firm with offices in New York, Boston, Chicago, Singapore and Colombo. Piyumi oversees the end-to-end delivery of projects across industries, with a special focus on the healthcare space. She can be reached at piyumik@stax.com

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Held in

Risk Assessment and Early Detection Key to Timely Treatment of Breast Cancer

Breast cancer is most common among women worldwide.

Of late, it has been observed that the age group of women who fall prey to this disease has reduced to 30s and 40s. Women using contraceptive pills for 10 years or more are at an increased risk of getting breast cancer.

Aditi Bhatt, Consultant Surgical Oncology Fortis Hospital, India

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A

s the incidence of breast cancer sees a sharp increase, creating awareness about the disease and diagnosing it on time can make the difference between life and death for many women.

Among all the ailments that affect women, breast cancer seems to be the

MEDICAL SCIENCES

leading cause of cancer deaths among women in India. While cervical cancer still remains the number one cancer affecting women in the country, breast cancer is most common among urban Indian women accounting for 29 per cent of all female cancers.

According to recent research, breast cancer cases have increased manifold and most often patients present to the doctor in the later stages of the disease, decreasing the chances of their long term survival. Doctors feel that of late, there are a number of contributing factors about the disease that are unique to India: 1.Younger women are worst affected: Breast cancer is making its appearance among women who are still in their 30s and 40s.

2.Late diagnosis: Women are presenting to hospitals in the later stages of the disease lowering their chances of survival 3.Low awareness and screening among Indian women: Since there is a general lack of awareness about getting screened and checked for breast cancer, even among the high risk female population, the disease is not detected early.

Breast Cancer: Definition, Symptoms And Risk Factors

most dreaded, mostly because of the stigma attached to the disease and the apparent increase in the number of cases in recent times.

Breast cancer is the leading cancer among women worldwide and recent studies have revealed that the disease has replaced cervical cancer as the

Breast cancer is a malignant growth in the cells of the breasts. It mostly affects women but some men can also get breast cancer.

Symptoms • A lump or abnormal thickness inside the breast that feels different to the touch • Blood or discharge from the nipple • Sudden inverting of nipples • Change in size or shape of the breast/ dimples on the breast • Dry or scaly nipples with peeling skin around it • Redness of skin over the breast • Pain Risk Factors • Being a woman: Since the disease is very rare in men, being a woman

increases ones chances of getting breast cancer.

• Age: The risk of developing breast cancer increases with age.

• Menstrual and reproductive factors: Early onset of menarche and late onset of menopause, late pregnancy and women who have not breastfed are more at risk of developing breast cancer.

• Radiation exposure: An increased rate of breast cancer has been observed in women who are survivors of the atomic bomb explosions or those who have been treated with radiation for a particular disease.

• Contraceptive pills and hormone replacement therapy: Women using contraceptive pills for 10 years or more are at an increased risk of getting breast cancer. Similarly, women who use hormone replacement therapy (HRT) for prolonged periods are at risk.

• Alcohol: Women consuming alcohol are at a higher risk of getting breast cancer than those who do not.

• High-fat diet: Women who have diets high in animal fat or high-fat dairy foods.

• Obesity: Women who are overweight or obese are at a higher risk of getting breast cancer.

• History of breast cancer or other cancers: A woman who has already been treated for breast cancer is at a significant risk of being afflicted a second time.

• Family history: Breast cancer can affect one or more members of the same family because of a defective gene or because of being exposed to the same environmental or dietary factors.

According to doctors, 5 to 10 percent of breast cancers are linked to gene mutations passed through generations of a family.

• Gene: A number of inherited mutated genes that can increase the likelihood of breast cancer have been identified.

The most common are breast cancer gene1 (BRCA1) and breast cancer gene 2 (BRCA2), both of which significantly

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increase the risk of both breast and ovarian cancer. BRCA1 and BRCA2 are human genes that are linked to breast cancer. Genes control cell division and any abnormality (mutation) in the gene can lead to abnormal/ increased cell division which could lead to cancer.

Specific inherited mutations in BRCA1 and BRCA2 increase the risk of female breast and ovarian cancers, and they have been associated with increased risks of several additional types of cancer.

Risk Assessment and Awareness of Breast Cancer

Oncologists reiterate the fact that creating awareness among women about the disease and assessing the risk a woman has of developing cancer can go long way in prevention and timely treatment, especially because, in India, majority of women seek medical attention at later stages when the options of treatment may be limited.

“Women may have lot of apprehensions and fears about getting breast cancer, if close family members have been diagnosed or if they find any abnormality in the breast. About 80 per cent of the breast lumps are non-cancerous and do not require surgery, therefore awareness in making women aware of which lumps are dangerous and which are not and also when they should opt for diagnostic tests such as mammography is a must,” says Aditi Bhatt, consultant surgical oncologist at Fortis Hospitals.

Based on various factors, a risk assessment of a woman can be done to check how susceptible she might be to the disease and if the risks are high, how it can be managed to ensure timely diagnosis and treatment, and long term survival.

“In our country women with average risk under30 years of age are generally not recommended to undergo mammography. But those with family history or personal hisptory, a genetic mutation known to increase risk of

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According to recent research, breast cancer cases have increased manifold and most often patients present to the doctor in the later stages of the disease, decreasing the chances of their long term survival.

breast cancer (such as BRCA), and women who had radiation therapy to the chest before the age of 30 are at higher risk. Those at average risk should do breast self-examination every month and clinical breast examination once a year. For any abnormality an ultrasound of the breast is useful. Women aged 40 to 50 years should have the choice to start annual breast cancer screening with mammograms if they wish to do

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so. Those above 50 should continue yearly screening as long as they are in good health,” adds Dr Bhatt.

Women with high risk can get a mammogram every year. This includes women who have a lifetime risk of breast cancer of about 20 per cent to 25 per cent or greater, according to risk assessment tools that are based mainly on family history; have a known BRCA1 or BRCA2 gene mutation; have a close relative (mother, sister, child) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves; had radiation therapy to the chest or have certain rare genetic disorders such as Li-Fraumeni Syndrome, Cowden Syndrome, or Bannayan-Riley- Ruvalcaba Syndrome, which increases their risk of breast cancer.

Screening for Breast Cancer

Cancer screening is looking for cancer before a person has any symptoms.

Screening tests can help find cancer at an early stage, before symptoms appear, which may make it easier to treat or

MEDICAL SCIENCES

Genetic Counselling and Testing and for Breast Cancer

Genetic counselling is recommended before and after any genetic test for an inherited cancer syndrome. This counselling should be performed by a health care professional who is experienced in cancer genetics. Genetic counselling usually covers many aspects of the testing process, including: A hereditary cancer risk assessment based on an individual’s personal and family medical history, medical implications of a positive or a negative test result, the psychological risks and benefits of genetic test results, the risk of passing a mutation to children and explanation of the specific test(s) that might be used.

“A thorough history is taken to determine if the person could be harbouring a genetic mutation. The test itself is done on a blood sample that is drawn from the individual who is to be tested. A positive test result indicates that a person has inherited a known harmful mutation in BRCA1 or BRCA2 and, therefore, has an increased risk of developing certain cancers.

However, not all persons harbouring the mutation develop cancer and some of them may never develop any cancer in their lifetime,” explains Dr Bhatt.

Getting a genetic test done resolves uncertainty regarding future cancer risk and may allow people to make informed decisions about their future, including taking steps to reduce their cancer risk.

Reducing the Risk

Some women might choose to take preventive measures if they are found to have a higher risk of developing cancer. These include Prophylactic (risk-reducing) surgery that involves removing as much of the breast tissue as possible; and chemoprevention: this is the use of drugs, vitamins, or other agents to try to reduce the risk of, or delay the recurrence of, cancer.

Treatment

A group of specialists comprising of a surgical oncologist, medical oncologist,

Author BIO

cure. By the time symptoms appear, the cancer may have grown and spread, which makes it harder to treat or cure.

Diagnostic Tests Used for Breast Cancer Screening Mammogram: A mammogram is an X-ray of the breast. This is the best way to find breast cancer early, when it is easier to treat and before it is big enough to feel or cause symptoms. Having regular mammograms can lower the risk of death from breast cancer.

Clinical breast exam: A clinical breast exam is an examination of the breasts done by a doctor or nurse. It can be done by the gynaecologist or general practitioner at the time of consultation for other reasons.

Breast self-examination: Being familiar with how ones breasts look and feel can help one notice symptoms such as lumps, pain, or changes in size that may be of concern. These could include changes found during a breast self-exam. Any changes noticed should be reported to the doctor.

Breast MRI: A breast MRI uses magnets and radio waves to take pictures of the breast. This is used along with mammograms to screen women who are at high risk of getting breast cancer.

radiation oncologist, radiologist and pathologist with review the patient’s reports once all the diagnostic tests have been done. They will also look at factors like the age of the patient, personal and family history, as well as other illnesses that may affect the choice of treatment and draw up a treatment plan that is best suited for the patient. The treatment choice depends on the stage of the tumour and the pathological classification as well.

Breast Cancer Requires One or a Combination of the Following Treatments: Surgery: This involves removal of the tumour with the surrounding normal breast tissue and glands from the armpit. In some cases the whole breast may have to be removed.

Radiotherapy: Radiation therapy is the use of electromagnetic waves to destroy tumour cells. It is generally used in combination with surgery to treat the remaining breast and/or glands in the armpit and around the collar bone.

In patients with stage 4 cancer, it may be used to treat cancer spread to other areas, e.g. bone, brain.

Chemotherapy: It is drug therapy to kill the cancer cells. It is given in the form of injections or tablets.

Hormone therapy: This comprises drugs that alter the hormone levels in the body.

Aditi Bhatt is a consultant surgical oncologist. She has an experienced over 10 years and has been working at renowned cancer centers in the country and abroad and has performed around 1,000 major cancer related surgeries.

Aditi is a specialist in the management of peritoneal cancers (stage 4 cancers which have spread in the abdominal cavity like pseudomyxoma peritonei, colorectal cancer, ovarian cancer, endometrial cancer, and mesothelioma). She has wide experience and has performed extensive surgeries related to her specialisation.

She is the first surgeon in Bangalore and South India to perform HIPEC (hyperthermic intraperitoneal chemotherapy) for these cancers.

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MEDICAL FAIR THAILAND 2017 Rehabilitative care & connected healthcare

The 8th edition of MEDICAL FAIR THAILAND 2017 is set to reaffirm its place as the leading medical and healthcare exhibition in the region with its upcoming staging from 6 - 8 September 2017 at Queen Sirikit National Convention Center. With an international line-up of 700 exhibitors, 17 national pavilions and country groups that include first time participation from India, Russia, and the European Union, and more than 8,500 qualified trade buyers, MEDICAL FAIR THAILAND 2017 is the premier meeting spot for medical and healthcare professionals.

As Thailand aims to become a high-income country by 2025, and with new development plans in place with Thailand 4.0, the country is transforming itself from

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being industry-driven to innovation and technologydriven. Among the 10 targeted industries are Smart Electronics, High-income Tourism and Medical Tourism, and Biotechnology, as well as additional growth engine sectors such as automation and robotics, digital, medical and healthcare. Against this backdrop, MEDICAL FAIR THAILAND 2017 is the ideal platform to network and source for business opportunities.

The exhibition is supported by some of Thailand and the region’s most prominent government and industry trade associations, including Thailand’s Ministry of Health and the Asian Hospital Federation.

Staying relevant to the changing needs and demands of the Southeast Asian market, which

include an ageing population where 46 million people will be over the age of 65 by 2020, alongside a techsavvy growing middle class population, two special platforms will take centre stage at MEDICAL FAIR THAILAND 2017 -Rehabilitative Care and Connected Healthcare. The extensive showcase will feature a wide range of products and solutions, from patient therapy, exercise and mobility devices to a full suite of smart wearable technologies.

Complementing these two platforms will be the 3rd Advanced Rehab Technology Conference (ARTeC) 2017, with the theme “Robotics for Mobility: Quality of Life for the Ageing World�. Thought-leaders in their respective fields will cover a spectrum of topics such

as robotic rehabilitation, neurological rehabilitation and more.

With a well-established history since 2003, MEDICAL FAIR THAILAND continues to grow from strength to strength as the region's No. 1 medical and health care event. Focused on equipment and supplies for the hospital, diagnostic, pharmaceutical, medical and rehabilitation sectors, the exhibition provides the best business opportunities to navigate the dynamic marketplace of Thailand and Southeast Asia. Plan your visit today!

For more information, log on to: www.medicalfair-thailand.com Advertorial www.asianhhm.com

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MEDICAL SCIENCES

New Approaches for the Development of Diagnostic Systems for Prostate Cancer

Current prostate cancer diagnostic approaches fail to provide sufficient evidence for treatment decision-making.

Since many prostate cancers are slow growing or non lifethreatening, over treatment of indolent disease has become a major issue for doctors and prostate cancer patients.

The ongoing trend towards multiplex biomarker detection holds promise for enhancing current standards of care.

Julia Zapatero Rodríguez, Postdoctoral Researcher, Dublin City University, Ireland, and Project Manager of AbYBiotech Richard O’Kennedy, Professor of Biological Sciences, Dublin City University, Ireland, and Chief Scientific Officer& Founder of AbYBiotech

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P

rostate Cancer (PCa) is one of the most common malignancies of men. The incidence rates are especially high in developed countries, which have the oldest population profiles and, therefore, increased risk of prostate cancer (around 6 in 10 prostate cancers cases are diagnosed in men over the age of 65).The diagnostic incidence of prostate cancer across the US, France, Germany, Italy, Spain, UK, Japan, Brazil, and Canada is expected to increase at an Annual Growth Rate (AGR) of 3.6 per cent from 2013 to 2023 (GlobalData Report, 2015).

MEDICAL SCIENCES

Thus, the diagnostic and screening market for prostate cancer is estimated to reach over US$17 billion by 2017 (BCC Research, 2013). The unmet need for reliable and highly-specific diagnostic tools indicates a requirement for new diagnostic approaches aimed at overcoming the two main problems associated with current Prostate Specific Antigen (PSA)-based testing: high overdiagnosis rates and inability to predict aggressive disease.

Current Standard for Early Detection

Prostate cancer can be detected at early stages by Digital Rectal Examination (DRE) or the PSA test. During the DRE a doctor inserts a gloved finger into the rectum to feel the prostate surface for swelling, harder areas or lumps that can indicate the presence of a tumour. Men with abnormal DRE should be referred to an urologist for further testing, regardless of PSA results. PSA, a serine protease kallikrein protein secreted by the prostate epithelial cells, is involved in seminal liquefaction. PSA testing measures the levels of this protein in blood. Normally, serum PSA levels are low in healthy men, but they increase if there is a disruption of the basement membrane of the prostate gland (e.g. during prostate cancer) and PSA is released into the peripheral circulation. PSA levels under 4 ng/mL are considered ‘normal’; levels between 4 and 10 ng/mL are considered ‘intermediate’, with cancer present in 30-35 per cent of patients; and PSA levels over 10 ng/mL are considered ‘high’, with a 67 per cent probability of advanced disease (National Comprehensive Cancer Network, 2016). DRE and PSA tests are only indicators of cancer risk and, if abnormal results are obtained, a biopsy is often recommended to examine prostate tissue samples for cancer cells. If cancer cells are present, the pathologist will assign a Gleason score on a scale of 2 to 10, based on the appearance of cancer cells compared to normal cells, to help evaluate the prognosis of patients.

The Need for Better Diagnostic Tests

Despite PSA having been considered the gold-standard biomarker for the detection of prostate cancer for almost two decades, PSA screening has led to a high rate of over-diagnosis resulting in men with indolent disease undergoing unnecessary biopsies and subsequent treatment (Etzioni et al., 2002). This is because PSA is not specific for prostate cancer, and can be elevated in other prostate conditions, such as prostatitis or Benign Prostatic Hyperplasia (BPH).

PSA Derivatives and Isoforms The specificity of PSA for prostate cancer can be improved due to the fact that PSA can be found free in serum (free PSA, fPSA) or bound to other serum proteins (complexed PSA, cPSA) and that complexed forms (mainly bound to α1-antichymotrypsin) are more abundant in prostate cancer.

Therefore, the free to total (fPSA plus cPSA) ratio could help to differentiate

prostate cancer from benign prostatic diseases such as BPH. In current clinical practice, the percentage of fPSA is used to avoid unnecessary biopsies in men with normal DRE and total PSA levels between 4-10ng/mL. In this group of patients, a ‘cut-off’ point of 25 per cent fPSA can detect 95 per cent of prostate cancers while reducing unnecessary biopsies by 20 per cent (National Comprehensive Cancer Network, 2016).

Furthermore, it is now known that free PSA can be found in three different isoforms (Figure 1): pro-PSA, accounting for 33 per cent of fPSA; benign PSA (BPSA), which comprises 28 per cent fPSA; and inactive PSA (iPSA) (Özen et al., 2006). ProPSA is the precursor form of PSA and it is composed of inactive truncated forms ([–2]pPSA, [–4]pPSA and [–5]pPSA), as well as the native form, [-7]pPSA, which contains a seven amino acid pro-leader peptide that is removed after its release into

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MEDICAL SCIENCES

Figure 1: PSA biosynthesis. Prostate Specific Antigen (PSA) pre-pro precursor (PreProPSA) is produced in the prostate secretory epithelium and processed to a 244-aa non-catalytic zymogen (proPSA), which is secreted into the seminal lumen. Humankallikreins 2 and 4 (hK2 and hK4) remove the pro-leader peptide to form the active PSA (237 aa). Other inactive, truncated precursor forms are also produced (pPSA). Total serum PSA is composed by PSA complexed (cPSA) to α1-antichymotrypsin (ACT), α2-macroglobulin (A2M)or α1-protease inhibitor (API); and free PSA forms (fPSA), including inactive PSA (iPSA), benign PSA (BPSA) and truncated proPSA.

the prostate lumen to be transformed to active PSA by the action ofhK2 and hK4. Some commercial tests, such as the FDA-approved 4Kscore test (OPKO Health, Inc.) have explored the potential of combining a panel of prostate-related kallikreins to improve PCa detection.

The 4Kscore test combines four prostatespecific kallikrein (fPSA, iPSA, tPSA and hk2) assay results with other clinical information (age, DRE and prior biopsy results) in an algorithm that calculates the individual patient’s percent risk for aggressive prostate cancer (Gleason score ≥7) on biopsy. In a recent multiinstitutional prospective study, data from 1012 men scheduled for prostate biopsy was used to confirm the utility of the 4Kscore test to detect significant prostate cancer (AUC = 0.82). Furthermore, using various 4Kscore thresholds, the number of biopsies could have been reduced by 30–58 per centwhile delaying

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the diagnosis on only 1.3–4.7 per cent of aggressive cancer cases (Parekh et al., 2015).

In addition to this, numerous studies suggest that [–2]pPSA is a cancerspecific form, significantly elevated in the peripheral zone of the prostate (where more cancers occur) and in the serum of prostate cancer patients (Hori et al., 2013; Filella et al., 2015). Further evidence for the association of [–2]pPSA with prostate cancer is provided by the FDA-approved Prostate Health Index (PHI), currently available from Beckman Coulter Diagnostics. This non-invasive blood test measures serum PSA, fPSA and [–2]pPSA to help physicians distinguish prostate cancer from benign conditions. With more than 80 clinical studies published, PHI provides risk stratification to aid in decision-taking management when PSA is in the 4–10 ng/mL range.

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Focus on Multiplexing

As seen with previous examples, multiplexing paves the way towards the development of improved diagnostic and prognostic strategies for prostate cancer. The benefits of using multiplexed assays include improved differential diagnosis of malignant diseases, due to the use of biomarker panels, and enhanced cost-effectiveness, as a result of saving time and reducing sample volume requirements (Table 1) .

Emerging commercial tests for prostate cancer detection and management are exploiting the advantages of multiple-marker detection approaches (Table 1). Further information on these tests can be found in our recent review (Sharma et al., 2017). Most have already been CE marked, FDA cleared and/ orCLIA-waived for different clinical applications, from diagnosis and biopsy recommendations to prognosis and risk

MEDICAL SCIENCES

stratification following a positive biopsy result. However, the majority of them are genomic- or proteomic-only based assays. New efforts should focus on the combination of protein and nucleic acid markers to allow the investigation of tumorigenesis-associated changes that occur at both transcriptional and translational levels. Multiplexing technologies are continuously evolving and platforms like the Verigene system (Nanosphere, Luminex Corporation) ornCounter Vandage 3D assays (NanoString Technologies) enable ultra-

sensitive, multiplexed detection of both protein and nucleic acids using a single platform. The gold nano particle-based Verigene system is used for ‘on-site’ diagnostics of protein (Biobarcode detection) and nucleic acid (direct genomic detection). Despite the main application of this system is in the field of pathogen detection, Verigene assays could be easily configured and implemented for a wide array of potential biomarkers (Shipp, 2006).

The NanoStringn Counter Vantage 3D, recognised by The Scientist as a Top

In current clinical practice, the percentage of fPSA is used to avoid unnecessary biopsies in men with normal DRE and total PSA levels between 4-10ng/mL.

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MEDICAL SCIENCES

Mft

Test name and regulatory approval

Biomarkers tested

Sample required

Clinical application

Sarcosine, alanine, glutamate and glycine

Post-DRE urine cell pellets

Enhanced decisionmaking in relation to biopsy in patients withPSA of 2.5-10 ng/mL and a suspicious DRE Enhanced decisionmaking for repeat biopsy in men ≥50 years with previous negative prostate biopsies

Metabolon Inc.

Prostarix •LDT •CLIA

Hologic Gen-Probe

Progensa PCA3 Assay •FDA •CE

PCA3 and PSA RNA

Post-DRE urine

University of Michigan Health Systems

Mi-Prostate Score (MiPS) •LDT •CLIA

T2:ERG gene fusion, PCA3noncoding RNA, PSA

Urine and serum

Enhanced decisionmaking in relation to first biopsy in patients with elevated PSA levels

Exosome Diagnostics, Inc.

ExoDxProstate (IntelliScore) •LDT •CLIA

Three-gene signature

Urinebased liquid biopsy

Identify high-grade prostate cancer (HGPCA) both at the time of biopsy and at surgery

MDxHealth

Confirm MDx assay •LDT •CLIA

Aberrant methylation in GSTP1, ACT and RASSF1 genes

Biopsy tissue

Enhanced decision-making for repeat biopsy

Genomic Health, Inc.

Oncotype DX Prostate Cancer Assay •Awaiting FDA approval

17 genes involved in androgen pathway, cellular organization, stromal response and proliferation

Biopsy tissue

Risk stratification tests following a positive biopsy result

Myriad Genetics, Inc.

Prolaris •FDA

31 genes

Biopsy tissue

Risk stratification following a positive biopsy result

Bostwick Laboratories

ProstaVysion •LDT •CLIA

DNA methylation of HOXD3 gene, fusion/translocation of ERG and loss of PTEN

Biopsy tissue

Risk stratification following a positive biopsy result

Metamark Genetics

ProMark •LDT •CLIA

8-protein signature (DEL2L1, CUL2, SMAD4, PDSS2, HSPA, FUS, pS6 and YBOX1)

Biopsy tissue

Risk stratification following a positive biopsy result

Stockholm 3 (STHLM3) • Available for clinical use in Sweden

Plasma proteins (PSA, fPSA, iPSA, hK2, MSMB, MIC1), 232 single-nucleotide polymorphisms, and clinical variables

Blood

Karolinska University

Risk stratification following a positive biopsy result

Table 1 Examples of multiplex biomarker tests commercially available for the management of prostate cancer. Adapted from Sharma et al. (2017) 22

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10 Innovation of 2016, uses an optical barcoding technology for simultaneous DNA mutation detection, RNA and protein expression detection and even protein phosphorylation status.

NanoString’s technology has already proved useful for medium throughput validation of prognostic markers and therapeutic targets in prostate cancer (Lee et al., 2016).

Autoantibody Signature When cells become cancerous, they undergo a series of transformations that can result in the synthesis of tumourassociated antigens (TAA). Our body’s immune system responds by producing specific autoantibodies (AAbs) to these TAA. These autoantibodies are emerging as promising biomarker candidates due to their high specificity, their easy detection in serum and their presence during the initial, otherwise undetectable, stages of tumorigenesis.

Several prostate cancer associated AAbs have been identified, includingNYESO-1, XAGE1b, SSX-2 and 4, AMACR, p90, LEDGF, TARDBP, TLN1, PARK7, CALD1, TTLL12, p62, Koc, Cyclin B1, PKACA, HIP1,Survivin, MUT, RAB11B, CSRP2, SPOP, RalA, ZNF671, ERB, HERV-K, PSA and HER2 (McNeel et al., 2000; Rastogi et al., 2016).To increase the sensitivity and specificity of these autoantibodies for a particular stage and type of cancer, multiplexing approaches are especially useful. An AAb panel like this has already successfully been validated for early diagnosis of bowel cancer by DCU scientists from the Applied Biochemistry Group (Dublin City University).

Targeting glycosylation in cancer

Changes in glycan (sugar chain) structures in glycoprotein biomarkers during the tumorigenesis process are also a main focus of cancer diagnostics research. Glycosylation is the most common post-translational modification in proteins and the collection of glycans present in cells at a

MEDICAL SCIENCES

companies such as GlycoSeLect Ltd. are now genetically engineering lectins with wider specificities and improved affinities. Electrochemical biosensors with a “sandwich” format in which the analyte of interest is captured by immobilised antibodies on the electrode for subsequent glycoprofiling using lectins could provide a means of highly sensitive biomarker detection coupled to glycan analysis.

Conclusion

proteins (lectins), instead of antibodies (immunoglobulins). Lectins can also be used for the analysis of the glycosylation state of particular proteins that had been previously captured by an antibody.

Panels of proteins can be probed in parallel using antibody-lectin sandwich arrays (ALSA) to examine protein glycan alterations associated to pathological conditions (e.g. tumorigenesis), which is especially valuable for cancer biomarker studies (Haab, 2012). However, the use of lectins may be limited due to their lower affinities, which in return leads to poor sensitivity, and their limited availability, particularly those specific to less common glycan structures. In order to overcome these limitations,

Author BIO

particular time, known as the glycome, can be characteristic of various stages of tumorigenesis. Aberrant glycosylation patterns in glycoprotein prostate cancer biomarkers such as PSA, prostatic acid phosphatase (PAP), prostate stem cell antigen (PSCA), prostate specific membrane antigen (PSMA) and haptoglobin (Hp) have been reported as a result of oncogenic transformation (Belický and Tkac, 2016). Analysis of glycans has traditionally required sophisticated instrumental techniques, such as mass spectrometry (MS), capillary zone electrophoresis (CZE), high performance liquid chromatography (HPLC) or ultra performance liquid chromatography (UPLC). In recent years, lectin-based biosensors are getting attention as a feasible alternative to such systems for biomarker glycoprofiling.

In contrast to more complex glycan analysis strategies like MS, lectin-based assays can discriminate different glycan structures on intact glycoproteins and even viable cells, because they do not require chemical or enzymatic separation of the glycan from the starting material.

Enzyme-linked immunosorbentlectin assays (ELLA) are conceptually similar to standard enzyme-linked immunosorbent assays (ELISA), but they rely upon non-immunogenic glycan-binding

The ambiguity associated with total PSA test-based prostate cancer diagnosis is probably the main driving force behind the search for new biomarker panels to distinguish between cancerous and non-cancerous conditions. The use of multiplexed tests based on PSA isoforms and additional cancer-specific biomarkers and glycosylation patterns may help reducing unnecessary biopsies while enhancing the capability for early detection of aggressive disease.

Acknowledgements

We would like to acknowledge support from the European Commission FP7 Programme through the Marie Curie Initial Training Network PROSENSE (grant no. 317420, 2012–2016) and the Biomedical Diagnostics Institute (BDI) though Science Foundation Ireland (SFI) under Grant No. 10/CE/ BE1821.

References are available at www.asianhhm.com

Julia Zapatero Rodríguez is the Project Manager at AbYBiotech, a Dublin City University spin-out company specialising in recombinant antibody production. Before joining AbYBiotech, she was part of the prestigious Marie Curie ITN project PROSENSE, a multidisciplinary network which aimed to develop new diagnostic tools for prostate cancer.

Richard O’Kennedy is a Professor at Dublin City University (DCU), has published extensively (220 peer-reviewed papers, 50 reviews, 40 book chapters, 2 books), has many collaborations with industry, 7 patents, multiple licences and many of his innovations have been licenced. He is Founder and Chief Scientific Officer of AbYBiotech.

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Value-Added Healthcare for Asia Pacific Ms. Staudinger, you are President of Siemens Healthineers in Asia Pacific. Could you briefly elaborate on the company?

Let me start with our brand name which we’ve introduced last year, as this might sound rather extraordinary to you.

“Healthineers” is designed to underline our pioneering spirit and engineering expertise in the field of healthcare. In our opinion, the name best describes our organization and its people – the people accompanying, serving and inspiring customers, the people behind outstanding products and solutions.

What products and solutions are we talking about? First, it’s in-vivo products and in-vitro products. So we cover everything from a basic X-ray machine to a high-end CT scanner and a diabetes test. Secondly, we’re continuously expanding our value-added services to improve outcomes and reduce costs for healthcare providers.

So what’s happening in the field of healthcare?

Industry-wide, we notice shifts towards consolidation and industrialization. What do I mean by consolidation? Healthcare providers are merging to gain competitive advantages by offering more specialized care. Within the region Asia Pacific, Australia is a very extreme example of a highly consolidated

market: We’re looking at only a handful of providers, who run very large-scale operations.

The picture looks different for emerging countries, of course. We see that they all take their very own approach towards healthcare. Look at Indonesia, for example, where a universal coverage healthcare model has been established to provide insurance for everyone.

You also mentioned industrialization in the field of healthcare – what does that mean?

Lowering costs while improving outcomes. And while that sounds like an easy formula, it’s not so simple in real life.

Processes need to be scrutinized and complexity reduced – constantly. Here, we step in, providing our customers with tools to monitor their equipment in regards to workflow and maintenance. Subsequently, idle times of machines, but also waiting times for patients are being reduced.

In the field of lab diagnostics, we’ve recently introduced Atellica Solution, a highly-flexible immunoassay and clinical chemistry solution. It comes with a bi-directional magnetic sample-transport technology that is ten times faster than conventional conveyors. Atellica allows our customers to focus on business and clinical outcomes and spend less time handling operational tasks. We have developed Atellica

Atellica Solution comes with a bi-directional magnetic sample-transport technology that is ten times faster than conventional conveyors

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based on our customers’ needs and it is a great proof point of our innovation leadership.

You mentioned that you are continuously expanding your value-added services?

Exactly, and there are two dimensions to that. One is what we call Enterprise Solutions. What does that mean? In the past years we have been entering into long term managed equipment services contracts with customers where we supply them with the latest in medical technology and also provide services beyond our products.

At the moment, we have around 40 such agreements in place – with life spans of up to 40 years. Only recently, we established an agreement with a newly constructed hospital in Perth, Australia, to procure, install, and manage the entire base of medical devices. We also have our people on the ground in charge of running biomedical services within the hospital.

To us it is all about Performance through Partnerships.

The second dimension is connected to a buzzword: Big Data. Everyone has heard about it, but in the field of healthcare, what does it imply? Well, we have a massive amount of installed equipment all around the world – in fact a total of 600,000 systems. And they all produce data: Clinical images, dosage levels, examination types and so on. Our calling is to make use of that data and create value for our customers. Thus, we have come up with a platform called “teamplay” that allows institutions to benchmark their performance standards against others and eventually identify areas of improvement.

We’ve also entered into the field of population health management by forging a global alliance with IBM Watson Health. By that we aim to help hospitals, health systems, integrated delivery networks, and other providers deliver value-based care to patients with complex, chronic and costly conditions such as heart disease and cancer.

What are considered “hot topics” within your organization at the moment?

We’re definitely keen to step up our engagement in the services space and aim towards more complex business models.

This requires partnerships and joint ventures, and changes in organizational dynamics. To establish great relationships with our customers, proximity to them is vital. Therefore, we have decided to strengthen our regional organizations.

As Asia Pacific mostly consists of emerging markets, it is also a region with great demand for better healthcare delivery for large populations. To meet this demand, we do not only sell but also manufacture here. In our factory in Goa, India, we design and produce basic X-ray systems which are also sold in the country. The rationale behind manufacturing in the countries the products are designed for is that we make sure that local market needs are met and

Elisabeth Staudinger President, Siemens Healthineers Asia Pacific

products are readily accessible. On top of that “local to local” approach, Bangalore, India, is a fantastic example of how local knowledge influences our global organization: We have around 1,500 software engineers employed on-site whose vast knowledge has a great impact on product development on a global scale.

Overall, we see it as our task to develop innovations that are not only of high quality but that are also affordable enough to benefit everyone and make our customers’ lives easier. Take our new MRI scanner Magnetom Sempra. It is a particularly cost-effective scanner that covers many clinical fields and allows for really fast examinations, while operating at a low energy level. Our latest CT scanner platform Somatom Go on the other hand offers automated, standardized workflows that help users achieve profound clinical results. In addition, it also comes with high financial reliability. I’m excited to see those systems in use with the first APC customers anytime soon!

So you’re facing the future with confidence?

Well, all afore mentioned aspects make healthcare an exciting field for us to be in. We’re keen to support our customers on their journey to providing health. And yes, we are confident that we can equip them with the right solutions to do so.

True to our motto – Engineering Success and Pioneering Healthcare. Together.

Disclaimer: The products/features (here mentioned) are not commercially available in all countries. Due to regulatory reasons their future availability cannot be guaranteed. Please contact your local Siemens Healthineers organization for further details.

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technology, equipment & devices

Are We Close to a Global Ban on Powdered Medical Gloves?

Powdered medical gloves can cause allergic reactions, severe airway inflammation, wound inflammation, adhesions, and postsurgical scar tissue formation. These concerns provide the stimulus for the banning of powered gloves and the transition to the use of powder-free or synthetic gloves as the new standard of care.

Patty Taylor, V.P. Professional Education & Clinical Affairs, Ansell, US

G

loves are the most common type of Personal Protective Equipment (PPE). Gloves are considered a barrier protecting both healthcare worker and patient from the transfer of harmful microorganisms. Powder has been used as a lubricant in the manufacture of medical gloves in order to facilitate donning and to avoid blocking of the glove. Nowadays, the more widely used dusting powders are cornstarch that coats the glove inside, and Calcium Carbonate (CaCO3) that coats the outer surface.

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technology, equipment & devices

Complications Associated with Glove Powder

Years of clinical studies, research and industry input have provided ample data about the adverse reactions to both workers and patients that may arise from the use of gloving powders.

For healthcare workers, the reactions caused by powdered gloves vary from well-known allergy symptoms and upper respiratory-tract disorders to pleuritis, myocarditis and irritation of the central nervous system. For the patients, the reactions caused by powdered gloves includes the development of adhesions and granulomas, delayed healing and increased risk of surgical site infections.

The adverse effects of powdered gloves use are caused by the powder itself as it enters the patient’s body during surgery and contaminates the wound, despite glove washing or wiping prior to undertaking the surgical procedure.

The wound retains a substantial amount of residual powder granules at the conclusion of the operation with the amount of residual granules found to be proportional to the number of powdered gloves used in the operating room, rather than directly related to whether the surgeon is using powdered or powder-free gloves. This is a critical issue as glove powder can act as a vehicle for opportunistic and pathogenic microorganisms to spread and potentially act as a food source for bacteria including MRSA and VRE, which increase the risk for post-operative wound infections.

The US Food and Drug Administration (FDA) enacted a rule banning the use of powdered surgical gloves, powdered exam gloves, and absorbable powder for lubricating surgical gloves.

The presence of powder in the wound may trigger a range of responses such as a delay in the healing process, alteration of the normal reparative process and an increase of the wound’s inflammatory response. In addition, researchers have shown that the presence of glove powder significantly decreases the inoculum of bacteria required to produce abscesses.

This increases the surgical site infections occurrence risk, which poses a significant burden on the hospital budget.

Another common problem that can arise from the use of powdered gloves is the development of adhesions triggered by the increased inflammatory response, and granulomas. Adhesions are the major cause of postoperative intestinal obstruction. Uterine and fallopian tube adhesions, resulting from glove powder, are a significant risk of female infertility, which is the reason why powder-free gloves should be used even for routine vaginal examination. These effects have been well documented not only in the peritoneal cavity and uterus, but reported in almost every anatomical site such as the eyes, cranial cavity, middle ear, and thorax among others.

One of the best documented consequences of the use of powdered gloves in the healthcare setting is the sensitisation and development of diverse allergic reactions to Natural Rubber Latex (NRL) such as upper respiratory tract symptoms or eye irritation. These reactions are not caused by the powder itself, but rather by its capacity to bind with NRL protein antigens. These allergen/protein coated powder particles can be aerosolised when the gloves are donned or removed, thus contaminating the hospital environment. Powdered latex gloves aerosolise more latex proteins into the air than any other medical product in a hospital and those hospital areas where powdered gloves are used have 300 times more aerosolised latex proteins that areas of powder-free usage.

The inhalation or ingestion of these powder particles can remain in the air, on instruments and equipment for

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technology, equipment & devices

many hours, and can lead over time to the development of sensitisation and allergies. A decrease in the number of healthcare workers with suspected NRL allergy including occupational asthma and contact urticaria when powdered gloves are substituted by powder-free gloves has been reported. This is not surprising if we take into account that it is estimated that the use of powdered gloves will deposit in excess of 2kg of glove powder per year per theatre. The presence of glove powder can result in many other undesirable effects, such as the contamination of catheters, perfused donor kidneys and cosmetic dentistry materials (crowns, prostheses) among others.

All the issues outlined in this article can be easily reduced by switching from a powdered to a powder-free environment.

This may have additional cost-savings in reduced healthcare personnel sickness and post-operative complications.

Also, it must be stated that the cost of washing surgical powdered gloves prior to use, has been reported as being at least seven times higher than the cost of using powder-free gloves while at the same time being inefficient in totally removing the glove powder.

Restrictions and Bans on Powdered Gloves

The documented adverse effects caused by the use of powdered gloves are the reason for a global decrease in powdered gloves usage, and a shift towards powderfree gloves. Realising the dangers of cornstarch on examination and surgical

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gloves, hospitals around the world starting moving to powder-free gloving alternatives. Germany's regulations of personal protective equipment banned the use of powdered medical gloves in 1997.In 2000, the Purchasing and Supply agency for the United Kingdom ceased to purchase any gloves lubricated with cornstarch.

The US Food and Drug Administration (FDA) enacted a rule banning the use of powdered surgical gloves, powdered exam gloves, and absorbable powder for lubricating surgical gloves. The ban, first proposed in March 2016, was announced by the FDA on December 19, 2016 and became effective on January 18, 2017.

FDA’s rationale for the ban is based on the risk of illness or injury to patients and healthcare providers exposed to the powdered gloves, when internal body tissue is exposed to the powder, which may include severe airway inflammation and hypersensitivity reactions. Powder particles may also trigger the body's immune response, which can lead to an array of conditions from allergic reactions to surgical complications. Alternatively, there are other medical gloves available that are powder-free and provide the same degree of protection, hand dexterity, and performance without posing the same risks to individuals.

In addition, on January 8, 2017, the Saudi Food and Drug Authority (SFDA)

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banned the manufacture, import, sale and distribution of powdered surgical and patient examination gloves as well as the absorbable powder used to facilitate wearing of medical gloves. In a statement on its website www.sfda.gov.sa, the Authority explained that the reason for the ban is the probable link of using such gloves with many health risks, including acute respiratory infections; anaphylaxis; allergic asthma; inflammation and damage of lungs' airways (bronchial tubes); skin rash and adhesions of abdominal membranes. The ban is to go into effect March 27, 2017.

On December 27, 2016 Japan announced their intention to enact a similar ban with a two-year transition through to December 2018.

The Ministry of Food and Drug Safety Korea in a January 24th 2017 meeting announced they too are considering a powdered glove ban transition through to December 2018.

Hospital Authority (HA) of Hong Kong implemented a ban to local hospitals effective 19th January 2017, following the ruling of US FDA. This applies to government hospitals which is under the responsibilities of HA. Private hospitals which are not under control of HA have also adopted the same stance.

technology, equipment & devices

Improved Glove Technology

Improved technologies and manufacturing techniques can eliminate the need for powder entirely. The application of a polymer coating to the inside film of latex or synthetic gloves enhances the donning attributes of the glove in both wet and dry conditions.

A wide array of synthetic glove choices are available today such as polyisoprene, neoprene or nitrile which are latex free (safe for those with a latex / Type I allergy), some are chemical free (safe for those with a chemical / Type IV allergy) and all provide excellent barrier protection. The bottom line is: there are other, better clinically relevant solutions available that have all the same fit, feel and comfort of powdered gloves.

And while many healthcare providers have already moved away from powdered gloves, many are still actively exploring the new offerings to determine which option is right for them. That’s where education is critically important to help workers select the best option that ensures performance, protection and safety.

When it comes to clinical education in this area, Ansell leads the way globally with a comprehensive program available for healthcare professionals around the world.

powdered ban in the United States are expected to range between $26.6 million and $29.3 million. As powdered bans continue, the global impact in terms of savings will be measured potentially in the hundreds of millions of dollars.

Conclusion

Undeniably, we need gloves which provide excellent barrier protection, which do no

harm to patient or worker, and provide a financial benefit. The literature indicates that these gloves should be powder-free.

The use of powder-free gloves has been demonstrated to reduce the spread of infection, improve the safety and health of patients and healthcare professionals, as well as provide a financial benefit to the healthcare facility.

References are available at www.asianhhm.com

Financial Savings

Author BIO

The prices for these new technologies can besomewhat higher. But the return on investment for powder-free gloves well outweighs the initial higher cost: protection afforded to both the worker and patient and reduced adverse events associated with gloves powder. The FDA estimates that total annual benefits of the

Patty is a registered nurse with international experience focusing on perioperative safety and education. Patty utilises her years of experience in healthcare, knowledge of perioperative practice, and concern for infection prevention to support CLINICAL research, create accredited education courses, lecture, and author articles.

www.asianhhm.com

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Facilities & Operations Management

Modelling Facility and Operations in Design of and Transition to a New Healthcare Space Physical design and process design are inseparably connected in healthcare facilities. Modelling facility and operations aids in evaluating design alternatives and in familiarising an organisation and its staff to a new space during transition. This article explores simulations of various fidelity, their characteristics, and their uses in healthcare management.

Marvina Williams, Senior Healthcare Operations Planner, Perkins+Will, US Amanda Hobbs, Healthcare Operations Planner, Perkins+Will, US

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ll across the world, healthcare organisations face changes from their payers. Insurers and governments are changing reimbursement models while the healthcare consumer, the patient and their family, is increasingly informed and discerning. This pace of change is driving the need for improvement in healthcare management. While operational improvement projects can be nearly continuous, facility projects occur more intermittently.

Facilities projects represent an opportunity for great transformation in the management of a hospital or other healthcare organisation. The permanence of a built facility and the large investment required mean that incremental testing of various design options is both more important and more difficult. A full build of multiple facilities to “test” which results in the outcomes important in healthcare–improved health for the population, improved experience

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of care, and reduced costs–-is not reasonable financially. Instead, various models of facility and operations can allow for testing alternatives through other mediums.

What is Modelling and Simulation?

Modelling and simulation allow for building and testing operations and facilities in a different medium than the medium of the finished project.

Merriam-Webster defines the verb model as “to produce a representation or simulation of ” and the noun simulation as “the imitative representation of the functioning of one system or process by means of the functioning of another.” Thus, the terms modelling and simulation can, and will within this article, be used interchangeably.

However, there are many different types of models. This article discusses various simulations popular in operational and facility improvement projects along their focus and their

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fidelity. Simulations can focus on operations or facility or integrate both operations and facility process and constraints.

Simulations can be of various degrees of accuracy and exactness in terms of how well they represent the final product. In modelling, this degree is usually referred to as fidelity; a low-fidelity model is designed in a system less representative of the final product, while a highfidelity model more closely represents the final product. Models that take a more integrated systems approach and focus on both operations and facility tend to be of a higher fidelity than more-singularly-focused models.

There is no single best way to model or sequence of models that works for every project. While highfidelity models more closely represent the final product, they tend to require a greater investment of resources: more time and more money. The progression of simulation is iterative and at times

Facilities & Operations Management

disordered throughout the lifetime of a project, but the fidelity of simulations generally increases as time passes.

Overall, it is best to match your method of modelling to the phase of the project and the resources and goals of your organisation. It is also important to understand your stakeholders and what simulations will best communicate new operations designs and/or facility designs so that the users themselves can evaluate and learn the new healthcare space. Engaging the right simulations of your operation and your facility at the right times can lead to many improved outcomes.

A Sample of Simulations

Listed below are some simulations that range from those most established and common to those on the cutting edge of the industry. However, there are limitations. Different people and/ or different organisations may call the same model by different names. Often, the distinguishing characteristics that categorise or name simulations are not black-or-white, making their naming tricky. Additionally, this is by no means an exhaustive list.

Floor Plans In the world of healthcare architecture, a floor plan is the most utilised and recognisable facility simulation. A floor plan is a scale diagram of the arrangement of rooms in a story of a building. The fidelity of a floor plan can range from an initial hand-drawn sketch to fully detailed computer drawings that act as construction documents.

Process Flow Mapping Process mapping is a very common simulation that focuses on operations.

The fidelity of process flow mapping can range from rudimentary to quite complex, while being constrained to a 2D representation. At its bare minimum, mapping generally involves rectangles representing processes and arrows representing direction and order of processes; often, diamonds serve to represent decision points.

Lean, a quality management methodology that views value from the customer’s perspective, tracks the processes a patient experiences in a “value stream map.” Further developments of this methodology have suggested mapping processes for patients and families, staff, medications, supplies, equipment, information, and process engineering. There are many different ways that process flow mapping can simulate the operations for a healthcare organisation. Visio is a common tool for process flow mapping.

Spaghetti Diagraming A spaghetti diagram is a beneficial simulation that incorporates the facility modelling of floor plans and the operational modelling of flow mapping into one 2D simulation. Often, multiple flows are diagrammed on top of a floor plan in a hybrid simulation that address both facility and operations.

and understanding than a floor plan.

Tape or paint representing boundaries and fixtures create a mock-up floor plan. At the highest end of fidelity, a 3D mock-up room outfitted as the designed room fully represents the final product. While this is costly, healthcare organisations find this useful to make final decisions before building when the facility may contain hundreds of these standardised rooms. Other materials can be used to move into 3D while containing modelling cost; for example, cardboard mock-ups have represented entire floor layouts.

Discrete Event Simulation While process flow mapping represents a relatively basic form of event simulation, computerised models built with complex software packages provide even greater fidelity. Modelling software, such as SIMIO, is grounded with an operational focus, but can also

Figure1: A spaghetti diagram modeling flows of various resources on an inpatient unit

Mock-Ups Mock-ups refer to full-scale representation of a facility ranging from a mocked floor plan to an entire room fitted with the materials determined for use in the actual healthcare building. Mock-ups are facility-focused, but their life-size scale empowers more operational testing

incorporate facility models to constrain the operations. It is high-fidelity–taking healthcare process mapping to a new level by incorporating mathematical variation. Today’s software can visually represent stakeholders and resources as they move throughout the system, which communicates well to the

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Figure 2: A basic discrete event simulation of an outpatient MRI center developed in Simio

Virtual Reality Virtual Reality (VR) is on the cutting edge of simulation. Traditional facility modelling software files, such as Revit and BIM files, transform into a Virtual Reality (VR) experience. While it is possible that a user could try to simulate certain operations while “inside” a VR of a healthcare facility, this model remains a high-fidelity and facility-focused simulation.

VR is already giving stakeholders at healthcare organisations a look into the future of their facilities, and VR will be used more and more frequently in the coming years.

Intermountain Healthcare Alta View Hospital: 3D Full-Scale Cardboard Room and Module Mock-up Alta View Hospital located in Sandy View, Utah, USA engaged Perkins+Will in the strategic re-imagination and structural reconfiguration of their campus after its integration into the Intermountain Healthcare System. This

was a highly interactive process guided

by Lean methodologies. Through usercentred design events, the schematic design that emerged was representative of integrated operational and facility goals.

For this project, cardboard 3D full-scale mock-upswere used to demonstrate important rooms and spaces. The modelled spaces included a standard inpatient room, operating room, emergency department exam room, prep/post-surgery room, and a clinic module (which included patient rooms and staff space in the core). The integrated design-and-client team called this model a “cardboard city.” Cardboard was the chosen material because of its cost and flexibility; as alternative ideas were developed, the cardboard walls were quickly dismantled or revised into a new model. A two-fold perspective is gained through the model: 1) the design team better understands the users’ needs, and 2) the users better understand their future space. Ultimately, this results in better health outcomes, increased

Case Studies

Perkins+Will engages in various facility and operational modelling depending on what is mostly suitable to the needs of the stakeholders and the project’s scope, cost, and schedule. During the course of a project, Perkins+Will will employ many different types of modelling. The following case studies describe four simulations that the design-and-client teamemployed at a certain time for a specific client and project. These case studies serve to demonstrate how modelling aids in evaluating design alternatives and familiarising stakeholders to a new space in the healthcare sector.

Figure 3: A user explores a healthcare facility through virtual reality (VR)

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Facilities & Operations Management

Figure 4: Users gather around a room in the 3D "Cardboard City" at Intermtounain Healthcare Alta View Hospital

time and cost efficiency, and better experience of care for users.

Intermountain Alta View’s users, clinical and staff stakeholders as well as patient focus groups, visited the cardboard city during “open houses” to explore and provide feedback. With a facility-focus, users visualised their rooms exploring alternatives like standardised rooms. Operationally, users could explore the Lean flows of healthcare (the movement of key resources such as patients, staff, medications, and supplies) in a full-scale model. The cardboard city successfully facilitated a feedback loop that led to improved design interventions including: • Placing telehealth in all emergency department and critical care rooms as well as some acute care rooms • Relocation of provider documentation areas to increase clinical team teamwork and patient and family interaction • Standardisationof clinic module for the ambulatory clinic building • Placing smart board technology in inpatient rooms to provide integrated, timely information Rush University Medical Center: FullScale Floor Plan Mock-Up Rush University Medical Center located in Chicago, Illinois, USA engaged Perkins+Will in an expansion project

that resulted in a new bed tower. The site for the new tower that the system had acquired consisted of fenced-off tennis courts - a site ideal for a fullscale floor plan mock-up. With white tape on the court, entire floors with rooms and corridors were modelled to scale with Rush doctors, nurses, and administrators directly participating in the design process.

Modelling the inpatient unit layout allowed for users to explore efficiency and flexibility by understanding the size and adjacencies of different spaces.

The modelling aided in finalising the decision to have all patient rooms samehanded, as opposed to mirrored, to provide Rush opportunities to engage in research on evidence-based design for safety. Developing the hospital design from the inside out was key to increasing value and decreasing waste in the new expansion for the healthcare system. Walking through the model with an eye for minimising the travel distances for patients and nurses and distributing staff strategically among patients resulted in floor layout matching the tower’s butterfly-like shape.

After the mock-up aided in envisioning, testing, and adjusting the inpatient floor plan, the design team focused on creating an arrival experience

for patients and their families. Users participated in developing designs for a large entrance to the new hospital tower and gardens provided respite for patient and families. Through modelling, an unused tennis court transformed into an arena for design that embraced interaction and feedback from the administration, clinical staff, patient and families, and the community.

University Health System: HighFidelity Room Mock-Ups University Health System in San Antonio, Texas, USA engaged Perkins+Will for design of a new trauma tower at University Hospital to include additional beds, an expanded emergency department, and an interventional platform. When the integrated design-and-client team discussed modelling, the client desired to utilise full-scale room models that would evolve throughout the design process into fully-outfitted rooms. To maximise the value of the high-fidelity and higher-cost model, the University Health System (UHS) partnered with the University of Texas Health Science Center at San Antonio (UTHealth) School of Nursing to jointly fund and jointly benefit from the models. First, the mock-ups aided UHS users and the design team in the design process for the tower; after the design was completed, the fully-outfitted space served, and continues to serve, as a simulation lab at UTHealth where hundreds of students each year receive hands-on clinical training.

The rooms modelled included a trauma room, an emergency department exam room, an inpatient room, and two operating rooms. From schematic design through design development, users including physicians and staff from different departments met inside the space to experience it and provide input.

Operationally, the UHS project focused on leveraging technology and research to provide cutting-edge, evidence-based healthcare to their

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emergency room. For example, the simulation utilises a room preference order for different types of patients by their acuity and resource needs.

Ultimately, the modelling process provided data to allocate rooms to each room type and aided in defining the operations that would bring the client’s vision to life.

Conclusion Figure 5: Users interact with a full-scale floor plan mock-up painted on the tennis courts at Rush Univeristy Medical Center

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designed space, but to also model what would occur in the space. This simulation allowed the design-andclient team to define and redefine operations, including processes and staffing, while investigating facility alternatives.

This modelling focused on utilising operational processes to determine the correct numbers of different types of rooms in the emergency department including, but not limited to, rapid medical evaluation rooms, emergent rooms, behavioural health rooms, resuscitation rooms, and paediatric rooms. The model is data-driven, utilising statistical distributions and probabilities that model real-world variation and able to incorporate multiple options for room assignment.

This ability to model chance and change in operational processes is especially valuable in a dynamic system like an

Author BIO

patients. To incorporate the latest technology into each room type, users met with medical equipment vendors for demonstrations in the modelled space. As a result, rooms are equipped with a patient engagement system and tele-conferencing capabilities that allow for consultation and learning with colleagues and students at the facility and around the world. The mock-ups were vital to the users understanding and participating in designing the ideal rooms for their units. As a bonus, the finished mock-ups, fully sheet-rocked and equipped with technology, now continue to serve as a simulation lab for UTHealth nursing students.

Jackson Health System: Discrete Event Simulation Jackson Health System in Miami, Florida, USA engaged Perkins+Will in a greenfield project to design a new emergency department with diagnostic capabilities. The innovative vision for the project focuses on leveraging a hospitality model, operational efficiency, and technology to deliver the highest level of patient-centred care.

During programming and schematic design, computerised discrete event simulation was a modelling method chosen for its ability to consider facility design simultaneously with operational design at a higher fidelity. Because the vision of this greenfield project unprecedented operational efficiency, the client wanted the chosen method of modelling to not only model the

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The case studies demonstrate various simulations engaged at different phases of the design project. Intermountain Healthcare Alta View Hospital, Rush University Medical Center, University Health System, and Jackson Health System are unique clients, and Perkins+Will customising our modelling approach to each client’s needs is crucial to success. The case studies represent the many ways simulation can aid in the design of and transition to a new healthcare space.

Hospitals and other healthcare entities should embrace facility projects as an opportunity to redefine operations and improve quality in their organisation. Integrated facility and operational design can improve health for the population served by the organisation and improve the experience of care all while reducing costs. Modelling and simulation allow for iterative testing of and familiarisation to new facility and operational designs to meet an organisation’s goals.

Marvina Williams is a registered nurse and Senior Healthcare Operations Planner on Perkins+Will’s Healthcare Planning + Strategies team. She previously directed a large emergency department and enjoys connecting the architectural team and clinical users. She is an expert in workflow, workload and staffing, clinical procedures and support services.

Amanda Hobbs is an industrial engineer and Healthcare Operations Planner on Perkins+Will’s Healthcare Planning + Strategies team.

Amanda is experienced in human factors engineering, systems engineering, and quality improvement methodology. Amanda is passionate about concurrently designing operations and facilities to improve health and the care experience while increasing value.

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Cover Story

AI in Healthcare New software tools powered by Artificial Intelligence (AI) are going to be dominant components of nearfuture healthcare. Soon, medical practitioners and researchers will routinely adopt a wide range of machine-learning techniques in most of their daily tasks. Here, I show some of the most exciting results obtained in this space and discuss how future developments of AI will radically change the way we diagnose and cure people.

Nicola Pastorello, Lead, Data Science and Analytics Group, Deakin Software and Technology Innovation Lab, Australia

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rtificial Intelligence (AI) is going to heavily affect how we will research, diagnose and cure diseases in the very near future.

The adoption of machine learning tools and algorithms by physicians and researchers will be of incredible benefit for the whole community. It will allow prompter and more accurate diagnoses, help doctors navigate the plethora of new medical research in order to better define their curing strategies and allow researchers to develop new cures and better identifying new patterns in complex data.

Two main components are responsible for the rapid adoption of AI in healthcare: the availability of large volumes of personal health data, and the massive advancements in computing technology.

Big and deep Data

Until few years ago, the only way to measure most health biomarkers required systems and devices available only in the hospital environment. As

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a consequence, health data records in the past were obtained in a hospital environment only in cases where the actual analyses/scans were required (i.e. not in a continuous fashion all-over the daily life of the patient).

But the growing use of cheap and always-recording sensors embedded on wearable smart devices and smartphones today for personal health data collection and sharing is changing this. These sensors are increasingly efficient and accurate, often competing in quality with their medical-level counterparts.

The affordability of such devices and their capacity for continuously collecting data has provoked an explosion in the amount of personalhealth data available to researchers and practitioners. Moreover, an easy and continuous monitoring of biomarkers outside the hospital environment can provide physicians with a much more frequent measure of their patients wellbeing. Of course, this raises a number of ethical and privacy concerns, which will be discussed later.

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Meanwhile, analysis and patient examination technology in healthcare facilities is becoming more detailed and able to record huge amounts of information in single scans. As an example, DNA sequencing is no more an inaccessibly expensive exam as it used to be, and even a simple blood analysis is able to return dozens of different

Information Technology

biomarker measurements. However, when all this personal health data is aggregated in order to obtain a more complete picture of a patient’s health status, the number of parameters to be studied can largely exceed the number that humans are able to evaluate.

Most diagnoses are based on finding patterns in symptoms that can be

linked to known diseases. The better the mapping of these symptoms, the lower the likelihood of a wrong diagnosis (assuming that the diseases’ symptoms are known in advance). However, large overlapping in the symptom space exists among number of different diseases.

Thus, to increase the accuracy, multiple and different exams/scans are needed,

but these might be expensive and require specialised technicians. Generally, a worthwhile approach is moving one exam at time in an exclusion pattern and diagnose the most likely disease given the available results. However, the larger and more complex the space of explored parameters, the harder it is for the doctor to discern real signal

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Information Technology

(i.e. what is actually linked with the disease) from statistical noisy information.

A similar issue is faced in several fields of medical research. For instance, finding the sequence in human DNA that links with a searched response is a beefed-up version of the needle in a haystack problem. Despite the first complete human genome sequencing dating back almost twenty years, we are not much closer to understanding what are the genetic causes for diseases like cancer or leukaemia. Here, the information we can extract from a single genome is huge, and understanding which components are causally related to the phenomenon of interest is a massively complex problem.

The second component for the advent of AI in healthcare is the availability of technologies that allow for the efficient training of machine learning models in complex problems. Although most of currently used AI core algorithms date back decades, only in the past few years have they become applicable to real-word problems. Thanks to the evolution of CPU (and GPU) technology, AI models that needed weeks to be trained on a limited dataset, now can be trained over Gigabytes of data in only a few hours.

With these algorithms, we are finally able to explore incredibly vast parameter spaces, deal with noisy and missing information and learn high-dimensionality patterns that would be otherwise inaccessible.

The human body is a complex system, where only high-level components are well known. While, for example, we are able to explain the relations between viruses and flu, we are still not yet able to fully understand the processes that rule the biological cell or which differences in the genomic information are linked with high level differences among individuals.

Furthermore, when studying the effects of a medication or the health status variation in time of a patient,

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medical records are limited to a sporadic sampling. Since most exams and scans still require the patient to be in a hospital environment, they are limited in most situations to when they are actually needed (e.g., when the person is sick) instead of on a higher frequency base (which, in turn, would help mapping the whole course of the illness to the full recovery). As a consequence, most collected medical data is biased towards the periods when the patient is affected by some diseases, or whenrecovering from it. Often, no records exist for the periods when a person feels healthy, and the same exam might be conducted years apart. AI in healthcare must be able to include such a sparse and nonrepresentative information in its input dataset, and integrate it with personal lifestyle and population profiling

Two main components are responsible for the rapid adoption of AI in healthcare: the availability of large volumes of personal health data, and the massive advancements in computing technology.

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(e.g., age, assumption of alcoholic beverages), to better predict the risk factors for a single individual. These same systems should also cope with sporadic missing data, noise and errors/uncertainties in the historical datasets (as is the case for most manually-compiled information) in a similar or better way than its human counterparts. Finally, they have to intelligently include in their analysis centuries of historical medical research (mostly from medical literature) and consider the aided doctor medical experience-matured knowledge.

All these problems would require a Strong AI, an intelligent system that is able to mimic the learning and generalisation skills of the creative human mind, thus being able to find creative solutions to unknown and unseen problems. At the present stage, we are at least decades away from such an artificial intelligence, but under certain constraints, current state-of-the-art AI has been already productively used in this space. In particular, when problems are narrower in scope and better defined, Weak AI solutions have shown remarkable results.

Information Technology

Examples of Weak AI in Healthcare IBM’s intelligent system Watson has been one of the first examples of AI applications in healthcare. Since the first project helping lung cancer treatments in 2013, IBM has created a whole suite of AI tools for clinical decision support (Watson Health) that process medical information from a large number of resources (e.g.,encyclopaedias, taxonomies, treatment guidelines) and evidences (e.g., scans, images, tests) in order to build-up an easily accessible knowledge base that can help physicians choose the best treatment for their patients. Once the symptomatic information is submitted to Watson, the system starts mining the historical personal health records and formulating hypotheses regarding the potential cause for the illness.

A more recent project, Watson for Oncology has been trialled in collaboration with the Manipal Hospitals in India. The outcome of this project is an online tool which helps cancer patients identifying personalised care options and physicians accessing an “expert-level” second opinion. The system is continuously trained on a dataset from almost 300 medical journals and 12 million pages of text.

Also Google, initially known for its web search engine, entered this space in a big way by acquiring DeepMind in 2014. This was a startup mainly based in UK, which gained large attention when its AlphaGo AI engine defeated the best Go players in the world.

DeepMind Health is a research project involving a number of healthcare providers and universities all over the UK. From these collaborations, AI tools and models have been designed

The future

In future, the vast majority of physicians will use AI tools in their clinical and research work. Faster and more precise diagnoses will be the norm, as well as exploiting these tools to select the best treatments for most issues.

However, some potential risks have to be taken into consideration. First, personal health information is sensitive data: adequate security and privacy

policies must be established around any pipeline and algorithm that make use of it. Second, the predictions or decisions obtained are only as good as the data that has been used to train the models. For example, if the input dataset is biased towards some non-homogeneous distribution, this could lead to catastrophically inaccurate results.

Training an AI skin cancer image classi-

Author BIO

A limitation with these approaches is the need for massive labeled data for training (i.e. where the ground truth for the problem is available for a large number of cases) and the assumption of all useful information being somehow encoded in such data.

and tested to search for predictive signs of blindness, to classify cancerous and healthy skin tissues, and to develop clinical mobile apps that can link to the digital health record of a person.

Finally, AI is an important component of many privatelyfunded healthcare projects of the Deakin Software and Technology Innovation Lab (Deakin University, Australia). For example, it has been designed and deployed for early prediction of the occurrence of epileptic seizures and quantitatively assess mental health conditions such as stress, anxiety and depression.

In the first case, thanks to the large amount of high-quality data collected by the Comprehensive Epilepsy Program at the Royal Melbourne Hospital, DSTIL’s researchers have been able to train deep learning algorithms to identify patterns and features in detailed clinical and imaging signals. AI in this case can predict whether a convulsive epileptic seizure is going to occur in the next few minutes, potentially leading towards a better understanding of the causes for such events and massively improving the lifestyle of people affected by this pathology.

On a different project, DSTIL developed an AI that is able to quantitatively and accurately detect stress and mental health conditions from biomarker profiles obtained with customer-level wearable smart devices. Stress levels are detected with more than 90per cent accuracy, while anxiety and depression can be confidently identified in more than 85per cent of the cases.

As a comparison, professional psychiatry assessments show consistent agreement only in less than 70% of cases.

fier with just examples of a specific variation of this condition would prevent the model to generalise to other cancer forms. While this is not a critical issue in most non-medical AI applications, in healthcare this could cause wrong life-and-death decisions. Policymakers, healthcare professionals, and patients need to be aware of these issues while this technology is in its early stages.

Nicola Pastorello is a Data Scientist and former Astrophysicist, who currently leads the data science and analytics group at Deakin Software and Technology Innovation Lab. He has an extensive track record of collaborations with both academia and industry in data science, artificial intelligence and deep learning. Thanks to his passion for solving problems, Nicola is involved in a broad range of projects, including smart home for aged care, improving traffic congestion, and seizure prediction.

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Information Technology

Leveraging Information Technology in the Healthcare BPO Industry Information technology plays a crucial role in almost all industries determining their growth and expansion. The healthcare BPO industry is no stranger to this phenomenon and the evolution of IT will continue to increase the demand for more specialised services.

Julius Raj Stephen, Joint Head of Operations, Omega Healthcare Management Services Pvt. Ltd., India

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recent Accenture report says that nearly 66 per cent of health systems in the US will have self-scheduling by the start of 2020. That there will arise the need to focus on training machines just as much as training employees in the next 3 years, will be yet another impact of technology in the healthcare industry predict experts. What does this mean exactly?

Probably this could mean more intelligent software, newer algorithms and advanced machine learning.

Studies from Markets & Markets indicate that the US Healthcare BPO Market is estimated to be worth $141.7 Billion by 2018. Approximately

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75 per cent of the US companies are said to outsource their work to external locations. Medical coding, medical billing, transcription services, insurance claims and adjudication, Revenue Cycle Management (RCM) and clinical outsourcing, are some of the services that are commonly outsourced among others. This BPO outsourcing market is propelled to grow owing to various government regulations and reforms, measures to reduce healthcare cost, and the increased use of Electronic Health Records (EHRs). Developments and innovation in information technology and regulatory changes are the other key factors furthering the

Information Technology

growth and advancement of this industry.

Historical Progress of IT in Healthcare

TheuseofInformationTechnology in the healthcare industry started as early as the 1960s. The abilities and advantages of computers were slowly being recognised in the healthcare domain. This was an era where hospitals and healthcare providers shared expensive mainframes and storage owing to the expansive and large sized computers and peripheral storage devices. The 70s saw the development of the Problem Oriented Medical Information System (PROMIS). Applications were implemented to automate manual and routine tasks.

Hospitals and healthcare units began integrating applications so that financial and clinicalsystems could work in union, minimising administrative paperwork.

Moving from discrete departmental systems that were transactional in nature in the 70s to integrated applications and networking solutions in the 80s, the presence and use of IT across the healthcare industry has proliferated.

1990s–2000s

At the early beginning of the 1990s the healthcare industry was being driven by competition and consolidation was rampant. This was a period that saw the boom of ICT and internet in general, with computers and technology being available in each and every household and industry. The need to implement and harness the benefits of ICT was evident in the healthcare service industry.

There was a radical albeit gradual, shift from process-oriented systems towards patient centred, outcomeoriented systems that became the focal point of healthcare automation. The use of PDA’s to capture data at the pointof-care saw daylight during this period.

Integrated delivery network (IDN)-like integration, including the impetus to

US EMR Adoption Model Stage

Cumulative Capabilities

Stage 7

Complete EMR, CCD transactions to share data; Data warehousing, Data continuity with ED, ambulatory, OP

Stage 6

Physician documentation (structured templates), full CDSS (variance & compliance), full R-PACS

Stage 5

Closed loop medication administration

Stage 4

CPOE, Clinical Decision Support (clinical protocols)

Stage 3

Nursing / clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology

Stage 2

CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging, HIE capable

Stage 1

Ancillaries – Lab, Rad, Pharmacy – All installed

Stage 0

All 3 ancillaries not installed

The EMRAM is an eight stage (0-7) model that measures the adoption and utilization of EMR functions required to harness technology to enhance and optimise patient care, and progress towards a paperless environment.

www.asianhhm.com

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integrate data and reporting, started emerging.

All these led to the need for more integrated hospital, provider, and managed care offerings in the healthcare BPO industry towards the end of the 90s.

The early 2000 saw increasing demand for enhanced decision support using IT. Integration and the start of outcomes-based reimbursement were the factors driving the US healthcare industry.

Technology was being implemented to increase mobility and move gradually towards Electronic Medical Records EMRs. EMRs and EHRs were being widely adopted with the HIPPA act being passed by the Congress in the late 90s. This was also to create a more global digital healthcare infrastructure and enable a seamless flow of information within this infrastructure. Emerging cloud computers and cloud-based big data analytics were other factors that were driving customer requirements for more value added services over and above the regular automation and data entry services.

The period also saw the development of Health Information Exchanges (HIEs), formerly called RHIOs (Regional Health Information Organization), along with the establishment of Health Information Technology Standards Panel (HITSP) and National Alliance for Health Information Technology (Alliance).

7 Stages of Technology Advancement in Healthcare

Over the years Healthcare Information Technology (HIT) strategies have evolved to a point where Healthcare Information Systems (HIS) have emerged to be a critical requirement for the healthcare industry. Global healthcare advisor Healthcare Information and Management Systems Society (HIMSS) Analytics have launched two models: Electronic Medical Record Adoption Model (EMRAM) and Outpatient Electronic Medical Record Adoption Model (O-EMRAM) to monitor and

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measure EMR adoption. The EMRAM is an eight-stage (0-7) models that score hospitals and clinics around the world relative to their EMR capabilities. The O-EMRAM eight-stage model measures the adoption and utilisation of EMR functions and O-EMRAM. This model is intended for clinics where there is an encounter between a caregiver and a patient, and the caregiver is licensed to assess, diagnose, treat, prescribe and generate orders and documentation.

The Q4 2016Acute EMRAM adoption analysis released by HIMMS indicates that approximately 60 per cent of the providers are in between the Stages 5 & 6. These are advanced stages in the technology adoption model indicating that at every instance of patient interaction with the healthcare providers, all orders are entered electronically, which enables clinical

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decision support interaction, and all reports are electronically submitted, thus leading to the creation of a consolidated digital personal health record. In the process, huge amount of data is being generated daily. Data is available in medical coding and billing, processing and adjudication, and across the entire cycle of revenue cycle management.

Move from Basic Data Entry to Value Add Services

With more and more healthcare providers adopting the EMRAM Models and advancing to Stages 6 &7, the demand for more value-added service from the healthcare service and solution providers will only increase. There is a growing need to improve operational performance to provide enhanced, cost effective healthcare services, leading to the necessity of integration of healthcare

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Big Data and the Healthcare Industry

Analytics in the healthcare industry is now going beyond just data management.

Better data leads to better insights and thereby improved outcomes. Predictive Analytics and Big Data are the way forward in the healthcare industry. They are seen as key tools to help predict epidemics, cure diseases, improve quality of life, economies of scale quality of healthcare. Analytics can help improve the overall patient-outcome.

Providers feel that with the help of analytics, they will be able to understand as much as they can about a patient and his healthcare history, as early as possible, pick up warning signs of any alignments or chronic disease, administer preventive and better care as well as reduce readmission rates. At the management level, many healthcare organisations that have already implemented analytics, see improved decision making, hospital

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Studies from Markets & Markets indicate that the US Healthcare BPO Market is estimated to be worth US$141.7 Billion by 2018.

operational performance and improved financial reporting capabilities as direct benefits.

Big Data, when used across the entire span of revenue cycle management, can help the healthcare organisations reap more benefits. Starting with billing and collection cycle, to tracking payment and denial management, Big Data can help improve revenues.

Insurance claims are denied for a myriad of reasons impacting the Accounts Receivable (AR) cycle and eventually the profits for the providers.

With the help of Big Data, the history of denials can be analysed to identify the top reasons and prepare insights which can be worked upon. Based on these insights, pre-checks can be built into the RCM system to process only those claims that have the request information and auto-approve them.

Big Data can also help in reducing the collection period. The time and effort spent in recovering claims can be analysed and the optimal time determined. This will help set a threshold limit on the revenue collection time and identify and follow-up on those that exceed the

Author BIO

systems and analysing the readily available digitised data.

Regulatory reforms such as the Affordable Care Act (ACA) re-emphasize the need for healthcare services that are more customer/patient-centric and economical. With the advent of technology, consumers demand services that are more flexible—preferring choices on the mode of delivery of services, multiple payment options and much more—to suit their convenience. This augments the responsibility of providers to give the end consumers value-added services, while keeping a check on the cost and not slipping on the quality.

For this to happen the focus would have to be on merging the clinical systems, financial systems, and patient satisfaction systems and work on the analytics derived thereof. All these propel the need for data warehouse management and complex analytics solutions that will enable more strategic decisions for healthcare service providers, as well as dashboard reporting providing snapshot of information about the hospital management.

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set limit. This will help strategise the Accounts Receivable (AR) collection period on a real -time basis and improve profitability.

Technology & Innovation, the Way Forward

With the Internet of Things (IoT), the impact of wearable technology in the healthcare industry, and the use of the data generated from such devices cannot be ignored. A study from Aruba predicts that nearly 89 per cent healthcare organisations will adopt IoTby 2019.

Organisations are slowly adopting the many benefits of wearable technology such as monitoring vital stats, reminding patients to take medication, possibly monitor their health conditions and, in some cases, modifying medication too.

With such complex systems of digitised data available, analytics and innovations are the way forward for the healthcare industry. Electronic Data Warehousing (EDW) and analytics with the ability to mine into the pet a bytes of patient information, understanding the meaning of historical and real time data to predict future outcomes, are now being widely adopted. Organisations need to adopt a data warehouse model that can easily adopt the advances in big data and other analytics.

Information technology will continue to play a major role in the evolution of healthcare services. Be it the payer services, provider services or pharmaceutical services, technology and harnessing the digital data that are stored in silos across departments, will drive solutions that the BPO organisations deliver to their customers.

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Patient-Physician Communication by Using Mobile Technology in Developing Countries The positive outcomes of a successful patient-physician communication are widespread considering the health related aspects. The rapid proliferation of mobile technology has facilitated the healthcare system to provide better support and establish sustainable implication of standard procedures in a broader range of healthcare services.

Yasmin Jahan, Graduate school of Biomedical and Health Sciences, Hiroshima University, Japan Md Moshiur Rahman, Institute of Biomedical and Health Sciences, Hiroshima University, Japan Pradeep Kumar Ray, Engineering Research Centre on Digital Medicine and Clinical Translation (DMCT), Shanghai Jiao Tong University, China Michiko Moriyama, Institute of Biomedical and Health Sciences, Hiroshima University, Japan

P

atient-Physician communication is one of the foremost important part in patient care, given the godlike stature of physicians in many countries.

This is critical for every physician to deliver a high-quality healthcare. Patient health outcomes depend on effective communication with the physician. Many physicians encourage open communication and complete information for getting more accurate diagnosis, proper counselling, improving treatment plans and better health outcome.

The Institute of Medicine (IoM), allied with American College of Obstetricians

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and Gynecologists, has identified the use of information and communication technology (ICT) as one of the perilous forces obligatory for improving the quality of healthcare in the developed countries. Currently, more physicians are becoming handy in using mobile health technology for keeping health records and web messaging to communicate with their patients. The South-East Asia region still has some barriers to implement mobile health technology including policy, technical knowledge and expertise and service costs for implementation of such services. To make mobile healthcare technology more effective and user friendly, our understanding is, that it is essential to improve the way of implementation from top to bottom.

Despite of fragile infrastructure, in developing countries, telecommunication technologies are heading towards a ground-breaking platform rapidly for the last couple of years. Consequently, it has already created an ample of scopes to develop and utilise this technology in patient-physician communications. Easy accessibility, reasonable expenses of the mobile phone, catchy advertisement and different types of tariff servicesenable mass acceptance among the consumers unlike with some other technologies.

The service providers introduce their value-added services (VAS) through the integration of healthcare for those people who live in comparatively remote areas of the country. This article presents issues focused on patient-physician communication in the context of a fastdeveloping country, Bangladesh.

Serious health challenges like non-communicable diseases are hindered by several core impediments; among them a universal scarcity of healthcare workers. According to the WHO, there is a perilous shortfall in healthcare workers, in lieu of a total deficit of 2.4 million healthcare workers worldwide and among the 57 countries, mostly in the developing countries. This human resources constraint intensifies

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Topics

Developing Countries

Developed Countries

>33%

>90%

Difficult to afford due to budget constrain

Easily affordable

Not so available

Available

Weak

Strong

Limited

Common

Improving

Improved

Proliferation of mHealth technology in health sector Affordability of mobile technology Technological advances considerable infrastructures Positive health outcomes associated with effective communication Health Information Technology (HIT) such as Electronic Medical Records (EMR) Effectiveness of patient care through mobile technology

Table: The comparison of mobile technology usages between developing and developed countries

the already increasing pressure on developing countries’ health systems. To cope with the burden of containing the spread of non-communicable diseases (NCDs), governments, businesses, NGOs, foundations, and multilateral organisations all recognise the importance of leveraging new tools and solutions to address these distinct but interrelated health challenges.

In the meantime, mobile communication offers an effective means of bringing healthcare services to developing countries with low-cost handsets and the penetration of mobile phone networks globally.

Tens of millions of peoplethat never had consistent access to a fixed-line telephone or computer now use mobile devices as daily tools for communication and data transfer. Now, a full 64 per cent of all mobile phone users can be found in the developing countries.

Furthermore, estimates show that half of all individuals in remote areas of the developing countries use mobile phones.

This growing ubiquity of mobile phones is a vibrant element in the aptitude of mobile technologies for health.

Furthermore, greater emphasis on patient-centred care could improve

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communication between doctors and patients in developing countries and increase the effectiveness of care so that it can be as competent as developed countries. The penetration of mHealth is more than 90 percent in the developed world and 33 percent in the developing world. South Asian countries like Bangladesh adopt appropriate initiatives. in the development of Electronic Medical Records (EMRs) to fulfill their specific necessities. Technological advances often need substantial infrastructure investment in electricity, computer equipment, and telephone/internet networks; but in developing countries healthcare budgets are also inadequate and strained. Moreover, depending on the obtainability of time and the patient load, managing EMR during care delivery has been a cumbersome process for the clinicians, particularly in the developing countries where the doctor-patient ratio is much worse than in developed countries. However, developing countries, with their less extensive healthcare infrastructure, would benefit the most from mobile health (see Table).

Due to the existing diversified opinions regarding mobile phone

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technology services and usage, it has an optimistic impression on patient healthcare. The ongoing practice shows that the physicians provide paper-based prescription for detailing patient grievances.

Moreover, you will find a completely different scenario where the doctor-patient ratio is very low and the physicians almost perpetually have to work in a time-constrained fashion. Using mobile technology in such a situation could be problematic. This paper, however, mainly pointed the patient-physician common practice of health care-related information, storage and uses as well as develop communication in such a setup.

Healthcare services delivered through mobile phonein developing countries like Bangladesh, are becoming popular both in urban and remote rural areas due to the significant shortage of highly trained healthcare personnel, and expenses. For example, Grameen phone (GP), the largest network coverage mobile phone company in Bangladesh, covers over 98 percent of the total population and over 87 percent of the land area for providing healthcare services through mobile phone.

Even though the service is playing a vital role, unfortunately, lack of

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tele-health education, proficient manpower, and frequent monitoring by the physicians are hindering the process.

In Bangladesh, Grameen’s mobile phone created a “HealthLine” where anyone can call a mobile hotline and consult a doctor on 24/7 basis. More than two million people, mostly women, use the system each year from the remotest part of the country. That apart, there is “Aponjon”, a brand of mHealth service through mobile phones for expecting and new mothers in Bangladesh under the auspices of Mobile Alliance for Maternal Action (MAMA). Another service called “Healthlink” was launched by Banglalink for its customers to provide innovative and convenient health services.

The usability of mobile health systems is a key factor in the acceptance and diffusion of such technology in disease management and wellness promotion.

In this context, four factors need to be addressed: user-friendliness, usability, user competence, and confidence. The first two factors deal mostly with the type of mobile technology (hardware matters such as size, noise, aesthetic presence, and obtrusiveness, and software matters such as user interfaces and device operation), whereas the last two factors relate more to users and their perceptions.

Mobile technology services seek to increase access to between-visit support by augmenting clinician contact with automated services delivered via smart/ feature phones, short message service (SMS), and interactive voice response (IVR). Recently, the strategy for improving outcomes of people with noncommunicable diseases (NCDs) has been widelyaccepted through tele-health management. For instance, linking the hypertensive patients and homebased blood pressure (BP) monitoring with telehealth follow-up service creates effective outcome. Therefore, automated mobile phone management and behaviorchange calls can improve self-care as well as health outcomes among NCD patients and may be more cost-effective than in-person visits.

Among the NCDs, hypertension is an increasing problem in Southeast Asia, particularly in Bangladesh.

The statistics show that it is an emerging epidemic and prevalence was found within 15-20 per cent adults and 40-60 per cent among elderly people of Bangladesh. A common digital infrastructure can be used to generate the automated calls with the help of Bangladesh Telecommunication Regulatory Commission (BTRC) such as local telephone systems via session initiation protocol lines and voice over Internet protocol (VoIP) technology. Automated calls will use as tree-structured

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According to the WHO, there is a perilous shortfall in healthcare workers, in lieu of a total deficit of 2.4 million healthcare workers worldwide and among the 57 countries, mostly in the developing countries. been allied with every health sector especially for hospital healthcare providers; they used web cam and publicly accessible mobile phone for monitoring patient care. Physicians can unify videoconference and send advisory SMS such as vaccine alerts, medicine reminder plan, and pregnancy related suggestions to the patient. Electronic data are transferred into patient record and management.

In developing countries like Bangladesh, criticisms about doctors are often interrelated to issues of communication, not quantifiable aptitude. Every patientdesires that the physician may perhapsdexterously

diagnose and treat their sicknesses and effortlessly communicate with them. Physicians with improved communication and interactive aids can identify difficulties earlier by using mobile technology. Moreover, it can avert medical emergencies and intervention, afford better provision to their patients and begin sustainable superlative practices in a broad range of healthcare services.

Finally, the explanation provided here can be executed for a developing country to trial in a multi-care setup that treats NCD patients. Nevertheless, in the Bangladesh context, physicianpatient ratio is average 1:2000 and the solution can be implemented in a setup where physicians have to manage a huge number of patients. Moreover, they need to document all patient-related information manually and have no inter-legislative connection for patient information sharing response, when it comes to abridging the total procedure by using mobile phone technology.

References are available at www.asianhhm.com

Yasmin Jahan is a doctoral student at Hiroshima University, Japan and completed masters and medical graduation degree from Bangladesh. She has been involved in various clinical research activities such as Pneumonia etiological research, Diarrhea, Pneumonia and Febrile illness surveillance study in International Centre for Diarrheal Disease Research, Bangladesh (icddr,b).

Author BIO

algorithm in order to gather information of the patient’s BP, self-monitoring BP, medication adherence, and diet (according to the World Health Organization) and to provide tailored advice based on the patient’s responses. Mobile tools can monitorpatient’s hypertension status, drug and diet adherence, and seeking laboratory investigations. SMS through mobile phone can be used as a two-way communication system between wired hypertensive individuals and healthcare providers. It will provide primary health education and BP measurement reminders to encourage adherence to medical advice. Hypertensive individuals will receive standard hypertensive healthcare services, and counselling as well as behavioural change educations over the mobile phone as a competent and effective way.

During the call, patients receive a reminder to check their BP regularly and are asked about recent systolic values, medication adherence, and intake of salty foods. Based on their reports, hypertensive individuals will receive additional selfcare information and prompts to seek medical attention or medication refills to address unacceptably high or low BP. A structured e-mail alert for healthcare providers will be generated automatically once the patients report their health status. In addition, the patients will get reminders if they don’t report regularly or never take BP medications or when they have less than a 2-weeks supply.

Patients will have the option of enrolling with a family member or friend, who will receive a brief automated mobile update regarding the patient’s self-reported health status each week, including information about the patient’s hypertension self-care and how that caregiver could help the patient make their self-management more effective.

For accomplishing ‘Vision 2021’ milestones, Bangladesh government has executed e-health as an e-solution to the health sectors due to lack of accessibility of doctors as well as digital Bangladesh ingenuities. Mobile technology has

Md Moshiur Rahman is a Lecturer at the Institute of Biomedical & Health Sciences in Hiroshima University, Japan. He has multidiciplinary experiences in clinical science, public health, and molecular research. Expertise in planning, implementing, monitoring and evaluation of public health programs in developing countries. He has national and international public health experiences.

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

Michiko Moriyama is a Professor of Division of Nursing Science under the Institute of Biomedical & Health Sciences in Hiroshima University, Japan. She has been involved in various types of research activities such as Chronic Care and Disease Management, Family Nursing, Population Sciences. She has multidisciplinary collaboration in various countries.

www.asianhhm.com

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The VACUETTE® System One step ahead

In the mid-1980s, Greiner Bio-One developed the first-ever vacuum blood collection system made from PET plastic. The VACUETTE® brand has stood for progress, innovation and safety in the field of sampling ever since. The system not only helps to simplify the process of collecting body fluid samples in hospitals, laboratories and in doctor's surgeries, but also, and most importantly, enhances safety.

The VACUETTE® line comprises an extensive range of products The key advantage of this user-friendly vacuum sample collection system is that it collects a clearly specified amount of blood, urine or saliva without the need for any other steps. The transparent VACUETTE® tubes are made of almost unbreakable plastic and can be changed quickly and hygienically, without any risk of coming into direct contact with the sample.

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Their reliable results and ease of use make VACUETTE® tubes the ultimate primary containers for all standard analysers. All tubes bear the CE mark.

All products that are also produced or distributed in the USA are approved by the US Food and Drug Administration (FDA).

Innovations lay the groundwork for progress Greiner Bio-One has developed a wide range of safety products, needles with a view window, plastic blood sedimentation tubes and double-walled coagulation tubes in recent years to make the working environment safer and improve the quality of laboratory diagnostics.

One such innovative product is the VACUETTE® CLIX Safety Hypodermic Needle. It comes in a wide

range of needle thicknesses and lengths, which are easily distinguishable thanks to their colour-coded safety shields. The integrated safety mechanism can be activated using a solid surface or the user's thumb.

An audible click indicates to the user that the safety shield is positioned securely around the needle and he or she can proceed without any risk of a needl stick injury.

A major benefit of the VACUETTE® QUICKSHIELD Safety Tube Holders is their ease of use. The needle is enclosed safely within the protective sleeve immediately after blood collection. The safety mechanism can be activated using just one hand. An audible click indicates to the user that the safety mechanism has been correctly activated.

Currently Greiner Bio-One is working on the market launch of the new MiniCollect® capillary blood collection system. Innovative product enhancements, such as the integrated blood collection scoop, have made the system even more straightforward and user-friendly. The products in the MiniCollect® line form a practical capillary blood collection system for people whose veins are fragile or difficult to access, children, and patients from whom only small quantities of blood can be collected.

Supplementary products The VACUETTE® System also comprises a range of special products and accessories, such as the VACUETTE® Super-T Disposable Tourniquet, the

VACUETTE® Transport Line for safe transport of samples and the VeinViewer® Flex vascular access device, which provides an HD image of peripheral veins in real-time. The range is rounded off by manual and automatic ESR (Erythrocyte Sedimentation Rate) systems, disposal boxes, transport containers and equipment for automatically decapping tubes.

Greiner Bio-One International GmbH Greiner Bio-One specialises in the development, production and distribution of high-quality plastic laboratory products. The company is a technology partner for hospitals, laboratories, universities, research institutes, and the diagnostic, pharmaceutical and biotechnology industries. Greiner Bio-One is split into three divisions – Preanalytics, BioScience and OEM. In 2015, Greiner Bio-One International GmbH generated turnover of EUR 427.5 million and had over 1,890 employees, 23 subsidiaries and numerous distribution partners in over 100 countries.

Greiner Bio-One is part of Greiner Holding, which is based in Kremsmünster (Austria).

Advertorial www.asianhhm.com

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Harnessing Big Data Analytics to Deliver Optimal Care

With the advent of wearable healthcare devices and remote monitors, Internet of healthcare things is now a reality. Using the power of big data analytics it is possible to monitor and intervene in health events to ensure maintenance of health in all its aspects.

This article discusses the various issues involved.

Suman Bhusan Bhattacharyya, Head, Health Informatics, TCS Member, National EHR Standardisation Committee, MoH&FW, Govt. of India Member, IMA Standing Committee for IT, IMA Headquarters, India

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W

ith the advent of ‘electronics age’ in healthcare, humungous amounts of data of varied types from verifiable sources is continuously getting generated in ever-increasing volume.

By analysing this ‘big’ data, for that is what it exactly is, the practice of preventive medicine and ensuring continued wellness is now moving

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from the academic world of debates and discussions to the real world of healthcare services.

Big Data in Healthcare

Before getting into big data in healthcare, it is necessary to try and understand the term ‘big data’. It is important to realise that not all data qualifies as ‘big data’. Big data is data having certain special characteristics.

These are high volume, high velocity, high variability, and high veracity – the 4V’s of big data. In healthcare context, a good amount of data of various types from verifiable sources gets generated during a single patient encounter irrespective of the care setting (OPD, IPD, or emergency), even in non-electronic environments, at quite a reasonable rate.

With just the use of electronic medical records, this amount increases dramatically as more data gets recorded and retained. When data collected by an individual gets added to this, the volume becomes pretty high. By 2015 it was estimated that average US-based hospitals alone were generating 665 terabytes of patient data per year. This relates to volume.

Through the use of health monitors, medical devices and wearables, the rates at which the generated data get collected is also quite significant. This relates to velocity. The types of this data ranges from binary to alphanumeric text including audio and visual, and in structured, semi-structured as well as unstructured formats. This relates to variability. The sources of these data are known and trusted with lot of it being collected by those who have been authenticated prior to data collection like doctors, nurses, paramedics, etc.

This relates to veracity.

Coupled with the availability of large quantities of electronicallyprocessable data are a number of concomitant technical advances that are driving big data analytics. These advances include multi core processors,

The world of healthcare, especially delivery, is changing significantly and in many instances rapidly with the various technological advances beginning to have a positive impact on the various underlying processes.

low power-consuming devices, low storage costs overall and high-speed local networking.

It is the very nature of big data that makes their analysis demand special consideration. The process needs to factor in the high volumes of varied types of data in varied formats arriving very rapidly in real-time. As a consequence, the traditional analytical processes are rendered impracticable, forcing special methods to be adopted.

Special systems for data storage, data retrieval, data preparation and data analytical are employed to ensure this.

Data Sources The sources of such data are many.

To name a few, care providers supply data via Electronic Medical Records (EMR), Electronic Prescription or Order Entry (CPOE) systems, Medical Administration And Reconciliation Systems (MAR), Hospital Information Systems (HIS), and health monitors (used mostly in critical care settings).

Increasingly, however, the patients themselves are proving to be substantial generators of such data through the use of data collecting agents in the form of wearables, home-based monitors and medical devices, and mobile health apps;

not to forget their social media posts that include Twitter feeds, Facebook entries etc. The payers contribute through generation of insurance claims data and the government through generation of regulatory compliance data.

Data Exchange Generation of data is one thing, but until that data is pooled prior to its processing, it is as good as being unavailable. Salvation in this regard comes from the ‘Internet’, or more precisely, the ‘Cloud’ that provides the necessary networking infrastructure that facilitates data exchange. Internet of healthcare things is expected to play a crucial part in this regard.

Internet of Healthcare Things The Internet of things (IoT) is the internetworking of ‘things’ represented by physical devices, vehicles (also referred to as ‘connected devices’ and ‘smart devices’), buildings, and other items embedded with electronics, software, sensors, actuators, and network connectivity that enable these objects to collect and exchange data. Typically, IoT is expected to offer advanced connectivity of devices, systems, and services that goes beyond machine-to-machine (M2M) communications and covers a variety of protocols, domains, and applications.

As of 2016, the vision of the Internet of things has evolved due to a convergence of multiple technologies, including ubiquitous wireless communication, real-time analytics, machine learning, commodity sensors, and embedded systems. This means that the traditional fields of embedded systems, wireless sensor networks, control systems, automation (including home and building automation), and others all contribute to enabling the Internet of things.

When these ‘things’ are healthcarerelated, they get christened as ‘healthcare things’.

Healthcare Big Data and Analytics Some of the different types of healthcare bigdata analytics that can be performed are as follows:

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Data from the various monitoring devices at the patient-end get streamed in to various processing systems where using techniques such as signal processing, cluster analysis, pattern recognition, logistic regression, network analysis, etc., deviations from normal and potentially problematic clinical states get identified rapidly in realtime.

With the help of these alerts the care providers monitoring the patient are able to proactively intervene, thereby preventing health events, even stopping them before they occur or cause any significant or long-lasting, serious harm.

The care providers are able to get in touch with the patient/person and instruct them accordingly e.g., asking them to visit a healthcare facility or visiting them where they live (extremely useful in ageing population with chronic illnesses) or instructing them to carry certain tasks out. For example, lying down on bed, taking some medication, or avoiding some food items.

• In the area of health monitoring and intervention, where vital changes are monitored and alerts raised using signal processing, rule-based algorithms, etc., for proactive intervention at the bedside and at home • In the field of population health management by facilitating targeted decisions to improve care and outcomes of chronically ill patient population • Analytics for care management and transitions help in improving transitions of care by identifying high-risk patients and formulating alternative care plans • Supporting healthcare consumer insight and engagement by creating a patient-focused view to enable targeted personalised marketing and clinical engagement strategies • In the field of translational research by facilitating identification of the genetic basis for diseases to help

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clinicians provide personalised medical care • By providing biomedical insights and facilitating search and discovery by helping accelerate data sharing in support of research, new product development and clinical trials.

Health Events Monitoring & Intervention

Probably the most important benefit of big data lies in real-time data processing and analytics, something that is almost impractical in other types of data analytics. The real-time aspect permits identification of the various indicators at an early stage. This leads to generation of appropriate proactive warnings that in turn leads to early intervention. This, in turn, helps in preventing more serious problems, averting crises and lessening morbidity and mortality, more frequently and sometimes considerably.

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Health Management

Although not as dramatic as health intervention but equally as important, health management is significantly improved through the use of big data analytics. Early warning systems for possible outbreaks of endemics, longterm monitoring of patients with non-communication diseases through trends and analysis for treatment effectiveness and further planning – all become very useful to provide improved care impacting overall morbidity and mortality rates of the population.

Challenges

Big data inherently suffers from the same challenges as any patient data in terms of privacy, confidentiality and secrecy issues. However, due to its realtime aspect big data comes with a few unique challenges.

The first of these is under investment in the technology due to the

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Benefits

The benefits promised by big data analytics are many. These include optimised care, improved clinical

efficiency, quality and outcomes, disease outbreak prediction, risk stratification, reduction in cost of care, reduced hospital readmissions, reduced fraud through pre-adjudication fraud analysis, etc.

Organisations Deriving Benefits Some organisations that have been successful in deriving benefits are as follows.

• Kaiser Permanente® through HealthConnect™ achieved ~US$1 billion savings from reduced office visits and investigations • Blue Shield® of California with NantHealth™ enabled delivery of more coordinated and personalised evidence-based care

As of 2016, the vision of the Internet of things has evolved due to a convergence of multiple technologies, including ubiquitous wireless communication, real-time analytics, machine learning, commodity sensors, and embedded systems.

• AstraZeneca® with HealthCore™ was able to conduct real-world studies to determine the most effective and economical treatments for some chronic illnesses and common diseases.

Conclusion

The world of healthcare, especially delivery, is changing significantly and in many instances rapidly with the various technological advances beginning to have a positive impact on the various underlying processes. In retrospect, this was inevitable since healthcare could not have continued to remain in isolation totally immune to the many changes permeating through to every other aspect of daily existence.

The encouraging news is that general awareness of big data and analytics is present and growing, as isolated cases of successful outcomes get reported. This causes the various stakeholders gather enough confidence in it to adopt it in their daily routine in ever-increasing numbers.

With emphasis on Smart Cities where digital health is an important component, big data and its associated analytics will help make a real difference to the health sector through improvement of the various health-related indicators and efficient addressing of various health processes and resources-related issues.

References are available at www.asianhhm.com

Author BIO

uncertain return on investment. With all the stakeholders not being entirely sure of the accrual of ultimate benefits of many of its promises notwithstanding, it is quite understandable to discover that they are unwilling to commit themselves in any significant way. Too many technological promises have fallen flat far too often to provide any serious comfort to the concerned stakeholders. With increasing instances of use and successes in terms of lowering of morbidity and mortality coupled with ease of use, this situation should improve.

Next is the cumbersome nature of data sharing process, much of which resides in non-interoperable silos. Data needs to be aggregated first to be useful in any kind of analysis and interpretation.

Although things are improving — with increasing number of Continua as well as non-Continua complaint devices in the form of wearables, monitors, devices, and electronic systems that are getting inter-connected through the use of many useful networking protocols like Bluetooth, Wi-Fi, GSM, ZigBee, etc., along with the increased instances of use of interoperable electronic systems — there still remains some way to go.

Lastly, and perhaps most significantly, resistance to change remains the most difficult hurdle to surmount and it not just a case of convincing the doubting Thomas’ per se. Where one’s life and limb are concerned, who can be blamed to err on the side of caution? It is possible to address this issue, but it takes a whole lot of time and effort backed up with sound evidence of success. This will happen only through increased and proper use of the technology with patience and perseverance proving to be a key success factor.

Suman Bhusan Bhattacharyya is a practising family physician and a business solution architect for medical devices and healthcare IT applications with nearly twenty nine years of experience. He has worked for several IT MNCs in India and is currently Head of Health Informatics in TCS based out of Delhi-NCR region.

Currently, he is a member of National EHR Standardisation Committee, Ministry of Health and Family Welfare, Government of India, member of Healthcare Informatics Standards Committee, Bureau of Indian Standards and also member of Standing Committee for IT, IMA Headquarters. His main areas of interest include clinical data analytics particularly treatment protocol planning using predictive analytics, designing EHR& EMR systems, mobility applications and application of machine learning techniques in healthcare.

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Steve Lieber President and CEO, HIMSS, Chicago, US

Providing High-Quality, Physician-Led Team-based Care Hear from the experts We are about to embark on a topic that invites a few questions.

Is team-based care new? Does it need to be physician-led? What benefits can this care model bring?

How to ensure high quality with a team comprising physicians, nurse practitioners, administrators and others?

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Well, team-based care is not new. Its origins could be traced to sources including the Chronic Care Model in the 1990s. It is a strategic redistribution of work among members of a practice team. By involving other staff in patient care, it frees up the physician to focus his time and attention on the patient. At the same time, other team members are kept abreast on the patient’s health history and status with the objective of handling care coordination, treatment follow-through, administration, documentation and post-visit care.

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Information Technology

All members of the team are essential and just as important. But strong reasons exist for physician leadership. We speak with HIMSS President & CEO Stephen Lieber and he answers a few questions about physician-led team based care.

Stephen, the complexity of modern healthcare is demanding – more than ever – effective healthcare provider teams. What is the advantage of physician-led teambased care?

SL: First, I think it is important to emphasise the importance of multi-disciplinary teams, regardless of who leads the team.

There are many aspects to care: clinical, administrative, technical, to name a few and there are different components to each of those. For example, the clinical component is made up of medicine, nursing, and numerous therapies. It is important that all of these components are valued participants on the care team.

With any team, there does need to be one who has the ultimate authority to make decisions, based upon the input from the other team members. The physician is the traditional care leader in virtually all parts of the world usually due to educational, experiential and regulatory environments. The challenge for physicians though is typically the amount of time asthey have to give to a single patient is very limited so the physician team leader should rely greatly on the more frequent patient monitoring that typically is performed by nursing.

Finally, technology is bringing new dimensions to patient care and providing care teams with new information never before available. This is another component that is now part of the care environment. Again, the knowledge and skills that are more typically found in the physician community reinforce the role of physician as the team leader; but the caution about time is worth repeating. Someone, perhaps a patient advocate, with sufficient time to compile all inputs needs to be involved to ensure the patient receives the best care.

How does team-based care look like to you now?

SL: The physician as the “captain of the ship” is the dominant model and for good reason. Typically, it is the physician who has the breadth of knowledge and the regulatory authority to perform this role.

In some parts of the world — US, Northern Europe, Australia and a few other areas — there is a very sufficient role and scope of practice for nursing that provides great value to the patient and to help ensure quality of care. Also, therapists relevant to the patient’s condition are also key players. This is the typical model with nursing being the clinical discipline where there is the greatest variety around the world as there are countries who have not adopted the necessary nursing education and training for these professionals to contribute in the way they do elsewhere.

Generally, team-based care is operating satisfactorily but the rise of technology is challenging this traditional model.

How do you think it will evolve over the next 5 – 10 years?

SL: The change in the next 5-10 years will be the rise of the clinical informaticist as a key team member. The collection, analysis, and utilisation of data to guide patient care is becoming more important now and will only increase in importance over the next number of years.

The growth of information is so great that no one can possibly know and retain all of the new clinical information that is coming out daily. The use of clinical analytics to develop personally-designed care will also increase the importance of an informaticist on the care team.

As a healthcare leader yourself, what are the key principles to uphold in developing effective teams? Elaborate briefly on each.

SL: 1. Be fact based: We need to ensure that care is based upon science in that we now know more about patients (genetic sequencing) and disease and how the two interact differently among patients. One treatment protocol may work for one patient while it is a different protocol for another patient with a similar condition.

2. Value all input: Sometimes it is the verbal interaction between nurse and patient, family member and patient or other interactions that can give the team the best insight as to what is going on with the patient; don’t ignore input.

3. Ensure clarity of roles: Everyone has a role and clarity as to what that role is will avoid an aspect of care not being handled or conflict between team members with different understandings as to who is responsible for something.

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Information Technology

Regional thought leaders also weigh in on PhysicianLed Team-based Care.

This is what they say: As healthcare gets more complex and patients live longer with more co-morbidities, it’s become evident that no one single medical practitioner can provide the gamut of care needed.

EMRs are the foundational units for providing good high quality care in that they can capture discrete data elements that can be analysed and acted upon for cycles of improvements.

Physicians who can navigate the complex world of medical knowledge and who can tailor for the specific needs of their patients need to be guided by the input of their fellow medical colleagues, nurses and allied health professionals. Medical IT can bridge that communication gap in a multi-disciplinary team and can even value add by bringing relevant information to the forefront.

Adj. A/Prof. Gamaliel Tan, Chief Medical Informatics Officer; Head, Orthopaedics, Jurong Health Services, Singapore

The American Medical Association defines the term “physicianled” in the context of team-based care as the consistent use by a physician of the leadership knowledge, skills and expertise necessary to identify, engage and elicit from each team member the unique set of contributions needed to help patients achieve their care goals.

It has been decades that Healthcare IT has continuously evolved and now is proving its benefits on efficient patient flow, lean processes, and most of all safer and higher level of care for our patients.

At this stage, technologies can integrate practice units and care facilities altogether across geography and be able to help care providers to have care solution(s) planned and provided at the point of care as well as the outcome(s) predicted for each patient.

At this stage, having multispecialty, multi professionals working “collaboratively in a blameless way” would be considered as a crucial step to move forward that would open up everyone to speak while physician leaders shall then use their knowledge & expertise together with their leadership skills for the team. Great teamwork that plans to achieve measurable goal(s) for each of their patients.

Dr. Korpong Rookkapan, Hospital Director, Paknampo Hospital, Thailand

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The patient-centered medical home (PCMH) is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes.

It is "an approach to providing comprehensive primary care for children, youth and adults."

As one of the key founders of PCMH, IBM has played a significant role in the PCMH principles and many of its employees are part of this initiative. The medical homes allow better access to health care, increase satisfaction with care, and improve health all at a lower cost. At the core of the PCMH is the patient’s personal, comprehensive, long-term relationship with his or her primary care physician (PCP).

Patients with a PCP will incur about a third less healthcare expenditure and will have 19% lower mortality. They are 7% more likely to stop smoking and 12% less likely to be obese. Thus, PCMH’s team-based care places the PCP at the forefront as the physician’s role drives quantifiable health improvements across patient populations. Rather than being just a resource for episodic care, the PCP-led care team assumes proactive prevention, wellness, and chronic illness care, becoming the patient’s confidant, coordinator and advisor for all aspects of healthcare.

Farhana Nakhooda, Healthcare and Social Services Director, IBM Asia Pacific, Industry Academy Member

China started embracing private healthcare delivery as a welcomed addition to the legacy public healthcare institutions.

One of the differential factors for our organization is to offer a distinguished multidisciplinary team-based model of care to our patients and clients supported by technology.

Clinician-led service planning demands a relentless drive to make our cared communities much healthier based on the value of care offered. Such model requires iterative consultation and creative co-design and co-management of care amongst our clinicians and patients.

There is a need for innovation to achieve excellent care through integrated care delivery model, and how individual and community outcomes are enmeshed. We hope that provider and patient relationships can be preserved at the same time as the health of much larger groups is advanced.

Dr. Francis Qiu, Chief Medical Information Officer, Jiahui International Hospital, China

Information Technology

The physician is the traditional care leader in virtually all parts of the world usually due to educational, experiential and regulatory environments.

The positive outcomes of physician-led team care are clear in our Code Purple program where pre-critical patient conditions are proactively defined and monitored. Once established criteria are fulfilled, the code is activated. This reduced the number of Code Blue calls and subsequent mortality rates from 57% to 13%. Additionally, the average cost of care is lower by 20% and the lengths of stay are shortened by 13%.

The formation of the Brain Attack Team to respond to acute strokes has resulted in the time to response and imaging to steadily decrease from double to single digit minutes. This has increased the number of rtPA eligible patients to fall within the optimal time window of administration.

At the Asian Cancer Institute, the multidisciplinary teams of physicians, nurses and counselors are designed around the patient. This has brought down the fallout rate for treatment and subsequent follow up. Expanding team based care evidently is the way forward.

Dr. Juan Antonio G. Javellana, MD, Director of Medical Informatics, Asian Hospital and Medical Center, Philippines

To cope with the ever-increasing burden on, and demand for, healthcare services new approaches are required that will increase the productivity of healthcare providers without an increase in administrative burden.

Team-based care provides unique opportunities to reduce non-essential tasks and duplication of work through a model that promotes greater engagement of patients with all their care-givers to accomplish shared goals.

Essential in such an approach is the availability of an ICT system that allows all stakeholders to securely access and effectively use the information being generated, which has a user-centric design and organises all the work for team members in an intuitive way. In recognition of the growing role patients play in the delivery of their own care, such a system must also allow the

patient to be fully engaged, informed and integrated in all applicable care team activities.

The Agfa Healthcare Engage Suite provides a platform for (physician led) team-based care that supports care management and access to patient health information beyond hospital walls, for patients and care providers alike. It offers features and functionality for care coordination and integrated care, enabling each stakeholder to prepare, follow and monitor the patient’s care through greater collaboration and communication, as part of a team-based care environment.

Matthew Koch, Imaging IT Product Manager ASPAC, Agfa HealthCare

Physicians will continue to experience pressure to become more efficient while improving the delivery of patient care.

The reality is, they can’t do it alone.

A team-based care approach provides a foundation for better communication among physicians, nurses, and other care team members.

That’s where Spok comes in. The Spok Care Connect® platform improves care team communication and allows delivery of critical information quickly to clinicians on the device of their choice. One Spok customer reduced formal complaints regarding a lack of communication by 75 percent. Another customer was able to cut the amount of time it takes to initiate a code by half.

Spok’s patient-centric messaging capabilities allow physicians and nurses to get the information they need when they need it, allowing more effective collaboration among care team members.

Hemant Goel, President, Spok

Author BIO Steve Lieber is President and CEO of HIMSS, a global, cause-based, not-for-profit organisation focused on better health through information technology. A recognized healthcare management executive, Lieber brings to the HIMSS over 30 years of experience in healthcare, primarily in healthcare association management. He joined HIMSS in 2000 as CEO/President of the organisation.

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Products&Services Company................................. Page No.

Company................................. Page No.

HEALTHCARE MANAGEMENT

TECHNOLOGY, EQUIPMENT & DEVICES Cantel Medical.....................................................OBC Device Informed.......................................................05 Greiner Bio-One GmbH......................................50-51 Siemens Healthcare PTE Ltd..............................24-25

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Facilities & Operations Management Greiner Bio-One GmbH......................................50-51 Lessa......................................................................IBC Siemens Healthcare PTE Ltd. ............................24-25 INFORMATION TECHNOLOGY Cantel Medical.....................................................OBC Greiner Bio-One GmbH......................................50-51

SuppliersGuide Company................................. Page No.

Company................................. Page No.

Cantel Medical.....................................................OBC www.cantelmedical.com

Medical Fair Thailand...............................IFC, 16 & 17 www.medicalfair-thailand.com`

Greiner Bio-One GmbH......................................50-51 www.gbo.com

RadiologyAsia Conference......................................03 www.radiologyasia.com

Fleming....................................................................43 https://fleming.events/

Siemens Healthcare PTE Ltd..............................24-25 www.siemens.com

MAMD2017..............................................................35 www.mamd2017.com

Device Informed.......................................................05 www.deviceinformed.com

IAOC.........................................................................45 www.aocongress.com IUMS.........................................................................11 www.iums2017singapore.com Lessa......................................................................IBC www.lessap.com

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