Asian Hospital & Healthcare Management Magazine - Issue 37

I s s u e 37

2017

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Healthcare Business Models in Southeast Asia

Evolution is vital

Industry 4.0 Manufacturing and the future of medical things Dawn of the Future IoT-driven medical devices service enterprises

Foreword Healthcare in Southeast Asia Opportunities and challenges alike The Southeast Asia’s emerging countries are expected to witness tremendous growth in healthcare spending by 2020. These include Indonesia, Philippines, and Vietnam which are witnessing a widening reach and expansion of their healthcare systems to serve thousands of patients that have for long been deprived of proper care.

According to the Economist Intelligence Unit, the CAGR of healthcare spending in Indonesia and Philippines during 2016-20 is expected to be 10.6 per cent and 10.8 per cent, respectively, exceeding growth of the BRIC nations. These merging economies have focused on social health insurance to provide affordable healthcare for low-income families. Indonesia has made a reasonable advancement in healthcare provision through its universal health insurance that covered more than 65 per cent of its population as of 2016, growing from 46.7 per cent in 2013.

Meanwhile, Vietnam has more than 77 per cent of its population covered under universal insurance scheme, while the coverage for Philippines was just under 90 per cent by 2016. Implementation of the health insurance policies was dependent on partnership with private hospitals as government hospitals were unable to meet demand because of inadequate supplies and lack of proper infrastructure.

While Singapore and Brunei are the most developed healthcare markets in the region, the former is looking beyond a strong healthcare system and aims to drive healthcare innovation to address challenges such as chronic diseases and ageing population. In the fast maturing markets of Malaysia and Thailand, the rise of healthcare systems locally meant better choice of care for patients. Malaysia in particular, has seen rise in spending on healthcare as the health ministry planned to spend around $350 million as of 2016 to better integrate public and private healthcare systems by sharing of data.

Economic growth has spurred funding in public healthcare expenditure in the region’s emerging countries; nevertheless private players do see a great opportunity in the longer run and continue to expand their services. Rising income groups and an affluent popula ion have fueled the demand for access to better healthcare facilities and higher quality of care. The challenge of healthcare delivery is being addressed through allocation of heavy budgets for upgrading healthcare infrastructure and closing in on the demand for hospital beds in the regions. Myanmar is slowly moving towards becoming a growing healthcare market, while Cambodia and Laos have been dependent on private players for healthcare.

These merging countries present significant opportunities for private companies. For the universal health programmes to sustain in the long run, governments will look to players that finance and deliver care by improving efficiencies through development of generic drugs and providing affordable healthcare. For healthcare companies, this means widening their reach through higher volumes of affordable products, and innovative business models for serving middle and affluent income groups.

In the cover story, Yoshihiro Suwa of Roland Berger, provides deeper insight into how private players in the region have experienced an i ncreasingly competitive environment and reduced margins in the recent past. While the outlook remains optimistic, private healthcare providers should continue to look at innovative business models to evolve and remain relevant for sustaining in the long-run.

Prasanthi Sadhu

Editor

Contents

HEALTHCARE MANAGEMENT

06 Nurses are Expected to Embrace Technology Who is there to address their woes?

Lt Col (Retd) Binu Sharma, Senior Vice President Nursing Services Columbia Asia Hospitals

Cover Story 16 Healthcare Business Models in Southeast Asia Evolution is vital

12 National Health Policy A welcome move in the healthcare industry

Yoshihiro Suwa Partner, Roland Berger

Suresh Ramu, CEO, Cytecare Hospitals

20 Becoming World Class, with Class Jeffrey E Thompson, Pediatric Intensivist and Neonatologist Gundersen Health System

26 ACO Meets Triple Aim and Save $millions Peter A Gross, Chair, Board of Managers, HackensackAlliance ACO

MEDICAL SCIENCES 30 The Global Advancement of Diabetes Management Sanjiv Agarwal, MD & Founder, Diabetacare

34 Head and Neck Cancer Symptoms, early detection and prevention Vikram Kekatpure, Senior Consultant, Head & Neck Surgical Oncology Cytecare Hospitals

38 Risk Factors for Development of Cardiovascular Disease KATM Ehsanul Huq, Graduate School of Biomedical & Health Sciences Hiroshima University

48 Dawn of the Future IoT-driven medical devices service enterprises

Michiko Moriyama, Graduate School of Biomedical & Health Sciences Hiroshima University

Ram Meenakshisundaram, Senior Vice President and Global Delivery Head Life Sciences, Cognizant

Pradeep Kumar Ray, Engineering Research Center on Digital Medicine and Clinical Translation (DMCT), Shanghai Jiao Tong University Susumu Nakayama, Graduate School of Biomedical & Health Sciences Hiroshima University Md Moshiur Rahman, Graduate School of Biomedical & Health Sciences Hiroshima University

Technology, Equipment & Devices 42 Industry 4.0 Manufacturing and the future of medical things Francisco Almada Lobo, Chief Executive Officer and Co-Founder, Critical Manufacturing

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INFORMATION TECHNOLOGY

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50 Data Security and Analytics Shaping the future of healthcare Baskaran Gopalan, Senior Vice President, IT & Projects Omega Healthcare Management Services Pvt. Ltd.

54 HealthTech Innovation Optimising telehealth services Dave Waldrop, Co-CEO/CRO, Calgary Scientific

58 EHR Interoperability Why, what and how SB Bhattacharyya, Head, Health Informatics TCS Member, National EHR Standardisation Committee, MoH&FW, Govt. of India Member IMA Standing Committee for IT, IMA Headquarters

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Advisory Board

Editor Prasanthi Sadhu Editorial Team Debi Jones Grace Jones Art Director M Abdul Hannan Product Manager Jeff Kenney Senior Product Associates David Nelson Peter Thomas Sussane Vincent Product Associate Ben Johnson Jennifer Wilson John E Adler Professor Neurosurgery and Director Radiosurgery and Stereotactic Surgery Stanford University School of Medicine, USA

Circulation Team Naveen M Nash Jones Sam Smith Subscriptions In-charge Vijay Kumar Gaddam

Sandy Lutz Director PricewaterhouseCoopers Health Research Institute, USA

Head-Operations S V Nageswara Rao

Peter Gross Chair, Board of Managers HackensackAlliance ACO, USA Asian Hospital & Healthcare Management is published by

In Association with

A member of

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

Confederation of Indian Industry

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Nurses are Expected to Embrace Technology

Who is there to address their woes?

Historically, developed under the British rule, nursing was one of the first profession to develop in India. This noble profession has witnessed tremendous evolution strides in all spheres including technology, medicine and medical equipment. From being considered as an art based human subject, it has evolved into the field of technology. However, the status of nursing in our country is still a subject of debate. With organisations coming forward in the leadership of influential public figures, will the status of this noble profession remain the same even in 21st century?.

Lt Col (Retd)Binu Sharma, Senior Vice President Nursing Services, Columbia Asia Hospitals

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istorically, nursing in India had evolved under British rule. The British Medical Services, later known as the Indian Medical Services, were the first to develop nursing as a profession in India.

Nursing as a profession has evolved over the years from being an art based human approach to a technology oriented science subject. The role of nurses has changed dramatically over the last couple of decades. I have seen evolution in this field from the time I had entered this profession, exactly 40 years ago.

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In any health system, the health worker determines the nature and quality of services provided. Data demonstrate that most health systems across the globe face nursing shortages, varying across regions and rural-urban distribution. Although nursing services are an integral part of both preventive and curative aspects of India's health system, the nursing estimates of the country shows that India has been facing a shortage of nurses since independence.

Earlier, nursing had little to do with formal training on clinical practices, infection prevention and patient safety.

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A few decades back it was more about following the doctor’s orders and comforting the patients and counselling them. Nursing curriculum didn’t include training & exposure to vital aspects to handle patients independently.Young nurses lacked confidence in infection control protocols, basic & advance life support measures and doing skill based procedures. The role of nurses was given prime importance in terms of basic still sets with a human touch.

However, over the last two decades,with technology playing a key role in healthcare and with hospitals adopting digitization, cloud data

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Nurses should be considered as active members of the health team, in terms of not only providing services, but also as a part of the decision-making processes, so that it is possible for her to participate in providing holistic and comprehensive healthcare to the patient. storage, and electronic documentation, nursing as a subject has become more science and technology driven. Nurses today are expected to hone their skill sets on the latest technologies.

For instance, we at Columbia Asia Hospitals are completely paperlesswhen it comes to patient’s medical records and other documentation. Nurses very easily adopt technology once they are inducted & trained in the Hospital Information System.

This apart, now,focus is given on imparting knowledge to the nurses along with hands on skills in operating the newer medical devices and equipment

for handling patients likesmart drug infusing pumps, drug delivery pumps, and patient’s monitoring systems.

Nurses are using newer technology for assessing and monitoring patients The good news here is that since majority of the nursing professionals belong to the younger age group, they are flexible with the evolving systems which never existed in earlier days.

However, we should understand that training of nurses should ideally go much beyond imparting technical and

medical skill sets. As nurses anddoctors are the pillars of patient care in the hospital, it is vital for them to work in coordination. Thus, it is important for nurses to get trained to enhance their integration with the doctors. Also, nurses and doctors should be trained together in disease management, from the point of medical management and nursing management, so that they can work as a team with a common clinical goal which improves patient outcomes.

This helps in ensuring that they all

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speak the same language with no miscommunication when they involve in patient communication.

Counselling plays a vital role in a nurse’s skill set today.

Nurse Counsellors are trained to educate the patient and his family about a disease and how to handle it. Nurse Counsellors are also expected to counsel the patient’s family, educate them about patients’ safety in the hospital and at home, and focus on ways to maintain hygiene for the patient. These are new training guidelines which go much beyond the traditional nursing training.

A nurse in a private or a corporate hospital has to internalise communication etiquettes, communication content and other soft skills. At Columbia Asia, there is a standard script designed for nurses for all the communication that she must do with the patient. For instance, there are exact drafted words that she should speak to a patient on hospital bed or during discharge.

Another important factor today is grooming of the nurses. Nurses hail from various parts of the country, with many coming from smaller towns and many of them are not comfortable in communicating in English. Hence, they are trained in English communication and grooming. A little make over with knowledge about carrying themselves presentably, maintaining personal hygiene, adopting pleasing manners goes a long way in adding to their overall personality and service offered.

They are also trained in body language and how not be rude to the patient.

Also, training is given on computer skills, keeping in mind the rising standards of the hospital. Now-a-days, apart from conventional nursing skills and nursing procedures, a customer also looks at a seamless experience or approach. Therefore, nurses have to be trained to work in integration with other departments for establishing inter-departmental coordination and communication.

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Standardisation of Salary for Nurses in India:

Nurses form the backbone of any medical services or patient care in the health sector. But in India, this important section of workers are highly exploited, with lack of respect and dignity at workplaces and more importantly paid extremely low salaries with lack of job security.

The demand and supply ratio of nurses in India is getting wider with trained nurses from India are settling for greener pastures abroad. For decades now, nurses are taking up jobs in Middle East, many European countries, Canada, andvery minuscule numbers are relocating with jobs in the US. The nursing profession in India lacks high professional status, has low and unattractive salaries, gets inadequate recognition from the community for the services provided by them and has little incentives for quality performance (Gill 2009). The institutions responsible for nursing training lack the required physical and human resources.

The nursing profession is given low social status because of the prevalent societal traditions. Nursing work involves rendering services on a

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personal level to the patient and has chances of being exposed to bodily fluids and contaminations. The work undertaken by nurses still has social stigma attached to it . This can be cited as one of the main reasons behind the low perception held by the Indian society towards the nursing profession.

The nurses are considered to be secondary in position as compared to other health professionals in India.

There is a vast difference in the prestige and recognition accorded to doctors as compared to nurses (Gill 2009). The nursing profession continues to be neglected in India. Some of the causes behind this neglect are more emphasis on medical education, political influence by the medical community and less allocation of financial resources on health by the Indian government (Rao, Rao, Kumar, Chatterjee, & Sundararaman 2011).

Thus, with time and experience, they prefer to move overseas as there is respect, good compensation with annual perks like free vacations, good living conditions and other benefits.

In India, most of the women in nursing would want to move to a government set-up because of job

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Nurses form the backbone of any medical services or patient care in the health sector.

Future of Nursing Industry Over The Next Decade:

Since healthcare is growing,demand for nursing as a profession is bound to grow. However, students choosing nursing as profession are dropping drastically. Younger generation is not motivated enough to take up nursing.

They rather choose a career path with a BBA, engineering or MCA degree, where life is better with good salary to start with and a respectable social status. Today, as much as

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30-40 per cent seats during enrolment are left vacant. Hence, India is going to struggle with availability of nurses, unless the working condition, compensation and social status of nursing professionals are elevated. This calls for animmediate change in the social framework at par with international standards.

Strong political commitment is required for improving the nursing situation in India. Goodworking conditions must be provided so that nursing workforce can be developed and deployed in the health services fulfilling the recommended staffing norms. Nurses should be considered as active members of the health team, in terms of not only providing services, but also as a part of the decision-making processes, so that it is possible for her to participate in providing holistic and comprehensive healthcare to the patient.

The nursing education programme in India should be strengthened. The Indian Nursing Council should be vested with requisite powers, so that it can work with in tandem with the

Author BIO

security, accommodation and medical benefits. They would choose to work for a government establishment even though there is not much professional growth, as they get various benefits which is not available in private sector. Experienced nurses in India also prefer taking up teaching jobs in nursing colleges as they get position of assistant professors which is of a much better social status as compared to nurse.

It is about time that various stakeholders seat together and decide on a standardization, when it comes to salary for nurses. There have been some efforts in the last two years where FICCI along with other stakeholders came up with an advisory panel to reforms nursing condition in India.We have worked for the last two years and have come up with a white paper for reforms including compensation, growth, speciality vacancies and many more.

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State Nursing Councils for the purpose of regulating and maintaining standard in nursing education and training.

The government should take initiatives to create and empower leaders from the nursing fraternity itself. Moreover, there should be efforts to provide adequate infrastructure, remuneration and working conditions to the nurses. Efforts should be made by the government to retain qualified nursing personnel in the country. Reducing movement of nursing personnel outside the country must form one of the priority areas of the government.

The nurses choose migration as a realistic option arising out the circumstances existing in the country.

Adequate incentives, both financial and otherwise, need to be provided in order to retain health staff. Addressing the issues and problems faced by the nursing fraternity will help not only to in reducing migration of nurses from the country but also to some extent it will help in reducing the nursing shortages faced in the country.

Col. Binu Sharma is also a certified NABH assessor and the General Secretary Infusion Nursing Society-India - an international affiliate to INS - US. Her current role involves: Designing the nursing architecture and leading the team to deliver high quality nursing services; to facilitate nursing education and training for overall nursing management; to participate in strategic planning, budgeting, resource allocation, planning & opening new hospitals.

A market intelligence leader delivering research and consultancy for the Global Healthcare Industry

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National Health Policy

A welcome move in the healthcare industry The revision in the national health policy is a landmark event as this has been revised in India after 14 years. The policy highlights the increased spend in healthcare which will go up to 2.5 per cent of GDP, hopefully in the next 5 to 10 years. The policy also recognises that there are certain types of cancers which can be addressed early through screenings.

Suresh Ramu, CEO, Cytecare Hospitals

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A

health policy is a structured framework of a set of decisions and plan of action undertaken to achieve specific healthcare goals within the society. These health policies help the government to implement and monitor various health services across the country to ensure basic health benefits reach citizens across all demographic and economic class. While there are smaller health policies initiated on a need based approach, there is a master nation health policy in place which is essential in defining a country's vision, priorities, budgetary decisions and course of action for improving and maintaining the health of its people. Most countries have been using the development of national health

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policies, strategies, and plans for decades to give direction and coherence to their efforts to improve health.

Such a master health plan is paramount in India, especially due to the fragmented socio-economic structure and lack of education & awareness among the large pool of the population in the rural and small towns.

While technology and infrastructure is slowly connecting these remote regions to development and better standards of living, having easy access to affordable and quality healthcare services is still an arduous task.

The National Health Policy was endorsed by the Parliament of India in 1983, updated in 2002 and recently it was largely amended in March this year, with the focus to provide healthcare to all, in light of the emerging challenges arising from the ever-changing socioeconomic and epidemiological situation in the country. The amendment in the national health policy is a landmark event as it has been revised after 14 years and the key goals of the policy are expanding access to medical facilities, providing affordable treatment to the masses and improving the quality of medical services. With these three main objectives, this policy system encapsulates preventative methods without bounding anyone by financial shortcomings. This shows that our country is focused on creatinga healthierIndia, as the PMO echoed the same sentiment by stating that the National Health policy marks a historic moment in their endeavour to create a healthy India where everyone has access to quality healthcare.

The policy highlights the increasein expenditure in the healthcare sector which is expected to go up by 2.5 per cent of GDP in the next 5 to 10 years.

The vision of the policy is to bring about a positive and noticeable social, economic and technological change to strengthen India’s healthcare system.

It involves reorientation of public hospitals where there is a cost recovery

According to the World Health Organization, an Indian today has over twice the odds of dying of a non-communicable disease than a communicable disease.

approach, access to free drugs and emergency services for people from all strata of the society.

The NHP passed this year is standing boldly on four pillars – clarity in objective, clarity in design, clarity in financing and clarity in incentives. The policy also puts light on investment and action in school health-by incorporating health education as part of the curriculum. Broadly the policy envisages providing assured comprehensive primary healthcare and indicates important change for major NCDs [non-communicable diseases], mental health, geriatric healthcare, palliative care and rehabilitative care services. In addition, the policy will look at offering free drugs, free diagnostics and free emergency and essential healthcare services in all public hospitals in a bid to provide access and financial protection. It also looks at a three-dimensional integration of AYUSH systems encompassing cross referrals, co-location and integrative practices across systems of medicines and also will develop their grievance redressal mechanism.

The ‘giving back to society’ initiative in the new Health Policy extends a helping hand by providing voluntary service in rural and under-

served areas supported by recognised healthcare professionals. It believes in extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system and proposes establishment of National Digital Health Authority (NDHA) to regulate, develop and deploy digital health across the country.

The Key Principles of This Policy are:

• Professionalism, Integrity and Ethics that are to be to be maintained in the entire system of healthcare delivery in the country, supported by a credible, transparent and responsible regulatory environment • Equity: It would mean curtailing inequality on account of gender, poverty, caste, disability, other forms of social exclusion and geographical barriers. Pooling financial resources for the poor will also come under this • Affordability: Access to free drugs and emergency health services, making medical equipment cheap is also one of the key principles • Universality: This includes stoppage of exclusions on social, economic or on grounds of current health status • Patient Centered & Quality of Care: Giving dignity and maintaining confidentiality on certain issues like gender sensitive, effective, safe, and convenient healthcare services is priority this time • Accountability: Transparent decision building and making healthcare systems both in public and private sectors corruption free is one most important reason of revision of the policy • Inclusive Partnerships: A multistakeholder approach with partnership & participation of all non-health ministries and communities. This approach would include partnerships with academic institutions, not for profit agencies, and healthcare industry as well

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• Pluralism: AYUSH care providers are small extensions of the Government where patients get themselves treated for speedy process encouraging home and community based practices and thus meeting the national health goals and objectives through integrative practices • Decentralisation: With practical considerations and institutional capacity decentralisation of decision making to a level is a prudent principle of the policy.

• Dynamism and Adaptiveness: Based on new knowledge that is from national and international knowledge partners there is a constant need of improving dynamic organisation of healthcare system in India.

Clearly different from the previous two policies; this time it is the detailed elaboration of areas in which private sector services will be contracted for training, skill development, community training for mental health, disaster management, purchase of services to fill gaps and preferentially for Central Government Health Scheme members, and primary healthcare in urban areas. Partnership with the private sector for infectious disease control, immunization services, disease surveillance and health information and manufacture of medical devices is taken in consideration. The policy also pursues to take steps to improve, upgrade and incentivize the quality of services being provided by the private sector in rural and remote areas and among underserved populations along with facilitating of diagnostic laboratory support.

Our health system is burdened by emerging and re-emerging diseases like drug-resistant TB, malaria, SARS, avian flu and the current H1N1 pandemic. The actions taken to protect public health of India had witnessed many hurdles in its attempt to improve the standard of living of its people. Since independence major public health problems like malaria

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have been curtailed through the health policy chalked by the government. For the first time the policy emphasised on , specific targets like the elimination of certain diseases like kala-azarby the end of this year, leprosy by next year and lastly the most important or rather the most challenging target of eliminating Tuberculosis by 2025. The policy also aims to reduce the fertility rate to 2.1 by 2025. There is a focused approach on AIDS awareness also and the NHP plans to attain ’90:90:90’ global target by 2020. This means that 90 per cent of all people living with HIV are aware of their HIV status, 90 per cent of people infected with HIV receive sustained antiretroviral therapy and about 90 per cent of those receiving the therapy will have viral suppression.

The policy also emphasizes on early detection through screening for certain types of cancers. To accelerate this process ASHA workers across the country are trained for oral, breast and cervical cancer treatment. This is a great initiative as it will help early detection and reduce mortality rate even in the lower strata of the society.

The National Health Policy has a target

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to reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 25 per cent and increases life expectancy at birth from 67.5 to 70 by 2025. Another major preposition in national health policy was to manage costs for generic drugs and medical devices in government hospitals, as a lot of patients currently prefer treatment from private institutions.

The policy also plans to reduce the prevalence of blindness by 2025 to 0.25 per 1000 persons. To provide a health card to every family, so that they have access to primary care facility as well as access to a well-defined package of services nationwide is also one of the aims on the NHP. This policy seeks to reduce neonatal mortality rate as well as stillbirth rate by improving home based facilities for sick newborns. Also an effort will be aimed towards pre-emptive care, so as to attain the most favorable levels of adolescent health. The policy is of the view that if they strengthen the existing medical colleges and if converted to new medical colleges it could increase the number of specialists and doctors in regions where there are a deficit

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doctors and other medical personnel.

Rural areas are the ones that bear the brunt, hence the policy aims at starting with medical colleges in rural areas, mandatory rural postings etc. A continuous effort will be made so that the public health systems do not collapse and are able to retain the manpower. An outline of positive aspects and issues of the policy has been noted below.

Some Positive Aspects of the NHP • The policy along private sector partners looks at problems and solutions at a universal level • From the point of view of the less privileged population, the policy proposes to provide free medical aid right from free drugs to emergency healthcare services so forth and so on at public hospitals • Aims at providing 2 beds per 1,000 populations. This will enable victims to get a bed within the first hour of injury, because that is the time which is most crucial for the victim and is most likely to benefit from treatment • The policy seeks to provide easily accessible and affordable secondary and tertiary care medical services.

Some Issues of the NHP • To make National Health Policy function flawlessly, the Centre has to get robust and updated health data • To reduce high out-of-pocket spending, early deadlines should be set for public institutions essential medicines and diagnostic tests free to everyone • The policy mentions an increase in health expenditure from 1.5 per cent to 2.5 per cent by 2025, which entailsa span of another 8 long years.

As a cancer care hospital, the policies introduced for Non-communicable Diseases (NCDs) are of prime importance to us. According to the World Health Organization, an Indian today has over twice the odds of dying of a NCDs than a communicable disease.

As the cost involved in care and medical equipment of treating NCDs is extremely

high, government’s focus onincreasing spend on non-communicable diseases will help to reach out to a larger scale of patients.

We need to give a push to innovative technology development, clinical trials and medical care in India itself. This will not only ensure timely care along with western countries but also reduction in cost.

Along with all of this, we also need to ensure that the cost of diagnostics and medical equipment is controlled.

A widespread public awareness of

voluntary donations is important particularly for cancer victims and other NCDs as it entails huge money.

After heart and lung disease, cancer is the third largest cause of death in the country. However the policy needs to have a separate section to address the issues in cancer care. The new policy needs to be executed so as to achieve a milestone especially in India where deaths per day is in thousands due to cancer and the majority of the population is under the poverty line.

Author BIO

Suresh Ramu is also a Co-founder & Director of Cytespace Research and Co-founder of Medwell Ventures. Prior to establishing Cytespace in 2011, Mr Ramu spent 10+ years with Quintiles Transnational. As Vice President and Head – India, for Clinical Development Services, he managed all aspects of clinical trials conduct in the country. Holding diverse senior leadership positions, he was instrumental in creating two valuable assets for the organisation – the world’s largest multi-shift data management operations to process clinical trial data, and Asia’s largest cardiac safety lab. In his consulting role, Mr Ramu advised on process improvement, cost management and customer relations at PricewaterhouseCoopers. He was also an early team member at a telemedicine start-up in India. Mr Ramu has a Bachelor’s degree in Engineering from the Indian Institute of Technology in Madras, and a Master’s in Business Administration from the Indian Institute of Management – Calcutta. He is a member of the American Society of Clinical Oncology and has presented at various professional conferences in India and abroad.

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Cover Story

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Healthcare Business Models in Southeast Asia Evolution is vital

Healthcare facilities in Southeast Asia are facing a triple threat of more insurance claims, a slowdown in medical tourism and increased competition. A uniform slide in third-quarter earnings of major facilities providers last year was the clearest indicator yet, that they must initiate business model transformation. YoshihiroSuwa, who leads Roland Berger's healthcare consulting practice, explores innovative business models that can be profitably adopted.

Yoshihiro Suwa, Partner, Roland Berger

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espite an increasing demand for higher quality healthcare, fuelled by an expanding middle class, the private healthcare industry has lost some of its lustre.

Hospitals in general, are seeing a triple threat of general decline of medical tourism, reduced margins and an increasingly competitive environment.

While external demand looks promising in the long-term, recent financial results of major private care and hospital groups exhibit symptoms that show not all is well.

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An analysis of the financial statements of major private care and hospital groups in Asia showed a uniform slide in their third quarter earnings of 2016. IHH Healthcare did achieve 18 per cent year-on-year increase in sales RM 2.4 billion in the third quarter of 2016 and EBITDA grew 15 per cent RM155 million YoY. Even though sales and EBITDA achieved double-digit growth, the sales volume to EBITDA rate fell slightly from 23.1 per cent to 22.4 per cent in the same period in 2015. The group’s biggest earner, its Singapore market, grew less than double digit for the first time, at 8 per cent increase in sales and a 15 per cent growth in EBITDA, when compared to the same period in 2015.

A statement by the group's spokesperson acknowledged that one of the main reasons for slowed revenue growth was fewer medical tourists, who typically spend more than local patients.

This is not the only difficulty on record. Increasing use of healthcare insurance as a payment scheme has also dogged healthcare facilities providers.

KPJ Healthcare–a major healthcare facilities provider in Malaysia– contracted 1.86 million outpatients (-0.9 per cent YoY) till the third quarter in 2016, and 210,000 inpatients (+0.8 per cent YoY). While KPJ sees stable visits from patients with insurance, which pays 70 per cent of the hospital's earnings, patients paying out of pocket

have declined, putting a squeeze on margins. According to the hospital, the trend will remain until 2018.

Indonesia’s Siloam Hospitals opened three new facilities in 2016: Siloam Hospitals Labuan Bajo, Siloam Hospitals Buton and Siloam Hospitals Samarinda. Labuan Bajo is located in the port city Flores Island with a population of 100,000, Buton is located in Southeast Sulawesi with a population of 300,000 while Samarinda is the capital city of East Kalimantan with a population of 800,000. There are also plans to open more hospitals in 2017 in major cities and rural areas in Indonesia.

While it could target only major cities to make the operations commercially viable, competition is stiff, not just from a marketing perspective. Adding to the group's headaches is that fact that it cannot operate its rural hospitals the same way it manages its urban locations.

This is because the population size and economic scale in smaller cities are a fraction of the capital city Jakarta.

To add to its difficulties, the cost of personnel may be lower on average in smaller cities, but that is not the case for doctors. At the early stages of the establishment of a hospital, it is essential for a reputable skilful doctor– who can be difficult to recruit–to be at the forefront of the hospital’s brand to attract more patients.

The Siloam group classifies its portfolio of 23 hospitals into four catego-

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ries based on opening dates and location: Mature, Developed, Distinct and New. 40 per cent of patients come from five of the oldest hospitals classified as ‘Mature’, which saw a 6 per cent increase in the number of outpatients and 3 per cent increase in the number of inpatients in the third quarter of 2016, the lowest growth recorded. This, and other factors mentioned above, underscores our third point, that increased competition has reduced margins and volumes of many private care groups in the region.

Despite these stumbles, it would be wrong to conclude that investing in the private healthcare industry could be unviable in the long-term.

The national medical expenses for the six major Southeast Asian countries (Indonesia, Malaysia, the Philippines, Thailand, Singapore and Vietnam) amounted to US$105 billion in 2014 and Roland Berger expects it to reach US$240 billion by 2020. The average annual growth rate during this period is 14.7 per cent and the region is still an attractive market that will continue to achieve double-digit growth. Historical trends indicate that governments will continue to shift the healthcare financing burden to the private insurers or to individuals.

What is evident is that these factors show the industry may have reached a critical turning point in 2016 and it could be the start of a future that has no more double digit growth. Some players may have even experienced more than one factor, deepening the case for them to consider adopting fresh business models that may augment future operations.

Evolution of Business Models

While new business models are replacing existing ones, new players are also injecting fresh thinking to gain an edge. Our analysis identified three new business models that may help private healthcare players to operate in the future.

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Expand Local Capacity and Quality Some healthcare players have opted to expand locally and grow their patient base to capture the growing middle class locally. BDMS–Thailand's largest healthcare player–has done exactly this. The group’s share of hospital beds in Thailand’s domestic private hospital market has reached 16 per cent in 2014. By region, BSMS’s presence has increased across different regions in the country: 18 per cent in Bangkok, 17 per cent in central Thailand, 24 per cent in Southern Thailand, 12 per cent in Northeast Thailand and 5 per cent in Northern Thailand.

While there were plans to establish presence in the Middle East, BDMS ultimately decided that replicating the same service levels and quality would be commercially unviable, and opted to expand capacity locally and woo medical tourists from that region.

To improve on quality and excellence, the group partnered with leading global medical institutions on their area of specialisation, to gain insights on latest innovations

ISSUe - 37 2017

in specific branches of medicine. This is strategically sound not only from a services perspective to attract discerning medical tourists, but also helps with margins. Since better technologies will enable shorter patient stays by helping them recover faster or recover at home, more patients can be accommodated or the same number of beds.

To further diversify its business, BDMS has begun transitioning its non-hospital services–originally intended as internally shared services amongst all business group –to generate income. For instance, National Health Systems, the laboratory services arm of BDMS, now offers its laboratory services to customers outside the BDMS group.

The conversion of non-hospital business to a revenue generating one also reduces BDMS' dependence on its general hospital business. Its decision not to expand the general hospital presence abroad means that it must reduce the dependence on general hospital revenues, since it did not

HEALT HCARE MANAGEMENT

The national medical expenses for the six major Southeast Asian countries (Indonesia, Malaysia, the Philippines, Thailand, Singapore and Vietnam) amounted to US$105 billion in 2014 and Roland Berger expects it to reach US$240 billion by 2020.

The business model of Sanitas is simple. After receiving a regular fee from subscribers, the group will manage their health and hopefully profit. The healthier the subscribers, the more profitable it is for Sanitas.

The emphasis is placed on health management and disease prevention of the subscribers. Subscribers can view information ranging from their medical information to the management of medical fees online, which encourages subscribers to be highly aware about their health.

They are also encouraged to go for regular checkups to prevent hereditary diseases such as cancer from reaching dangerous stages.

On the other hand, if the subscribers are sick, they are able to receive some discount on the medical fees if they were to receive treatment at the group’s clinics and testing centres. This business model eliminates the possible conflicts of interest between hospitals and insurers by Author BIO

diversify the business geographically.

With the expansion of the network into different types of medical facilities, it can further farm revenues from within the network.

Focus on Cost Management Medical expenses will continue to rise for the foreseeable future and is a concern for many people and employers, where the latter often offers medical insurance as part of local employment packages to attract staff. To manage these costs, some medical providers are now offering Medical Billing Management Services (MBMS) to employers to lift some burdens off employers' shoulders. Fullerton Health –headquartered in Singapore– is doing just that.

The group has operations in four markets in Southeast Asia, and Australia. It focuses on primary care and has hospitals and clinics. The latter provides checkups and outpatient care for fees lower than general hospitals.

MBMS provides claims management for corporate clients. In all the markets they operate, MBMS provides cashless services at facilities; medical examinations financed by insurance claims and payments; and consultation to control medical expenses for its corporate clients at all of its facilities. This not only saves time and helps identify where wastage occurs, but also prevents medical claims fraud and overcharging.

Patient Insurance that Supports Preventative Care Some private care groups are expanding their business model to integrate insurance, providing a one-stop solution for customers.

One group in particular, Spain’s Sanitas International, has created a prepaid form of health insurance to complement its vast network, which comprises clinics, medical centres, laboratories, ophthalmology and dentistry facilities, and pharmacies.

matching the interests within the network, so that subscribers can remain satisfied and healthy while Sanitas (and its network) profits. The result is a highly efficient healthcare network and community.

Survival of the Fittest

With economies in the region maturing, business models for private medical players must continue to evolve to remain relevant, even if the outlook is generally optimistic.

As our analysis of the private healthcare providers in the second half of 2016 showed, the industry is not immune to shocks and must learn the warning signs early and heed their own advice, which is to take preventative steps to maintain and improve their own business health.

While private care providers primarily targeted high net worth individuals in the past, many providers are now seeking new addressable growth areas and can apply new business models that have emerged in other regions.

Private healthcare providers must be reminded that despite strong demand for high quality healthcare and rising incomes in the region, there will always be a possibility of black swan events. This may include overnight introduction of a strict regulation, or a blockbuster drug or technology introduced which can cause an upset in the market.

As the famous saying by Charles Darwin goes, "It is not the strongest or the most intelligent who will survive, but those who can best manage change."

Yoshihiro Suwa is Partner at the Jakarta office. He has worked with Ronald Berger in the firm’s Japan office for most of his career, joining the firm after graduation. Mr Suwa also spent time working on new products in Novartis in Japan.

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Becoming World Class, with Class Conventional wisdom and thousands of business books spend an endless amount of time talking about the keys to outgrowing, out profiting and out maneuvering your competition. Many will use this ‘wisdom’ to attempt to crush those in their path resulting in occasional , usually short term, success. But there is another way. There is another way to be successful not just for the short-term but for the long-term. Not just successful for you personally or even your organisation but bring along your staff, your community and your region.

Organisations and leaders focused on values-based, not ego-based leadership can attract rising stars, find amazing partners and build momentum to last well into the future.

Jeffrey E Thompson, Pediatric Intensivist and Neonatologist, Gundersen Health System

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

ISSUe - 37 2017

C

onventional wisdom and thousands of business books spend an endless amount of time talking about the keys to out-growing, out-profiting, and out-maneuvering your competition. Many will use this ‘wisdom’ to attempt to crush those in their path, resulting in occasional, usually short-term, success. But there is another way. There is another way to be successful— not only for the short-term but for the long-term. And

HEALT HCARE MANAGEMENT

not just for you personally, or even just for your organisation—instead, the kind of successful that brings along your staff, your community, and your region. Organisations and leaders focused on values-based, not ego-based, leadership can attract rising stars, find amazing partners, and build momentum to last well into the future.

Our approach was developed in the midst of enormous competition. The Mayo Clinic, maybe the best known healthcare brand in the world, was our closest adversary. It is nearly 10 times

our size and was originally just over 100 km away. We thought that was a problem until they moved a major branch less than 10 blocks away. In addition, large insurance giants like United Healthcare, a hundred times our size, looked to expand in our region and impart their version of healthcare. In addition, if we were to recruit the brightest and the best, we had to recruit from across the country to a small market area without the glitter and excitement of a big city or medical school. These were a pressing collection of challenges.

Figure 1

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The key to succeeding for the long term was not complicated, it was just hard.

We made a decision to compete not for size and profit but for the long-term health and wellbeing of the community. We believed we could deliver ever-increasing quality of care and have strong finances and improve the health and wellbeing of the community. The key word is ‘and’.

Not this goal or that goal, but all of them. In addition, we were sure we would find partners from across the region that would help us deliver on that promise.

To build an organisation that serves the whole community, we had to start with a strategic plan that declared the purpose of the organisation to be something more than just taking care of sick people.

We decided that our purpose would be to improve the health and well-being of our patients and our communities. We would focus all our efforts on that solitary purpose. We put the entire plan for this billiondollar organisation responsible for hundreds of thousands of lives on a single sheet of paper (Figure 1).

This outwardly focused purpose is the first thing people read when they are recruited into our organisation and connects to how they will be evaluated. It helps build a focus on others.

Our mission focuses on distinguishing through excellence. We are not going to be satisfied with beating our mediocre peers or our own mediocre past. And we certainly are not going to just be focused on crushing the competition or just getting bigger; rather, we are going to deliver on our responsibilities to those who trust us.

Our vision proclaims the extent to which we will go to deliver on our promise to improve the health of our communities. We aim to deliver on our promise so well that we will be nationally recognised. Finally, our

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Greatness is not a function of circumstance.

Greatness, it turns out, is largely a matter of conscious choice and discipline.

JIM COLLINS

commitment is to never rest on our laurels, to always strive to be better today than yesterday. Greatness is not an accident, it is intentional. You have to aim for it and drive for it.

It seems obvious, but implementation of the values statement is critical if you're going to accomplish these lofty goals. Too many organisations have clear values on their Web site or on the wall of their building, but do not have the courage or discipline to live those values.

It is a package. The purpose tells us why we exist, the mission tells us where we are going, the vision convey show far we will go, the commitment asserts our relentless drive to do better, and the values tell us how we will behave on the journey.

Present this package to the brightest and the best when they interview with you, and you have a good start at building an extraordinary team.

Use daily as the basis of your decision making and priority setting, and you have the start of a great organisation. Living your values becomes a strategic advantage. Then reinforce the message at orientation, during staff training, and at performance evaluations. This plan

ISSUe - 37 2017

gives staff a clear path forward for day-to-day work, as well as the freedom to innovate.

The strategic plan applies to every person, and everyone knows it applies to every person. No exceptions. We all have the same purpose, work toward the same mission, intend to accomplish the same vision, and are committed to continuous improvement. And most importantly we're going to do it with the same values. We all know how we will behave, how we will be treated, and how we will prioritise our decisions.

We purposely built this type of culture to be able to implement the next part of the strategic plan. These strategies needed an outwardly focused, values-driven staff to compete. Our focus on superior quality and safety intentionally includes “through the eyes of patients and caregivers”. Our mission and vision require that we achieve national-level excellence— that we measure up to the best data available. But that means nothing if our patients and their families do not believe that they receive the best possible care. Likewise, our goal for patient experience is to genuinely understand what patients and their families need, not just what we think they need.

Our third strategy is to make our organisation a great place to work— a great place, but not an easy place. We expect very high performance in an environment that has clear expectations for behaviour—where all must embrace a passion for caring and a spirit of improvement. Many would consider this a very hard place to work. It's a hard place because the purpose is outwardly focused, not on ourselves or monetary goals. The mission is to be excellent, not just to survive but to be excellent in multiple categories— to be so good that we can be nationally competitive. Finally, we have adopted a set of values that we will not compromise. If you want to play outside the values, it means that you will be playing outside the organisation.

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Figure 2

Our financial strategy is not to make a set amount of money. Our plan is to make care more affordable for patients, employers, and our communities.

Again, this strategy has a values-based, outward focus. We look at finances and facilities as tools.

Important tools, valuable tools, but just tools—never the prime goal. Our staff is well compensated, and savings, facilities and technology all are well funded, but never to the detriment of serving the broader mission.

The final major strategy is growth.

We included growth as a strategy

not to dominate the world or crush the competition. Rather, growth is beneficial when it supports our mission and other strategies, never growth for growth’s sake.

The plan is simple, but hard. The culture is crucial. One of the key tools to build a culture to serve this plan was the medical staff compact (Figure 2). We made it clear that the organisation would meet its responsibilities, that it was committed to providing an environment that would achieve excellence through recruiting great colleagues and by providing clear communication, strong

education programmes, competitive compensation, and thoughtful change management. Just as the organisation has responsibilities, individuals have responsibilities on their side of the agreement. All medical staff are to lead quality and service, demonstrate integrity at the highest levels, treat all people with respect, and understand that things will steadily change in their job. Part of the work is to help make that change for you and your staff.

We started using the compact with medical staff, but eventually the approach included all leadership and all staff positions.

This simple but consistent approach was a critical part of moving our strategic plan forward and developing a culture that would serve a higher purpose. Another important factor in building a culture that can compete at a high level is understanding the big difference between a leaders’ lines of responsibility on an organisational chart and their actual breadth of influence. Outstanding leadership and strong, responsible behaviour can cast a bright light across a broad swath of the organisation—far beyond the leader’s immediate peers or staff. Likewise, bad behaviour can cast a shadow across an equally broad swath and result in poor outcomes, worse service, remarkably less efficient work, and attrition of valuable next-generation stars and leaders.

The more influence your leaders have, the more important it is for them to be people builders, not just rules police. They need to understand that their job is to serve, not just manage.

They need to be shown how to get close enough to the work so they understand the complexity of the challenges that staff face and the moral imperative of strong outcomes being delivered in a supportive culture. This is so important that we expected leaders to set aside time early in the day, every day (e.g., 8-9am), to physically walk to their areas of responsibility to talk with the staff, to

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Potential High

Low

Performance

High

DC Low

Figure 3

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they were responsible, to talk about how they viewed them, and to discuss their plans for development. It was also an opportunity to get feedback from other senior leaders about how they saw the young leaders’ performance and potential from a different point of interaction. The nine-box sessions had two important values. First, leaders gained clearer and broader views of their staff, and second, it set a tone of everyone being responsible for the growth and development of every young leader in the organisation.

You have to be completely clear about what you expect from leaders and give them the tools to deliver it to

Author BIO

make sure they have the right tools and adequate staffing, and to get a better understanding of the work.

As we evaluate our leaders, we must understand the difference between doing things and accomplishing something of substance. If all we, as leaders, do is hold our staff accountable, to follow rules or checkboxes, the most talented staff become disillusioned, disengaged, and will not help you build forward. Holding staff accountable is always looking backward; being responsible for the success of your staff is looking forward. To deliver on excellence, young leaders will need to find a balance between the two. This is consistent with our theme that leadership is a responsibility to serve, not a license to rule.

To build leaders, you need to be intentional and disciplined. A key tool we learned from General Electric was the nine-box matrix (Figure 3).

Our senior-most leadership group would gather, and each would score the performance and potential of all their managers, supervisors, and directors. It was a chance for each to present the young leaders for whom

ISSUe - 37 2017

the staff. Assuming that mid- or even upper-level leaders are all on board is a mistake. Make expectations, lines of communication, and performance as transparent as possible. This will build a culture and an ever-increasing level of performance from all staff.

Maureen Bisognano from IHI said “You cannot give what you do not have. If the staff do not feel cared for they can't care, to embrace you have to been embraced, to respect you have to been respected. Do not be stunned by your staff’s lack of care, connection or respect if they have not through their eyes been cared for, connected with and respected.”

I would argue that this applies not only to the frontline staff but across all levels in your organisation.

To compete against the best, you have to aim to be the best. That starts with developing the best environment for your staff. To attract and retain the best young leaders, you have to know and be clear about why you're here (the purpose) where you're going (the mission, vision, and commitment) and what values will guide the culture in which they will be immersed. It takes courage to set bold goals and clear standards for all.

It takes discipline to follow through on both systems and people building.

And it takes durability to stay with your plan despite constant pressure to compromise your values in the interest of short-term gains.

The path is not complicated, it is just very hard.

Jeffrey E Thompson, MD, is executive advisor and chief executive officer emeritus at Gundersen Health System. Dr. Thompson is a trained pediatric intensivist and neonatologist, and served as Gundersen’s chief executive officer from 2001 to 2015. After completing his professional training in 1984, Dr. Thompson came to Gundersen with a desire to care for patients and to teach. He was asked to serve on Gundersen’s boards beginning in 1992 and was chairman of the board from 2001 to 2014.

Author “Lead True, Live your values, Build your people, Inspire your community”

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ACO meets Triple Aim and save $millions Accountable Care Organizations (ACOs) are the new path for healthcare reform in the USA. Medicare’s Shared Saving Program (MSSP) promotes it. The MSSP’s 33quality performance measures and emphasis on care coordination meet the Triple Aim goals. Medicare shares the savings with the ACO if compliance with the quality measures is high.

Peter A Gross, Chair, Board of Managers, HackensackAlliance ACO

T

he Triple Aim as described

by Berwick states that the health of populations should be improved and at the same time the costs of the healthcare system should be reduced(1). What is new in the Triple Aim is an emphasis on the experience of the patient in the healthcare system.

These three aims can take place without incurring additional costs.

In fact, the expectation is that these improvement should occur with an overall reduction in costs. The Triple Aim was a stimulus for developing the concept of the Accountable Care Organization in the George W Bush administration and adopted by the Obama Administration.

Accountable Care Organization

The definition of an Accountable Care Organization (ACO) is as follows: “Accountable Care Organizations are groups of doctors, hospitals, and other healthcare providers, who come together voluntarily to give

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ISSUe - 37 2017

HEALT HCARE MANAGEMENT

coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending healthcare dollars more wisely, it will share in the savings it achieves for the Medicare program (2).”

Because of the sharing of savings, the program is called the Medicare Shared Savings Program (MSSP).

• Improved the health of populations • Reduced costs of the healthcare system • An emphasis on the experience of the patient.

Quality Performance Measures

The issue that distinguishes the ACO movement from most past cost containment efforts is the requirement to comply with a list of 33 quality performance measures.

Because of this new emphasis, I will take up some space to show what this noble effort consists of. The Centers for Medicare and Medicaid Services (CMS) put together the quality measures. They are divided into four domains 1.Patient /Care giver experience domain a. Get timely care b. How well does your physician communicate c. Patient’s rating of doctor d. Access to specialist e. Health promotion and education f. Shared decision making g. Health status and functional status 2. Care Coordination / Patient Safety Domain a. All-conditions readmission risk standardised b. Ambulatory care sensitive conditions i. COPD or asthma admission in older adults ii. Heart failure admissions c. Percent of primary care physicians who qualified for the electronic health record incentive

d. Medication reconciliation performed e. Screened for falls risk 3. Preventive Health Domain a. Influenza immunisation b. Pneumococcal immunisation c. Adult weight screening and follow-up d. Assessment of tobacco use and cessation information given e. Screened for depression f. Screened for colorectal cancer g. Had mammography screening h. Proportion of adults screened for high blood pressure in the past two years 4. At Risk Population Domain a. Diabetes i. Haemoglobin A1C <8 per cent ii. LDL cholesterol <100 mg/dl iii. Systolic blood pressure <14 mm Hg iv. Tobacco non-use v. Aspirin use vi. Percent of patients with diabetes whose Haemoglobin A1C is poorly controlled, that is, >9 per cent b. Hypertension i. Percent of patients with hypertension whose blood pressure is <140/90 mm Hg c. Ischemic vascular disease (IVD) i. Percent of patients with IVD with a

complete lipid profile and an LDL cholesterol <100 mg/dl ii. Percent of patients who use aspirin or other anti-platelet medication d. Heart failure i. Receive beta-blocker therapy for left ventricular systolic dysfunction (LVSD) e. Coronary artery disease (CAD) i. Percent of patient with CAD who meet all of the following criteria: 1. Medication for lowering

LDL-Cholesterol 2. ACE inhibitor or ARB therapy for patients with CAD

and diabetes and/or LVSD The scoring of the quality measures is complicated. It can be found in the first reference by Gross et al. (3). In general, for most quality measures, a high score is the goal. For some measures such as Haemoglobin A1C greater than 9 per cent, a low score is preferable. CMS collects the responses to the first domain on Patient / Care Giver Experience and also collects most of the results for the second domain on Care Coordination. The physician practice has to provide the responses for the later measures in the second domain on Patient Safety and responses for measures in the third and fourth domains.

The connection between the Triple Aimshown in round bullet points below and relevant examples of the 33 quality measures shown in the check symbol points below: • Improve experience of care • Getting timely care, appointments, and information • Shared decision making • Improve health of population • Prevention with mammography and colonoscopy • Better care of diabetes, CHF, CAD, BP, and IVD • Reduce per capita costs of healthcare • Reduce admissions, readmissions

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Category

1st Q. 2015

4th Q. 2015

Percent drop

$3,664

$3,148

14.08 per cent

Emergency Room visits (#)

612

556

9.15 per cent

30 day All-Cause readmits/ 1000 discharges (#)

202

167

17.33 per cent

Ambulance cost/patient

$203

$92

54.58 per cent

Chronic obstructive pulmonary disease

10.27

8.82

14.12 per cent

Congestive heart failure

13.68

9.95

27.27 per cent

Bacterial pneumonia

8.40

6.82

18.81 per cent

Component Expenditures/Patient Short -term admissions

Amb. Care Sens. Cond. Discharge Rate/1000*

Table 1

Decreasing Expenditures/Utilisation

Next we will address how savings are achieved by first going after the ‘low-hanging fruit’ such as hospital admissions, readmissions, and emergency room visits.

The total amount spent on admissions, readmissions, and emergency room visitsare the largest expenses and these were addressed first.

As shown above, these costs were decreased each year as exemplified for the year 2015 (sourced via confidential data from the A1006 Hackensack Physician-Hospital Alliance ACO, LLC, Consolidated Aggregate Expendiure Utilization Trend Report ACO A1006 Performance Year 2015, of the MSSP [April 1, 2012, agreement start date]). In addition, discharges of Ambulatory Care Sensitive Conditions (ACSC) were decreased over time. The idea behind ACSC is that these three diagnoses very often can be managed as outpatients and do not need to be admitted to a hospital. Ambu-

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*Ambulatory Care Sensitive Conditions

lance expenses, although not a large part of our resource use, were very high for our ACO. It turned out that ambulance services were being over used. Once we realised this and CMS realised it, they enforced the appropriate use of ambulances and our costs per patient plummeted.

Patient-Centered Medical Home Certification

Interestingly, these cost reductions were achieved with an indirect approach. Our emphasis at the formation of our ACO was on selecting the right physicians to belong to the ACO. Our selection criteria were that the physician’s office should be certified as a Patient-Centered Medical Homes by the National Committee for Quality Assurance (NCQA). A PCMH is defined as a practice “that provides first contact, continuous, comprehensive, whole person care for patients across the practice. PCMH has at its foundation the Joint Principles developed by the primary care

ISSUe - 37 2017

medical societies (American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, American Osteopathic Association): • Whole-person care; • Personal clinician provides first contact, continuous, comprehensive care; • Care is coordinated or integrated across the healthcare system; • Team-based care. (4) If physicians wanted to join and were not yet certified, we would pay for training the physicians and their office staff to become certified within one year. In addition, the physicians had to use an electronic medical records system immediately or at least within one year.Failure to do so meant that the physicians could no longer remain in our ACO. NCQA has published the evidence that PCMHs are cost effective and improve quality (5). In March 2017, NCQA redesigned their criteria for certification to account for recent changes by Medicare and to simplify the process. We will not review these changes (i.e., the Medicare Access and CHIP Reauthorization Act of 2015 [MACRA] and the Merit-Based Incentive Payment System [MIPS]), and Advanced Alternative Payment Models) at this time.

The point of our heavy emphasis on PCMH certification is that certified physicians understand the future of healthcare and the inevitable changes taking place. Given this point of view, the physicians would be more likely to comply with the goals of the ACO by naturally providing more efficient care. Indeed, this is what happened. So no instructions had to be issued requesting that the physicians decrease admissions and emergency room visits. It just happened from the inception of the ACO. An important approach that facilitated the decrease in resource utilisation and costs was the fact that the physicians saw the patients in

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their offices more frequently than in most other ACOs. The more frequent office visits permitted the physicians to keep an eye on the patients with chronic illnesses and manage the changes as they occurred rather than have toadmit the patient to a hospital because these changes were neglected in the outpatient setting. This point is reflected in the 30-day post-discharge provider visits per 1.000 discharges where our office visits per patient increased over the average for other ACOs. Care Coordination with ACO Nurses

Besides the PCMH certification policy, the other important factor in our initial creation of our ACO was the hiring of nurse care coordinators. We started with 3.5 for 11,000 patients and eventually hired over 15 as the patient population grew to over 30,000. The purpose of the nurse coordinators was to assist the practicing physicians in managing their high-risk patients and in complying with the quality measures.

Nurses were carefully selected to be out-of-the-box thinkers and ‘do-ers.’

They had to come with the right work ethic and know how to deal with people in a gentle manner. They were not to perform clericalduties, were not responsible for data analysis or business development. They were to be part of the group at practice meetings even though the practice didn’t have to support their salaries. They are supposed to provide feedback to the physicians on compliance with the quality measures and are to take part in value-based decisions. It took some time to insinuate the ACO nurses into the practice, but they eventually became a key part of it. With the physician leaders, the ACO nurses wrote care coordination policies.

significant expenditures (3, 6).

In the first year that covered April 2012 through December 2013, we saved US$10,747,669.

In the second year (January-December 2014), we saved US$6,464,895. In the third year, the savings increased dramatically to US$33,353,310.

Theoretically, we were entitled to receive 50 per cent of the savings and Medicare would keep the other 50 per cent. But remember that the amount an ACO receives is dependent on their quality score. In the first year of the MSSP, every one received 100 per cent credit for reporting activity with the quality measures, so we received US$5.266.358. In the second year, actual compliance with the measures was required. Our quality score was 89.43 per cent, as a result we only received (89.43 per cent times 50 per cent = 44.72 per cent) or US$2.83.988. In the third year our quality score rose to 95.70 per cent, therefore, we received {95.70 per cent x 50 per cent = 47.85 per cent) or US$15,640,878. If you do the math, the numbers are off a little because CMS took out a sequestration adjustment for when the US Government closed down for a few months. The large increase in the third year resulted from a large increase in the number of physicians in the MSSP that resulted in a significant increase in the number of patients in the program.

Volume to Value Challenge

ACOs are expanding at a rapid rate in the United States. Each year, Medicare approves approximately 100 new ACOs. There are now over 700 ACOs in the United States.

Will thepredominant approach remain unchanged so that volume continues to be the ultimate goal and keeping hospital full is still the byword? Or will we switch to value as the prime driver and keeping patients out of the hospital unless absolutely necessary is the new byword? To improve quality and decrease costs, ACOs appear to be a reasonable approach to facilitate the switch from volume to value.

References: 1. Berwick DM, Nolan TW, Whittington J. Health Affairs 2008; 27:759-760.

2. Accountable Care Organizations (ACO) – Centers for Medicare and Medicaid Services – CMS.gov https://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/ACO/ Accessed July 18, 2017.

3. Gross PA, Easton M, Przezdecki E, et al.The ingredients of success in a Medicare Accountable Care Organization.Am J Account Care 2016; 4(2): 42-50.

4. PCMH Eligibility.http://www.ncqa.org/ programs/recognition/practices/patient-centeredmedical-home-pcmh/before-learn-it-pcmh/pcmheligibility.Accessed July 18, 2017.

5. PCMH Evidence.http://www.ncqa.org/programs/ recognition/practices/pcmh-evidence.Accessed July 18, 2017.

6. Gross PA, Menacker M, Easton M, et al.Case study: how does an ACO generate savings three years in a row?Am J Account Care2017; 6(17):27-31.

Author BIO

Peter A Gross is Professor of Preventive Medicine and Community Health at RutgersNJ Medical School. Past national leadership positions include JCAHO, SHEA; and FDA. He is a graduate of Amherst College and Yale Medical School and published more than 250 articles.

Achieving Cost Savings

For the first three years of the program we were able to save

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The Global Advancement of Diabetes Management

Over the years there has been tremendous advancement in pharmaceutical science, biomedical and technology to manage people with diabetes to lead a normal life.

This article provides a brief overview of how diabetes management has evolved over the years and how 24/7 monitoring of diabetes helps in managing the condition better and increases life expectancy.

Sanjiv Agarwal, MD & Founder, Diabetacare

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I

t is hard to believe that 95 years ago diagnosis of diabetes meant death. Since the discovery of insulin in 1921, the mortality rate has decreased, but people with diabetes have suffered from long-term complications leading to blindness, kidney failure, amputation and heart attack. With time, the focus on the management of diabetes has shifted from â&#x20AC;&#x2DC;keeping

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patients alive’ to ’keeping patients free of complications’. Over the years there has been tremendous advancement in pharmaceutical science, biomedical and technology to manage people with diabetes to lead a normal life. This article provides a brief overview of how diabetes management has evolved over the years.

The story of diabetes mellitus — its discovery, description, and treatment— is a remarkable chronicle covering thousands of years of medical history.

3500 years ago the ‘experts’ of the pharaoh of Egypt, preferred the option of a mixture of ‘water from the bird pond,’ elderberry, fibres from the asit plant, milk, beer, cucumber flower, and green dates to manage diabetes.

Diabetes has been described under the heading ‘PRAMEHA’ in Ayurvedic texts like Charaka Samhita and Sushruta Samhita. In Charaka Samhita, it is described that Prameha (Diabetes) is of two types.

1) Sahaja: Due to genetic factors. This can be compared to Type 1 and is seen mostly in lean individuals.

2) Apathya Nimittaja: Due to sedentary lifestyle and diet. This can be compared to Type 2 and is seen mostly in obese individuals.

It was Thomas Willis’ observations in the year 1674 and Matthew Dobson’s experiments in 1776 that established the diagnosis of diabetes as the presence of sugar in urine and blood. Before the 1920s, there were no effective treatment for diabetes and it was a fatal disease.

Dr.Frederick Allen prescribed low calorie diets that restricted patients to 450 calories per day. It prolonged the lives of some people with diabetes by a year or two. However, this changed dramatically with Frederick Banting's work, who discovered and isolated insulin at the University of Toronto in 1921–22. This was one of the greatest events in the history of medicine. The innovation of insulin therapy has helped prolong the life expectancy of people with Type 1 diabetes.

Scientific evidence demonstrates that most of the diabetes complications can be reduced by managing blood sugar level with diet, exercise, and medication.

Gradually the knowledge on diabetes improved and clinicians learnt to distinguish between Type 1 diabetes, where insulin was lacking and Type 2 diabetes where insulin was working inefficiently. The mainstay of treatment was still insulin. For many years, beef/ pork pancreas were the only source of insulin. Human insulin became available in the early 1980s and was the first commercial product developed by the recombinant DNA technology.

In the 1950s, oral medications (sulfonylureas) were developed for people with Type 2 diabetes. These drugs stimulate the pancreas to produce more insulin, helping people with Type 2 diabetes keep complete control over their blood sugar level. This has been considered the beginning of the history of Type 2 diabetes treatments.

Earlier, there was no treatment. Hence, those diagnosed with Type 2 diabetes had to take more insulin with a hope that their cells would absorb enough to manage their condition.

Metformin was introduced as another tablet for diabetes in 1959 but was not approved in the United States until the 1990s. Today, metformin is the most widely used treatment for Type2 diabetes in the world. Its primary

mechanism of action is its ability to reduce glucose production from liver, but it also reduces glucose via a mild increase in insulin-stimulation mechanism.

In recent years, many other treatments have been discovered and have been put to use. These includes α-Glucosidase Inhibitors (to prevent absorption of glucose from intestine), Thiazolidinediones (to reduce insulin resistance), Meglitinides (to increase insulin secretion), GLP 1 analogues (to increase meal related insulin secretion), DPP 4 inhibitors (to increase own GLP 1 levels) and SGLT 2 inhibitors (to increase glucose excretion in urine).

Another major advancement has been in the field of self-blood glucose monitoring by patients. One drop of blood is placed on a disposable test strip which is connected to a digital meter.

The level of blood glucose will be shown immediately and patients now can alter their treatment. There have been advances in alternate site testing such as skin, tears etc. This technology will have the potential to give continuous blood glucose readings. Nowadays, there are smart glucometers available with a SIM card that can transmit data in real time to the care givers, based on which they can then provide guidance in managing the patient’s diabetes.

In the late 1970s, the insulin pump was designed to mimic the body’s normal release of insulin. The pump dispenses a continuous insulin dosage through a cannula (plastic tube), using a small needle that is inserted into the skin.

The new-age pumps are light, compact and can easily be carried in a pocket or clipped to a belt. Most of the recent pumps are linked to continuous blood glucose meter and can automatically adjust the dose of insulin.

Yet another innovation in the treatment of diabetes has been Islet transplantation. Islet cells are present in pancreas and are responsible for secreting insulin. These cells are isolated from a donor pancreas and purified.

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real-time access to patient data to provide the best care options. Diabetes management may be challenging and patient’s caregivers may need special guidance to take care of the patient.

Keeping this in mind, progressive healthcare organisations have developed 360-degree comprehensive care for diabetes with a 24x7 monitoring team for the patient. Organisations have introduced IoT-enabled personal devices with in-built decision-making capacity to enable the patient to self-manage his/ her diabetes. On one hand, this solution supports patient profile management based on electronic medical records and on the other hand, it provides seamless connectivity between the patient’s

IoT device, doctor’s mobile app, nutritionists’ information system and patient’s electronic medical records.

Scientific evidence demonstrates that most of the diabetes complications can be reduced by managing blood sugar level with diet, exercise, and medication. Blood pressure and blood cholesterol control is also important to prevent complications. Technological advances and connected devices help patients to improve their blood glucose level. Unfortunately, there is still a significant disparity between available and ideal diabetes care. Health coaching with self-monitoring of blood glucose is still the cornerstone of care for all people with diabetes.

Author BIO

This is then injected into the patient's liver under ultrasound control without any major surgery. Once transplanted, these cells produce insulin and regulate glucose levels in the blood. It is an experimental treatment for Type 1 diabetes mellitus.

Another new development that has evolved over many years is the HbA1c test. This was devised in 1979 in order to create a more precise blood sugar measurement (The oxygen-carrying pigment in red blood cells, is used to track glucose changes over a period of three months). The HbA1c became a standard measurement for blood sugar control in the comprehensive ten-year study from 1983 to 1993-the Diabetes Control and Complications Trial (DCCT). With the conclusion of the DCCT in 1993, studies showed that people who were able to keep their blood glucose levels as close to normal as possible had less chance of developing complications, such as eye, kidney and nerve disease.

Diabetes is a multi-faceted chronic illness requiring continuous monitoring. Today, physicians require

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Sanjiv Agarwal is the MD & Founder of Diabetacare. With over 20 years of entrepreneurial experience in the field of healthcare in India and the UK, he has a brilliant knack of understanding the healthcare needs of the consumer. The gaps and voids he noticed in diabetes management programs in India led him to establish Diabetacare, a 24x7 diabetes care service that utilises mobile technology to manage and monitor diabetic patients’ health.

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11th Edition of International Conference on

Proteomics

March 22-23 | London, UK

Theme: “Exploring Novel Drug in the Field of Proteomics”

Keynote Forum

Oral Presentations

Poster Presentations

Young Researchers Forum

Welcome Euroscicon Ltd likes to take this opportunity to welcome all of you to “11th Edition of International Conference on Proteomics” which is to be held during March 22-23, 2018 at London, UK. Through our theme “Exploring Novel Drug in the Field of Proteomics”, the conference will analyse the recent advancements and new modes that can be enforced to the research to take Proteomics, one step further.

Proteomics Euroscicon 2018 will impact an attractive moment to meet people in the research field and therefore it takes a delight in opening a gate to meet the ability in the field, young researchers and potential speakers.

The conference also includes essential topics on: • • • • • • • •

Proteomics in Drug Discovery Protein Expression and Analysis Chromatin Proteomics Protein Microarrays The Cancer Proteome Proteomics for Bioinformatics Neuroproteomics Proteomics and cell Signalling

Contact: Caroline Thomas Program Manager Direct: (+44) 020 3807 3712 E-mail: proteomics@eurosciconmeetings.com proteomics@eurosciconconferences.com

Website: http://proteomics.euroscicon.com/

• • • • •

Metabolomics Transcriptome Sequencing Phylogentic Analysis of Protein Genomic, Proteomic, and Metabolomic Data Integration Strategies Molecular Docking and Structure-Based Drug Design Strategies

Venue & Accommodation : London, UK

medical sciences

Head and Neck Cancer Symptoms, early detection and prevention

Head and Neck Cancer is a major health problem globally.

Males are affected significantly more than females with a ratio ranging from 2:1 to 4:1. The incidence rate in males exceeds 20 per 100,000 in regions of France, Hong Kong, the Indian subcontinent, Central and Eastern Europe, Spain, Italy, Brazil, and among African Americans in the United States.

Vikram Kekatpure, Senior Consultant, Head & Neck Surgical Oncology, Cytecare Hospitals

H

ead and Neck Cancer refer to tumours that develop in the region of mouth, throat, larynx, nose and sinuses. The symptoms of Head and Neck cancer may include a lump or a sore throat or a mouth ulcer

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that does not get healed, difficulty in swallowing or change in the voice. There may also be neck swelling, unusual bleeding, facial swelling or difficulty in breathing. About 80 per cent of head and neck cancer is due to tobacco use.

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Excessive consumption of alcohol is an additive risk factor. The other primary risk factors are Human Papilloma Virus (HPV) infection and Epstein-Barr Virus (EBV) infection. Most of these cancers usually start in the squamous cells that

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line the moist, mucosal surfaces in the region. The disease can also begin in the salivary glands which is relatively uncommon.

Head and Neck Cancer is a major health problem globally. In the United States, this cancer grows by 3 per cent per year, with approximately 63,000 Americans developing head and neck cancer annually and 13,000 succumbingto the disease. On the other hand, in Europe, there were approximately 250,000 cases and 63,500 deaths in 2012; and according to recent reports, the numbers are increasing. Males are affected significantly more than females with a ratio ranging from 2:1 to 4:1.

The incidence rate in males exceeds 20 per 100,000 in regions of France, Hong Kong, the Indian subcontinent, Central and Eastern Europe, Spain, Italy, Brazil, and among African Americans in the United States. Mouth and tongue cancers are more common in the Indian subcontinent, nasopharyngeal cancer is more common in Hong Kong, and pharyngeal and /or laryngeal cancers are more common in other populations and these factors contribute to the overall cancer burden in Asian countries. In India, the burden of Head and Neck cancer is massive. Head and Neck cancers account for more than 550,000 of the total cancer cases reported in India every year. Since a large per centage of Indian population uses some form of tobacco and the fact that Indian population has grown at nearly twice the rate of the world in last 15 years, India is likely to experience a significant increase in burden of head and neck cancer.

Cancers of the head and neck are categorised by the region of the head or neck in which they begin. Some common cancers of the head and neck are: Oral Cancer

Mouth cancer is the most common type of head and neck cancer. It can affect the lips, tongue, cheeks, roof or floor of the mouth and the gums.

About 80 per cent of head and neck cancer is due to tobacco use. Excessive consumption of alcohol is an additive risk factor. The other primary risk factors are Human Papilloma Virus (HPV) infection and Epstein-Barr Virus (EBV) infection.

Symptoms of the disease can include persistent mouth ulcers or a lump in the mouth. This cancer may also affect areas like the lips, the front two-thirds of the tongue, the gums, the lining inside the cheeks and lips, the bottom of the mouth under the tongue, the hard palate (bony top of the mouth), and the small area of the gum behind the wisdom tooth. Oral cancer or mouth cancer comes under a wide umbrella of Head and Neck cancer, which is caused due to a destructive tissue developed in the oral cavity. In the Indian subcontinent oral cancer is considered to be one of the major health complications, as it ranks among the top three types of cancer accounting to over 30 per cent of all cancers. This type of cancer is commonly caused due to excessive smoking, chewing of tobacco and drinking. Oral Cancer in India is seen in both, men and women. This is a common disease in both the genders as now both, men as well as women are induced to tobacco addiction. The primary symptoms of oral cancer can be identified when one notices red or white patches or ulcers in the mouth cavity, i.e., tongue, gums or at the

side of the mouth. Surgery to remove the tumour in the mouth and affected lymph nodes in neck is a common treatment for oral cancer. The surgeons will also perform reconstruction at same time to minimise the functional and cosmetic problems. Patients may have surgery alone or may be combined with radiotherapy for advanced stages.

Pharynx

The pharynx (throat) is a hollow tube about 5 inches long that starts behind the nose and leads to the oesophagus. The throat has three parts: the nasopharynx, the oropharynx and the hypopharynx.

Throat cancer can affect any part of the throat. The most common symptoms of this cancer in the throat include a lump or a persistent sore throat. Ear pain, neck pain, any foreign body sensation, any itching sensation in the throat or sudden weight loss are also a few other symptoms of throat cancer.

It is also important to look out for swelling of the neck. The treatment is planned according to the stage and options available for this cancer are Surgery, Radiotherapy, targeted therapy and Chemotherapy.

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blocked nose, pain above or below the eyes or blockage of one side of the nose.

The treatment for this kind of cancer is surgery followed by radiation therapy.

Larynx

The larynx, also called the voice box, is a short air passage bound by vocal cords below and front of the pharynx in the neck. Laryngeal Cancer affects the various parts of the larynx, namely epiglottis and vocal cords. Laryngeal Cancer is also considered to be one of the easiest cancers to detect as it starts off with hoarseness of voice and then advances to breathing problems in the latter stages. If the hoarseness of voice persists for more than 3 weeks, it is advisable to get a laryngoscopy. Other symptoms enclose a change in the voice, difficulty in swallowing, shortness of breath, noisy breathing and a persistent cough. The treatment for laryngeal cancer is radiation therapy or laser surgery for early stage. However in advanced stage voice box removal (laryngectomy) may be required. Following laryngectomy various techniques are available to voice rehabilitation.

Paranasal Sinuses and Nasal Cavity

Nose and sinus cancer affects the nasal cavity â&#x20AC;&#x201D; above the roof of the mouth and the sinuses. The symptoms of the disease could be similar to the common cold or sinusitis along with a decreased sense of smell, pus or blood stained discharge from the nose, persistent

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Salivary Glands

The major salivary glands are in the floor of the mouth and near the jawbone. The symptoms of the cancer affecting salivary glands are a lump or swelling on or near the jaw or in the neck or mouth, numbness in part of the face, drooping on one side of the face, difficulty in swallowing, trouble opening the mouth widely or persistent pain in the area of a salivary gland. The treatments for this are surgery with or without lymphadenectomy followed by radiation therapy and chemotherapy.

The most effective form of detecting head and neck cancer early can be regular clinical examinations may identify pre-cancerous lesions in the head and neck region. When diagnosed early, oral, head and neck cancers can be treated more easily and the chances of survival increase significantly. It is expected that HPV vaccines may reduce the risk of HPV-induced head and neck cancer.

There are various types of treatments for Head and Neck cancers. Surgery, radiation therapy, chemotherapy and targeted therapy are a few treatments for the ailment.

Surgery

Surgery as a treatment is frequently used in most types of head and neck

Author BIO

Head and Neck cancers account for more than 550,000 of the total cancer cases reported in India every year.

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cancers. Usually the aim is to remove the cancerous tissue completely along with margins or surrounding normal tissue. The lymph nodes in neck which can harbor tumour are also removed during surgery. Reconstructive surgery is performed to achieve optimal cosmetic and functional outcomes.

Radiation Therapy

Radiation therapy is also routinely used for treatment of head and neck cancer.

Radiotherapy can be used as primary modality or as adjuvant following surgery depending on the stage of disease. Various techniques such as 3D Conformal radiation, IMRT, IGRT, etc., are used to reduce morbidity associated with Radiation Therapy.

Chemotherapy

Chemotherapy for head and neck cancer is used as part of curative or palliative protocol. In curative protocol platinum based chemotherapy is used as radiation sensitiser. Palliative chemotherapy is used to alleviate acute symptoms.

Targeted Therapy

Targeted therapy is a type of treatment that uses agents such as monoclonal antibodies or inhibitor to specifically target a receptor of pathway in cancer cells. Some targeted therapy used in squamous cell cancers of the head and neck include cetuximab, nimotuzumab, bevacizumab and erlotinib. Recent studies have shown promising results for immune targeting PD1 inhibitors.

A renowned oncologist with over 14 years of experience in clinical care, teaching and research, Kekatpure specialises in the management of head and neck cancers. Dr. Kekatpure is a member of various medical and scientific societies at national and international levels, including the Foundation for Head and Neck Oncology India (FHNO), Indian Association of Cancer Research, American Association of Cancer Research (AACR), AO foundation, and the Head and Neck Cooperative Oncology Group. He is a recipient of several awards and is credited with an award from the FHNO for his research paper and a Scholar-in-Training award from the AACR.

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Risk Factors for Development of Cardiovascular Disease The largest proportion of global mortality is attributed to Cardiovascular Disease (CVD), withmore than three-fourths of CVD relateddeaths occur in low-and-middle incomecountries.

The primaryrisk factors of CVD are strongly correlated with health behaviours and overall physical condition. CVD can be effectively prevented by controlling the associated risk factors and proper medications management.

KATM Ehsanul Huq, Graduate School of Biomedical & Health Sciences, Hiroshima University Michiko Moriyama, Graduate School of Biomedical & Health Sciences, Hiroshima University Pradeep Kumar Ray, Engineering Research Center on Digital Medicine and Clinical Translation (DMCT), Shanghai Jiao Tong University Susumu Nakayama, Graduate School of Biomedical & Health Sciences, Hiroshima University Md Moshiur Rahman, Graduate School of Biomedical & Health Sciences, Hiroshima University

C

ardiovascular Disease (CVD) is the number one killer in the world. Globally, about 17.5 million people die every year due to CVD. More than three-fourths of the deaths occur in developing countries. Sustainable Development Goals (SDGs) target 3 is to reduce premature mortality through prevention and treatment of non-communicable diseases by 2030. In the World Congress of Cardiology and Cardiovascular

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Health in Mexico in June 2016, the World Heart Foundation declared 25 per cent reduction of premature CVD related death by 2025. In September 22, 2016, World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), World Heart Federation, World Stroke Organization, International Society of Hypertension, World Hypertension League and other partner organisations took the â&#x20AC;&#x2DC;Global Hearts Initiativeâ&#x20AC;&#x2122; to prevent and control the CVD.

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CVD consists of heart and its circulation. It includes coronary heart disease, angina, heart attack, heart failure, congenital heart disease (CHD), valvular disease, cardiomyopathy, atrial fibrillation, arrhythmia, stroke, rheumatic heart disease, venous disease and peripheral arterial disease.

CVD occurs when arteries become narrowed by a gradual build-up of fatty materials (atheroma) within the walls.

When atheroma breaks away from the arteries, after clotting it can block

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coronary and obstruct the oxygen-rich blood supply to the heart muscles. Then heart muscles become permanently damaged and cause heart attack. When the blood clot blocks the arteries of the brain, then it causes stroke. Eighty per cent of the CVD patients died due to heart attack and strokes. Narrow arteries canâ&#x20AC;&#x2122;t carry enough oxygen-rich blood to the heart, that can cause pain and discomfort in the chest called angina.

The risk factors for CVD include unhealthy behaviours; e.g smoking,

Globally, about 17.5 million people die every year due to CVD. More than three-fourths of the deaths occur in developing countries.

less physical activities, salt containing diet and overweight, and health factors including cholesterol, Blood Pressure (BP) and glucose. High BP is the highest risk factor to develop CVD.

BP related with several genetic factors and environment also influence to contribute. Genetic factors influence about 30-50 per cent and environmental factors about 50 per cent for developing BP. The factors including enzymes, receptors and channels that regulate BP. About 50 per cent of the hypertensive patients develop stroke and ischemic heart disease. Next is smoking, the most important preventable cause of death for CVD. It causes about 10 per cent of CVD. Globally, over

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1.1 billion people smoke tobacco as of 2015, and about 6 million people die and it will increase to more than 8 million in 2030. It makes fatty substance in the arteries and causes coronary heart diseases that leads to heart attack.

Patients with diabetes are also at high risk to develop cardiovascular disease.

CVD is the leading cause of diabetes related morbidity and mortality. Obese people are prone to diabetes due to less physical activities that increase the risk of CVD. Congenital Heart Diseases (CHD) are associated with genetic syndromes and about 30 per cent of the congenital heart diseases are related to genetic illnesses.

Environmental factors including rubella infection, significant alcohol intake, insulin-dependent diabetes and obesity of the mother are also contributing to develop CHD. The genetic risk factor includes the family history influences for CVD. If both father and mother suffer from heart disease before the age of 55, the risk of getting heart disease rise to 50 per cent compared to other people.

There are also increased chances of a stroke, if there is any family history.

Hypertension, high lipid profile and

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type 2 diabetes also have the genetic component to develop CVD. It means, if father or brother develops CVD under the age of 55 and mother or sister under the age of 65 diagnose with CVD, then screening is recommended after the age of 40 years for CVD. CVD also varies in different ethnic groups. CVD burden is the highest in the South Asian population. It is the most alarming that younger age groups in South Asia develop CVD more compared to other continents. With the conventional risk factors, congenital, adult metabolic, environmental pollutions, social, and psychological factors also act as risk factors for developing CVD. In South Asian people, the risk of getting coronary heart disease, stroke and diabetes are higher compared to other UK populations. Compared to women, men are more prone to develop CVD at an early age. With age, the chances of getting CVD also increase.

Stress, alcohol consumption, and type of work further influence the development of CVD. WHO has developed evidencebased guidelines for the prevention of CVD. People need primary prevention who have the risk for developing CVD

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and secondary prevention to avert recurrence of the CVD. The people who are at risk need to maintain risk prediction chart for specific preventive actions and the degree of intensity they need.

However, CVD risk is higher in contrast of the risk prediction chart for those who are on antihypertensive therapy, obese, have family history, maintain sedentary lifestyle, elevated triglyceride, C-reactive protein, fibrinogen, homocysteine, apolipoprotein B or Lipoprotein(a), fasting glycaemia, impaired glucose tolerance, microalbuminuria, low HDL cholesterol, increase pulse rate, socioeconomic deprivation, and premature menopause in case of female. For the secondary prevention, intensive lifestyle interventions and appropriate drug therapy are empirical.

For prevention and early detection of CVD, exploring the risk factors is crucial. Unstructured clinical narrative health records data can be extracted and calculated to get the risk scores for developing CVD. Data from electronic health record (EHR) systems are a major source for identification of risk factors and assessment of the prognosis of heart diseases. Information extraction (IE) system has been used to take out unstructured data from EHRs and risk factors were successfully evaluated by assigning indicators and time attributes.

Researchers and institutes have developed different CVD risk assessment calculator based on the scoring system.

These systems can help the patients to predict the risk and control the risk factors to prevent CVD. Framingham CVD risk calculator includes age, sex, present smoking status, total cholesterol, high density lipoprotein cholesterol (HDL-C), systolic blood pressure and drug history for blood pressure control. The estimation was calculated for CVD within 10 years. The scoring systems didnâ&#x20AC;&#x2122;t include the diet and level of smoking as a risk factor. Reynolds risk scoring system wasdeveloped for men and women separately and includes family history and C-reactive protein

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with the Framinghamâ&#x20AC;&#x2122;s variables.Some other scoring systems included height, weight, race, diabetes, history of heart attack, family history, physical activities and diet.

The American Heart Association (AHA) developed a Health Campaign especially for the young and adult people to avoid smoking and smokeless tobacco products, be active by engaging daily physical activities, eat healthy diets, maintain healthy weight and control blood pressure, cholesterol and glucose. A meta-analysis of prospective cohort studies found that ideal cardiovascular health metrics significantly reduced CVD, cardiovascular mortality and overall all cause of death. Improved cardiovascular health metrics can reduce death related to coronary heart diseases between 2010 and 2020 by 30 per cent. Interventions were recommended to complete cessation of smoking and stop environmental exposure. Asking patients to stop smoking refers to smoking cessation programme. Patients should control blood pressure <140/90 mmHg and seek counseling for lifestyle modification. All patients should maintain lipid profile, use omega-3 fatty acids, and perform physical activities.

Body weight should be maintained and in conditions of obesity and overweight, therapeutic lifestyle intervention should be initiated.

Diabetic patients should check blood glucose and maintain lifestyle modifications and treatment. Patients should take antiplatelet and antihypertensive therapy when necessary. CVD patients should have influenza vaccine annually. Depressive illness patients should be evaluated and treated, and cardiac rehabilitation programme should be implemented. Evidence approves that inclusive risk factor management can improve survival, reduce recurrence rate, and improve quality of life. Healthcare providerâ&#x20AC;&#x2122;s support to the patients, is also essential for the wellbeing of the patients.

CVD causes an enormous burden in health and economy globally. Access to healthcare facilities and prevention of CVD intervention is inexpensive.

To implement the universal health insurance system can reduce the risk of CVD; however, primary prevention is the key. In South Asia, one of the main risk factors is shifting in dietary behaviour for CVD. Low cost, local tailored intervention practice for changing the health risk behaviour can prevent CVD. To improve cardiovascular health, (1) changing the individual level lifestyle

and treatment of the risk factor, (2) encouraging healthcare providers and patients to improve healthy behaviour, and (3) targeting schools, worship places, workplaces, local communities and, consequently the states and the whole nation, is important. It needs innovative research, advanced technologies and appropriate interventions to save lives. Moreover, along with the health professionals, governments, businesses and public partners need to be involved to achieve the goals.

References available at www.asianhhm.com

Author BIO KATM EhsanulHuq is a doctoral student of Hiroshima University.

He completed his masters from Uppsala University, Sweden, diploma from Swiss Tropical and Public Health Institute, Switzerland and medical graduation from Bangladesh. He worked at International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in different clinical researches specially vaccine trials, bioequivalence studies and drug development.

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, and Population Sciences. She has multidisciplinary collaboration in different countries for sustainable development.

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 Healthcare Delivery (eHCD) involving a number of countries in the Asia-Pacific region.

Susumu Nakayama is a doctoral student at Hiroshima University, Japan and completed masters graduation degree from Hiroshima University. He has engaged in construction of community cooperation system for heart failure patients in Hiroshima prefecture of Japan.

Moshiur Rahman is a Visiting Associate Professor at the Graduate School of Biomedical &Health Sciences in Hiroshima University, Japan. He has multidisciplinary experiences in clinical science, public health, and molecular research. Expertize in planning, implementing, monitoring and evaluation of public health programs & research in developing countries.

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technology, equipment & devices

Industry 4.0

Manufacturing and the future of medical things

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technology, equipment & devices

The I4.0 revolution is already re-defining how we manufacture. It will help meet demand for increasingly sophisticated, higher quality and rigorously regulated medical devices. It delivers solutions in innovative new areas such as patient-specific devices and ‘Lab on a Chip’ electronic diagnostics. What does the future look like for manufacturing The Internet of Medical Things (IoMT)?

Francisco Almada Lobo, Chief Executive Officer and Co-Founder, Critical Manufacturing

T

he Industry 4.0 (I4.0) revolution is already re-defining how we manufacture ‘things’ today. It sets out the concepts for how companies can achieve faster innovation and increase efficiencies across the value chain. But, in the world of medical device manufacturing, which is burdened with regulatory compliance and is still largely dependent on paper-based processes, what does Industry 4.0 really mean?

How will it help manufacturers meet demand for increasingly sophisticated, higher quality and rigorously regulated medical devices, and beyond that highly personalised custom devices?

New trends in how medical devices are made and how they deliver value is fundamentally changing, devices are moving more and more into the world of the Internet of Things, utilising highly sophisticated chipsets, processing capabilities and sensors.

They are mobile and connected like never before, delivering solutions in innovative new areas such as patientspecific devices and ‘Lab on a Chip’ electronic diagnostic testing. What does the future of manufacturing medical devices, efficiently and profitably, look like? Or, should we say manufacturing the ‘Internet of Medical Things’ (IoMT)?

Industry 4.0 embraces a number of automation, data exchange and manufacturing technologies that are changing the landscape of how we make products and expanding the boundaries of innovative, new manufacturing opportunities.

It is modelled on a Value Chain Organisation that merges real and virtual worlds usingthe Internet of Things (IoT) and the Internet of Services (IoS). It provides factories with real-time intelligence allowing them to efficiently produce products of higher quality that can be completely customised. Five years ago the medical device connectivity market was largely insignificant but it is now expected to grow at a CAGR of 38 per cent over the next five years by adopting the capabilities of the IoT. The IoT brings together physical objects with embedded electronics, software, sensors and network connectivity that means they are able to collect and exchange data with each other. In the manufacturing environment this becomes the Industrial Internet of Things (IIoT) with added machine learning, machine-to-machine communication and integration of existing automation technologies. Smart machines are able

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technology, equipment & devices

to accurately capture real-time data and communicate with each other and the products or materials they are processing to make the best production decisions. This not only increases productivity but also identifies any inefficiency, increases quality consistency, and reduces waste both in terms of better utilisation of machines and reduced scrap. Alongside making existing manufacturing processes more efficient, I4.0 offers new opportunities in terms of increasing competitiveness; accelerating innovation; bringing new products to market more quickly; adding capability to easily customise individual orders, and enabling faster response to customer demands.

Medical device manufacturers are experiencing increasing challenges in terms of price and margin pressure, speed to market, increased product (and so manufacturing) complexity and

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more stringent regulatory compliance.

Pressure on the cost of medical devices stems from excise taxes and increased costs of meeting new regulatory initiatives. Hospitals are also changing the way in which they purchase equipment, working to optimise their costs in the â&#x20AC;&#x2DC;Value-Based Careâ&#x20AC;&#x2122; model.

All of this is combined with increased product complexity which can lead to greater risks to quality and require investment in better technology and deeper analysis of production data to improve processes.

Value-based care means a shift in financial incentives for care providers as they are compensated based on how patients fare, rather than the number of tests, visits or procedures performed.

Medical devices will almost certainly become Cyber Physical Systems (CPS), forming an Internet of Systems where the value of information from sensors

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within the devices is higher than the value of the devices themselves. Patient information gained from device sensors or self-monitoring can reduce the overall care model costs with a stronger focus on disease prevention and early detection. For example, integrating electrocardiogram capability or blood pressure cuffs within a device increases its value. However, this all requires a single platform through which devices can be connected across a care setting or disease continuum. The Internet of Medical Things (IoMT) brings together technology, medical devices and applications that enable personalised patientspecific devices and care programmes.

Mobile devices that can track chronic and lifestyle associated diseases such as diabetes is a fast growing market area and one which responds to the connectivity delivered by the IoT. Device examples include contact lenses

technology, equipment & devices

that can detect glucose levels and devices to monitor calorific intake. A new area of bioelectronic medicine is also emerging, facilitated by the miniaturisation of electronics. Here miniaturised devices are implanted in the body may help treat illnesses such as arthritis, diabetes and asthma by influencing electric signals in nerve pathways.

Other areas of innovation include robotic-assisted surgery; next generation of smart inhalers that track inhaler use, avoid triggers and warn of asthma attacks, and biometric stamps that act as a â&#x20AC;&#x2DC;lab on a chipâ&#x20AC;&#x2122; (LOC) alternative to reagents and chemicals. A LOC is an automated, miniaturised laboratory system that can be used inside and outside of a hospital for a wide range of patient measurements such as blood gases, glucose and cholesterol levels.

This technology enables fast diagnostics with only small amounts of samples and

materials required. This biochip market is estimated to be worth around USD17 billion by 2020.

In the future, innovation and agility is clearly going to be vital for medical devices manufacturers to respond to a rapidly changing market place. The rate at which manufacturers can get a new product to market is being influenced by the time to gain necessary FDA device approvals. Regulatory approval requires the collection of vast amounts of data through the complete product lifecycle.

If design, process engineering, and manufacturing systems are disjointed, this further impacts the efficiency of new product releases the whole product development cycle can become cumbersome and error prone. Strong competitive forces in the market place may mean that any delay in product release results in missed opportunities and loss of market position.

Although strict regulations mean that changes may happen more slowly in the medical markets compared with some other industries, I4.0 offers medical device manufacturers such incredible benefits that it will happen. It provides a pathway for efficient production of increasingly complex products while capturing and analysing data flows to assist with regulatory compliance and process improvement.

Regulatory compliance does not guarantee high quality but the end to end traceability and complete visibility of production processes within the I4.0 model means compliance can be less painful while product quality, and so customer satisfaction, is increased.

To remain competitive, medical device manufacturers need the ability to innovate and respond quickly to the changing ways in which patients can now be treated. Customisation of patient-

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and complex event processes may also be used to further drive efficiency in the future.

Industry 4.0 embraces a number of automation, data exchange and manufacturing technologies that are changing the landscape of how we make products and expanding the boundaries of innovative, new manufacturing opportunities.

(SPC) can be triggered and checked against limits within SPC rules.

The smart shop floor will use the IoT as a communication pathway supported by technologies such as Cloud computing, which can provide ‘anytime, anywhere’ ability and storage for the huge amounts of data generated.

The MES needs to be able to expand to accommodate both the diversity and volume of this ‘big data’. It needs to aggregate it and put it into context to turn it into valuable information that may be used to improve processes, identify any discrepancies and resolve quality issues before they reach the customer. Real-time analysis using advanced techniques such as ‘in-memory’

Author BIO

specific devices will require high quality, high mix production that particularly lends itself to the greater automation and higher levels of intelligence provided by the I4.0 model. Physical objects passing through production processes will incorporate their own embedded Software and Computing Power (CPS) to interact with more intelligent machines, Cyber-Physical Production Systems (CPPS), on the plant floor.

The products (CPS) will be the service consumers and the machines (CPPS) the service providers. Intelligent exchanges of information within this completely networked environment will enable production to be self-managing and self-optimising.

This changes the plant floor from a centralised control model to a de-centralised one that requires little or no operator intervention. Vertical integration of the plant floor operations, however, must not be forgotten as this is vital for compliance with enforcement of product quality at each production stage. It is also needed to accommodate other business processes such as logistics, engineering, sales or operations — all of which have components inside the plant as well as others that reside beyond the factory that are crucial to a business process being executed effectively.

Without these, it’s almost impossible to properly manage a production floor of a certain complexity. A modern Manufacturing Execution System (MES) based on decentralised logic offers a way to vertically integrate systems so that corporate processes cannot be avoided. For example, quality processes may demand that a device requires additional verification steps before processing continues as part of a higher level quality sampling strategy.

This requires communication to intersect the business rules so the quality procedures are not bypassed before the device continues through its production processes. The MES also provides a platform whereby collection of data for Statistical Process Control

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Summary

The medical device industry is going through an exciting time with many new opportunities in innovative routes to patient care. Those that ignore the opportunities I4.0 offers will be in serious danger of not being able to compete in the near future as others drive down manufacturing costs and increase business agility in response to developing technologies. One of the main areas of benefit the decentralised, smart manufacturing model offers is the ability to efficiently individualise products with high quality results — something that will be critical to success in the patient-specific devices market.

The implementation of I4.0 will certainly be a transitional process for the medical device industry because of the importance in retaining compliance and the need to prove quality systems.

Nevertheless, itcan and should be planned into business strategies now and benefits will be realised over time. Modern MES platforms that utilise decentralised logic provide a realistic pathway to transitioning from homegrown systems and paperbased production models to the latest technologies while ensuring control of business process rules, managing compliance and assuring quality control and high product quality.

Francisco Almada Lobo holds an MBA and an Electrical Engineering Degreefrom University of Porto. He started his career in a CIM R&D institute, and joined Siemens Semiconductor in 1997.

Throughout Siemens, Infineon and Qimonda, hegained experience in several manufacturing are as having, in 2004, led the first migration of an MES system in a running high-volume facility. Between 2005 and 2009, he managed the Porto Development Center for Infineon and Qimonda, with implementation of automation projects in the group plants worldwide.

Francisco acted as Chief Operating Officer of Critical Manufacturing where, among other areas, he was responsible for the Product business unit. Since 2010 he's the company's CEO.

Day 1: 29 August 2017: Health Day Mainstreaming Ayush: Staying Healthy Yoga: Science of InďŹ nite Possibilities Diet, Therapy, Exercise for Fitness

Day 2: 30 August 2017: Bio Day Medical Biotech: The Future of Healthcare Agri Biotech: Produce More with Less Animal Bio: Move the World for Animals Bio Informatics: Introduction and Overview

Day 3: 31 August 2017: Organic Day Organic Farming: Scripting a Success Story for India Smart Foods for Wellness Organic Medicines: Ancient Preparations for Modern Times Organic Consumer Products: Together for a More Organic World

Information Technology

Dawn of the Future IoT-driven medical devices service enterprises

The ‘things’ in IoT can refer to a wide variety of devices including implants, physiological monitors, wearables, capital intensive diagnostic equipment, and so on. The expanded sensing and communicational capabilities of these ‘things’ herald the next big wave of the Internet.

Ram Meenakshisundaram, Senior Vice President and Global Delivery Head Life Sciences, Cognizant

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ndustries across segments are moving from selling products to selling services; even wind turbines, locomotives and jet engines are now sold as services. The emergence of the Internet of Things (IoT) has now enabled medical devices companies to create a new business model premised on services, personalization, and other innovations.

IoT, where physical devices are instrumented to capture and transmit data covering everything from environmental conditions to usage patterns and user behaviours, is arguably the next wave of information technology advancement. The ‘things’ in IoT can refer to a wide variety of devices including implants, physiological monitors, wearables, capital intensive diagnostic equipment, and so on.

The expanded sensing and communicational capabilities of these ‘things’ herald the next big wave of the Internet. Estimates indicate that some 12 billion devices1 are already connected to the Internet. This figure is expected to grow to 50 billion devices by 2020.

IoT’s power lies in connecting dots in an innovative fashion. The transformative possibility is evolving across a broad spectrum: connected homes, connected healthcare, connected factories, and connected enterprises.

The healthcare industry is well on its way to a smart, connected future enabled

by IoT, as market leaders recognise that sensors connected through IoT can transform business models and harbinger new possibilities. Healthcare organisations that integrate these ‘connected health’ trends into their practices, processes and workflows can offer patients better care and greater satisfaction while reducing the cost of care. The global healthcare IoT market is expected to grow from USD 32.47 billion in 2015 to USD163.24 billion by 20202.

1 http://www.cisco.com/c/dam/en_us/about/ac79/docs/innov/IoT_IBSG_0411FINAL.pdf

2 http://www.marketsandmarkets.com/PressReleases/iothealthcare.asp

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Game-Changing Possibilities

Physicians and patients increasingly believe that ‘wearables’ could help them better manage health and potentially improve long-term care. Roughly 72 million wearable devices were shipped

in 20153, a figure that will nearly double to 156 million by 2019. These trends indicate strong growth in the sector.

With IoT, the medical device manufacturer can usher in true customer-centricity.

There are three types of transformational opportunities: • Greater operational efficiency, as a result of preventive maintenance of devices and remote diagnostics and software upgrades, improving customer satisfaction • Digital innovation around the communication of vitals and device information, and new services that can help customers contextually understand the insights • Connected ecosystem, as a result of the ability to link devices and systems together, bringing superior intelligence to the customer.

Let’s look at some opportunities for digital disruptions. The number of product recalls of medical devices has increased nearly 100 per cent4 between 3 http://archive.eetasia.com/www.eetasia.com/ ART_8800713348_499488_NT_cf5904f0.HTM

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4 https://www.fda.gov/downloads/AboutFDA/CentersOffices/OfficeofMedicalProductsandTobacco/CDRH/ CDRHTransparency/UCM388442.pdf

Information Technology

Harnessing IoT Analytics to Transform the Medical Device Value Chain

Traditionally, manufacturers have introduced new efficiencies to their value chain by employing lean manufacturing and Six-Sigma quality techniques. While this can certainly 5 https://www.fda.gov/downloads/AboutFDA/CentersOffices/CDRH/CDRHReports/UCM277323.pdf 6 https://www.cognizant.com/perspectives/how-iot-analytics-can-transform-the-medical-device-value-chain

The global healthcare IoT market is expected to grow from USD 32.47 billion in 2015 to USD 163.24 billion by 2020

drive optimisation, manufacturers can also accelerate transformation by introducing new business decision services powered by IoT and big data analytics.

Success in developed markets varies greatly from emerging economies, which require a very specific understanding of stakeholder needs. By using data mining techniques, such as Natural Language Processing (NLP), medical device manufacturers can costeffectively obtain this information and influence the product development lifecycle for each market. When these data sets are assessed in isolation, their meaningful impact on the value chain is limited. By identifying effective ways to integrate these data sets and apply analytics capabilities to them (for example, predictive analytics and NLP), organisations can more effectively optimise the value chain. By analysing IoT and an array of big data assets, for example, an insulin pump maker can enhance various components of its value chain.

Author BIO

2003 and 2012. By investing in realtime predictive analytics powered by IoT, manufacturers can proactively determine quality issues to reduce the number of product recalls and strengthen brand image.

According to the US Food & Drug Administration (FDA), the number of serious complications from medical device use has outpaced industry growth by 8 per cent each year since 20015. By gathering information about the device and its usage environment, medical device manufacturers could reduce these complications by informing future product design and proactively improving post-sales service support.

A leading medical device manufacturer logs an average of 200,000 product-related customer services complaints6 every year. The ability to predict and proactively address even a fraction of these complaints would spell significant competitive advantage for the company. IoT powered devices have brought such services within the realm of possibilities.

Managed care at home can now be a reality, providing relief to patients, insurance companies, governments, and hospitals. Devices can communicate patient vitals in real time. Alerts can be generated to flag patient need for attention. This can be creatively used in post-discharge care as well, such as monitoring patients after a major cardiac surgery.

From a ‘process’ standpoint, IT would need to engage with the business much earlier in the lifecycle to build a comprehensive data and analytics strategy. From a ‘technology’ standpoint, companies would need to invest in IoT capabilities, such as changing device design (for example, installing sensors to monitor real-time device usage), and building or buying predictive analytics systems and NLP tools to analyse the information gathered through these devices. From a ‘people’ standpoint, investing in knowledge management and learning systems would go a long way in improving the organisational adoption of these new capabilities.

IoT should be viewed as a business solution. The true value of IoT will be realised when systems are designed to provide impactful business outcomes.

For example, a medical device manufacturer can offer a service to labs around the most profitable categorisation and bundling of tests. Fertile ecosystems that connect the dots must be visualised where IoT can provide deeper insights into a device’s operating environment and its internal state.

There are some challenges that we need to be wary of: the diversity of data communication protocols, energy needs, exposure to new security vulnerabilities due to data exfiltration, and privacy apprehensions. These concerns are not intractable and will abate in the coming times. The dawn of services-based medical devices and connected ecosystems for greater customer centricity positions us on the cusp of digital disruption and presents a great opportunity to shape the future.

Ram Meenakshisundaram is the Senior Vice President and Global Delivery Head for Life Sciences at Cognizant.

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Data Security and Analytics

Shaping the future of healthcare

The article talks about digitisation of medical records highlighting role of Predictive Healthcare Analytics & Big Data in optimising Indian and global healthcare industry. It also brings out the need of IT security in the healthcare domain for data protection and compliance in the same segment.

Baskaran Gopalan, Senior Vice President, IT & Projects Omega Healthcare Management Services Pvt. Ltd.

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he healthcare industry has been undergoing tremendous change thanks to the ever advancing innovation in computing technologies. According to a recent report released by Springboard Research, the growth in healthcare IT market in India has been the highest in Asia. A few studies also forecast Indian medical technology market to grow from US$2.7 billion in 2008 to US$14 billion in 2020.

The recent advent of analytics has impacted the scenario of patient services in healthcare including the management and delivery of healthcare, governance and more. As the demand for improved

Information Technology

healthcare services rise, the need for securing patient healthcare data and easing access to it also grows manifold.

The need and demand for big data analytics has grown tremendously owing to the deep insights that can be obtained to help resolve challenges and improve services. Data analysis and insights have been made a lot easier with the use of big data platform that is capable of processing terabytes and pet bytes of data.

Big data analytics has now become a necessity for all healthcare service providers.

Insightful information regarding their management, planning, and the relevant measurements can help healthcare organisations to develop their future vision, optimise time and resources, and scale their financial outcomes.

Data Analytics in Healthcare

Data Analytics can be utilised in the healthcare industry for many purposes: Public Health: Public health issues can be addressed with a detailed analysis of healthcare data covering disease patterns and records of disease outbreaks.

Healthcare crises can be predicted and prevented, thereby improving the quality of care provided.

Electronic Medical Record (EMR): An EMR is a consolidation of structured and unstructured medical data for a given individual. A digitised version of the healthcare reports and prescriptions will help in continual treatment giving quick access to a patient’s healthcare history.

Patient Profile Analytics: This advanced analytics when applied to patients’ profile can help identify any impending health risks and facilitate preventive care.

Fraud Analysis: Effective data analytics can reduce fraud, waste and abuse by thorough analysis of claim requests and identifying claims with incorrect and incomplete information well before submission.

Safety Monitoring: Data analytics can

A few studies forecast Indian medical technology market to grow from US$2.7 billion in 2008 to US$14 billion in 2020.

help in safety monitoring and negative event prediction by real time analysis of large volumes of data in hospitals.

Baby Steps of IT in Healthcare

While the World Wide Web came about in the late 1900s, Gustav Wagner had already foreseen the need for technology in healthcare and came up with a professional organisation for health informatics in Germany. The platform Health Information Technology (HIT) created by him is dedicated to process information using hardware and software. HIT is beneficial in storing and using information on healthcare, data and knowledge to communicate and help make decisions. The platform utilises communication and computers to build systems and share health information.

In early 1990, the United States healthcare industry started to be driven by competition. Many households and industries resorted to using ICT as momentum in Internet usage grew.

This gave rise to the need of adopting IT in healthcare. Even though it started only with helping the service provider with process-oriented systems, the focus eventually shifted to being a patient-centered and outcome-oriented platform.

In the late 1990s, the need for more integrated healthcare facilities, providers, and better managed care offerings was felt in the healthcare BPO industry.

Year 2000 saw the use of technology to increase productivity. Electronic Medical Records (EMR) started being adopted. The HIPPA Act which was passed in late 1990s, brought in a greater emphasis on EMRs and EHRs. With continuous flow of information, it created a platform for global digital healthcare infrastructure.

Cloud computers along with cloud-based big data analytics came together and became the driving force for customer requirements for value added services.

At the same time, Health Information Exchanges (HIEs) earlier referred to as RHIOs (Regional Health Information Organisation) came about.

Need for IT in Healthcare

The Indian Brand Equity Foundation (IBEF) states that India is considered to be the largest Information Technology (IT) sourcing destination in the world.

It accounts for approximately 67 per cent of the US$124-130 billion market, with about 10 million workers.

India’s USP, according to the report, is its cost competitiveness in providing IT services. This accounts for services being approximately four times cheaper when compared to the United States. The recent change observed is in the growth of intellectual capital in the country with a number of global IT firms setting up their innovation centers in India.

The emergence of IT solutions in healthcare is a consequence of the need to improve outcomes and slash costs. But, this process is heavily dataintensive. The need to protect data came along with the changing process.

IT started playing an important role in the healthcare sector in late 1960s when the techniques to utilise its advantages recognised. This was when hospitals and healthcare providers understood the need to save data digitally.

The benefits of this are many: it eases access to patients’ medical histories during follow-up; with data being saved in the cloud, it can be accessed from anywhere. Likewise, IT has also made

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medical billing easy and accurate. With the help of medical coders, the hospitals are able to utilise their resources optimally and not engage them with the process of manual billing.

Use of Electronic Health Records (EHRs)

How many times have physicians opened a file containing lab reports and prescriptions without dropping any of them? While handwritten prescriptions have been a norm since ages, their drawbacks are aplenty. Apart from the trouble in analysing the content on the prescription, papers are difficult to store as they age with time. Sometimes, they also get misplaced which leads to loss of valuable data. They also cannot be accessed with ease at any given point in time. However, data that is stored digitally can be accessed anywhere through cloud. The format in which it is stored is also understood by everyone. This data will remain there till such time it is manually deleted. And in case data is lost, there are many ways to retrieve the same.

The format maintained in an EHR is better organised than paper charts or prescriptions. EHR also gives a consolidated list of complications such as major illness, surgeries, allergies and medications that should not be missed during follow-up care or consultation for any other ailment.

One study notes that 25 per cent of paper charts are usually found missing.

Even in the presence of papers, specifics were missing in 13.6 per cent of times.

President’s Information Technology Advisory Committee reported that they found 20 per cent of laboratory tests being re-ordered as previous medical records were not available.

This makes it important for hospitals to maintain records digitally.

To find out how digitising patient’s medical history has improved the efficiency of hospitals, Harris Poll, on behalf of Ricoh Americas Corporation, conducted a survey. His subjects

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included 2,053 adults in the United States in 2015. He found that 74 per cent hospitals that used digital platforms such as tablets or some mobile devices to store patient’s information were more efficient. He also found 54 per cent patients to be less anxious when they found healthcare providers to be using digital platforms for data collection.

Improving Revenue Cycle Management

While there is a need for affordable healthcare, the changing regulations and the delayed cash flow directly impact the revenue generated by healthcare facilities. Data is much more than the final outcome of analytics for a healthcare provider. It involves a lot of cost to a company where they would have to employ resources to take care of all the aspects from on-boarding a patient to ensuring that all the data about them is well-maintained.

Innovative use of analytics can help these hospitals gain deeper understanding of the techniques to create quick, accurate, efficient and, most important of all, predictive revenues.

During the consultation process, a lot of iterations take place in claims.

They are denied for a number of reasons. Things that usually go wrong

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include incorrect claims submitted to payer; sometimes the information given doesn’t turn out to be authentic, and there would be additional negotiations in the process. The increasing number of iterations impacts the account receivable cycle. This further impacts profits.

With a sound RCM process in place, top reasons for claim denials such as incorrect patient demographics, eligibility issues and prior-authorisation numbers, can be mapped and a pre-check can be conducted to eliminate any possibility of denial scenarios. Any information found to be incomplete can be updated immediately and resent so that there is no time lag because of lack of information.

The analysis of historic data to understand the time and effort put in to recover underpaid claims can help understand the need for better strategies. For example, if the spent time does not justify the recovered amount, a strategy to automate the process can be devised thereby helping in optimal use of available human resources.

These insights will also help a service provider set a threshold limit on the revenue collection and determine transactions for follow-ups beyond the thresholds.

Information Technology

Predictive Analytics (PA)

Here a combination of statistical methods and technology are used to analyse large amounts of information and predict outcomes for individual patients. With the help of predictive analytics, there is a systematic process to monitor supply chain efficiencies and improve patient care, chronic disease management and hospital administration. The use of this analytical tool is fast gaining popularity as healthcare systems explore how to best use it to make improvements.

Predictive analytics is most useful when both the predictor and the care intervention are integrated with the same systems. It is easier to identify trends and obtain best results. Data can be compared to analyse the outcomes for all the diseases that a healthcare provider could encounter.

Physicians and insurance companies rely on predictive analytics for extensive research and statistical analysis that can range from improvement of patient’s health, post medication, to their readmission rates.

Health Information Privacy and Security

Privacy is a fundamental governing principle of the patient–physician relationship for efficient delivery of healthcare. Patients need to share information with their doctors to facilitate the right diagnosis and effective treatment, especially to avoid selective drug allergy. However, patients might not be comfortable in sharing important information in cases of health problems such as mental illness and HIV as their disclosure may lead to social discrimination. After a period

of time, a patient‘s medical record has a collection of personal information that includes identification, past medical history, digital record of medical scans etc. Safeguarding such data is a necessity and companies do all that it takes to protect the data.

Understanding the operational effectiveness of data disclosure technology from the field may help hospital administrations refine disclosure policies, as well as choose appropriate data disclosure technology solutions.

With the storage and access to patient information becoming more digital, and utilisation of Big Data and Predictive Analytics, the security and safety of such information in compliance with various government regulations becomes more critical.

Protecting the privacy of clients’ patient data is a core operating principle at Omega Healthcare. The number one objective of the company is to help hospital and health systems improve outcomes, and as a precursor to that objective, priority is given to the security of their data. Omega achieves this by creating a culture with a deep focus on HIPAA compliance through a security awareness program. This programme includes mandatory, rigorous HIPAA training for new employees, regular refresher trainings, monthly newsletters with a focus on security, and on-going dialogue about best practices.

We also instill an understanding of exactly why we are working so hard to protect data. HIPAA’s Privacy

Author BIO

The combination of data and its analytics play a key role in revenue cycle management process. They help unearth hidden and previously unseen insights to manage the revenue flow more accurately and provide results leading to profit generation for healthcare providers.

and Security Rules are designed to protect patients’ civil right to privacy.

Healthcare providers often feel a sense of ownership over PHI because they work so closely with it and are responsible for its protection. This can happen with vendors also. Our commitment to protect and secure PHI stems not only from our responsibility to our clients.

We also emphasise to employees that PHI really belongs to patients, and it’s our responsibility to protect patients’ privacy.

In addition to creating a culture that focuses on the security and privacy of PHI, our technology plays a significant role in preventing data breaches.

Technology features such as tracking and audit trails and features to protect physical security of the data ensure that patient information remains secure and HIPAA-compliant.

The use of various business intelligence tools makes data open to threats. At Omega Healthcare, data is protected from Internet threats using a firewall that is configured in High Availability mode and filters the data packets coming in and going out of the company network according to predefined access rules. The firewall has three layers - the first layer is Gateway Antivirus which checks for virus and spam. After this the data is filtered through Real Time Blacklist which is the second layer and then filtered through IDS/IPS which is the third layer for any unknown signatures. Further, content filter is used for securing HTTP and HTTPS traffic. All the firewall logs are reviewed and guarded.

Baskaran Gopalan comes with over seventeen years of experience in the healthcare billing industry. He has managed operations for hospitals and large physician groups in the past and possesses in-depth domain knowledge of the US healthcare industry, with a special focus on Receivables Management.

Baskaran also has expertise in Quality Assurance processes and client management having more than 8 years of experience at other India-based Healthcare BPO/KPO organisations. Baskaran joined Omega in its early months and has since then nurtured India operations with some of the best industry practices as well as fostered a culture of team loyalty.

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HealthTech Innovation Optimising telehealth services Telehealth access to patient images, via technology that supports secure, fast, diagnostic-quality image access without moving image data, significantly improves patient outcomes for both acute care and non-acute care.

Dave Waldrop, Co-CEO/CRO, Calgary Scientific

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elehealth combines communications tools and health IT, thus enabling healthcare delivery to bridge distance and time and provide high quality care irrespective of where the patient is located. Through anytime, anywhere provider-to-patient and provider-

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to-provider connections, telehealth improves outcomes, lowers costs and supports care coordination.

These benefits, which are spurring adoption of telehealth across the globe, are magnified when images are added to telehealth encounters. This article looks at how imaging increases the

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value of telehealth for both non-acute and acute care situations. In case of the former, including patient images allows providers to share the full patient picture improving care. In acute care situations, such as stroke, images provide critical information that saves lives.

Information Technology

Delivering Care Through Telehealth is Reaching A Global Tipping Point

Worldwide adoption of telehealth as a method of delivering care is growing.

While North America accounts for about 41 per cent of the global telehealth market, the market in Asia is expected to grow at a CAGR of 12 per cent through 2020, according to a report from US-based analyst firm Frost & Sullivan.

In Asia, telehealth modalities being used include real-time telemedicine encounters, remote patient monitoring and mobile health. While adoption is not moving as quickly as expected, Asia-Pacific governments are building the foundation to drive its adoption by investing in infrastructure, such as nationwide 3G and 4G access, developing telehealth and eHealth roadmaps, and creating policies that directly or indirectly attract investment in health technology, reports Frost & Sullivan.

Like the North American market, telehealth is an important tool for delivering care to the increasing global incidence of non-communicable diseases, including cardiovascular and metabolic disorders, cancer, diabetes, Alzheimer's disease and other neurological disorders.

The appeal of telehealth to providers is that it improves access to care and supports communications and collaboration without changing the actual care. “We are not changing the clinical service, but rather how, when and where such service is conveyed,” explains Alexis Slagle Gilroy, a partner at the law firm Jones Day and American Telemedicine Association board member.

As telehealth adoption grows, it is also projected to save money. An analysis of recently introduced telehealth legislation targeted at expanding reimbursement showed that some of its provisions could save the U.S. government US$1.8 billion.

“Telehealth is the future of healthcare. It expands access to care, lowers costs, and helps more people stay healthy,” U.S. Senator Brian Schatz said in a statement in May 2017.

As a tool for bridging both time and distance, telehealth solutions need to include access to images from any place on any device, whether desktop, laptop or mobile.

Telehealth is Digital Health too

Like virtually every aspect of modern healthcare, the foundation of telehealth is digital. As a digital tool, telehealth enables providers to harness digital health data and share itto overcome barriers and break down communications silos. In fact, at large hospital and health system campuses telehealth is sometimes used to facilitate cross departmental communications.

Whether telehealth transactions span a hospital campus, city, state, country, or globe, one key to their optimisation is the integration of digital patient images. Telehealth delivers care through real-time (synchronous) connections and through store-andforward (asynchronous) connections.

Integrating diagnostic quality image sharing into both synchronous and asynchronous connections optimises the benefits of telehealth for both non-acute and acute patient care.

In non-acute care situations, enabling providers to share patient images during telehealth transactions improves coordination between providers and significantly increases patient access to care. For acute care situations combining provider access to images with telehealth saves lives.

In all cases, imaging rounds out the picture of patient needs, providing critical information for diagnosis and treatment.

Telehealth and Image Sharing for Nonacute Care: Lowering Costs and Enabling Collaboration, and Care Coordination

Imaging is expensive and made more so by redundant, repeat imaging. According to a recent joint Healthcare Information and Management Systems Society (HIMSS) and Society for Imaging Informatics (SIIM) white paper, diagnostic imaging accounts for 10 per cent, or US$100 billion, of annual healthcare spending in the US Almost 9 per cent of this imaging is repeat imaging, which often happens when a patient has been referred to a specialist who cannot access the images at the referring provider’s location. As a result, specialists often have to reorder image studies creating an unnecessary cost.

In non-acute care situations, telehealth solves this problem by enabling referring providers to share images with a specialist along with a referral for a consult. This telehealth method of connecting specialists with providers, called e-consult, uses web-based, electronic communications to enable a primary care provider to contact a specialist regarding a patient issue. Related patient images are forwarded with the communication, enabling the specialist to determine if an in-person visit is required and then to have the images on hand for the in-person consult if one is called for.

By providing both critical information and a communications link between primary care providers and specialists, e-consult also solves the problem of so-called “referral silence” between primary care providers and specialists. In a study published in the Archives of Internal Medicine, 69 per cent of primary care physicians said they send specialists notification of a patient's history and the reason for the consultation all or most of the time and just 34.8 per cent of specialists said they routinely receive such information. E-consult, helps to minimise this issue by enabling referring

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providers to share as much information as they can, including images, in the communication.

Telehealth and imaging also form a powerful tool for addressing management of chronic disease. The leading cause of blindness in the U.S. is diabetic retinopathy. While early detection of retinal complications can decrease the risk of blindness by 95 per cent, long waits for access to specialists has resulted in an high rate of diabetic retinopathy among uninsured patients, shows a study in JAMA Network Internal Medicine.

To solve this problem among the uninsured safety net population in Los Angeles County, primary care providers take images of patient retinas using retinal cameras and then share those images with optometrists via e-consult.

After reading the images, optometrists would make recommendations for the patient to see a specialist or not. This process decreased the wait times for screenings by 90 per cent, which before the implementation of the telehealth process was five months. The results of the study show that this integration of imaging with telehealth delivers patientcentred, coordinated care.

Image Sharing Via Telehealth for Acute Care: Saving Lives

Image sharing via telehealth in acute care situations not only delivers the same benefits provided in non-acute settings, but also provides critical lifesaving benefits. When faced with urgent, severe and complicated conditions such as stroke or head trauma, emergency care providers need real-time access to neurologists and other specialists.

Telehealth provides the real-time access for patients in remote or rural settings and images provide the key patient data that enable neurologists to make timely diagnoses.

When a patient with head trauma arrives in an emergency department the first step is a CT scan. The next step is to get those images to a neuroradiologist

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for reading and diagnosis. If the patient is in a rural location or it’s 2 a.m. in an urban setting, access to a neuroradiologist typically happens via a telehealth connection. Once the connection is made, the remote neuroradiologist must access the images to make a care decision, such as whether or not to transfer the patient to a trauma centre.

If specialists have access to patient images during a real-time connection with the emergency providers, they can make decisions about transferring the patient or not, saving the costs of unnecessary transfers. In addition, if a patient transfer is required realtime image access allows the receiving trauma team to view the images before the patient arrives to prepare and saving the costs and time required for repeat imaging.

Revolutionising Stroke Care with the Integrated Imaging and RealTime Communications of Telestroke

Stroke is the leading cause of death and the third leading cause of disability worldwide,making time critical to its treatment. Telestroke, which combines real-time access to images and video communications, is a truly revolutionary method of delivering care that impacts global population health. For the

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15 million people who suffer a stroke annually in across the globe, today their chances of surviving are significantly improved thanks to the use of telestroke and advanced medications.

As stated in a recent study on the state of telestroke published in Journal of NeuroInterventional Surgery, “The mismatch between the distribution and incidence of stroke presentations and the availability of specialist care significantly affects access to care.

Telestroke, the use of telemedicine for stroke, aims to surmount this hurdle by distributing stroke expertise more effectively, through video consultation with and examination of patients in locations removed from specialist care.”

In the US, about 20 per cent of the population live in rural areas without access to either primary or specialist care.

When a patient with stroke symptoms arrives in an emergency room or clinic in one of these rural areas, there’s a good chance the doctor who saves their life will be located hundreds of miles away and providing diagnosis and treatment via telestroke.

The likelihood is strong that their life will be saved and often they’ll walk out of the hospital virtually intact thanks to the enabling capabilities of telestroke technology, which has at its heart image sharing between emergency room providers and remotely located stroke neurologists. By sharing images with remotely located stroke specialists, emergency room providers are able to get a diagnosis without having to transfer a patient over long distances.

Stroke specialists will also give orders, when appropriate, to administer tissue plasminogen activator, or tPA, to break up stroke-causing clots.

Patients must be given tPA within a three-hour window of a stroke’s onset.

Patients that receive tPA often have very limited physical impact from the stroke, leading to both less time in the hospital as well as much less time in rehabilitation facilities, if they require rehab at all.

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The Business Case for Telestroke Models The Value of Patient Image Sharing

Telestroke networks are structured around a hub and spoke system, with urban or academic medical centres providing the hub of expertise to spokes of rural and remote care centres. While telestroke systems can be expensive to implement they deliver significant ROI

for both the hub and spoke locations.

As reported by HIMSS, timely access to tPA enabled by telestroke been shown to be economically beneficial, saving millions of dollars each year.

Patients treated with tPA experience lower healthcare costs, reduced disability, and fewer long-term care needs.

With the direct costs of stroke reaching US$30 billion a year, the improved outcomes and long-term cost savings of telestroke offset its upfront costs.

The other value telestroke brings to hospital networks and healthcare systems is that it can provide a model for other applications of telehealth that incorporate patient images. The close collaboration between a spoke hospital and the hub provider builds a partnership and workflow that can be applied to other types of care, such as head trauma or cardiac care, which increasingly uses cardiac CT for diagnosis.

Image Sharing Technology used in Telehealth Requires Anytime, Anywhere Access to Diagnostic Quality Images Without Moving or Copying Data

Image viewing technology used in telehealth systems needs to support several critical features. First, image viewing tools must provide anytime access from any device, including desktop, laptops, tablets and smartphones, so that no matter where patients are located providers can use the device at hand to view images.

In addition, the image viewer must have appropriate accreditations for diagnostic use. In acute patient care settings, diagnostic clearance is particularly critical because providers have neither the time nor expertise to Author BIO

Follow up care is also made easier when images can be shared with primary care physicians, allowing them to collaborate and communicate clearly with the care providers after a stroke. Telestroke has proven so effective that during 2015 its use grew 38 per cent among hospitals in the United States.

A 2016 study conducted by US healthcare firm Kaiser Permanente examined the outcomes for 2,500 patients diagnosed with acute ischemic stroke. The results of the study showed a 75 per cent increase in timely use of the clot-dissolving drug tPA following telestroke consultation.

Patients treated via telestroke also received their diagnostic imaging test 12 minutes sooner, and the drug was administered 11 minutes sooner, decreasing the so-called door-to-needle time, or time from arrival to administration of tPA, to less than an hour.

“Particularly in hospitals with limited local resources and/or limited access to neurologic expertise, telestroke is an important tool to aid in the evaluation and treatment of potential stroke,” reports the study. The study also found that telestroke reduced variability in stroke care, enabling consistent outcomes.

For stroke neurologists, the imaging is key to their ability to make the right diagnosis for the patient. Working without the images and the real-time video links of telestroke is like “flying in the dark,” says Andrew D. Barreto, MD, associate professor of neurology of UTHealth in Houston.

interrupt their workflow to determine whether the the tools they are using are safe for diagnosis, notes Ryan Minarovich, a lawyer and consultant with the Tenzing Group which specialises in regulatory compliance for digital and mobile health products.

"Today's physicians have so many tools and so much information at their fingertips that it’s important to guard both doctors and patients from inappropriate use,” explains Minarovich.

Most importantly, image viewing technology must provide diagnostic quality image access on any device without requiring the transfer of image data from one system to another.

Keeping image data on its originating site is critical to modern healthcare for several reasons. Modern patient images are very large and providing access to image data without moving it saves time. In addition, this approach allows maintains the protection and safety of patient data by ensuring it stays on the secured originating system and isn’t transferred to less secure mobile devices.

Conclusion: Integration of Patient Images Increases Value of Telehealth

Imaging is a critical component of patient care. As a tool for bridging both time and distance, telehealth solutions need to include access to images from any place on any device, whether desktop, laptop or mobile. Without image access, the ability of telehealth to lower costs, improve care and save lives is cut short. To provide quality care, providers need access to a full patient picture, images included.

Dave leads global sales and marketing and is responsible for strategic corporate and operational decisions. Dave has been leading global sales and marketing teams at the executive level for over 25 years, spending 18 years with Microsoft where he was a key driver in building company wide initiatives in business development, product marketing and sales roles.

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E

lectronic Health Record (EHR) is a life-long record of all the clinical encounters, investigation results and reports, etc., that a particular person has throughout life. All of these clinical documents need to be lined up and merged together into a single continuous document to help provide that personâ&#x20AC;&#x2122;s health-related life journey.

Thus, there is a need to ensure that the consolidation of the related clinical documents of that person is made possible in a seamless manner. This requires that all electronic systems that generate the various clinical documents

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of a uniquely identifiable person be interoperable.

If merely displaying contents from other systems was the requirement, the need for extensive interoperability would have been superfluous since the external records could have been made into something like a scanned document in the form of JPEG image or PDF file and having it displayed would have been sufficient.

Such use, however, is severely limited in scope and does not justify the use of valuable computing resources as the needs are much more. These include the

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ability to analyse contents, help trigger important actions that could potentially be life-saving and automating routine repetitive tasks are some of the more meaningful use of electronic medical records, all of which are possible only through interoperability.

What is Interoperability?

Interoperability Interoperability is defined as the ability of two or more systems or components to exchange information and to subsequently use it. This is made possible by taking advantage of both

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EHR Interoperability Why, what and how

The ability to merge data from clinical documents like Electronic Medical Records (EMR), investigation results and reports, medical reconciliation, nursing records, operative notes, etc. authored by different persons at various times at diverse locations using disparate electronic systems from many manufacturers is critical to the creation and maintenance of lifelong electronic health records of an individual. For this, both the structure and contents need to be available in formats that can be properly processed by electronic systems to ensure that the right contents are matched and merged into a single life-long record. Interoperability is what makes this possible. This article discusses the why, what and how it can be achieved.

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

the structuring of the data exchange (syntactic interoperability) and the codification of the exchanged data itself including vocabulary (semantic interoperability) so that the receiving information technology systems are able to properly interpret the data for further action.

Syntactic Interoperability Syntactic interoperability defines the syntax of the data exchange and ensures that such exchanges between information technology systems can be interpreted at the data item level and is achieved through the use of a common

information exchange reference model.

Consequently, these standards specify either the record structure or the data exchange (messaging) formats.

Semantic Interoperability Semantic interoperability is the ability to automatically interpret the information exchanged meaningfully and accurately in order to produce useful results as defined by the end-users of the respective systems. This is achieved using a clinical code system, whose contents are unambiguously defined and coded, to ensure that the meaning of the information, as present in the

sending system, is identical to that interpreted by the receiving system.

Why is Interoperability required for EHR?

Persons have many encounters with different care providers throughout his life for the various illnesses they happen to suffer from or for receiving help in prevention and/or monitoring them.

Each encounter leads to the creation of a single medical record. To help maintain a life-long record of the progression of oneâ&#x20AC;&#x2122;s health, it is necessary to firstly uniquely identify all records belonging

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to the same person, then arranging them from the very first to the very latest, and thereafter understanding their contents that have been created by many authors using a wide-variety of systems from different manufacturers before consolidating them all together into a single record.

Further complicating matters is the fact that these records are usually made by different persons who work in various speciality areas like paediatrics, medicine, ENT, ophthalmology, skin, surgery, obstetrics and gynaecology, etc. Due to the specific demands of the various medical sub-domains, all of these require different types of information to be recorded in a particular way. Topping all this is the inescapable reality that each of the authors usually has a very unique style of record writing as a result of their medical training.

How can this be made possible?

Fundamentally, any type of record consists of two parts: (1) the structure, containing the individual data items along with their corresponding data types, data lengths and data formats,

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and (2) the content filled in by the authors.

Since the record contents created and maintained in one system needs to be exchanged with and ‘interpreted’ by another system, a way needs to be found whereby the other system is able to correctly perform these tasks. This is done by aligning the structure of the records in the two systems and then ‘interpreting’ the exchanged contents.

There are two ways of aligning the record structures. One would be to use a common information framework for exchanging data. The other would be to use a common messaging framework that can be mapped to by the systems participating in the data exchange to correctly identify the exchanged data items.

Solving the structural issues is simpler when compared to solving the content issues. Not only do these need to be accurately exchanged, but their meaning too needs to be preserved and subsequently ‘interpreted’ by the system for further action. This translates into the requirement that the content needs to be in the form of some machine-

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processable ‘code’. This ‘content coding’ is carried out through concept modelling using principles of linguistics, computer and information science.

These two types of models, namely the information model and the concept model, are based on the model of meaning of the data item in context.

Both of them need to be considered together for precisely deriving what the author meant when making the record entry.

Model of meaning The ‘model of meaning’ is a human conceptualisation of the world and its contents. This is done using an information model (model of the information) and a concept model (model of the concept) in order to ensure that a data/record item, is clearly understood by both humans and machines alike, so that further action may be undertaken as necessary by either.

Information Model An information model provides a sharable, stable, and organised structure of the information requirements or knowledge for the domain context.

At a very basic level, it is a structure that serves the syntactic aspects of interoperability. This can be used for designing records or data exchange messages.

Concept Model A concept model provides a way in which information knowledge can be represented and subsequently codified, thereby serving the semantic aspects of interoperability.

Example – Handing “Title” of a Person’s Name [NB, the following discussion related to the data item ‘Title’ is purely imaginary and has been provided here to help illustrate modelling concepts.]

It is important to recognise that when writing a record, one enters the thought that one has about the item in context. In the case of ‘Title’, this would be ‘Mr’ if the person is a male, ‘Ms’ if the person is not a male,’Miss’

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if the person is an unmarried female or ‘Mrs’ if the person is a married female.

This concept or thought or idea (all synonyms), is modelled by making a knowledge representation of the human-readable term ‘Title’, which is then transformed into machineprocessable code. This could result in the following.

• Title is a part of Person Name • Title is a. Mr, when the person’s gender is male b. Ms, when the person’s gender is not male c. Mrs, when the person’s gender is female and marital status is married d. Miss, when the person’s gender is

female and marital status is unmarried The above is what can be termed as ontology. By applying Description Logic to it machine-processable codes can be generated, which the systems can use to interpret what the data item actually means.

The ‘title’ data item in a record can be structured by using the followinginformation model.

Title: string 0..1

This means that ‘Title’ is of the data type ‘string’ and can be used either never (0) or once (1), i.e., it is optional.

The above could be exchanged as a message as structured below. The

user has chosen the title as ‘Mr’ in this instance. [The structure is shown in two different styles – JSON and XML, currently the most commonly favoured formats.] { “Title”: “Title”, “Type”: “String”, “Value”: Mr or <title: string> Mr </title> } In the above, the section enclosed by curly brackets ‘{}’ or tags “<></>” is the structural (syntactic) part and the ‘Mr’ is the content (semantic) part.

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If both the sending and receiving systems use the same structure for storing/exchanging data, there will be no problem in achieving interoperability as the data item will be correctly matched up (both the data items are named exactly the same, have the same data type (text in this case) and convey the meaning about the same thing (person’s title in this case).

Using the above, a computer system would be able to interpret the term ‘Mr’. Supposing the system is programmed to execute the rule that “if the title is ‘Mr’ then automatically fill in the person’s gender and ask the user to enter the marital status else if the title is ‘Mrs’ or if the title is ‘Miss’ then automatically fill in the person’s gender as well as the marital status” then the system can accurately carry them out.

Although this example demonstrates how a simple concept like the title part of a person can be handled, by adopting the same principle to handle complex concepts like complaints of productive cough-green sputum, on examination-grossly enlarged liver, diagnosis of recurrent appendicitis, procedure of laparoscopic emergency appendicectomy using flexible fiberoptic laparoscope, assessment of eating and drinking behaviour, family history of chronic obstructive lung disease, etc., presents immense possibilities for very detailed rules to be put in place to automate ordering, prompt for additional information, etc.

Using well-proven and widely available standards, interoperability is no more the maze that it was once considered to be.

the provider observes like vital signs, physical findings, etc.), Assessment (things that the provider concludes like clinical summary, diagnosis, etc.) and Plan (things that the provider decides will prove most effective in alleviating the patient's condition like medications, diet, etc.).

SNOMED CT is the most comprehensive clinical code system currently available that permits unambiguously coding of all parts of clinical documents. It ensures the maintenance of semantic integrity through its Machine Readable Concept Model (MRCM), which is a representation of the rules that comprise the SNOMED CT Concept Model in a machine-processable form.

The other clinical code systems happen to be WHO Family of International Classifications (ICD, ICF, ICHI, ICD-O), LOINC, CPT, CDT, DRG, NANDA, RxNorm, ATC, etc. that address parts of clinical document like diagnoses, investigation observations (results), procedures, diagnostic group, medication, etc.

Conclusions

A medical doctor is as effective as the body of information about the patient's health condition is available to him.

While neither everything is required nor is necessary (mostly due to lack of relevance of the information to the patient's current clinical status), more and detailed than less and sketchy is always preferable in providing optimal care – both from diagnostic and prognostic points of view.

Interoperability is a serious issue and is neither easy to understand nor easy to implement. However, it cannot be avoided either since without it no EHR can be generated and/or maintained in any shape, manner or form.

Using well-proven and widelyavailable standards, interoperability is no more the maze that it was once considered to be. By following good systems design practices and using standards, truly interoperable EHR systems can be made available to help achieve universal health coverage.

References are available at www.asianhhm.com

ISO 13606, open EHR or HL7 are basically information models that can be used for designing clinical records (all three) and messages (HL7 only) there by facilitating syntactic interoperability.

Handling the clinical record contents is a little trickier. Ideally, an EMR has four broad sections (SOAP)–Subjective (things that the patient states like chief complaints, history, etc.), Objective (things that

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Author BIO

How does SNOMED CT,ISO 13606, Open EHR, HL7, etc. Help?

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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 EMR Standards Committee, Ministry of Health and Family Welfare, Government of India and is also member of Healthcare Informatics Standards Committee, Bureau of Indian Standards. His main areas of interest include clinical data analytics particularly treatment protocol planning using predictive analytics, EHR& EMR, mobility applications and application of machine learning techniques in healthcare.

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