Asian Hospital and Healthcare Management - Issue 41 by Ochre Media Pvt. Ltd.

I S S U E 41

2018

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BUILDING MALAYSIA HEALTHCARE TOWARDS EXCELLENCE DEEP LEARNING IN MEDICAL IMAGING DIGITALISATION AS A STEP UP IN EARLY LIFE NUTRITION

Foreword Deep Learning in Medical Imaging Opportunities galore Medical imaging plays a vital role in clinical practice. Advancements in machine learning, especially deep learning, have contributed to a better understanding of medical images. Deep learning helps in providing accurate prediction from datasets and can diagnose disease as accurately as expert physicians. In 2017, Artificial Intelligence (AI) scientist Sebastian Thrun along with his colleagues at Stanford University demonstrated that a deep learning algorithm was capable of diagnosing potentially cancerous skin lesions as accurately as a board-certified dermatologist. Deep learning works through a structure of algorithms termed as Artificial Neural Networks. While the foundations date back to 1950s and 60s, there have been significant developments since 2006. In the past 5-7 years, availability of massive labeled data sets and GPU computing have changed things and now deep learning methods are being used extensively. Availability of large, high-quality labeled datasets, performing parallel calculation with GPUs, improved architectures with flexibility of the network, and new regularisation techniques played a greater role in the deep learning revolution. Deep learning can help unearth opportunities and patterns in clinical data, enabling care givers offer better patient treatment. Interestingly, deep learning algorithms become more effective in diagnosis with practice, pretty similar to physicians. Deep neural networks are transforming how physicians diagnose illnesses, making the process faster, cost-effective and more accurate than ever before. Physicians and care-givers can benefit from these by preparing themselves and investing in making their systems advanced and compatible to manage huge computational requirements of deep learning.

From models that can detect suicidal tendencies to ones that can detect tumours and cancerous skin lesions as good as a leading dermatologist, deep learning has taken over diagnostic evaluations. Deep learning systems in healthcare can derive more value by improving accuracy and developing efficiency in diagnosis and treatment of patient issue. In todayâ&#x20AC;&#x2122;s digital world, human-machine collaboration is key and deep learning will evolve into a stage where they will assist human beings. Healthcare as a sector has benefited with advancements in technology; AI tools and systems can contribute to effective disease diagnosis and treatment. There is huge potential and opportunities galore for deep learning in healthcare but the results depend on how well pain and suffering is reduced while staying focused on improving efficiency & accuracy. Deep learning applications have evolved over time and are ready to uncover a lot of new possibilities in healthcare. A research report by Frost & Sullivan indicates AI systems will contribute around US$6.7 billion in revenues for global healthcare, a surge of 40 per cent (in CAGR) from US$634 million in 2014. Major players in healthcare have been investing heavily in AI, including acquiring startups focusing on deep learning applications. The road ahead will be exciting but how smooth the path would be will depend on how companies and caregivers gain greater knowledge of the applications and make well-informed decisions.

Prasanthi Sadhu

Editor

CONTENTS 20 COVER STORY

BECOMING THE NUMBER ONE GLOBAL MEDICAL TRAVEL DESTINATION

Does Malaysia Healthcare have what it takes? Sherene Azli, CEO Malaysia Healthcare Travel Council (MHTC)

HEALTHCARE MANAGEMENT

TECHNOLOGY, EQUIPMENT & DEVICES

04 Hiring Healthcare Heroes Better hires, better outcomes

38 Medical Equipment Management NevenSaleh, Assistant Professor, Systems and Biomedical Engineering Department, Higher Institute of Engineering

Amogh Deshmukh, Managing Director, DDI

11 Materiovigilance and Haemovigilance In relation to patient safety Dipak Kumar Mal, Contai Polytechnic Iman Ehsan, Department of Pharmaceutical Technology, Jadavpur University Biswajit Mukherjee, Department of Pharmaceutical Technology, Jadavpur University

44 Primary Care

26 Steps to Establishing Effective and Long-Lasting Patient Family Advisory Councils

Gurrit K Sethi, CEO, Canta Health

Nancy Michaels, President, NancyMichaels.com

MEDICAL SCIENCES 30 Why is Crowdfunded Medical Aid so Popular and Successful in China? Ying Shen, Graduate Student, The School of Journalism and Communication Guangxi University Hairong Wu, Professor, The School of Journalism and Communication, Guangxi University, and adjunct Professor of Center of Animal Health and Epidemiology Pradeep Kumar Ray, Director, Centre For Entrepreneurship, University of MichiganShanghai Jiao Tong University Joint Institute, Shanghai Jiao Tong University (SJTU)

47 Digitalisation as a Step Up in Early Life Nutrition Rocio Martin, Director, Danone Nutricia Research

50 Digital Health Giving birth to new delivery models and fostering innovation SB Bhattacharyya, Founder & CEO, BC2RI

Ganapathy K, Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services

34 Deep Learning in Medical Imaging Nicola Pastorello, Data Analytics Manager, Daisee Kim Berry, Principal Writer, Daisee

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INFORMATION TECHNOLOGY

54 Technology Enabled Remote Healthcare A story from India

DIAGNOSTICS

FACILITIES & OPERATIONS MANAGEMENT

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Advisory Board

EDITOR Prasanthi Sadhu EDITORIAL TEAM Debi Jones Grace Jones ART DIRECTOR M Abdul Hannan PRODUCT MANAGER Jeff Kenney

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

SENIOR PRODUCT ASSOCIATES Peter Thomas David Nelson Susanne Vincent PRODUCT ASSOCIATES Austin Paul James Taylor John Milton

David A Shore Adjunct Professor, Organizational Development

CIRCULATION TEAM Naveen M Sam Smith

Business School, University of Monterrey, Mexico

SUBSCRIPTIONS IN-CHARGE Vijay Kumar Gaddam HEAD-OPERATIONS S V Nageswara Rao Gabe Rijpma Sr. Director Health & Social Services for Asia Microsoft, New Zealand

Peter Gross Chair, Board of Managers HackensackAlliance ACO, USA

Malcom J Underwood Chief, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong

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

In Association with

A member of Confederation of Indian Industry

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HEALTHCARE MANAGEMENT

HIRING

HEALTHCARE

HEROES Better hires, better outcomes

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Why hiring the right talent becomes crucial especially in the health care sector dealing with critical and lifesaving decisions. What aspects should Hospitals and Healthcare Institutions should especially focus on while hiring decisions which would directly impact the reputation of the institution and why Hiring the right talent is imperative to the success of a hospital or health care institution. Amogh Deshmukh, Managing Director, DDI

adical transformation is underway in healthcare. The industry is grappling with massive changes in areas such as regulation, competition, delivery, consumerism, technology, operations. The accelerated speed of change leaves little room for hiring missteps. And, in healthcare, poor hiring decisions endanger not only the business, but also the patients. For the longest time, India’s healthcare sector was fragmented and unorganised. But in the last decade or two it has witnessed some unprecedented growth. As per a recent report the Indian healthcare sector, which is worth around US$110 billion, is likely to grow at a CAGR of 23 per cent to US$280 billion by 2020. While the hospital and diagnostic centres attracted FDI worth US$4.34 billion for the period April 2000 –

March 2017 in the Union Budget, the overall health budget increased from US$5.96 billion to US$7.3 billion, which is almost 2.27 per cent of the budget. India produces over 50,000 doctors every year, yet the doctor to patient ratio is one of the worst worldwide, at 1:1,674 ratio compared to WHO’s standard norm of 1:1,000. The scenario with nursing staff is even worse at around 13:10,000. That puts lot of pressure of Indian healthcare system. So,while on one side the healthcare industry is facing an unprecedented growth, on the other end the system is not producing enough, which is compounded by several challenges such as brain drain, poor pay / working conditions, etc. Yet Indian healthcare shows a lot of promise. The complexity is heightened by the fact that this

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industry itself is going through a major shift with the growing use of technology, telemedicine, patient care standards, etc. With all these changes the race for talent is only going to get hotter. Research is evident that “a good training program is not a substitute for poor hiring”. No amount of development can salvage a poor hiring decision. Irony is that most of the times we are only talking about developing our leaders, but in the bargain, what sometimes gets missed is to analyse the root cause which is the talent acquisition system and analyse which link are we missing. Hence it is very critical that the healthcare sector looks at the talent selection in a more scientific way. Traditionally, talent selection has had a process that only looked for CV-specific information and an interview to understand the experience of the candidate before filling the position. But with the challenges on hand, healthcare organisations will have to think about the whole selection process a bit differently. Here are few factors that you may want to consider while hiring the right fit for your organisation. We compiled a study from 6,086 assessment participants from healthcare systems across the continuum of care globally. These included all-level employees up through first-line leaders. The competencies and attributes assessed were rolled up into five general categories. In each of the five categories, we compared the participants’ ratings/scores with their on-thejob performance. Approximately two-thirds of high scorers were shown to be high performers across all five categories. Idea was to demonstrate how to identify leaders who can be safety advocates, quality care givers, have a keen orientation for Service and, highly engaged and are looked upon as Inspirational Leaders.

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IDENTIFYING: SAFETY ADVOCATES Healthcare professionals who ensure patient safety not only improve the experience of care, but also drives down per capitacosts. In recent years, health systems have madegreat strides in reducing the occurrence of Hospital-Acquired Conditions (HACs). These include various types of preventable infections, as well as diagnostic and medication errors. Our report shows that top assessment scorers, for example,

were twice as likely to Maintain a Safe Work Environment and more than three times as likely to Maintain Low Error Rates. Integrated care-delivery systems need individuals who will nurture and contribute to a safety culture. At the hiring stage ensure your assessment can help differentiate candidates based on Safety Awareness and Stress Tolerance, in addition to Technical/Professional Knowledge and Skills.

Top Candidates Shine in Safety Practices

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IDENTIFY: QUALITY CARE-GIVERS Quality shapes the patient experience and impacts cost. It is commonly judged based on the Institute of Medicine (IOM) framework, which considers how safe, effective, patient-centred, timely, efficient, and equitable

The Measurable Difference in Quality Care

the care is. From the patient’s perspective, however, quality is less quantifiable and more “I know it when I see it.” Fortunately, healthcare systems need not leave patient perception—and reimbursements— to chance. Healthcare professionals who scored highest (vs. lowest) were stronger across four quality care indicators. For example, high scorers more than twice as likely (2.7 times to Exemplify Quality Care. They were also 2.4 times more apt to demonstrate superior Patient Assessment Skills and 1.7 times more apt to Contribute to Hospital Ratings.

IDENTIFY: SERVICE ORIENTATION Service is an increasingly important differentiator for health systems. Highdeductible plans have put the power of the purse in the hands of consumers, who look to social media and patient feedback sites to guide their out-ofpocket spend. But, unlike the average retail customer, patients are under duress. They are vulnerable. Beyond physical needs—medication, meals, vital sign monitoring, etc.—they have acute emotional needs. They are looking for reassurance, respect, and compassion. How can health systems confidently select employees who will deliver the kind of exemplary service that can increase patient satisfaction and HCAHPS/provider scores? High vs. low scorers on our healthcare assessments are 43 per cent more likely to be top performers in critical service predictors and outcomes, including Care Management and Patient Focus. They are also twice as likely to excel at making decisions and problem solving and have higher-level patient interactions.

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Quality Service as Predicted by Top Assessment Scorers Leads to Better Patient Outcomes

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Organisational Vision

IDENTIFY: INSPIRATIONAL LEADERS The ongoing transformation of healthcare requires a new type of leader. The rampant consolidation of entities has brought former competitors together, joined disparate cultures and disciplines, and centralised operational and strategic decision-making. As a result, health system leaders must work across silos and drive collaboration and care coordination. Frontline leaders, in particular, must translate the organisationâ&#x20AC;&#x2122;s cultural imperatives for their teams. Our assessment identifies these leaders who can build teams and strategic working relationships,

Wired for Efficiency

drive and facilitate change, delegate authority, and coach and develop their associates to achieve high standards. In addition, leaders who scored highest on the assessment were 3.7 times more likely to drive efficiency than those scoring lowest. This is especially critical in highly matrixed environments and for controlling costs. Top scorers were also nearly twice as likely to contribute to the achievement of their organisationâ&#x20AC;&#x2122;s vision.

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IDENTIFY: ENGAGED, LONG-TERM CONTRIBUTORS

Higher Engagement Drives Retention

A stronger economy is increasing turnover in health systems. Demand for labor, especially nurses, has grown as more—and increasingly older—patients have been added to the insurance rolls. At the same time, the most experienced nurses are retiring in droves (2015 Survey of Registered Nurses). The tight labor supply is forcing health systems to compete for the best talent, by offering attractive wages and benefits. Extensive research indicates that lack of engagement is compounding retention issues, negatively impacting productivity (especially when employees leave), as well as patient satisfaction and safety. It also undermines employees’ willingness to work to top of their licensure—the desired performance standard within all healthcare systems. Fortunately, identifying engaged employees can stop being a hit-or-miss proposition. Hiring assessments can accurately ascertain if a candidate is a good fit (for healthcare and your organisation),and whether he or she will thrive and continue to contribute to the organisation. High scoring leaders prove to be approximately four times more likely to be engaged than low scoring leaders. Overall (across all assessment participants), high scorers are twice as likely to be engaged vs. low scorers.

Incorporating these critical aspects in your hiring funnel will help you refine your way to hire the right healthcare leaders for your organisation.

AUTHOR BIO

As managing director for India, Amogh is responsible for the creation and implementation of the region's business strategy. Amogh is accountable for managing all aspects of the DDI operations in India (including Consulting, Sales, Marketing and Operations). An expert on a broad range of leadership and talent management practices, Amogh provides business-relevant counsel to a diverse range of both multinational and Indian organisations, identifying needs and proposing solutions primarily in the areas of leadership strategy, development, succession management, and talent acquisition.

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MATERIOVIGILANCE and HAEMOVIGILANCE In relation to patient safety

The incidents that might result from the use of medical devices are followed up by materiovigilance. It helps to identify the adverse events associated with the use of medical devices. Haemovigilance primarily aims to assure the surveillance of blood transfusion, from blood collection, storage and further steps involved. A collection of data in haemovigilance helps in framing vital changes in the whole blood transfusion process. To overcome problems related to medical devices and blood transfusion and in order to improve the standards of the healthcare system for the betterment of the patients, various software are introduced so that appropriate corrective actions can be taken in the field. Dipak Kumar Mal, Contai Polytechnic Iman Ehsan, Department of Pharmaceutical Technology, Jadavpur University Biswajit Mukherjee, Department of Pharmaceutical Technology, Jadavpur University

he healthcare system in India provides great discrepancy in quality. To maintain the quality of healthcare system and to protect the health and safety of patients, comprehensive vigilance is required. Materiovigilance and haemovigilance programs have evolved to reduce the likelihood of recurrence of the harmful incidents, thereby improving the quality of health products and health services. The need for this vigilance was felt due to malfunctioning of medical devices (instruments, apparatuses, and materials etc. which are intended for medical purpose and are an integral part of the health system to health providers and patients/ consumers). Thus, materiovigilance

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is a system to monitor the safety of medical devices in the country. Haemovigilance aims to improve the overall safety of blood transfusion by detecting and analysing all untoward effects of blood transfusion, to correct their cause and to prevent recurrence. Haemovigilance has evolved from pharmacovigilance. Haemovigilance as defined by Faber is “a set of surveillance procedures covering the whole transfusion chain (from the donation of blood and its components to the follow-up of recipients of transfusion), intended to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products and to prevent the occurrence or recurrence of such incidents". Materiovigilance is related to haemovigilance in relation to the patient’s safety. If material vigilance is not so strict in terms of quality assurance, several pyrogens, toxic chemicals or hazardous materials acquired by gaseous sterilisation or fibres which may release from poor raw materials or techniques might be entrapped into the cardiovascular system. On the other hand, if whole blood is not preserved properly, it may lead to the variety of problems associated with the safety of blood transfusion. However, constructive collaborations of industries, blood organisations, blood centres, clinical segment, and authorities in coordinated ways help in smooth functioning of materiovigilance and haemovigilance. There are many problems and difficulties at various stages of materiovigilance and haemovigilance to which the solutions need to be sought for the future. Various elements will be considered for the meticulous operation of the materiovigilance and haemovigilance such as the introduction of various softwares etc. In theory, the different vigilance systems are defined, but not implemented practically.

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MvPI prime functions include

The present scenario of healthcare system in India highlights the need for strict vigilance to safeguard the health and safety of patients.

Additionally, much focus has to be given for the organ vigilance since very limited information is available about the serious reactions and adverse effects related to the donation and transportation of organs. A national surveillance and vigilance system is essential for monitoring the donation and transportation of organs in order to improve the quality systems in these sectors. Therefore, the objective of our review work is to highlight the significance of materiovigilance, haemovigilance and organovigilance that have been proved to be quite vital components for quality management in heath care of human population. MATERIOVIGILANCE PROGRAMME of INDIA (MvPI)

MvPI was launched by DCG (I) on 6th July, 2015 at Indian Pharmacopoeia Commission (IPC) Ghaziabad. Indian Pharmacopoeia Commission functions as a National Coordination Centre (NCC) for MvPI. The details can be obtained from the website. Presently only some devices are included for the materiovigilance such as cardiac stent, drug eluting stents, catheters, intraocular lenses, bone cement, heart valves, scalp vein sets, orthopedic implants and disposal perfusion sets.

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• Analysing the benefit-risk ratio of various medical devices • The information on the safety of medical devices should be generated on the basis of the evidence • MvPI should support Central Drugs Standard Control Organisation in the decision-making process on the use of medical devices • To minimise the risk, the safety information on the use of medical devices should be communicated to various stakeholders • Proper functioning of MvPI would lead to emergence of it as a national centre of excellence for materiovigilance activities which can be further collaborated with other healthcare organisations for the exchange of information and data management. Medical Device Related Adverse Events (MDAEs)

MDAEs are meant to ensure and generate awareness among all the professionals involved in the healthcare segment regarding the importance of MDAEs reporting in the country and to keep a check on the benefit-risk profile of the medical devices so that independent and evidence based recommendations are generated for the sake of the safety of medical devices. It ensures further communication of the findings to all the concerned key stakeholders in the country including the stakeholders of the Pharmacovigilance Programme of India (PvPI). All the serious or not serious, known and unknown types of suspected MDAEs can be reported. The MDAEs reporting form should include all adverse events associated with the use of medical devices, the description of the incident, description of the device (deficiency or malfunction), and illumination of hazards linked with the device including the associated menace of the patient.

HEALTHCARE MANAGEMENT

Where to report MDAEs All the healthcare professionals involved including clinicians, pharmacists, doctors, nurses and patients/ consumers can report MDAEs to Sree Chitra Tirunal Institute of Medical Science and Technology (SCTIMST) or National Collaboration Centre (NCC). Duly filled MDAEs Reporting Form can be sent to SCTIMST, NCC, MvPI, Biomedical Technology Wing, Poojappura, Thrivananthapuram-695012, Kerala, India or can directly email the duly filled form to mvpi@sctimst.ac.in. Report MDAEs MDAEs Reporting Form can be downloaded from the website of IPC (www.ipc.gov.in) to report an adverse event associated with medical devices. MDAEs can also be reported via PvPI helpline number (1800 180 3024) on weekdays from 9:00 am to 5:30 pm.

HAEMOVIGILANCE PROGRAMME of INDIA (HvPI)

The haemovigilance system should cover process throughout the entire transfusion chain, from blood donation, processing, and transfusion to patients for the monitoring, reporting, and investigation of adverse events and reactions and near misses related to blood transfusion. The blood transfusion service should be well coordinated in each and every stage starting from the hospital, blood banks/ blood donors, clinical staff and transfusion laboratories, hospital transfusion committees, related regulatory agency and ultimately the national health authorities. The blood transfusion may often result in the detrimental manner in the donors and the recipients: 1. L ocal reactions occur predominantly because of problems related to venous access: The

Medical Device Adverse Event Monitoring (MDAEM) Centers S.No.

List of Proposed Institutions under MvPI

Department of Biomedical Engineering, PGIMER, Chandigarh

Department of Biomedical Engineering, CMC Vellore

Department of Biomedical Engineering, AIIMS Trauma Center, New Delhi

Department of Biomedical Engineering, PGIMS, Rohtak

Department of Biomedical Engineering, DMCH Ludhiana

Department of Biomedical Engineering, SGSM College & KEM Hospital, Mumbai

Division of Healthcare Technology, National Health Systems resource centre, New Delhi

Department of Biomedical Engineering, AIIMS Patna

Department of Biomedical Engineering, NIMS, Hyderabad

Department of Biomedical Engineering, KMCH, Kolkata

incorrect placement of the needle during the venipuncture may lead to haematomas due to extravasations from the veins. Pain, hyperemia, and swelling may develop at the site of extravasation. Other local events include pain due to slight trauma to the subcutaneous nerve endings. Local phlebitis and thrombophlebitis are more serious complications than the foregoing but very rare. 2. The systemic reactions in contrast to the local reactions can be divided into mild or severe type. In most cases, they are vasovagal reactions that can be triggered by the pain of the venipuncture. Apheres is procedures may lead to systemic reactions which require the use of anticoagulants (such as acid-citrate-dextrose) for the collection of blood component often causing hypocalcemia, because of chelation. 3. Recipient haemovigilance: The International scientific society has laid down criteria for â&#x20AC;&#x2DC;severity' (of an adverse event)and â&#x20AC;&#x2DC;imputability' (that is, the likelihood be attributed to the blood component transfused) of transfusion reactions. The reactions due to transfusion in a recipient are classified as acute (within 24 hours) or delayed (after hours of transfusion) reaction. 4. Haemovigilance related to blood donors: All the reports of unexpected adverse events in whole blood and component donors should be included in the donor haemovigilance and action must be taken. The recipient might be at risk due to the events such as adverse reactions or complications arising from the donation, selection, and management of donors, which in turn may harm the donor or affect the quality of the product. An active initiative from the International Scientific Society and European Heart Network

Table 1

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Flow chart of transfer of information under haemovigilance programme of India

Medical colleges and institutions, Private care hospitals, Nursing cares (collection of reaction reports related to blood transfusion and follow-up; Assessment of causality, Preparing reports via data entry into Haaemo-vigil software

National Coordinating Centre (NIB), Signal Review Panel, Core training Panel, Quality Review Panel

Advisory Committee

Core Group

DCGI-CDSCO (HQ)

Stakeholders (Patient healthcare professionals, NACO, SBTC, Blood Banks) Figure 1

has been taken to propose various classification and a set of definitions of complications related to blood donation. Mild to serious problems can be encountered if the process of blood transfusion goes wrong at any step. Unsafe blood transfusion procedures may result in various allergic reactions, diseases of infectious and viral nature, acute immune hemolytic diseases, sepsis from bacterial contamination, delayed hemolytic reaction, graftversus-host disease, trauma, hepatitis B and C, human immunodeficiency virus.

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NCC National Coordinating Centre issues Transfusion reaction reporting form to ensure risk minimisation, to put a check on the issues associated with blood transfusion process and to report adverse reactions and adverse events resulting from blood transfusion such as allergic or immunological reactions which arise from the blood transfusion. Prerequisites

1. The legal and other mandatory frameworks should be in place according to the country

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2. The common definitions must be agreed 3. Standardised method of reporting should be used throughout 4. To ensure proper functioning of the chain, continuous budgeting and financing should be guaranteed 5. Central evaluation site must be established with the culture of professionalism 6. Hospital Transfusion Committees should work efficiently 7. The mechanisms for corrective and preventive actions must be introduced

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The Role of Various Participants in Different Vigilance

The outline of this process is similar at each level where haemovigilance and materiovigilance are related as it applies to industries manufacturing disposables such as syringe, gauze, tubes and related items, blood centres, wards, hospitals, competent authorities, manufacturers, etc. The main participants involved in this process are manufacturers, physicians, pharmacists, nurses, medical technicians, etc. Communication channels between the different levels must be established and predefined. For adequate working of the whole system for the betterment of the public health, it becomes vital that close and constructive cooperation is established between the different participants of the different levels, at different sites, and with many different people involved. It becomes crucial to settle the organisational aspects, to expound the corresponding responsibilities and instructions, to increase responsiveness with clear written procedures in a â&#x20AC;&#x2DC;no blame environmentâ&#x20AC;&#x2122;, to offer adequate and continuous training.

Industry The blood centres and hospitals served by the manufacturers of materials, disposables, reagents, equipments, etc. hence, it becomes vital to regularise the requirements (community, national) and the post-marketing procedures of companies as a sturdy tool for the collection and compilation of data directly and indirectly related to haemovigilance. Acceleration of the input and involvement of the industry into haemovigilance will be beneficial in public interest. Blood centres and hospitals Blood centers/blood banks are the consumers of the materials such as disposables, reagents, equipments, etc., manufactured by the industry. At the same time, they are also the producers of labile blood components of all types, as well as the providers of transfusionrelated services. In this way, they play a vital role in haemovigilance, serving as users on one hand and producers on the other hand. The clinical segment The experts involved in the clinical segment are in a position to detect and report events, side effects, incidents, reactions, accidents, errors, near-

misses, etc. Being at the frontline, physicians and paramedics play a crucial role and should readily collaborate in a constructive and coordinated way for the fulfilment of its overall aim, for example, to increase safety and quality of the blood transfusion process in the best interest of those patients who are in need of labile blood. The problems and the difficulties There is still a deficit in relation to haemovigilance and materiovigilance when it comes to common definitions, terminology, standardised reporting and uniform matrix. Some of the most ubiquitous problem such as organisation problems due to lack of proper funding, lack of professionalism, unclear mandates, indeterminate responsibilities, low sensitivity, inadequate training, hesitation to move forward by implementing strong actions, lack of harmonisation of data collected from different sources, as a result of which exiguous results are generated, the final reports turns out to be mutable and less dependable.

The Role of Various Participants in Different Vigilance

Pharmaceutical Industry

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Hospitals

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Blood Centres

Clinical Segment

HEALTHCARE MANAGEMENT

Factors to be Considered for Accurate Functioning of Materiovigilance and Haemovigilance

Empowerment and enlightenment of knowledge and the right skills along with computer-friendly attitude had lead to the strengthening of the linkage of organisation with consumer/patient. The smooth working of organisations depends on the right type of people who have necessary perspective and understanding of function, products, organisation and a desire to be customer responsive. Introduction of software The seamless flow of work allows employees in the organisation to route consumer's communication through a virtual folder that combines documents, voice messages, e-mails, faxes, and so forth, to be delivered to the nearest consumer service points at the right time to ensure single point resolution of any consumer complaint or enquiry. Two software: (1)Haemo-vigil for recipient Haemovigilance and (2) Donor-vigil software for donor Haemovigilance was utilised as sample tracking web-application by National Institute of Biologicals, Ministry of Health and family welfare, the Government of India. The response and use of software depend on knowledge, integrity, and truthfulness of patent, otherwise the data obtained could be misleading in interpretation. Moreover, this software is used by different end users. There are serious inconsistency problems in the development of programs to access such data. The integrity (i.e. the accuracy and completeness) of the data was in question because there was no control over their use and maintenance by authorised end use. Time is an indicator of opportunity. Now the internet is a powerful tool for diffusing information and knowledge. Internet communication can also have some negative impact such as

the early version of Pentium chip in the 1990s contained a bug that made some mathematical expression and calculation go wrong. This was first discovered by Prof. Thomas Nicely,

professor of mathematics, Lynchburg Collage. Thus mishandling and misuse of internet facility can have a negative impact on ‘Haemo-vigil’ and ‘Donorvigil’ software.

Total Productive Maintenance (TPM)

Manufacturing organisations are concentrating on improvement by laying stress on productivity, quality, energy conservation, safety and also on environmental protection. They have been able to improve operational performance through significant improvement in its TPM, while the regulatory authority could not improve their operational performance to identify and prevent occurrence or recurrence of transfusion-related unwanted events to increase the safety, efficacy, and efficiency of blood transfusion, covering all activities of transfusion chain from donor to recipient. Through different projects, it provides healthcare activities for HIV positive patient's education and support for their children with challenges a hospice for dying destitute, basic education for children in rural areas, and support to government relief measures in natural calamities. Data mining Data mining acts as an essential tool in the extraction of hidden predictive information from large databases. It is a robust technology with great potential to help the regulatory organisations focus on the most important information. Data mining tools predict future trends and behaviours, knowledge-driven information and even decisions. Materiovigilance and haemovigilance program of India may collect and refine massive quantities of data. Data mining technique could be implemented rapidly on existing software and hardware platform to enhance the value of existing information resources and can be integrated with new systems as they are brought online. The regulatory authority can analyse its recent adverse drug reactions and their results to improve targeting of high-value physicians and determine which vigilant measures will have the greatest impact transfusion. The data needs to include NGOs’ activity as well as information about the local healthcare systems. The ongoing dynamic analysis of the data warehouse allows best practices from throughout the regulatory organisations to be applied in specific vigilance activity. Data mining algorithms embody techniques and advanced statistical and computational methods can interpret data from diverse sources into a meaningful signal to benefit patient safety.

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DISCUSSION

SWOT analysis SWOT analysis (strengths, weakness, opportunity, and threats) is to be used to evaluate the impact of both materioviglilance and haemovigilance. The MvPI and HPV's strengths are its core competencies and resources in which it functions. Weakness is areas of unexplored performances. Opportunities are the potential for new or innovative breakthroughs that might greatly expand its prospect. Threats are potential for disruptive new technologies both in MvPI and HvPI. The challenge is to understand not just the internet feedback but even the sociology of human networks. The reliability, responsiveness, and assurance of feedback on any vigilance are also important. An Adverse Event Following Immunisation (AEFI) and haemovigilance are important divisions of PvPI to which ADRs following immunisation and transfusion of blood / blood products are to be reported and recorded. One important aspect of haemovigilance and AEFI is that it is difficult to persuade the blood bank staff and clinicians to report cases of ADR due to the fear of legal and regulatory repercussions. Health records in electronic form: An integrated collection of data extracted from operational, historical and external databases at multiple locations such as from hospitals, physicians clinic, health management organisation (HMO). An expert system (ES) is a knowledgebased information system that uses its knowledge about a specific (materiovigilance, haemovigilance), complex application area to act as an expert consultant to end users. We know a variety of manufacturing information systems available and many of them web-enabled, which are used to support Computer-Integrated Manufacturing (CIM). It may be suggested that the pharmacovigilance, materiovigilance or haemovigilance may be designed in such a way that computerintegrated haemovigilance, materiovigilance or pharmacovigilance to get the highest quality of vigilance for the benefit of society. Nowadays, the virtual reality is applied widely in different field such as computer-aided design (CAD), medical diagnostics and treatment, scientific experimentation in many physical and biological sciences. It may also be applied to MvPI, HvPI's.

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The present scenario of healthcare system in India highlights the need for strict vigilance to safeguard the health and safety of patients. The patient safety requires continual enhancement of quality and safety of related materials and the blood products for the transfusion process by monitoring and safeguarding the adverse event associated with the use of materials and blood products. In this regard, materiovigilance and haemovigilance have proved to be essential components of quality management in healthcare fraternity. They have minimised the risk of any unwanted incidences, thereby improving the healthcare products and services. The materovigilance aids in combating the harmful incidents occurring due to medical devices, while haemovigilance aims to monitor any untoward reactions occurring during blood transfusion and to prevent their recurrence. Only some medical devices are enlisted as per MvPI, which includes cardiac stent, drug eluting-stents, catheters, intraocular lenses, bone cement, heart valves, scalp vein sets, orthopaedic implants, disposal perfusion sets, but several other devices are to be undertaken for surveillance for the benefit of patients such as glaucoma valve, eyeball (Brachy therapy radioactive plaque), retinal band and buckle, pacemaker, etc.[10]. Moreover, organovigilance may be considered as it is the latest technology driven so as organ transplantation hazards could be avoided and the safety of recipients of organs could be maintained. CONCLUSION

A streamlined mechanism along with good coordination using standardised tools at every level is required for proper functioning of materiovigilance and haemovigilance. The need to exercise prudence is

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indispensable starting from materials of the products, packaging, labelling, instructions, selection of the donors, collection, and handling, storage of the blood and blood products, and various stages of transfusion to monitor the adverse reactions if any. A functional hospital transfusion committee can act as a backbone for this by developing policies for transfusion practices, appropriate documentation, reporting and investigation of transfusion reactions. Following the draft recommendation on haemovigilance system by World Health Organization (WHO) may help in developing an efficient system in developing countries. Thus, considering patient safety as prime goal, materiovigilance and haemovigilance should be monitored by the national authority.

AUTHOR BIO Dipak Kumar Mal, Head of the Department, Pharmacy, Contai Polytechnic, Government of West Bengal, Contai, Purba Medinipur, India, is interested to find out the lacunae and loopholes of the regulatory affairs of medicines which affect the community.

Iman Ehsan is a research scholar of the Department of Pharmaceutical Technology, Jadavpur University, Kolkata (Calcutta) 700 032 , I N D I A . She works on nanoparticulate drug delivery system. Area of research includes novel drug delivery, nanotechnology, cancer therapeutics for prostate cancer.

Biswajit Mukherjee is a Former DAAD Fellow (Germany) and Former Guest Scientist, German Cancer Research Center (DKFZ), Heidelberg, Germany, Former visiting Fellow, School of Pharmacy, University of London, London, Former Indo-Hungarian Education Exchange Fellow, National Research Institute for Radiobiology and Radiohygiene, Budapest, Hungary. Coordinator, Quality Improvement Programme (All India Council of Technical Education, Govt. of India) Nodal Cell (Pharmacy), Joint Coordinator, Center for Advance Research in Pharmaceutical Sciences., Professor & Former Head, Department of Pharmaceutical Technology , Jadavpur University Kolkata (Calcutta) 700 032 , I N D I A . He works on novel drug delivery systems including nanomedicine.

References are available at www.asianhhm.com

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COVER STORY

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Sherene Azli, CEO

Malaysia Healthcare Travel Council (MHTC)

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BECOMING THE NUMBER ONE GLOBAL MEDICAL TRAVEL DESTINATION Does Malaysia Healthcare have what it takes?

1. What are the major initiatives required to become a Number One Global Medical Travel Destination? “Firstly, we focus on creating awareness of Malaysia Healthcare’s world-class quality, accessible and affordable service offerings through our branding campaigns and marketing initiatives both locally and internationally,” explained Sherene Azli, CEO of the Malaysia Healthcare Travel Council (MHTC). Malaysia is also known as a global Halal hub, a travel haven and a destination with ease of communication. She further explained that building strategic engagements such as G2G, G2B and B2B partnerships are also instrumental in advancing the healthcare travel industry. Trust has always been a factor of that kept the engine of Malaysia’s healthcare travel industry running. Our initiatives have always focussed on building this aspect to promote sustainable industry growth and reducing risks.” In order to reduce risks faced by healthcare travellers, one of the initiatives set-up by Malaysia Healthcare is a meet-andgreet service. “Registered healthcare travellers will be greeted at the point of disembarkation and escorted to customs and immigration via a fast-tracked lane. They will then be hosted at our exclusive lounge to wait for their transportation to their accommodation or hospital,” said Sherene as she explained the mechanism of the Malaysia Healthcare Lounge and concierge services.

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2. How do you see the future of Medical Travel industry evolving over the next 10 years? “Medical travel, though not a new tradition, will continue to see growth with the rise in ageing populations, spending power and more affordable and accessible options for healthcare services abroad,” Sherene commented. She also added that the healthcare industry will further integrate with new digital offerings that can expedite processes in receiving treatments.” “The global landscape for medical travel is highly unpredictable and constantly changing. We are continuously strengthening the foundation of our whole end-toend system to ensure that the delivery of affordable and accessible world-class quality care is maintained and can with stand any challenges ahead,” explained Sherene. She added “With the constant changes in the market, the healthcare travel industry is always on the lookout for opportunities to expand into new markets to ensure sustainable growth.” 3. Can you please explain the aspects you have been focusing on to enhance the standards of healthcare travel industry? “Prioritising the patient journey experience is key in building a leading global destination for healthcare,” said Sherene. She explained that Malaysia Healthcare has curated a seamless end-to-end system which cares for patients’ needs from the point of enquiry, to arrival, all through receiving treatment right up to post-care. Several

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facilities have been established to facilitate the healthcare traveller’s journey. One of which is a dedicated Call Centre which facilitates all queries of healthcare travel in Malaysia. “We have also seen an escalation in the standards of the industry through increased private-public partnerships, particularly between ministries and private sectors in the country,” she added. “We have also been encouraging healthcare providers to prioritise outcome and evidencebased reporting which can improve overall quality of patient outcomes.” 4. Please highlight some scenarios where Malaysia’s Medical Travel Industry has attained desired results? “Malaysia’s healthcare travel industry is now growing at an average rate of 16-17% every year, making it one of the fastest growing industry for export services. In 2018, Malaysia was sought for treatment by more than 1,000,000 healthcare travellers and we achieved the target RM1.3 billion in hospital revenues,” Sherene explained. She added, “Alongside these achievements, our reputation also precedes us through the awards and accolades received. Gaining acknowledgement on the international landscape for healthcare travel, Malaysia was recognised as the “Destination of the Year” by International Medical Travel Journal (IMTJ), United Kingdom for three years in a row between 2015 to 2017. This year, we received a highlight commended acknowledgement as the “Destination of the

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Year”. Malaysia Healthcare Travel Council also won “Cluster of the Year” in 2017 and 2018 by IMTJ, an additional mark of approval for Malaysia’s excellent healthcare travel facilitation. US-based International Living also acknowledged Malaysia as the country with the “Best Country in the World for Healthcare” based on their Global Retirement Index from 2015 to 2017. Recently, in their 2018 Index, Malaysia was listed as the top Asian country for retirement, ranking fifth globally after Costa Rica, Mexico, Panama, and Ecuador.” 5. In what ways do you push Malaysia Healthcare as a game changer in the healthcare travel industry? “As Malaysia Healthcare matures in the industry, the need to carve a niche identity for the Malaysia Healthcare brand becomes more prominent,” began Sherene. She went on to explain that Malaysia is being positioned as the Fertility and Cardio hub of Malaysia. “Anchoring on our strengths in these niche specialties and capacity to cater to growing demands, this unique identity for Malaysia solidifies our position further in the global healthcare travel landscape. As the aspiring Asian hub for Fertility, Malaysia Healthcare will be Giving Hope to Dreams of infertile couples aspiring to one day enjoy parenthood. Equipped with the latest technologies to provide a wide range of treatments at affordable prices, Malaysia’s fertility facilities are prepared to support couples in starting a new chapter in life. Our Cardio Hub, deemed the Heartbeat of Asia, boasts of a successful collaborative history between the Ministry of Health and the National Heart Association of Malaysia. As a result, we have reached new heights in technological conquests and successes in complex surgeries, attracting many to our shores and keeping them returning to receive satisfactory heart care.”

day one. Through this system, the quality of our medical professionals is monitored, ceiling rates for healthcare treatments are maintained and healthcare services are kept accessible for everyone who needs it.” She added, “All in all, the creation of a well thought out end-to-end health journey experience requires a concerted effort from industry players throughout the healthcare travel value chain. This includes strategic integration between airlines, in-bound travel agencies, hospitals and accommodation providers to present the best care and services reflective of Malaysia Healthcare’s abilities and potential.” 7. Any views on the next wave of convergence in Global Medical Travel and any steps to consider in going beyond in Medical Travel? “As the market for medical travel continues to develop, Malaysia has strengthened its medical travel offering to preventive care. The holistic care available in Malaysia gives healthcare travellers the opportunity to combine their treatments with alternative recovery packages,” said Sherene. “The range of wellness treatments available in Malaysia offers wellness tourists a host of alternative medicine and treatments such as Yoga, Ayurveda, and Traditional Complementary Eastern Medicine, Detoxification, Mental Health Retreats and Anti-Ageing treatments,” she added. Sherene also explained that Malaysia’s growth in medical travel will be linked to more infrastructural development, an expansion of serviceable cities, investment in human resource and advanced international patient training, quality standardisation, and enhance marketing to international markets on Malaysia’s vast benefits.

6. How do you ensure a seamless end-toend experience is provided to healthcare travellers? “It helps to get a solid backing from the government. Our healthcare system has been regulated by the Ministry of Health, Malaysia from

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8. How do you think Malaysia Healthcare Travel has shaped up so far and what do you think will be the future trends? “Malaysia’s medical travel industry has been performing well so far. That being said, we refuse to rest on our laurels, but continue to drive the industry forward by addressing gaps within the industry and keeping abreast on disruptions in the overall global economy, particularly in the digital world,” said Sherene. She further explained that, “We believe that big data will play a huge role in making decisions to further the industry within sustainable parameters. This will enable us to optimise our resources and talents carefully and strategically.” Sherene further commented that blockchain technology is already playing a large role within the global industry. “The medical travel industry would progress towards that direction, which would streamline further the entire endto-end patient journey experience. In the future, we foresee that artificial intelligence (AI) would be a very instrumental tool in complex surgeries where patients from countries with scare talent can have access to medical attention by foreign doctors without leaving their homeland, for example.”

About The Malaysia Healthcare Travel Council The Malaysia Healthcare Travel Council or better known as MHTC is an agency established by the Malaysian government that has been entrusted with the responsibility of curating the country’s healthcare travel scene. Founded in 2009 under the Ministry of Health, MHTC facilitates and grows the healthcare travel industry with the intended goal of making Malaysia the Contact Information: Malaysia Healthcare Call Centre Mon – Fri from 8AM - 5PM (+8 GMT) Outside Malaysi : +603 272 68 688 Within Malaysia : 1 800 188 688 Visit our website: www.medicaltourismmalaysia.com Email us at: Callcentre@mhtc.org.my

leading global healthcare destination. Since then, MHTC has worked to streamline industry players and service providers into a more focused development strategy and to raise Malaysia’s profile in healthcare travel on an international stage. It is an example of a successful model of public-private partnerships (PPP) in growing the healthcare travel sector in Malaysia.

MalaysiaHealthcare

Worldwide Representatives: China cn.marketing@mhtc.org.my India in.marketing@mhtc.org.my Indonesia callcentre.IDN@mhtc.org.my Myanmar mm.marketing@mhtc.org.my Vietnam vn.marketing@mhtc.org.my Advertorial

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Of Big Hearts and Little Ones

Caring for hearts and supporting dreams in a single destination

Year after year, Malaysia serves thousands of healthcare travellers with world-class quality and highly accessible healthcare services at competitive prices. A hidden jewel in the global healthcare travel industry, Malaysia has succeeded in positioning itself as a

Destination of the Year (2015 – 2017) Highly commended Destination of the Year 2018

top-of-mind destination for healthcare travel through an excellent track record of international recognition. Today, Malaysia is positioned as the Fertility and Cardiology Hub of Asia, anchored on its strengths in these niche areas.

“Best Country in the World for Healthcare” (2015 – 2017)

Giving Hope to Dreams

Heartbeat of Asia

Malaysia’s excellence in In-Vitro Fertilisation (IVF) treatment has

Malaysia’s reputable history in cardiology treatments services is built

resulted in top fertility centres posting average success rates of

on the collaborative efforts between the National Heart Association

65%, far exceeding the global average of 55%. Our fertility centres

of Malaysia and the Ministry of Health, attracting many to our shores

have equipped themselves with state-of-the-art technologies such

to receive satisfactory heart care. Today, the field of cardiology has

as Next Generation Sequencing (NGS), Time Lapse Embryoscope,

reached new heights in technological conquests and successes in

Piezo-ICSI, and 3D Laparoscope, providing treatments at highly

complex surgeries. Coupled with the capacity to serve a larger

affordable prices delivered by experienced embryologists. Support-

volume of patients, the Heartbeat of Asia is equipped to serve

ed by a well-structured end-to-end ecosystem, Malaysia’s well-reg-

healthcare travellers and keep hearts beating well.

ulated healthcare system also provides for certain policies which facilitate healthcare travellers’ access to fertility treatments.

Quality Care for Your Peace of Mind

MHTC Concierge and Lounge

Every healthcare travel journey is an adventure – and Malaysia Healthcare strives to ensure that it is a safe and pleasant one. Dedicated to providing a seamless end-to-end experience, Malaysia Healthcare has curated a system that cares for healthcare travellers’ needs before, during, and after treatment through follow-ups and calls by our dedicated Call Centre and worldwide representatives. With all this in place, we invite all healthcare travellers to come and Experience Malaysia Healthcare, Embrace Malaysian Hospitality !

Scan here to know more about Malaysia Healthcare

www.medicaltourismmalaysia.com

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HEALTHCARE MANAGEMENT

Steps to Establishing Effective and Long-Lasting Patient Family Advisory Councils

In our value-based system in today's healthcare, it's more imperative than ever to involve patients and family members in their care. A Patient Family Advisory Council can offer hospitals and healthcare systems just that—additional insights, opinions and help based on their own experience as a patient or a care giver to a patient. Nancy Michaels, President, NancyMichaels.com

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n our value-based system of healthcare, it's more imperative today than ever before to involve patients and family members in their own care. A Patient Family Advisory Council (PFAC) can offer hospitals and healthcare systems just that—additional insights, opinions and help based on an individuals’ experience as a patient, family member or a care giver. In nearly every industry, tapping into customer opinions is not only desired, but aggressively sought out. You can’t make a phone call these days without being asked by an automated ‘customer service’ representative to stay on the line to complete a survey at the end of the call – after you’ve finally spoken to a person at the other end of the line. This is true among cable companies, financial

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service firms, tele-communication organisations – the list goes on. The concept of ‘customer service’ is a relatively new one in medicine. At a recent professional healthcare association meeting a paediatrician took great offence when someone referred to a patient as a consumer. He vehemently disagreed with this concept, however, looking at patients as individuals who have choices, unique needs and wants, who more actively seek out the ‘best’ reviewed practitioners through online reviews

or personal referrals, it might be wise to consider patients as both – patients and consumers – who have the power to make choices based on their experience or what they want their experience to be. Rarely, if ever, has medicine engaged patients or family members in a survey to access the quality of the interaction between medical practitioners (front line personnel to interactions we might have with a doctor or more likely a nurse) and their patients or family members with the

exception of a quantitative survey that you receive weeks after being discharged from the hospital – when most of us want to not remember our hospital stay and are grateful to be home. One would think hospitals and healthcare systems might not be interested in hearing constructive feedback until recently with the advent of PFAC’s that are emerging within medicine to actively seek out the opinions of patients and family members on ways to offer constructive conversation on how to improve the patient or family experience within hospitals. In 1978, Dr. Warner Slack (late) wrote that “the largest and least utilised resource is the patient.” Other innovators who were in support of giving patients a voice in their healthcare includes Dr. Tom Delbanco, who was part of the group that adopted the slogan “Nothing about me without me” and later went on to co-found OurNotes with nurse Jan Walker. OurNotes is an initiative through which patients have access to their doctor's notes taken about them during appointments and can read and respond to them directly with their doctor online. The Society of Participatory Medicine (SPM) was also recently established by Dr. Danny Sands at Beth Israel Deaconess Medical Center and his patient Dave deBronkart — known as e-Patient Dave. The ‘e’ stands for ‘empowered, engaged, educated, enabled.’ Both Sands and deBronkart had a vision to establish SPM as a non-profit organisation dedicated to participatory medicine — whereby patients become involved and responsible decision makers for their own health and providers encourage and value patients input as true partners. Today, I’m on three PFAC’s (Beth Israel Deaconess Medical Center’s ICU PFAC, Partnerships for Patients – PFP, through the American Research Institute retained by Medicaid/

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Medicare, and the Consumer Health Council of Massachusetts Health Quality Partners – CHC MHQP) and each is unique in its approach to solicit the opinions of patients and family members. Clearly, there’s no “right” way to run a PFAC, however, I’ve experience three different models of how it can be done successfully that I’ll share in this article. I spoke at the Beryl Institute on Patient Experience’s national conference in April this year, when I sat in on a discussion about PFAC best practices. What surprised me, despite that I’m with several PFACs, I came to each in three different ways (application and interview to the hospital ICU PFAC, referral to a virtual PFAC for a research institute then an interview, referral then interview for an organization on health quality PFAC). Clearly there is not one standard of establishing or running an effective PFAC. At Beryl, it was even more obviously that PFAC’s were run in very different ways including how members were chosen to apply, extensive or brief interview processes, ability to meet frequently (monthly), desire for participants to review and make recommendations based only on the agenda of the hospital versus wanting to hear PFAC members out on ways they thought things could improve. Here’s my perspective given my own participation on several PFACs, as well as what I heard at Beryl and in doing research for this article. The Case for Establishing a PFAC

The primary reason for a hospital or healthcare system to want to establish a PFAC is to fully engage with individuals who have experience as a patient or family member and who want to make a contribution and improve the overall understanding of our (patient and family members) unique perspective. Ideally, bringing in a diverse group of people with unique experiences

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OurNotes is an initiative through which patients have access to their doctor's notes taken about them during appointments and can read and respond to them directly with their doctor online.

within a healthcare system come together to share insights and work together toward a common goal – to improve the patient experience – great things can happen that really make a difference. There’s overwhelming promise to improve overall patient care as well as to line up with a hospital’s mission, vision and overall goals in improving patient care and communication. For the investment – which is relatively low – a PFAC can be a huge asset to a hospital or healthcare system. What Makes a PFAC Effective?

The effectiveness of a PFAC is related to several aspects and pre-planning from the get go. Some considerations include • Seeking out a group of highly motivated patients, family members and caregivers • Engaging staff who apply firsthand knowledge in improving the experiences of patients and caregivers • Choose a diverse group of volunteer patient membership including young and old, people from varied demographic and geographic backgrounds and ethnicities and patients with different types of illness. The caregiver group is similarly diverse with partners, children, and parents volunteering time and energy

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Ideally, patient advisors come to the council from all points in care — from seeking treatment to surviving a major illness. What Does It Take to Run a PFAC?

Initially, you need to identify the right PFAC internal team to find hospital staff members who look at patients and families as having fresh perspectives on care based on their own personal experience. You do this in the same way you choose the patients and family members to participate. The internal committee should recognise that patient and family engagement is a quality improvement strategy, and are interested in creating, managing, and leading a PFAC. It’s always wise to engage staff, leadership, and clinicians to participate on a PFAC as well – so that patient and family member’s experiences are known throughout all levels of a division or department. A committed PFAC leader who will ensure the success of the PFAC and to help manage the work of the PFAC overall. That person serves as the main point of contact for the patient and family advisors, and coordinates the feedback process from the patient and family advisors to the leadership and staff. The leader ensures that the PFAC’s ideas and guidance are thoughtfully implemented, and communicates between meetings with other activities or assistance needed from PFAC members. At my ICU PFAC, our leader hosts a private Facebook group whereby we can read things about other members and comment as well as send our leader articles we’ve written, panels we’ve been on, etc. Other logistics and minor expenses (relative to the feedback PFACs can offer) include: • Coordinates meeting dates/times and locations • Ordering meals • Parking recommendations and reimbursements • Meeting materials

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• Minutes and other notes taken at PFAC meetings. Many PFAC meetings are held monthly or quarterly, although we are often asked to participate in project-based subcommittees when we meet more often or can assist virtually by sharing a story, experience or opinion. Creating a structure is helpful to establish patient and family expectations and maintain momentum. Establishing Benchmarks

Goals have to be established to ensure that a PFAC is making an impact and is worthwhile to patients and family members as well as to the hospital in making small or big changes that will positively affect the patient/family experience. Ideally a mission, vision and goals of the PFAC should be clearly articulated to each member during the on-boarding process and may need to shared throughout the process. Some items you may want to consider or establish with a PFAC are: What goals would you like to accomplish in three months, six months or a year? Why is this work important to your hospital or healthcare system? How will your success be measured? How will you continually foster relationships with patient and family advisors? Although this doesn’t occur in every PFAC, ultimately patients and family members should play a role in shaping the PFAC’s agendas and topics. • Determine how many patient and family advisors will participate in the PFAC – usually a minimum of eight to 10 people. Make sure that the advisors are representative of your patient population in terms of age, race, ethnicity, geography, family structure, clinical needs, etc. • Draft a document that outlines staff and patient and family advisor roles, responsibilities, and expectations. In my experience being on three

PFACs for more than three years now, each runs quite differently, I believe the strength of a PFAC is in the leadership as well as in the makeup of the individuals on the PFAC. It’s a unique experience to come together with like-minded people – from diverse backgrounds and situations – and find a way to discuss a common vision on how to improve patient and family experience based on our experience. It’s not often as patients or family members that we are sought out for our opinions on how things could be designed to be improved upon for our benefit on an ongoing basis. PFACs do

just that on a consistent and continued basis. Hospitals that create and utilise PFACs recognise the benefits of bringing in the very people they serve – patients and families – together with the real desire to make improvements for everyone. It appears that Dr. Slack was on to something 50 years ago when he made the statement that “the largest and least utilised resource is the patient.” It seems other innovators may have helped to convince medical professionals and hospitals to tune into patients and families and be open to their participation in medicine. AUTHOR BIO

In 2005, Nancy was the picture of success: a sought-after business speaker, the president of her own company, and a mother of three. Suddenly, Nancy found herself in a health crisis that would twice nearly end her life. Miraculously, her extensive rehab left her with no residuals; but, Nancy's life - and the message she wanted to bring to her audiences - were irrevocably changed.

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MEDICAL SCIENCES

Why is Crowdfunded Medical Aid so Popular and Successful in China? Crowdfunded medical aid, a new innovation in China, allows users to get medical aid if they are diagnosed with a serious disease by paying a small amount. The research aims to identify the social and psychological concerns of people when adopting such innovative medical risk management products. Ying Shen, Graduate Student, The School of Journalism and Communication, Guangxi University Hairong Wu, Professor, The School of Journalism and Communication, Guangxi University, and Adjunct Professor of Center of Animal Health and Epidemiology Pradeep Kumar Ray, Director, Centre For Entrepreneurship, University of MichiganShanghai Jiao Tong University Joint Institute, Shanghai Jiao Tong University (SJTU)

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new innovation in China allows users to get up to CNY 300’000 in medical aid if they are diagnosed with one of 30 serious diseases like cancer, heart attack etc. by paying only about CNY 30 (US$ 4.4) per year. Crowdfunded medical aid is based on the philosophy of “one for all, all for one”. It is a new type of internet insurance platform that aims to help critically ill patients, who cannot bear high medical fees, by crowdfunding money from all of its users. These

MEDICAL SCIENCES

platforms evolved from their original function, namely as donation websites for patients. Crowdfunded medical aid platform first became popular in 2016. One company for example, Waterdrop Aid, has recruited 40 million users and provided about CNY 100 million in medical aid to 720 users diagnosed with a serious disease in the last two years. This service is mainly popular with young people who were born during the 1980s and 1990s, as well as residents of third or fourth-tier Chinese cities. The research aims to identify the decision-making process of users when choosing medical risk management products. Twenty six participants and two employees from two platforms were invited to have a semi-structured in-depth interview with convenience sampling method. The transcripts of the interviews were collected by qualitative data analysis software Nvivo. The 26 participants (15 females and 11 males, age 22-52) included university students, company employees, freelancers, farmers, programmes, teachers, civil servants, and NGO workers. The participants live in big cities (e.g, Beijing, Shenzhen), smaller cities (e.g., Nanning) and rural areas. One participant made a successful CNY 200,000 claim with Waterdrop after her mother was diagnosed with nasopharynx cancer. Current Medical Insurance Coverage

The majority of participants were covered by either the rural or urban government health insurance. Civil servants in China are provided with a more comprehensive insurance by the government. Employees working in first and second tier cities would have government medical insurance paid for by their employers, and some university students are covered by the government student’s health insurance. Nine out of the 26 participants bought additional commercial medical

insurances. Those that did not, gave the following reasons for not taking up additional insurance: 1. Commercial insurances and their employees are not trustworthy, mainly because the participants received unsolicited calls or visits. In addition, there were a number of scandals involving these companies which were publicised on social media. 2. Commercial medical insurance is unaffordable for students, newly employed and those on a low income. 3. A lack of motivation to take action. Participants’ Reasons for Choosing Crowdfund Medical Aid

Among the 26 participants, 24 were users of Waterdrop Aid and QFund Aid. Crowdfunded medical aid programmes for the elderly and children with serious diseases were mostly purchased by young people for their family members, because they are frequent users of internet and social media platforms. When asked about how they found out about these medical aid programmes, 13 out of 26 participants stated that they were sent a link about these platforms after making a donation to a sick patient on the social media platform WeChat. Five people found out from friends, another five people learnt about it from internet forums, and three participants could not recall how they found out. Reasons why participants decided to join these programmes are as follows, according to frequency: 1. Low expense and high return. Paying very little money for CNY 30’000 medical aid if diagnosed with serious diseases is a good deal 2. Charity aspect of these programmes. The payment will help other patients instead of profiting the company, which gives them a feeling of satisfaction 3. Out of curiosity or bought on impulse. Some participants said they were attracted by the advertisement, and bought it on impulse, without understandings crowdfund medical aid

4. The initial donation has raised awareness about serious disease. They do not wish they themselves or their family would have to face a similar situation 5. Crowdfund medical aid programmes because they are doing charity for others and helping themselves at the same time, instead of donating money only out of responsibility 6. Special family structure shaped by the one-child policy. Young people who were born in 1980s and 1990s tend to be the only child in their families. The risk awareness of them is stronger because their family is or will be relying on them. Appraisal of Risks and Potential Benefits of Crowdfund Medical Aid

As for the probability of getting a serious disease, participants have two opinions: cancer rates are rising, with a sharp increase among young people too. Another is they is not likely to get cancer. They join these programmes for a peace in mind or simply for fun. Even though not every participant agrees that a serious disease would happen, all of them admit that it would be a disaster for their family if it would happen to them: “For me, a serious disease like cancer would cost a lot of money, and the patient may still not survive in the end.” “To some extent, it causes not only the financial pressure, but also the worries and pain of losing their family member, or even worse, some people may have to face the dilemma between extending the life of a family member with a terminal illness and a huge medical expense. Only five out of 26 participants think they can afford to pay the bill of a serious disease with their current resources and medical insurances. Others stated they cannot afford and do not know how to cope with a serious disease. After being asked about how much the crowdfunded medical aid could

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MEDICAL SCIENCES

help them, most participants said that if it doesn’t happen, then it is a good way to help others, and if it happens, the high medical aid would reduce their financial burden and help them or their family get better medical treatment, which means a better chance of survival. Risk Information Acquirement and Risk Awareness

The participants are interested in two types of health information: one is regimen, which is about how to avoid harmful behaviours or environment, and how to maintain good habits and a healthy diet. The second is disease information. People are interested in it mainly because of their personal health condition, profession, or life experiences. The main sources of health information are professional mobile health information and healthcare providers, and social media. DXY and Chunyu are leading online consultation and healthcare news providers in China. Because of the convenience and their professional healthcare team, young Chinese who were born in 1980s and 1990s trust and use them frequently. As for social media, all participants mentioned that WeChat and Weibo are also their important health information resources. Only one person said he watches TV occasionally. Though social media is one of main resources of health information, most participants do not fully trust it. However, very few participants have attempted to verify this information because they feel it is too difficult or time consuming. People who verified the information they obtained from social media did so because they have access to medical resources such as friend or family members who are medical professionals or they take the initiative to consult medical literature. Besides, the prevalence of social media has contributed to the increased risk awareness about serious diseases.

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In interviews, some participants believe more people have a serious disease nowadays, because they have frequently read information about serious diseases like cancer that has been spread by social media. There are also an increased number of cases where people are asking for donations online for high expense medical treatment. Three participants mentioned about the influence of “A young Beijingese in a flu”, a widespread article on WeChat at the beginning of 2018, which pointed out how weak people are. The article details how the writer’s father in law died from a serious flu in Beijing, despite the fact that one would expect the best medical treatment there in the whole country. The three participants have spent more time acquiring health information and exercising since then. Family and Social Circle Influence on Risk Management

When asked about their family members’ opinion on serious diseases, 19 participants admitted that they haven’t talked about serious diseases and how to cope with them with their family. Nine participants explained

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that one reason is that talking about death-related diseases is seen as bad luck. Another reason that they have avoided talking about it is because it is impossible for them to afford the expense of any serious diseases. Rather than facing the issue, pretending the risk doesn’t exist is easier. Seven participants who have talked about it with their family tend to have had adequate health insurance. Opinions on serious diseases in their family are as follows: 1. For preventable serious diseases, we should try our best to prevent it; 2. For curable diseases, we will spare no effort to cure it, no matter how much it would cost. 3. If it is incurable, we should respect the patients’ opinion, as excessive medical treatment would result in more pain for patients. To sum up, families who talked about serious diseases tend to be more positive and well-prepared. Most participants also talked about serious disease cases that happened in their life. Some people said it forced them to think about how to deal with it if it would happen on themselves. Serval participants convinced their parents to do health test regularly

MEDICAL SCIENCES

Userâ&#x20AC;&#x2122;s Attitude Towards Government Medical Insurance

About half of participants did not know much or had never tried to learn about details of government medical insurance policies, mainly because they have not had the need for it. Others commented that the public insurance has: 1. High coverage for common diseases and medication, but low coverage for serious diseases and newest and specialised medicine 2. The level of reimbursement between regions is different, and the reimbursement rate is lower in less developed areas 3. Self-employed individuals are at a disadvantage in the public insurance system 4. Senior public officials have too much priority, and it should be reduced to promote fairness Although there are many complaints about it, most participants still hold a positive attitude towards government medical insurance. On the one hand, only paying CNY 100-200 per year provides good value, and affordable medical insurance for Chinese citizens. On the other hand, they believe that the government is trying to continually improve it by adding additional medicine in the reimbursement list. Usersâ&#x20AC;&#x2122; Opinions on Crowdfund Medical Aid

Most participants agreed that crowdfund medical aid is a great innovation, not only because it has saved thousands lives, but also has encouraged users to prepare for potential medical risks in their life.

However, several participants have stopped to make payments to the crowdfunded medical aid, because: 1. Negative publicity about scams and misuse of money of these platforms has caused a lot damage to their reputation 2. Commercial marketing strategies (sensational and frequent advertisement posts and subscription system) has incurred detest of users 3. The process to make a claim is complicated and inefficient, and customer service needs to be improved. This is the opinion of to the participant who received payment successfully after persisting for four months. Opportunities and challenges

According to Shen Peng, the CEO of Waterdrop Aid, the reason for the success of crowdfunded medical aid is that they effectively created a new market by increasing the risk awareness of people through their widespread donation links on social media. Until now, they have stated that they are not worried about making a profit, because they have recruited 40 million users who would be their potential customers of their

supplementary commercial medical insurances, healthcare services, and other products. 1 Blockchain technology was introduced by Yang Yin2, the CEO of QFund, and implemented on the platform to create an open and transparent environment. Everyone can track where their money goes and how is it used. All in all, transparency and trust are vital for the development of crowdfund medical aid platforms. The application of new technology may offer them a good chance to develop trust with the public. Nevertheless, they face a number of challenges, such as addressing user complaints and provide improved customer service. These platforms are not considered as part of the traditional insurance industry. The absence of regulations is both an opportunity and a challenge for this new innovation, hence they need to plan every step carefully in the future. 1 http://www.sohu.com/a/225660506_545428 2 http://www.chinadaily.com.cn/interface/toutiaonew/1020961/2018-01-24/cd_35569129.html

Ying Shen is a graduate student at the School of Journalism and Communication, Guangxi University. Main research field is Health communication. Prior to that she was a program officer at KAB (Know About Business) office of International Labor Organization in China.

AUTHOR BIO

and one participant bought medical insurance immediately after she knew her friend was diagnosed with cancer. Others believe that some serious diseases are not preventable. Rather than worrying about the occurrence all the time, people should enjoy their life and make most use of their time.

Hairong Wu is a Professor at the School of Journalism and Communication, Guangxi University, and adjunct Professor of Center of Animal Health and Epidemiology, China. His research fields are mainly about the health and risk communication of zoonosis, and about ten projects have been completed. More than 40 papers and three books have been published.

Pradeep Kumar Ray is a 1000-talent Distinguished Professor in the University of Michigan-Shanghai Jiao Tong University Joint Institute and is currently leading a major collaborative project called mHealth for Belt and Road Region involving seven countries. He is the founder of the WHO Collaborating Centre on eHealth in the University of New South Wales (UNSW)-Australia.

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DIAGNOSTICS

Deep Learning in Medical Imaging

New Artificial Intelligence (AI) and deep learning techniques can help medical imaging technicians spot anomalies and diagnose conditions in a fraction of the time previously needed (and generally with more accurate results). AI increasingly enables human capabilities like understanding, planning, and perception to be undertaken by software efficiently and at lower cost. Here, we present the most recent results in the field and discuss how it will change the role of medical imaging professionals. Nicola Pastorello, Data Analytics Manager, Daisee Kim Berry, Principal Writer, Daisee

A SI A N H O S P I T A L & H EA LT HCA R E M A N AGE M E N T

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o field has seen the extensive and successful application of Artificial Intelligence (AI) to real-world problems more than those of imaging and computer vision. Deep learning â&#x20AC;&#x201D; a subset of machine learning â&#x20AC;&#x201D; is now a significant component in a wide number of vision-based solutions such as detecting and recognising people in videos and post-processing mobile phone pictures to a professional level in a matter of seconds. Specifically trained neural networks are now outperforming humans in classifying images, with the advantage of large scalability and fast processing times. But beyond the world of making us look better in selfies, vision-specialised AI algorithms have

DIAGNOSTICS

a logical application in the medical imaging field. In fact, it is generally considered one of the first domain of applications for image-focused AI. The reasons for this are generally considered 1) the availability of large volumes of (digitalised) healthcare data and 2) the massive improvements on the analytic techniques and, in particular, convolutional neural networks. The impact of this is enormous. Deep learning can be implemented to quickly process massive volumes of scans in a short time, a task that would otherwise take hours (if not days) for a trained professional. In 2016, Frost & Sullivan predicted 1 the AI in healthcare market would reach US$6.6 bn by 2021, a 40 per cent growth rate. It found AI would strengthen medical imaging diagnosis processes as well as enhance care delivery. It could potentially improve outcomes by 30-40 per cent and reduce some treatment costs by as much as 50 per cent. What AI in Computer Vision can do

Currently, deep learning algorithms (and, in particular, convolutional neural networks) are used in vision problems for: • the classification of images/frames according to some pre-set labels. In this case, a large number of images (usually in the range of millions) is used, together with previously known “labels” to train the model. Such a model does learn how to match images with labels and can then apply this learning to new images; • finding the position of objects in images (segmentation). The neural network in this case learns to find the pixels associated with an object in an image; and • generating new images starting from a pool of original pictures. In this case 1 https://ww2.frost.com/news/press-releases/600-m-6-billion-artificial-intelligence-systems-poised-dramatic-marketexpansion-healthcare

the use of generative models allow for the production of new (often realistic) images. In healthcare and medical imaging processing, classification and segmentation are the main applications of convolutional neural networks. Pros and Cons of Deep Learning

Applying AI algorithms and tools has some obvious advantages over existing manual and human-based processes, as well as some drawbacks. Firstly, a number of expensive medical errors and misdiagnoses are linked with long working hours and stress caused by prolonged tedious and boring tasks. AI models are not affected by boredom, stress or tiredness. Secondly, human effort is not easily scalable, whereas deep learning model inferences can be run in parallel with more processing and computational hardware. A trained medical practitioner needs years of clinical experience before mastering the “art” of correctly and completely interpreting complex scans as CT, MRI and ultrasound scans, while a model can be trained on millions of images in hours and then applied effortlessly to new scans in order to detect and diagnose problems. This also has an equity aspect to it. MMC Ventures’s 2017 State of AI report noted that traditional diagnosis by experienced professionals (whose training is time consuming and their scalability limited) by default inhibits supply and increases costs. This means that for developing economies, medical diagnosis can be inaccessible while being prohibitively expensive for many in developed countries. Automating diagnosis for a growing proportion of conditions will see barriers to access fall rapidly. By transferring the burden of diagnosis from people to software, global access will increase, the report predicts. Thirdly, there is the issue of consistency. Human diagnosis is not

100 per cent consistent in time and with different professionals (i.e. the same scan can be interpreted in different ways by different people or even by the same person at different times). AI trained models are instead consistent (low-variance) in their predictions and, in general, the same scan will return the same result. However, some caution is needed in applying AI to diagnostic problems. In particular, for models to become more advanced - and in turn - accurate, more training (tagged) data is needed. This ensures the model learns a thorough representation of the problem space but it can also be costly to obtain. Moreover, a model is just as good as the data that has been used in its training. Since human-tagged data will include errors, there is the risk that in massive datasets these errors might be overlooked and become part of what the model learns. Another issue that relates to model complexity is the loss of transparency. More complex models (e.g. neural networks) are very hard, in fact almost impossible to explain. The decision process regarding a scan is encoded in millions, if not billions, of different parameters. Understanding the interplay between them to produce a result is a human-prohibitive tasks. While a number of techniques to overcome this lack of explainability have been proposed over the years, none of them has delivered a full understanding of a model decision process. For this reason, AI is useful to highlight odd results and anomalies and filter out the results that a medical practitioner should focus on. As with most AI applications, its use in medical imaging comes into its own as a classification tool we can apply to data. Radiologists and other medical professionals will have incredibly powerful tools to help reduce the risk of misdiagnosis, while also letting them process more scans than ever before.

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DIAGNOSTICS

What’s Already Around

A number of medical imaging software system vendors have already started implementing AI in their tools. Daisee is developing a deep learning application to expedite and improve the diagnostic accuracy of brain scans. The initial pilot will focus on detecting the most common forms of head trauma to redirect clinical attention to cases requiring acute intervention. Philips included in its Illumeo software suite an AI-powered research tool that retrieves and presents all previous scans for the same patient on the region (and orientation) of the current scan in progress. This can be used with subsequent tumour size assessments, where the software can measure and compare in real-time the changes of the cancer region, speeding the analysis workflow. IBM Watson is another technology that is being used in evaluations of X-ray exams, and in particular for detecting signs of surgery and cancer in the images. Watson leverages a massive dataset of millions of pre-evaluated/ tagged X-ray scans (obtained by IBM with the acquisition of Merge Healthcare in 2015). Infervison, partnered with GE Healthcare, Cisco, and Nvidia, pairs Computerised Tomography (CT) scans with AI that learns the core characteristics of lung cancer and then detects the suspected cancer features through different CT image sequences. Earlier diagnosis allows doctors to prescribe treatments earlier.

Specifically trained neural networks are now outperforming humans in classifying images, with the advantage of large scalability and fast processing times.

Accenture includes automated image diagnosis in its top 10 for AI applications in healthcare and predicts it could be worth US$3bn in the near term. AI in the medical world is moving fast. In March, researchers at the Athinoula A. Martinos Center for Biomedical Imaging at Massachusetts General Hospital developed a new technique based on AI and machine learning that enables clinicians to acquire higher quality images without having to collect additional data. Called AUTOMAP (Automated Transform by Manifold Approximation), the correct image reconstruction algorithm is automatically determined by deep learning AI.

In the next few years, AI will change a big portion of our daily and professional life. In the healthcare space, it will massively reduce the time that medical practitioners and technician will spend on tedious tasks (e.g., browsing through thousands of scan slices in order to find the few that are meaningful) allowing them to be more productive and spend more time with patients.

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AUTHOR BIO

How the Medical Imaging Professional’s Work would Change

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Researchers have taught imaging systems to “see” the way humans learn to see after birth, not through directly programming the brain but by promoting neural connections to adapt organically through repeated training on realworld examples. According to Bo Zhu, a research fellow at the MGH Martinos Center, it means imaging systems can automatically find the best computational strategies to produce clear, accurate images in a wide variety of imaging scenarios. Because of its processing speed, AUTOMAP may help make real-time decisions about imaging protocols while the patient is in the scanner. AUTOMAP is a major advancement for biomedical imaging which wouldn’t have been possible just a couple of years ago because of the neural network models for AI and the Graphical Processing Units (GPUs) needed for image reconstruction. Healthcare providers and organisations will need to have a full understanding of AI, its breadth of application but also the implications it has on medical professionals and their work. Implementation of AI is not going to be an easy task, though, since the adoption of widely adopted (and complex) processes, as well as the presence of legacy systems will require massive operational changes.

Nicola Pastorello is Data Analytics manager of Daisee, an Australia-based Artificial Intelligence company bridging the gap between technical AI and commercial application in the fields of vision and natural-language processing. He has a extensive experience in applying impactful AI to healthcare-related problems (e.g. predicting epileptic seizures, improve medical diagnoses).

Kim Berry is Principal Writer for Daisee. She is an accomplished journalist, passionate about creating balanced, concise and informative content. Throughout her career she has written on: AI & technology; environmental science and law; climate change and the rise of the carbon economy; and education.

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TECHNOLOGY, EQUIPMENT & DEVICES

Medical Equipment is a core asset for any healthcare facility. To ensure medical equipment is safe and effective there is a need to understand its associated management methodology. Consequently, a typical life cycle approach for medical equipment management is identified and explained in terms of processes and applications. NevenSaleh, Assistant Professor, Systems and Biomedical Engineering Department, Higher Institute of Engineering

edical equipment plays an important role in healthcare delivery. It ranges from small and simple devices such as sphygmomanometer to complex and big devices such as Magnetic Resonance Imaging (MRI) machines. This ranking is as a result of differences in utilised technologies and intended applications. It is, therefore, of vital importance that healthcare organisations manage their assets to keep their expenditures under control as well as ensure the quality of healthcare delivery. Medical Equipment Management (MEM) takes place within the context of human, material, structural, organisational, and financial resources. It is a process which helps hospitals to develop, monitor, and manage their equipment to promote the safe, effective, and economical use

A SI A N H O S P I T A L & H EA LT HCA R E M A N AGE M E N T

and maintenance of equipment. Responsible organisations should setup and regularly review MEM to ensure that a suitable medical device is used in accordance with the manufacturerâ&#x20AC;&#x2122;s instructions, maintained in a safe and reliable condition, and disposed appropriately at the end of its useful life. A systematic way to manage medical equipment is to study and optimise all phases in the useful life of that equipment. A typical life cycle approach that was originally developed for major medical equipment, also applies to non-major but essential medical devices and may be extended to additional devices. It is a logical sequence of medical equipment management activities or stages, and each stage is dependent on and linked with other activities, as shown in Figure 1.

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It consists of nine stages as follows:

1. Planning 2. Acquisition 3. Delivery and incoming inspection 4. Inventory and documentation 5. Installation and commissioning 6. User training 7. Monitoring of performance 8. Maintenance 9. Replacement or disposal 1. Planning

Planning process is an important aid in decision-making because it provides essential information for management. In other words, it provides technology vision where healthcare facility should position itself; it can specify the following conditions in order to aid the decision-making process.

TECHNOLOGY, EQUIPMENT & DEVICES

Figure 1

• Demonstrated needs and benefits • Available qualified users • Confirmed maintenance services and support • Adequate environment support • Regulatory compliance These conditions are simple and should be applied to any routine acquisition of a medical device. A policy on medical device acquisition meeting these conditions as prerequisites to acquisition will reduce problems later in the life cycle of the device. For example,

appropriate financial planning for a medical device can ensure optimum position for operating and service costs of this device. Planning is the responsibility of the Medical Technology Advisory Committee (MTAC). The committee includes an administrator, a planning director, and a clinical engineering director. The role of planning is to ensure a balance between clinical and technology sectors of healthcare facilities in addition to meeting the community

needs. The procedure of strategic planning of medical equipment includes: • Performing an initial audit for existing technologies • Conducting a technology assessment for new and emerging technologies that fit the desired clinical services • Planning for replacement and selection of new technologies • Setting priorities for acquisition • Developing processes to implement equipment acquisition, and monitor ongoing utilisation

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TECHNOLOGY, EQUIPMENT & DEVICES

2. Acquisition

Healthcare industry is known for its continued innovation and production of new devices and techniques intended to improve the delivery and outcome of patient care. Funding constraint is considered the master key to evaluate incorporation of new technology to healthcare service. Thus, more attention should be given to the acquisition process keeping in mind both healthcare delivery outcomes and funding availability. Acquisition stage usually incorporates four main processes as shown in Figure 2. Needs identification usually starts from users of technology, i.e. the medical staff (physicians and nurses).Indeed, the need to acquire a medical device may be due to one or a combination of the following reasons: • Provide a new service • Improve service efficiency • Improve clinical outcomes • Improve cost benefits • Meet specific standards • Reduce a risk. In general, tendering process takes place to purchase medical equipment based on the required specifications. In tendering, all vendors are allowed to bid under a competitive and fair evaluation. Moreover, it gives a good opportunity

A typical life cycle approach that was originally developed for major medical equipment, also applies to non-major but essential medical devices and may be extended to additional devices.

for hospitals to select the best possible medical equipment. It is worthy to mention that technical specifications should include general requirements such as the warranty, technical services, technical documents, and any other necessary requirements for equipment operation. In the evaluation process, the purchased medical equipment should be evaluated from three different angles: technical, clinical, and financial. The purpose of technical and financial evaluations is to check the proposed

Needs & Requirements Identifications

Tendering Process

Evaluation Process

Awarding & Contracting Process

Figure 2 Main processes of acquisition stage

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technology, and to ensure the performance of the devices meets the desired outcomes. On the other hand, financial evaluation considers only the costs of the proposed technology. Both technical and clinical evaluations are carried out using either scoring or accept/reject approaches, whereas financial evaluation regards the lowest price among accepted vendors. After making the selection, an award must be issued to acquire the device. A purchase contract document is prepared by the purchasing department and it must cover all terms and conditions that have been agreed upon by the vendor and the hospital. 3. Delivery and incoming inspection

Clinical engineering department ensures an incoming inspection on equipment includes verification of accessories, manuals, and electrical safety and operation in accordance with all applicable policies. Incoming equipment should be carefully checked for possible shipment damage and compliance with specifications in the purchase order. One role of clinical engineer is to ensure an incoming inspection on medical equipment by verifying the following: • Accessories existence • Manuals existence • Electrical safety • Compliance with specifications • Possible shipment damage 4. Inventory and documentation

Medical device inventory and documentation is an assistive stage in the life cycle. It provides information to support medical equipment management in different stages. Upon completion of the incoming inspection, a device record file should be created and it should be active throughout the useful life span of the device. Each device is identified and tracked by a unique number called equipment record number. The device record file should contain the following data:

TECHNOLOGY, EQUIPMENT & DEVICES

• An Equipment Control Number (ECN) • A generic description of the equipment • The equipment manufacturer, model, and serial number • The owner department and the location of the equipment • The purchase order number and date • The equipment’s acquisition cost • The supplier’s name, address, and telephone number • The warranty conditions and expiration date • An abbreviated description of the inspection and preventive maintenance requirements and intervals • An abbreviated service history • Information regarding any applicable service contract • The location of the equipment’s user and service manuals. 5. Installation and commissioning

Installation and commissioning can be carried out by in-house technical staff if they are familiar with a given item of equipment. If the installation and commissioning are needed from the suppliers, in-house technical staff should monitor this process. In general, installation process should be compatible with standard policies for medical equipment installation. 6. User Training

To reduce the possibility of equipment malfunction following service or repair, all personnel involved in maintaining and servicing equipment must be trained to appropriate standards for the work they are carrying out. Operator error is a leading cause of device malfunctioning, especially in developing countries. Incorrect usage of medical equipment will also greatly increase maintenance problems. Therefore, training of users should be regularly monitored from the vendor to ensure an appropriate skill level that is required for equipment operation. In

fact, training should include all of the user staff as needed, such as clinical and technical staff. In addition, it should cover all aspects of medical equipment usage. 7. Monitoring of use

One common mistake in MEM is to believe that the warranty period is covered by the supplier, so no in-house technical attention is necessary. In-house technical staff should become the link between user and supplier and should observe any supplier's technical staff. This also will provide a learning opportunity for the in-house technical personnel. This performance should be also documented in the service history of the device by in-house technical staff. 8. Maintenance

Equipment maintenance involves all activities related to providing an adequate level of service and limiting downtime of medical devices. Maintenance or service activity is required in order to ensure the devices are kept functioning within the limits imposed by the test criteria and to return devices to the required level of functioning after breakage or other failure. The primary goal of maintenance activity is to reduce, or, if possible, to eliminate the need of repairs. Traditionally, equipment maintenance is categorised as Preventive Maintenance (PM) and Corrective Maintenance (CM). Preventive maintenance procedures are actions that are necessary or desirable in order to extend the operational intervals between failures to extend the life of equipment or to detect and correct problems that are not apparent to the user. On the other hand, corrective maintenance procedures are any services that involve medical equipment repair, in addition to any specific service include repairs performed under a service contract or repairs performed by vendors during the warranty period. It could be extended in case of a hazard notification or user error. In summary,

PM aims keep the device as new as possible whereas CM aims to keep the device as good as prior to failure as possible. Indeed, PM procedures are based on manufacturer's requirements, individual experience, and equipment service history, whereas CM procedures are mainly based on manufacturer's recommendations. Forward planning of maintenance calls for knowledge of maintenance requirements and the resources that are required in order to perform maintenance. These resources include labor, parts, materials, tools, and costs. PM should be performed based on the frequency and the procedure. Frequency of maintenance is based on the manufacturer’s recommendation and the equipment history. The maintenance procedure includes all actions that should be carried out on a device. It should be written down for each device as a check list and reviewed regularly.

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TECHNOLOGY, EQUIPMENT & DEVICES

Inventory of ME Medical Staff

Receive Replacement Request

BMET

Replacement Planning Process

Priortised list of ME

Replacement Plan for ME Figure 3 A synopsis diagram of medical equipment replacement process illustrating participants, inputs and outputs

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In addition, a manager or a service provider is stationed in the hospital. 9. Replacement

Replacement is the last stage of medical equipment's life cycle. All medical devices reach the point in their life where the cost-benefit ratio goes to the negative because of decreased reliability, increased downtime, safety issues, compromised care, increased operating costs, changing regulations, or simply obsolescence. A synopsis diagram that illustrates the replacement process in terms of participants, inputs, and output is shown in Figure 3. Disposal of equipment must follow safety procedures in order to protect people and the environment. The ideal healthcare technology replacement planning system should be facilitywide, and cover all clinical equipment

AUTHOR BIO

In CM, a response is carried out due to a service request. In this request, a summary of problem symptoms should be identified. Regardless of a technical service type, a set of factors can influence effectiveness of CM. These include experience, information, device complexity level, availability of spare parts, service manual existence, and equipped workshop. In this context, service modalities that provide CM are classified into four main classes; in-house service, contracted service, maintenance insurance, and contracted technology management. In-house service refers to maintaining the equipment by engineers and technicians in the clinical engineering department. The service contract is the most popular method for maintenance of medical equipment. Different options of this type are available based on labor and spare parts. In maintenance insurance, by its name, a hospital chooses to pay an insurance company instead of a service supplier. The insurance company then calls an appropriate service provider to support medical equipment. The last type is contracted technology management, in which all activities are completely assigned to management provider.

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employing accurate objective data for analysis. Moreover, it should be futuristic and include strategic planning relating to clinical marketplace trends and the hospital’s strategic initiatives relating to technology. The plan should encompass factors relating to cost-benefit analysis, safety, expected life span, standardisation, and clinical benefits. In application, decontamination requirements should be regarded prior to disposal. Furthermore, many benefits can be obtained by utilising scrapped equipment as listed below: • Use spare parts with similar equipment • Replace with new ones with the same vendors • Donate them to charity clinics after operation verification • Dummies in internal training • Use in research labs • Save them for museums. In fact, most of hospital planning processes tend to focus on current or short-term needs with little or no consideration of future replacement of medical equipment. An equipment replacement plan will help to guide the hospital on potential future spending obligations relating to medical devices. Different approaches are used for replacement of medical equipment. These approaches are either qualitative or quantitative. In qualitative approach, a combination of different criteria is regarded to approve replacement decision; whereas in quantitative approach, a mathematical model is proposed to determine replacement thresholds which lead to a realistic replacement decision. References are available at www.asianhhm.com

Neven Saleh is an Assistant Professor at systems and biomedical engineering department in Higher Institute of Engineering, El-shorouk city, Egypt. She comes with over seventeen years of experience in healthcare technology management. She participated in medical equipment management programs in Italian and Turkish hospitals. Also, her main research interest is clinical engineering.

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FACILITIES & OPERATIONS MANAGEMENT

PRIMARY CARE The evolution of primary care is the most critical aspect of healthcare – the foundation of the very health of nations. While the focus till now has been on building hospitals (secondary and tertiary care, with higher etches of research leading to quaternary care) and curative side of diseases, it has now been recognised that to have healthier nations – healthy beings as well as healthy economy, it critical to have a sound primary care system to ensure wellness, prevention and early detection of diseases – nip the evil in the bud! Gurrit K Sethi, CEO, Canta Health

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e, the urbanites, can we imagine a world without a doctor? In fact, vicinity to medical care and education facilities are part of the top key factors on deciding where to buy our new home….And yet, just the mere availability of good primary care (which actually meets from 80-90 per cent of a human’s healthcare needs) still remains a distant dream for many even in our community as well as country. A sound primary care setup can serve as a gatekeeper and whistle blower to the mass health issues and trends in health parameters faced by different populations—rural, urban around the geographic spreads. Growing insight from North America and Europe has spelled this out; however, there still is scanty data from other regions. Focus on availability of primary healthcare is a global strategy for the World Health Organization (WHO). Aided by Bill and Melinda Gates foundation, WHO is facilitating case studies across twenty nations to help understand and strengthen the systems through aggregated knowledge. Towards this pursuit, the World Organization of family doctors (WONCO) has been urging its members to participate and support WHO on this. In significance of this goal, they are increasingly encouraging family medicine to be promoted seriously. There are great examples of health systems that have kept primary healthcare as their core focus and the resulting health outcomes standout. An interesting model to look at is Cuba’s primary healthcare system

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with a focus on disease prevention. Cuba requires that all medical school graduates first go through a successful family medicine training before they can specialise. As a result, 70 per cent physicians remain in family medicine as primary care providers. In comparison, in US only 10 per cent work in family medicine. Of course, the world’s largest and most talked about healthcare systems (US healthcare and NHS) miss out from the list of top ten healthcare systems. In fact, there are great examples of Asian nations that boast of sound healthcare systems with a sound focus on primary care like Singapore and Qatar. Beneficial Geography and Population

In the current age, another aspect to be factored in creating a good healthcare system is the population dynamics as it changes with a growing geriatric populace the world over. Focus is required to facilitate these needs with care. And then there are multiple aspects of this not only within the non-communicable and life style disease spectrum with an increased life span, but also the fact that in the world of growing ‘nuclearism’ in the traditional family structure, there is a rise in the number of elderly living alone. In the west the concept of old age homes supported by medical care and hospices is common, it is indeed a need to adopt these kind of models in our world as well. With Geriatrics as one of the core of primary care, this can help curtail spend owing to illnesses that grow out of neglect by education, regular health tracking, and, timely care. Evolving models of ambulatory care for primary care as well as specialised needs supported by sound technology are definitely helping in bettering outreach as well as costs. Sleep labs, outpatient dialysis centres etc. are also making care more personalised as well as specialised. A few years ago I had the opportunity to visit Singapore’s out of hospital dialysis centres run in different

The spectrum of primary care in private healthcare as a structured line of service has picked up pace in India over the past few years taking a cue from the west.

condominiums and communities. It was a very impactful experience, not just looking at the passion of the medical teams, but also the stunning outcomes. It was touching to see the depth of thought that went into customisation of dialysis chairs so patients could sit, aquariums place next to each chair as the sound of water and seeing fish can be a soothing sight. The evolution of ambulatory care has helped build many specialised primary care models which can help in bettering outcomes as well as bettering outreach and availability. So, like the west we have seen many service providers in this space for Opthalmology, dentistry, IVF, mental health etc. A few of these providers work as a chain across the country / going international now — I wonder if the learning came from the early junk food chains! On a serious note, the strategy is working well for many of these providers as well as the patients. So, frankly, kudos to them! Digitisation needs to be better adopted as that can greatly impact cost and outreach and also aid in statistical analysis of trends. Some regional private companies in India have come up with very interesting low-cost offerings for primary care based on technology to reduce dependence on specialised manpower, enabling quality medical care for patients, speed to care, and, collect

data to track patients’ health. Think about walking into an ATM like enclosure for basic diagnostics and a video consult with the physicians and then getting medicine from an automated pharmacy. Yes, this is happening now. Of course, there are many more digital models emerging for specialised uses and adaption of these can be a game changer —think of attending a doctor’s consult sitting in the comfort of your drawing-room. There are many models of tele-health / - medicine, E-health that have come up. While technology has made a lot of things possible, adoption is key. Also to aid adoption, localisation of the concepts is key. One needs to understand the culture, and the infrastructure and availability of talent to introduce a new concept in any geography. There is a great benefit in cross pollination of ideas as different health systems try different strategies to overcome their challenges. Also as this happens, the governments and the private sector should ideally work more closely to create an ecosystem that is suitable for growth as well towards creating a homogenous spread. Logically, the basis of improvement in the health indices lies in strength of the primary care that targets wellness, early detection and cure. There is a growing focus on ‘living healthy’ now against the backdrop of many unhealthy trends that are visible to the naked eye — obesity being a glaring example. Again, with Family and Functional medicine being brought to focus, this hopefully will show us the light —not only in bettering general health of people but also in hugely reducing costs. This needs to percolate down to the far flung areas as well. Asia

Over 25 per cent of the world's population lives in South Asia, with many people living in dire poverty with limited or no access to health care. While we boast of quaternary care, we cannot afford to turn away from this stark reality.

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Different medical organisations have been working over the last few years to better the understanding of the policy makers across the south Asian countries. A lot of facilitation by South Asian region of WONCA (with many participating nations, including Bangladesh, Nepal, Sri Lanka, Pakistan, and India) has helped bring primary healthcare to the centre of attention by pointing this out as the core of good healthcare. The key objective has been to make healthcare sustainable with the foundation of a sound system of primary healthcare needs — this as a global strategy.

In the End

It is time to recognise the support that care provision can derive, driven by technology, owing to lack of trained medical professionals in far flung and rural areas. With well-developed Clinical Decision Support Systems, point of care devices, connected systems etc. to support better and quicker diagnosis, the world is indeed becoming a smaller place. Last but not the least, in this age of consumerism, we need to adopt an

all-inclusive approach with doctor and patient responsibility to make informed decisions and track health indices. The health care index of a country is not defined on the basis of what kind of superspecialties and advance care centres the particular country has but instead the primary health care robustness decides that and that is the primary domain of health standards and happiness quotient of the population living in. So let’s expand the reach of care….

The spectrum of primary care in private healthcare as a structured line of service has picked up pace in India over the past few years taking a cue from the west. Yet there are miles to go before it takes the shape of ambulatory care as it exists in the west. We should be drawing our learnings in implementing best practices early on as our overall health infrastructure matures. This would need a sound policy backing to ensure that all players follow standardised norms allowing further analysis of the health data aiding and impacting the national health challenges. Educational institutions need to help expand the primary care sector by introducing and enforcing courses for family medicine, functional medicine etc. Despite progress, and with states like Tamil Nadu setting examples, much remains desired because of a disproportionate health spend and the largest share of disease burden with lowest bed count per thousand people. While there is an effort on to increase the bed count and availability of care, a little focus on primary care infrastructure can go a long way to help better the health outcomes by way of preventive measures and early detection.

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AUTHOR BIO

India

Gurrit K Sethi is a transformational leader, with 20 years of work experience in Telecom and Healthcare verticals, with a flair to enable and maximise change benefits in business operations. She has over 17 years of experience across different verticals and domains, spans different geographies, with a keen interest in studying varied systems across the globe. She strongly believes in the power of cross pollination of ideas and implementing them successfully by localising the solutions. Over the 17 years she led business operations of hospitals and related healthcare services in companies like Fortis, Alere and Eli Global, having managed multi-scale operations from the shop floor to driving profitability. Demonstrated the ability to envision and create successful outcomes in complex situations and driving new initiatives and start-ups. Currently she works in the Eyecare Portfolio of Eli Global as Director Healthcare Services.

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Digitalisation as a Step Up in Early Life Nutrition Providing nutrition tailored to the specific needs in early life can be complex but with the use of digital technology, it can greatly benefit research by improving accuracy, providing new insights and tailored interventions. Rocio Martin, Director, Danone Nutricia Research

ith the global increase in smartphone and Internet penetration online health information as well as investment and development of digital healthcare technologies, the tech-enabled healthcare (TEC) sector is growing at an exponential rate. In Asia, the value of the mobile health (mHealth) market which encompasses all health services that uses mobile network, is estimated to be worth US$6.4 billion this year. There is consensus that digital healthcare transformation can alleviate acute resource and manpower shortages needed to tackle the rising disease burden. One potential application of digital technology is in paediatric healthcare, where the right nutritional interventions in early life can help improve health outcomes in later life stages.

The Importance of Gastrointestinal Health in Early Life

A growing body of research has shown that various diseases such as allergies are linked to imbalance of gut microbiota, or ‘dysbiosis’ that may originate from pregnancy and continue through the first 1,000 days. Experts have concluded that nutritional interventions promoting healthy microbiome environment in the 1,000-day window is critical in disease prevention. Despite the positive effects of early life nutrition on the modulation of gut microbiota, the final impact on individual health is dependent on the inter-relationships between a large variety of genetic and environmental factors within the gut microbiota system, such as mode of delivery and antibiotic administration in babies. Thus, predicting the impact of nutrition

on an individual’s health is a complex and multidisciplinary task. Identifying and developing tailored nutritional solutions targeted to the specific needs in early life rely on a wealth of data and research, as well as close collaboration between healthcare professionals, researchers and parents. This article looks at how adopting digital technologies can help in research and development of early life nutritional solutions. 1. Digital technology can improve research efficiency and accuracy Digital technology enables the transmission of real-time data at greater convenience with little cost. Healthcare professionals and researchers can remotely capture, store and process large data samples and cut down significant time for data collection. Conventionally, babies’ data are collected over multiple clinic visits, but, with the usage of smart connected devices, it equips healthcare professionals and researchers with comprehensive data without multiple face-to-face consultations and may help prevent drop-outs in clinical trials and research. According to a study published in the Journal of Pediatric Psychology, many participants in longitudinal studies involving infants often drop out mid-way due to inconvenience. Therefore, utilising wearable devices to capture data in research can provide convenience for parents due to user familiarity, given that close to 1 in 3 parents own wearable devices, thereby resulting in prolonged participation of clinical trials. Digital technology can also gather clinical data about babies accurately.

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In many published studies involving babies, parents are often asked to judge and report the baby’s symptoms, which could be prone to inaccuracies as parental perceptions can vary. Wearable technology, on the other hand, can gather data free from bias. In a recent pilot study done in the United States on the usage of automated crying device, the device captures the natural sound environment of baby through an embedded audio recorder and is able to distinguish between crying and fussing with up to 90 per cent sensitivity and 91 per cent overall accuracy. This was achieved through the application of machine learning algorithms, which allows the device to reliably and objectively identify and quantify both crying and fussing. Furthermore, the value of digital technology in research has been recognised by industry leaders. In the US, usage of digital technology in clinical trials has even gotten support from the Food and Drug Administration (FDA) as the technology offers, amongst other benefits, real-time monitoring of clinical trials. In addition, 58 per cent of pharmaceutical industry executives also agree that digital technology adoption in clinical trials can generate better data. 2. Digital technology can help generate new scientific insights The data captured by digital devices can complement data from new technologies such as DNA sequencing which has allowed researchers to determine the composition and functions of gut microbiome and its impact on overall health. Through computational systems biology, an integrative data approach, interactions between biochemical and metabolic pathways and external environment can be quantified and analysed. This aids nutritional research as the system can account for various biological feedback loops, which can be hard to analyse with human inference. As such, systems biology can be applied to generate novel scientific insights for complex and

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Digital technology enables the transmission of real-time data at greater convenience with little cost.

poorly understood conditions, such as infantile colic and allergy, which has multifactorial etiology. In addition, wearable technology provides an avenue for researchers to constantly track health indicators during a child’s developmental stage by analysing their risk of developing health problems such as obesity, asthma and allergies later in life. In clinical practices, the development of new analytical approaches in machine learning and artificial intelligence have increased the actionable insights we can derive from raw data. Machine learning algorithms can be designed to ‘learn’ from data points received and generate accurate predictions and analysis when validated. Such digital technological advances could potentially inform healthcare professionals and parents on babies’ health and nutritional needs by identifying novel correlations between clinical observations and health outcomes. For instance, a smart diaper is being tested to gather babies’ urination data, allowing parents to know when their babies are experiencing urinary tract infections or dehydration. The data will then be sent to a physician who would be able to make proper diagnosis on the baby’s health and nutritional needs. 3. Digital technology can provide tailored interventions In research, better understanding of the

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interplay between nutrition, genetics and environmental exposures, as well as the integration of human multiomic data with microbiome data can help researchers develop strategy for personalised nutrition. As research has shown that nutritional needs and responses to dietary intake may vary from person to person, it is vital for healthcare professionals to provide tailored nutritional recommendations to ensure optimal health. This can be facilitated by digital personalised care tools. Personalised care is relevant in a parent’s daily life where they can seek quick diagnosis, treatment and reassurance through chatbots and telemedicine services to provide timely advise and reassurance while reducing hospital services usage. The use of the deep-learning and AI approaches to analyse patient interactions are leading to the development of increasingly sophisticated chatbots, which are able to provide parents with tailored advice based on past interactions. In Singapore, virtual consultations are expected to translate to five times greater in cost savings for patients and their payers in the long-term. A study in Sweden on the usage of telemedicine to facilitate follow-ups for babies discharged from neonatal paediatric unit found that virtual consultation and a specially designed web page eliminated the need for parents to bring their children to the hospital since parents have access to timely advice. Soon enough, digital health platforms can be used to reassure distressed parents and help cut unnecessary clinic or hospital visits. According to a study by the School of Nursing and Midwifery in Ireland, parents want to be involved in caring for their child but lack guidance from healthcare professionals. Digital technology can strengthen parentprovider relationships as it facilitates regular communication. For instance, in a Danish study assessing the usage

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Further more, digital technology can aid the product innovation process by gathering real-time data from babies and parents, such as stool patterns. Accurate data of babiesâ&#x20AC;&#x2122; stool can help further validate current research on the impact of nutritional ingredients, such as synbiotics, in supporting gut health of young children. Conclusion

Adopting digital technology in healthcare for early life nutrition benefits parents, researchers and healthcare professionals. It can increase engagement between parents and healthcare professionals and AUTHOR BIO

of a smartphone app for new parents following postnatal discharge, nurses reported feeling that they could support at-home parents better through the provision of timely, professional information. Parents are increasingly open to personalised virtual support. According to the Nemours Childrenâ&#x20AC;&#x2122;s Health System survey in the United States, 64 per cent of parents are interested in using digital health platforms for their children, while almost 75 per cent of them feel that virtual telemedicine services are better than in-person visits. In Asia, as more parents turn to online resources for parenting advise and support, there may be increasing adoption and usage of these services. One report exploring opportunities and sentiments towards technology adoption in healthcare revealed that 72 per cent of healthcare organisations are already using virtual assistants to improve patient engagement.

improve service satisfaction while also strengthening collaboration between multiple parties to provide babies with better nutrition in early life. Harnessing digital technology in research enables researchers to discover new biological mechanisms, predict the risks of certain diseases and eventually drive long-term nutritional solutions. It also provides an exciting platform for partnership between technology companies, healthcare professionals and researchers to come together and devise practical evidencebased nutritional solutions. References are available at www.asianhhm.com

Rocio Martin specialises in gut microbiota with special focus on early life, and role and composition of the human milk microbiome. She is the Director of Precision Nutrition D-Lab, Danone Nutricia Research in Singapore, where she oversees the operations, people and ventures of the research centre and drive digital innovation strategies for the organisation.

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DIGITAL HEALTH

Giving birth to new delivery models and fostering innovation A 24 x 7 connected healthcare ecosystem where the care receivers and their care providers and receivers are able to be in touch anytime anywhere is changing the way services are being delivered and health is being managed remotely. This article discusses how this is being made possible and the various issues associated with it. SB Bhattacharyya, Founder & CEO, BC2RI

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et connected and stay connected is the new mantra for a new age. As applied to healthcare, digital health is the new paradigm that has the society extremely excited about it and rightfully so. The ubiquitous, relatively-affordable and ever-so-powerful smartphone from a computing perspective has led to a situation where almost every individual is never far from getting the latest information out there literally at his fingertips at any time,

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the source of which can not only be the Internet but also his own body. The multitude of mobility apps along with wearable sensors and devices has meant that the person can access instantaneous access to his health status. This has also led to a situation where anyone anywhere with the appropriate access privileges is able to remotely monitor the health status and provide required feedback almost instantaneously to help the individual maintain a healthy state. By coupling these with right machine learning algorithms, it is possible to run predictive analytics on the available clinical data, some of which are big data, and inform about any impending health issue that can have important consequences. At the heart of the new ecosystem created by digital health is wellness, i.e. maintaining health. While it has been well-known for quite a while now that prevention is better than cure, it is only recently that there has been any real tools available to that group of stakeholders who really matter — the people — to be able to take charge of their own health. Unless individuals are empowered to take charge of their own health and managing the prevention-methods that would help keep them healthy, the intent of being healthy and staying healthy would remain no more than fantasy at best. Digital health certainly helps address this lacunae in a very effective manner for it has the right components to help the care providers provide the ‘right care’ at the ‘right time’ to the ‘right individual’. Digital Health – A New Paradigm

‘Digital health’ is essentially an ecosystem where digital technologies such as telecommunications, information technology, information science and informatics converges with health, healthcare, living, and society to enhance the efficiency of healthcare delivery services and help

Advancements in technology are leading to a convergence of people, information, technology and connectivity to help improve healthcare and achieve better health outcomes.

make healthcare individual-specific and precise.1 Simply put, through the use of various electronic healthcare-related devices and telecommunication methods, healthcare is now turning from the hitherto traditional ‘sick care’ approach to the more modern and efficient ‘continuous care’ management by engaging the individual and care provider by connecting them on a 24x7 basis. Meeting Newer Demand

Gone are the days when a person would visit a consultant for evaluation and alleviation of his problems on an episodic basis. The increasingly prevalent trend that is certain to increase in the future too is to seek advice and be guided from a distance. This helps by having the individual to travel less and spending lesser time away from one’s daily activities leading to higher productivity and lesser loss of time and money. An important offshoot of this approach is lesser number of individuals visiting healthcare facilities for routine work like check-ups and follow ups, many of which can be done from a distance in cases where there are no complications 1 There have been authors who have argued that genomic technology is an integral part of this ecosystem and it definitely augments the precision and individualisation of healthcare, but it is an adjunct and not strictly “digital” in the commonly-understood sense of the term. (https://storyofdigitalhealth.com/definition/)

or causes for concern. This in turn leads to the situation where specialists are able to concentrate on those who really require their undivided attention and consequently provide better care to these individuals. The current day and age is a whole new connected world where ‘getting connected and staying connected’ is the new mantra. With smartphone and connectivity increasingly becoming affordable and ubiquitous and the advent of social media and streaming content has caused a tectonic shift in the way people wish to live their lives. The individual of today demands that he be ‘connected’ to all that he wishes to and expects all his ‘connects’ to respond as fast as possible. These ‘connects’ include service providers and even the government of the day. This has led to profound changes in the way businesses need to run and provide appropriate services to their customers. As online stores replace shops and malls, healthcare services need to be delivered not merely from within the confines of institutions with clinical encounters occurring only face-to-face and in person, but from afar using telehealth that encompasses remote consultation and monitoring. The availability of machines with significant computing power capable of delivering high performance and advanced healthcare IT systems that can leverage mobile technology has made health management of individuals both personal and precise. Successfully leveraging all this leads to elimination of inefficiencies, improved care access, reduction in costs due to less travel time. Repeated evaluations for the same condition as more and more past results, reports and records are instantly available online. Reduced incomes due to having to take enforced leaves to visit a consultant in person is well-addressed. Service quality and outcomes are significantly improved as the specialists are now able to devote more of their extremely

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valuable time to managing those who require their attention most. The easy availability of wearable devices of the affordable kind backed up by patients and consumers can use digital health to better manage and track their health and wellness related activities. The use of technologies such as smart phones, social networks and internet applications is not only changing the way we communicate, but is also providing innovative ways for us to monitor our health and well-being and giving us greater access to and exchange of information. Taken collectively, these advancements are leading to a convergence of people, information, technology and connectivity to help improve health care and achieve better health outcomes. Leveraging Current State

Let us look at what all exists today in the real world. Increased use of health information systems, with ever-increasing adoption and use of womb-to-tomb Electronic Health Records (EHR) coupled with widespread use of affordable mobile connectivity, has led to a situation where all healthcare stakeholders are able to appropriately harness cloud computing. The latter being a type of Internet computing where the Internet is used to deliver different types of computer-related services like server, storage, applications, etc. to connected computers and devices2. While the craze for wearables by healthy individuals appears to be tapering off mostly due to less-thandependable data they generate, Internet of Medical Things (IoMT) has an important role to play in monitoring of health status for both the healthy and those requiring monitoring on a long-term basis, which may even be life-long and is consequently here to 2 A DIY Guide to Telemedicine, SB Bhattacharyya, Springer Nature

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stay. The term is collectively applied to wireless sensors and devices like wearables, apps, monitors, etc. that are connected to other “things” or to a central system that performs storage, analysis and monitoring via aggregation devices located at the patient’s site. The data generated by them is analysed in real-time to help care providers take the necessary care-related decisions irrespective of the physical location of the person. The handheld devices like the nearubiquitous smartphone are almost close to a personal computer for all effective purposes in terms of computing power, storage and networking capabilities. These devices use GPS for location, accelerometer for motion, flashlight for light, sensors for proximity and temperature, able to capture and reproduce high fidelity sound (through microphone and speakers) and capture and display HD or better quality video (through camera and display screen). All of them additionally support a host of wireless connection protocols (Wi-Fi, Bluetooth®, NFC, etc.) that makes them able to exchange data with external devices having compatible capabilities. These features makes the affordable and commonplace enough for the smartphones to be considered an important health management tool in the hand of the various stakeholders3. 3 A DIY Guide to Telemedicine, SB Bhattacharyya,

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The availability of High Performance Computing (HPC) as it is commonly known, has made processing and analysing huge amounts of all data, including big data, possible. When clinical data is analysed using them, it is possible to flag impending clinical events and take corrective measures to ensure that morbidity and mortality can be minimised to near-zero levels. Individual genome sequencing of individuals is now relatively affordable in many geographies. Matching them with known health markers can help individuals and their providers to better manage their health. By leveraging HPC, it is possible to help deliver individualised care with high degrees of precision to patients relatively easily and as frequently as required. The available data can be analysed with relative ease and by appropriately leveraging machine learning they can be used to perform predictive analytics. These would be useful in alerting the various stakeholders of any areas of concern or impending clinical event with fairly reasonable degrees of accuracy. With the focus of care delivery having long since shifted from ‘sick care’ that only institutions could provide to ‘wellness and preventive care’ that is possible to be delivered remotely to the individual, irrespective of his location. The ecosystem requires appropriate tools that can enable the stakeholders to function optimally. Digital health for sure could not have chosen a more opportune moment to arrive like a gallant knight in shining armour. Proofing the Future

With increased availability of healthrelated information of varying dependability, increased awareness about one's rights, and desire to be healthy instead of just not-sick has led to individuals to take charge of their overall health and well-being. Better care Springer Nature

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patients and payers. However, this also means that the care provider will have to somehow be available on-demand to the individual. The humongous amounts of clinical data generated will need to be properly analysed to provide the best-possible solution as quickly as is practical and the care provider of tomorrow will need to separate noise from substance. By leveraging predictive analytics, he will need to be able to pre-empt clinical events and forewarn individuals of any impending events, potential or actual, and appropriately guide them to ensure that all preventive measures are undertaken well in advance, thereby helping to maintain health. This means that innovative care services delivery models need to be identified and put in place. To this end, telehealth, which essentially means remote monitoring and care appears to provide the best possible solutions. Need for Circumspection

Cyber safety and security-related issues assume all the more important role within the â&#x20AC;&#x153;Digital Healthâ&#x20AC;? paradigm. The underlying issues are serious and potentially life-threatening unless taken care of in a very robust manner. Electronic devices can be adversely affected by interfering with signals that connect the mobile devices to remote locations. Wrong data or instructions can ruin anything. While manufacturing them, appropriate levels of care needs to be taken to mitigate this. Dependable and well-proven techniques and processes exist that can help mitigate them, provided they are

AUTHOR BIO

outcomes has meant people are living longer, many with chronic ailments that require regular monitoring, which means frequent travels and visits to physician's offices for the elderly and the infirm â&#x20AC;&#x201D; something that needs to be at a minimum if not avoided. Occasionally, it is either not possible or the decision to move to a healthcare facility taken way too late, leading to consequences that were avoidable. The demands on healthcare providers has increased with increased population without concomitant increase in their numbers. A modernday care provider is overwhelmed by oversensitive and discerning patients who are sufficiently knowledgeable and very interested in their health. Not only are patients spending more time during every clinical encounter and the providers having to process more information as a result of better investigations being readily available and routinely undergone, their numbers are just way too many to be handled in the 24 hours that any care provider has. This has led to the need for connecting individuals with their providers 24 x 7, enabling the latter to intervene on-demand. The treatment provided needs to be both individualised and precise to help ensure optimal outcomes. This means that the provider needs to be sufficiently enabled to have the individual's latest health-status at his fingertips to help dispense the bestpossible care advice that will ensure optimal outcomes in terms of quality of life at minimal costs in terms of expenses, time and treatment-related adverse events. Increasingly, care will need to be provided mostly in the individual's location and minimally at any facility. This will reduce inpatient's stay, an offshoot of which will be lesser exposure to conditions that cause increased morbidity and mortality, while increasing patient's compliance. The overall expenses are reduced too, all of which is very good news for

implemented and followed with due dedication, application and devotion. The analysis methodology too needs to be well-formulated and repeatedly validated to ensure that the right information is made available to the stakeholders who take healthrelated decisions by basing their clinical assessments on them. By taking cognisance of these issues and applying due care, it is possible to alleviate them and provide the right confidence to the stakeholders with respect to the safety and security. Health data has serious privacy issues. These too need to be taken care of and provide sufficient assurances that confidential information shall indeed remain confidential. Conclusion

Digital health is the future of healthcare, there can be no doubt about it. With every new day comes new challenges and healthcare is not immune to it. The various regulatory pressures, increased competition, increased patient load and need to lower expenses are all causing enormous pressures within the healthcare delivery ecosystem, The care providers, both institutional and individual, need to be able to face the various challenges while remaining competitive in terms of efficiency, productivity and profitability. The ever-demanding and very discerning customer of their services need to have the necessary assurances that their care providers are sensitive enough to their needs and wants and are able to effectively address them to the satisfaction of all stakeholders.

SB Bhattacharyya is a practicing family physician and health informatics professional with more than 31 years of experience. Currently, Founder & CEO, BC2RI, and Member, Standing Committee for IT, IMA Headquarters, his main interests include EHR, applications of machine learning techniques for treatment protocol planning, predictive analytics in medicine and telehealth.

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Technology Enabled Remote Healthcare A story from India

In this well-illustrated article, Prof Ganapathy demonstrates how technology enabled remote healthcare has become a reality in India. Creating a passionate team to administer and implement well thought out operating procedures is the key to success. “Man management”, “change management” is more important than using technology to produce “Customer delight”. Ganapathy K, Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services

aking Geography History, ‘Making Distance Meaningless’, ‘A Hospital in your Pocket’, ‘Cost-effective, needbased, healthcare to everyone, anytime anywhere’ are all these hyperboles, a fertile imagination working overtime and hype. Is Remote healthcare through the internet possible in an ‘emerging economy’. On June 6th 2011 United Nations had declared that Internet Access Is a Human Right. India is no longer a third-world developing country. The new Digital India is an emerging economy. We no longer follow the west. We don’t piggy back or even leap frog. We pole vault. After all how much can a frog leap? That there is an insurmountable urban rural health divide in

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India is also well known. India is a paradox. We have centres of medical excellence better than the best. The tens of thousands who come to India every year for the most complex surgical procedures stand testimony. At the same time 750 million Indians do not have immediate physical access to secondary and tertiary medical care. The author in Feb 20151 conclusively showed that 934 million Indians lived in areas 1 http://www.neurologyindia.com/article.asp?issn=0028-3886;year=2015;volume=63;issue =2;spage=142;epage=154;aulast=Ganapathy;type=0c

where there was not a single neurologist or neurosurgeon. Not in the life time of our great grand children will there be enough brick and mortar hospitals or doctors in India. At the same time we have crossed the one billion mark in mobile phones. The country is getting geared to make available 5G. Technology-enabled Remote Virtual Healthcare is today a reality in India. The illustrations given below demonstrate that pilots and proof of Concept Validations have given way to make Remote Healthcare an integral part of the healthcare delivery system.

A Story from the Himalayas

Non availability of quality healthcare in mountainous isolated areas is a universal problem. Through an innovative, Public Private Partnership with the Govt of Himachal Pradesh 24/7, affordable, remote virtual healthcare is being provided at Key long and Kaza (14,500 ft, - 5C temp) in North India1. Collaboration within the institution, developing alliances within the community, developing external partnership, identifying critical services, engaging specialists, developing shared vision, exploiting funding opportunities, exploring technological options and improving administrative processes were important. During the last three years it has been proved that a dedicated passionate group of champions can truly effect a major cultural and behavioural transformation in an isolated community. Technology was used as a means to achieve an end. It was never an end by itself. 1 https://www.ncbi.nlm.nih.gov/pubmed/27135412

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INFORMATION TECHNOLOGY

eUPHC in Andhra Pradesh

In a first of its kind initiative the Govt of Andhra Pradesh outsourced the complete maintenance of 164 Primary Health Centres located in suburban areas. Over the last 20 months Remote Healthcare in the form of speciality

teleconsults have been provided on 220,000 occasions constituting 7.5 per cent of all footfalls. All teething troubles have been sorted out. The operational details have been fine tuned. A combination of deployment of state of the art technology, continuous

monitoring of patient satisfaction, learning, unlearning and re learning has led to acceptance of teleconsults by the community and the administration. This success story has resulted in other state governments following this model. ( Ref http://www.euphc-ap-gov.in/ )

REMOTE EYE CARE

Millions of people around the world are at risk of developing permanent visual impairment due to lack of eye care services. In India, the ophthalmologistpatient ratio is dismal, at 1:10,000. The Andhra Pradesh Tele-Ophthalmology Services under the brand nameâ&#x20AC;&#x2DC;Mukhyamantri e - Ey e K e n d r a m - Me E K â&#x20AC;&#x2122; i s a specialised Telemedicine program using state of the art eye care equipment comprising of Fund us Camera and Autorefractometer integrated with

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INFORMATION TECHNOLOGY

a complete EMR system enabling remote grading of high resolution medical grade fund us images for diagnosing important eye ailments. With 60 ophthalmologists located 150 to 300 km away and two spectacle manufacturing factories also located far away this tele ophthalmology service is demonstration of Remote Eye care at its best. Real time Teleconsultations in Camp Mode

Over the last 3 years, half a million individuals have been screened for diabetes, hypertension, obesity and recently for lumps in female breasts. More than 7000 individuals have availed of teleconsults and tele diet counselling during the screening camps.

TAKE HOME MESSAGE

Acknowledgments These projects are being successfully implemented only because of a dedicated passionate team whose motto is “ Failure is never an option” . The author acknowledges the leadership of Vikram Thaploo,

AUTHOR BIO

Technology-enabled Remote Healthcare is now a reality. Though an administrative decision, for PPP’s to be successful, political and community support is essential. Used judiciously and customised, PPP can change the healthcare landscape, if interests of all stakeholders are considered. Formulating legal and regulatory framework together, the confidence of government and private players to invest in such partnerships would increase. PPP will help mobilise resources for specialist healthcare. Creating a passionate team to administer and implement well thought out Standard Operating Procedures make all the difference between success and failure. With proper ‘Man management’, producing ‘customer delight’ is doable.

Premanand, Dr Ayesha, other heads of the support staff and the hundreds who together form a TEAM, who “unwept, unhonoured and unsung” work day and night responding to most unreasonable demands.

K Ganapathy, Former Secretary and Past President Neurological Society of India, Telemedicine Society of India & Indian Society for Stereotactic & Functional Neurosurgery. Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services. Emeritus Professor TamilNadu at Dr MGR Medical University & Formerly Adjunct Professor IIT Madras & Anna University Madras . URL www.kganapathy.com, e-Mail: drganapathy@apollohospitals.com

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VACUETTE® Super-T Disposable Tourniquet

More hygiene in daily routine

As a safety products company, Greiner Bio-One support hygiene and safety in routine healthcare. The use of the VACUETTE®Super-T is a significant step in the right direction. Studies indicate that it is poor hygiene and the handling of equipment such as tourniquets acting as fomites that is more likely the cause of cross-contamination, as opposed to cross-contamination occurring by contact to the skin of the patients. tourniquets that are the cause of cross-contamination, as opposed to the patients’ skin being the risk being the skin of the patient. In a study at a hospital, only 37 per cent of the

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team did hand-washing with soap and alcohol prior to venipuncture. As a conclusion of that, “poor hygiene combined with the unawareness in use of tourniquets make re-usable tourniquets a vehicle of hospitalacquired infections” 1. To minimize the window of opportunity for crosscontamination, a disposable tourniquet should be used and immediately disposed of after use. The surface of a tourniquet “has the potential to act as fomite and can harbor pathogenic microorganisms”. Furthermore, in this study to determine the prevalence of Multi-Resistant Organisms (MRO), it was found that the highest rate of MRO colonization was in the ICU, putting the most fragile patients at risk. The risk with a re-usable tourniquet is that there is constant handling, possibly without gloves, between patients. Even with a ‘single-patient tourniquet’ – limited to one patient, there is no of tracking which healthcare worker has handled the tourniquet, or with which patients and medical devices previous contact has been made. To minimise risk and maximise safety for the patient, a single-use product should always be the tourniquet of choice.

1 Anesthesiologist’s hand hygiene and disinfection of reusable rubber tourniquet with alcohol swabs before intravascular cannulation; Ji Yeon Kim, Hyun-JooAhn, Eun-Kyung Lee and Hyun Byung Chae

For this reason, Greiner Bio-One recommends the VACUETTE Super-T for your daily routine care. • Single-Use • Easy application and quick release • Protects from cross-contamination • Not made with natural rubber latex and non-DEHP • Practical reclosable box Greiner Bio-One specialises in the development, production and distribution of high-quality plastic laboratory products. The company is a technology partner for hospitals, laboratories, universities, research institutes, and the diagnostic, pharmaceutical and biotechnology industries. Greiner Bio-One is split into three divisions – Preanalytics, BioScience and Sterilisation. As an Original Equipment Manufacturer (OEM), Greiner Bio-One provides individual solutions in the area of custom-made design developments and production processes for the life sciences and medical sectors. In 2017, Greiner Bio-One International GmbH generated a turnover of 473 million euros and had over 2,200 employees, 26 subsidiaries and numerous distribution partners in over 100 countries. Greiner Bio-One is part of Greiner Holding, which is based in Kremsmünster (Austria). More at www.gbo.com. Advertorial www.asianhhm.com

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HEALTHCARE MANAGEMENT Malaysia Healthcare Travel Council.............................IBC, 20-25

FACILITIES & OPERATIONS MANAGEMENT

Newster Group......................................................................... 19

Cantel Medical......................................................................... 07

Turkish Cargo.........................................................................OBC

Greiner BioOne................................................................... 58-59

World Hospital Congress........................................................ IFC

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TECHNOLOGY, EQUIPMENT & DEVICES

RamSoft Inc............................................................................. 49

Cantel Medical......................................................................... 07 Greiner BioOne................................................................... 58-59 Newster Group......................................................................... 19

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www.medivators.com

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Greiner BioOne................................................................... 58-59

Turkish Cargo.........................................................................OBC

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Newster Group......................................................................... 19

World Hospital Congress........................................................ IFC

www.newstergroup.com

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ONLINE CLIENTS Spok Inc

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MedicalExpo

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MEC Singapore

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Computer Sciences Corp www.csc.com

Abbott Laboratories www.abbott.com

Schneider Electric

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HIMSS Asia Pacific www.himss.org

Siemens Healthcare Pte Ltd

www.siemens.com www.healthcare.siemens.com.sg

Hong Kong Trade Development Council www.hktdc.com

Cogora Limited

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Harvard Medical School https://hms.harvard.edu/

European Society for Medical Oncology (ESMO) www.esmo.org

Informa Life Sciences Exhibitions www.informalifesciences.com

PerkinElmer (India) Pvt Ltd www.perkinelmer.com

Zebra

https://www.zebra.com/us/en/solutions/ healthcare.html

Unisys Corporation www.unisys.com

Techmagnate

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To receive more information on products & services advertised in this issue, please fill up the "Info Request Form" provided with the magazine and fax it. 1.IFC: Inside Front Cover 2.IBC: Inside Back Cover 3.OBC: Outside Back Cover