w w w. a s i a n h h m .

c o m 
 Contents

Interviews
23
Cover Story

Genetic Tests 24

Medical Sciences
All about interpreting
Stephen M Sammut, Senior Fellow,
Wharton Health Care Systems,
University of Pennsylvania and
Venture Partner, Burrill & Company, USA

Genetic Testing 28

Medical Sciences
The ethics side
Arthur Caplan, Emanuel & Robert Hart
Professor of Bioethics, Chair, Department of Medical
Ethics and Director Center for
Bioethics, University of Pennsylvania,
USA

MEDICAL SCIENCES Genetic Testing 30

Medical Sciences
Personalised Medicine 32 All set for growth
Future architecture Julian Awad, CEO & Co-Founder,
Timothy Yeatman, Executive Vice President, Translational Research Smart Genetics LLC,
H. Lee Moffitt Cancer Center & Research Institute, HIVmirror LLC,
USA
University of South Florida and President & CSO, M2Gen,
USA

Personalised Medicine 34 Life Sciences Industry 39

Convergence
An idea whose time is approaching Converging for better care
Robert Roberts, President & CEO, University of Ottawa Heart Institute, Robert Go, Managing Director,
USA Global Life Sciences and Health Care,
Deloitte Touche Tohmatsu,
TECHNOLOGY, EQUIPMENT & DEVICES USA

Convergence in the 36 Combination Products 41

Convergence
Life Sciences Industry Enabling localised care
Combination products show the way Chris Cramer, Principal, Life Sciences Practice,
Akhil Tandulwadikar, PRTM Management Consultants,
Healthcare Editorial Team USA

HEALTHCARE MANAGEMENT
Improving Patient
Health Insurance in Asia 06
Strengthening the insurer-healthcare provider Safety
relationship
Focussing on non-technical skills
Jean-Michel Chatagny, Managing Director, Strategic Corporate
Rachel J Vickers, Consultant Anaesthetist,
Development-Asia, Swiss Re,
Queen’s Hospital,
Singapore
England
15
08 Consumerism SURGICAL SPECIALITY
in Healthcare Laparoscopic Repair of Inguinal Hernia 17
Impact on business models Pradeep Chowbey, Chairman,
Minimal Access & Bariatric Surgery Centre,
Harald Pitz, Vice President,
Sir Ganga Ram Hospital, India
Industry Business Unit Healthcare Higher
Education and Research, SAP AG,
Germany DIAGNOSTICS
Rapid Diagnostics 20
Hospitals That Heal 11 Fighting emerging diseases
Hospital design for the 21st century Albert Cheung-Hoi Yu, Chairman & CEO,
Anjali Joseph, Director, Research, The Center for Health Design, Lok Ting Lau, COO & General Manager,
USA Hai Kang Life Corporation, Hong Kong

w w w. a s i a n h h m . c o m 
 Asian Hospital & Healthcare Management ISSUE-13 2007
 CONTENTS

TECHNOLOGY, EQUIPMENT & DEVICES

Operating Room of the Future 43
Emerging technologies Issue 13 2007
Olivier Wenker, Professor of Anesthesiology, Division of Anesthesiology,
Critical Care and Pain Medicine, University of Texas,
USA Chief Editor : Rajeshwer Chigullapalli
Healthcare Editorial Team : Grace Jones
Medical Devices 47
Going the generic way Akhil Tandulwadikar
Prasanthi Potluri
Richard Kuntz, President & CEO, Generic Medical Devices, Inc.,
USA Aala Santhosh Reddy
Copy Editor : Jagdeesh Napa

FACILITIES & Operations

Art Director : Hannan M A

management
Product Manager : Yuvraj Sahni
Project Coordination Team : Sunny Roger
Stella Powell
Patient Safety 49 N Sweta
The next level Shadaan Osmani
James B Battles, Senior Service Fellow, Project Associates : Sam Smith
Patient Safety, CQuIPS, AHRQ, United States Bhavani Prasad Pasupuleti
Department of Health & Human Services,
Sreevardhan Rao
USA
Rajkiran Boda
Madhubabu Pasulla
INFORMATION TECHNOLOGY
Asian Hospital & Healthcare Management is published by
Cardiovascular Medicine 51 Ochre Media Pvt. Ltd. in association with Frost & Sullivan
Integrating IT for better care
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Dartmouth-Hitchcock Medical School
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University of Arkansas for Medical Sciences
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Intelligent Health Networking 59
Changing our way of healthcare
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Director, e-Health Research Unit, Monash University,
Australia
Interview
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Srishti Software Applications Pvt. Ltd., India
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w w w. a s i a n h h m . c o m 
 Asian Hospital & Healthcare Management ISSUE-13 2007

Healthcare Genomics
The healthcare markets are witnessing launch of genetic tests, personalised medicines,
therapies, which in turn are influencing the clinical care and patient outcomes.
E
ver since the beginning of the Human Genome
Project (HGP) in 1989, the talk of revolutionary
changes it could unleash on medicine and
healthcare as a whole began. However, for a while it
appeared to be a mere mirage and science seemed to
enrich science without ever leading to delivery of any
useful products or services affecting human life. That
is now beginning to change. The lab-to-market place
transition seems to have begun.
The whole healthcare continuum is likely to be
influenced by the progress in genomic science. The
healthcare markets are witnessing launch of genetic tests,
personalised medicines, therapies, which in turn are
influencing the clinical care and patient outcomes.
Genetic tests seek to identify an individual’s
predisposition to a disease, given the genetic makeup and
hence susceptibility to disease, enabling the physicians to
customise the precise treatment option that is right for
that individual. This changes the healthcare paradigm
into preventive care as opposed to the existing event-
based, reactive healthcare.
Tests that are already available in this category include
BRACAnalysis from Myriad Genetics, a genetic test for
hereditary breast and ovarian cancer and HIVmirror
which tests people for a gene that can slow the progress
of HIV.
The FDA too has taken cognizance of this potential
of genomics to revolutionise healthcare. It has issued
elaborate guidelines for data submissions, organises events
and publishes new considerations and findings regularly.
Foreword
Personalised medicine is another offshoot of
progress in genomics. It is based on the premise that
each individual is unique in terms of genetic makeup
and use of traditional one-size-fits-all drugs has limited
results in some cases and adverse patient outcomes in
others. The products that emerged in this area include
ImClone Systems Incorporated's Erbitux for Cancer and
Genentech's Raptiva for Plaque Psoriasis.
Against this backdrop, this issue presents a collection
of articles and interviews focused on this topic. The articles
talk about how personalised medicine can transform the
treatment of Cancer and Cardiovascular diseases. The
three interviews give unique perspectives on the potential,
challenges of genetic testing. The cover story also presents
a perspective on the convergence in the life sciences
industry and how it can improve care. This convergence
is also most likely to be influenced by genomics in the
future.
However, it is still early days. Formidable challenges
lie ahead for the full potential of genomics to emerge in
the healthcare arena. The significant ones among these are
limited understanding of the interplay of genes as well as
effect of other aspects such as lifestyle, confidentiality, and
ethical dilemmas.
Rajeshwer Chigullapalli
Chief Editor
Essential reading for the
healthcare professional.
Subscribe / register online at
w w w . a s i a n h hw m
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a nm
hhm.com 
 H E A L T H C A R E M anagement

Health Insurance in Asia

Strengthening the insurer-healthcare
provider relationship

As Asia’s MSPs evolve, so too will Asia’s health insurance sector—and the symbiotic
relationship that binds the two together. Indeed, it is not inconceivable that Asia’s large hospital
chains may one day seek to enter the health insurance industry themselves.

a proactive approach to dealing with insur-
Jean-Michel Chatagny ers and Third Party Administrators (TPAs),
Managing Director who are destined to play an ever bigger role
Strategic Corporate Development-Asia in controlling Asia’s healthcare costs, ensur-
Swiss Re
ing quality healthcare, and laying the foun-
dation for sustainable growth of the health-
care industry.
using the tools and products that deliver the
most appropriate healthcare coverage in the
most efficient manner.
In India, until recently, cooperation
between the insurance and healthcare in-
dustries was minimal. In spite of this lack
of cohesion, private hospitals and health-
care providers have proliferated through-

A
cross Asia, governments are grap-
pling with the serious challenges
of providing adequate medical
coverage against a backdrop of rising costs,
inefficient healthcare insurance systems,
and growing public pressure for change.
In many countries poverty exacerbates the
need for change, particularly in rural com-
munities, where medical expenses not only
put earnings at risk but also destroy sav-
ings. At the same time, a growing middle
class throughout the region is demanding
far more choice in the form of new and
innovative healthcare products.
These challenges and their solutions
will have a tremendous impact on Medical
Service Providers (MSP), insurers and the
increasingly demanding public that both
serve.
MSPs and insurers are bound to grow
closer in coming years, working together
to provide creative solutions for patients’
needs. In developed markets, insurers help
provide cost-effective healthcare, covering a
large range of both conventional and uncon-
ventional treatments. They also bring many
benefits to hospitals, namely increased pa-
tient traffic, cashless transactions and strong
support for positive regulatory outcomes.
For Asia’s MSPs to enjoy the benefits such
a relationship can offer, they need to adopt
China and India: Growing role of out the country. While this growth made
insurers medical care accessible to many more Indi-
Any doubts about the radical changes ans, healthcare bills drove many into debt
underway in Asia’s healthcare sector are and poverty—a situation which still exists
dispelled by examining recent history, par- today. In the last few years, however, insur-
ticularly in Asia’s future economic super- ers and medical service providers are work-
powers, China and India. ing more closely together achieving very
In China, reform of the healthcare encouraging results.
system is at the top of the State agenda: Several major changes have driven the
in March, Premier Wen Jiabao announced trend for cooperation in India, namely the
that the country would spend CNY10.1 introduction of TPAs for medical insurance.
billion (US$ 1.26 billion)
to extend coverage of the
Rural Cooperative Medi- Growth trend in private healthcare provision
cal Scheme, aiming to
deliver basic medical cov- 300
erage to 80% of the rural
population by the end of 250
2007. He also formed a
task force to draw up plans 200
for reforming the urban
healthcare system. 150
Meanwhile, China’s
insurance regulator is ac- 100
tively encouraging greater
partnership between local 50
authorities and private in-
surers. Its goal is a multi- 0 India China Japan Korea Taiwan Australia
level coverage system that
will serve different seg-
2001 2002 2003 2004 2005
ments of the community,

 Asian Hospital & Healthcare Management ISSUE-13 2007


Key areas of cooperation between
insurers and MSPs
• Reimbursement models that encourage
cashless transactions
• Increased bed utilisation rates at
hospitals
• Focussed cost cutting programs
• A broader range of services and
treatments for patients
Although the hospital/TPA/insurance rela-
tionship is complex, it has led to service im-
provements at both hospitals and insurers,
with the end result of more affordable care
for patients. Cashless transactions at hos-
pitals have risen sharply and more hospital
beds are filled, boosting their profitability.
Tellingly, Indian doctors and hospital ad-
ministrators are increasingly becoming con-
versant in TPA and insurance terminology
and practice, helping them make the most
of their partnerships with insurers.
In the longer term, such partnerships
will yield even greater benefits. By 2050,
India is expected to be the world’s most
populous nation with 1.63 billion people
compared to China’s projected 1.44 bil-
lion. If just 10% of this massive population
buy healthcare insurance, it will represent
a customer base of 307 million people. By
fostering close relationships with insur-
ers, healthcare providers will be ensured of
access to this large patient base.
Additionally, the emergence of medi-
cal tourism, with many hospital chains in
Asia setting themselves up as centres of
excellence, will lead to increased collabora-
tion. Indeed, Asia's medical travel market
is projected to be worth US$ 7 billion in
the next five years, boosted in part by an
increasingly affluent consumer in India and
China alongside poor healthcare provision
throughout the rest of the world.
The winds of change across Asia
Change is also underway in Asia’s other
countries, as the economic realities of
modern healthcare force governments to
review their relationship with the popula-
tion in regard to healthcare costs. In Japan
and Korea, rising medical costs pose grave
problems for both the countries’ national
healthcare systems. In Southeast Asia, the
public provision of healthcare is increasingly
becoming unsustainable owing to increas-
ing usage and expectations. In Australia,
an ageing population is putting strain on a
system that is already running at overcapac-
ity. Although the solutions may differ by
country, what is certain is that the relation-
ship between healthcare insurers and MSPs
will be strengthened.
Many models exist to define the role
that both MSPs and insurers should play in
healthcare systems. Often, this depends on
the current market infrastructure, mainly
the structure of the insurance industry and
medical service provider network, as well as
the regulatory frameworks that govern both.
Experience in developed markets shows that
the more advanced the infrastructure, the
more interaction there is between insurers
and MSPs. A robust infrastructure provides
many incentives for MSPs and insurers to
work together, ensuring a closer alignment
of interests. Key areas for cooperation in-
clude mutually beneficial managed care and
intervention programmes, guaranteed cus-
tomer payments via cashless transactions,
guaranteed bed capacity and cost reduction
strategies.
Less cash, more cash flow
In virtually every case, this closer interac-
tion has led to the gradual increase of ad-
vanced reimbursement models among the
insurers, MSPs and insured—a great im-
provement over traditional fee-for-service
The trend is for markets to evolve and mature and then eventually reach
their natural saturation point. For private healthcare, this cycle will often take
many years before the market reaches a natural state of equilibrium.
Growth trend in private
healthcare provision
Integrated state and
private offering
Increasingly
mature market and
sophisticated buyers
Regulatory burden, Life only
little incentive
Stay away
Risk not insurable
No opportunity
Administration Underwriting, Active claims
H E A L T H C A R E M anagement
arrangements. Such models also give doc-
tors strong incentives to balance the needs
of patients with economic realities.
The fee-for-service model, moreover,
can encourage the prescription of unneces-
sary medications and treatments, sharply
raising costs for the party least able to af-
ford it—the patient. A more consistent fo-
cus on costs can also be of benefit to the
MSPs themselves, as ultimately a strong
relationship with insurers can provide the
much needed quantum leap in patient traf-
fic, which in turn boosts income needed to
upgrade facilities and enable expansion.
While the changing healthcare land-
scape in Asia presents many challenges for
medical service providers, it also presents
unprecedented opportunities for growth.
As Asia’s MSPs evolve, so too will Asia’s
health insurance sector—and the symbiotic
relationship that binds the two together.
Indeed, it is not inconceivable that Asia’s
large hospital chains may one day seek to
enter the health insurance industry them-
selves. Ultimately, the changes afoot across
Asia will result in more preferred provider
arrangements, with hospitals and insurers
playing a dual role in customising afford-
able solutions and designing affordable
products for the most important party in
the mix—the patient.
Managed
care
Full
reimbursement
Hospital
cash
Critical
illness
Insurer's Involvement
Product devt management
w w w. a s i a n h h m . c o m 
 H E A L T H C A R E M anagement

D
uring the last decade we have
seen significant efficiency gains
in many industries – specifi-
cally in industries such as manufacturing,
automotive, trading etc. Processes have
been optimised and streamlined within
enterprises, as also significantly across
enterprises. Costs have been reduced
through closer collaboration with suppli-
ers. Customer service has improved, for ex-
ample, through provision of information,
access to products and services any time
and anywhere.
The driving force of this change is com-
petition, which has been created by the

Consumerism
consumer, who is shopping for the best price
and best quality for almost every product or
service. This has forced enterprises to reduce
costs while improving services, and it has re-

in Healthcare
sulted in more intelligent business processes
and improved business models. Today,
flexibility, adaptability and speed of change
are the key for enterprises to survive in the

Impact on increasingly competitive environment.

All these changes have been enabled by

business models the increasing use of Information Technolo-

gy. In fact, many of the innovations wouldn’t

and processes have been possible without a strong IT

support. IT has become strategic in enter-
prises, enabling efficiency through standar-
disation, and providing the flexibility to
accelerate innovation.
In healthcare, we have seen great
innovations and significant improvement in
the healthcare product arena. The increase
Harald Pitz in life expectancy is an achievement which,
Vice President
to a high extent, comes from improved
Industry Business Unit medicines. It is very characteristic
Healthcare Higher Education and Research that a majority of the change has hap-
SAP AG pened in ancillary departments, but
Germany
not in core processes that directly face

Key challenges put the sustainability of

the current healthcare system at risk

Healthcare providers lag behind other industries as

far as transformation to customer-driven or customer-
focussed organisation is concerned. For this to happen,
the customer needs to be equipped with information
about products and services, which in turn necessitates
collaboration along healthcare continuum.

Figure 1

 Asian Hospital & Healthcare Management ISSUE-13 2007

 H E A L T H C A R E M anagement

the healthcare customers. Little has been changed in the way

Collaboration along the complete healthcare continuum in a patient-
healthcare is approached and delivered. For example, little attention centric landscape enables pro-active health management
is being paid to prevention, which in other quality-critical industries
Figure 2
such as the airline industry, is fundamental to do business.
What is the reason for the lack of change and transformation in
healthcare? By nature, healthcare in terms of diagnostics and treat-
ment is something people need and nothing people want. Today in
most of the healthcare systems, health insurers or the government
are covering the majority of the cost, so that patients do not really
look at costs or better prices. Due to lack of incentives, individual
stakeholders such as provider organisations, insurers or pharmaceu-
tical companies have not driven cross-organisational change. The
patient today is not in a strong enough position to drive changes.
This is mainly because the patient does not have the necessary infor-
mation and understanding to assess, for instance, whether a service
or a treatment is good or bad, whether there are alternatives and
what a best choice can be. This is very different from other indus-
tries where product information is widely available that allows to
Patient Advocacy Groups and Health Information Broker to support
assess quality and go for the best alternative. Through making more
the patient in a patient-centric landscape
information available, the patient first needs to be enabled to behave
Figure 3
and act as a consumer.
In some areas, where the insurance system has cut funding
and where significant co-payments need to be made by patients, a
consumer-oriented environment has developed. For example, in-
surance coverage for eyeglasses has been significantly limited which
in turn has opened a competitive market where prices have fallen far
below the traditional levels. But consumerism, a key market force in
many other industries, so far has had limited effect in healthcare.
More significantly, healthcare faces major challenges which
have put its affordability and sustainability at significant risk. Key
challenges are ageing population, quality issues, increased cost and
skill shortage (Figure 1).
One impact of these challenges is that our daily life is more
affected than it has been before. While healthcare in general has
been very event-driven, so that the patient has had to deal with the Transformation through Collaborative and Patient-Centric
health system mainly when a disease had to be cured, the increase of Healthcare Network
chronic diseases, for example, makes healthcare much more home Figure 4
bound and affecting our daily life.
One of the impacts of an ageing population is that elderly
people living alone require more long-term care and a continuous
services support, less an event-based care.
The cost pressure has started to lead to more cost-effective mod-
els, e.g. we see more healthcare services being moved from inpatient
to outpatient and from outpatient to home. So the environment
where healthcare delivery is taking place becomes increasingly con-
sumer-driven. In addition, reduced insurance coverage leads to
more awareness and shopping attitude of the patients.
The discussion around increasing number and influence of dis-
eases such as obesity, diabetes and back pain causes recognition in
the population that we all can individually influence health, which
creates a demand for more and better information. As a first step, provider collaboration is the key, allowing shar-
These examples indicate that the health system needs to be ing of patient information not only between hospitals and primary
patient-centric in the future. A patient-centric system that is de- care providers, but also with pharmacies. This collaboration should
signed to provide more and better information and high quality also include other and new providers that will enter the market such
services will require true collaboration between all stakeholders, as home health organisations, disease management and wellness
collectively using and sharing knowledge and information. companies.

w w w. a s i a n h h m . c o m 
 H E A L T H C A R E M anagement
Collaboration along the healthcare
continuum places the patient at the centre
of this ecosystem, creating what we call a
patient-centric landscape (Figure 2). Pro-
viding patients access to information that
is available from all of these sources enables
them to improve the decisions they make
concerning their health and their lifestyle.
Further down the road, more informed
patients will wield more power to make the
health system work in the interest of the pa-
tients themselves.
Patient advocacy groups will support
individual patients in getting their interests
respected.
We also believe that there will be an
increasing need to support the patients in
understanding and handling the increasing
information flow they confront. 'Health
information brokers' will assist patients in
making informed choices and decisions to
better manage their own health.
Incentives for healthy behaviour and
healthy lifestyle from the payer community
will increase patient interest in prevention
10 Asian Hospital & Healthcare Management
and health awareness and in turn lead to a
reduction of overall healthcare cost.
Since health data is particularly sensitive
information, a legislation framework will be
required that enables information exchange
while protecting patient privacy and honor-
ing the consumer rights. (Figure 3).
In summary, a collaborative healthcare
network that places the patient at the centre
of the health system enables the transforma-
tion from a passive patient to an informed
consumer who is able to select wellness
maintenance and treatment from a collab-
orative global healthcare community that
provides personalised, evidence-based care
(Figure 4). The patient, in fact, may become
the owner of his data and decide about its
distribution and use.
The transformation creates space
for new or enhanced business models in
healthcare. Examples for that are:
• Walk-in clinics leveraging the infra-
structure of the retail industry
• Organisations providing combination
of wellness and treatment
ISSUE-13 2007
• Provider of unconventional medicine
as a response to increasing number of
diseases which cannot be related to a
specific diagnosable issue
• Organisations that provide a more inte-
grated view on chronic diseases
Summary
Consumerism has driven transformation
and innovation in industries. Healthcare—
despite significant improvement in the
healthcare product—has seen limited trans-
formation in the way it is approached and
delivered. However, major challenges put
the affordability and sustainability at risk.
Collaboration and patient-centricity
will make information more easily available
and understandable, change the patients’
behaviour and give patients wider choice.
The passive patient will be transformed to
an informed consumer who is able to se-
lect wellness maintenance and treatment
from a collaborative global healthcare
community that provides personalised,
evidence-based care.

Hospitals
That Heal
Hospitalst design for
the 21 century
The evidence-based design elements are quickly becoming
mainstream in the design of US hospitals. Clearly, they are
as applicable and relevant to hospitals the world over.
Anjali Joseph
Director
Research
The Center for Health Design
USA
H
ospitals are extremely stressful
places for patients, their families
and the staff who work there. Pa-
tients are not only faced with the prospect
of dealing with their illness and injury but
are forced to reckon with an environment
that further exacerbates their pain and
stress. Hospitals that are noisy, have com-
plicated layouts and confusing wayfinding
systems, poor ventilation and air quality
and few positive distractions are common
the world over. Such environments con-
tribute to nosocomial infections, medical
errors and other outcomes including lack
of sleep and increased anxiety. At the least,
this can slow down the healing process
and at work, may even result in death and
serious injury.
There is increasing awareness that the
physical environment is a critical compo-
nent of the care provided in hospitals and
plays an important role in promoting pa-
tient and staff safety and health as well as
H E A L T H C A R E M anagement
overall quality of care. A large body of research
exists that attests to this. A study conducted
by researchers at The Georgia Institute of
Technology and Texas A&M University
in 2004 identified more than 600 articles,
most published in scientific peer-reviewed
journals linking the physical environment
of healthcare facilities with patient and staff
health, financial and operational outcomes
(Ulrich, et al., 2004). Just as medicine has
increasingly moved toward “evidence-based
medicine,” where clinical choices are in-
formed by research, healthcare design is in-
creasingly guided by rigorous research link-
ing the physical environment of hospitals to
patients and staff outcomes and is moving
towards “evidence-based design”.
Evidence-based design refers to the pro-
cess of using the best available evidence from
research and project evaluations to create
healthcare environments that are therapeu-
tic, supportive of family involvement, effi-
cient for staff performance, and restorative
for workers under stress. Many new hospi-
tals in the United States are being designed
based on evidence based design principles.
Further, healthcare clients are now demand-
ing that architects be able to demonstrate
their knowledge of evidence-based design
process. Hospitals that carefully consider
how physical environmental design likely
impacts patient, staff and organisational
w w w . a s i a n h h m . c o m 11
 H E A L T H C A R E M anagement
outcomes will go a long way toward sup-
porting the efforts of healthcare administra-
tors and clinicians as they deal with issues of
patient safety and quality in their hospitals.
The Center for Health Design, a non-
profit research and advocacy organisation
has pioneered a joint research effort with
healthcare providers called the Pebble Proj-
ect. These healthcare organisations are at
different stages in the design and construc-
tion of new replacement projects, renova-
tions or hospital additions. By becoming a
Pebble Project Partner, these organisations
commit to utilising the best available infor-
mation to make informed decisions during
this critical phase of their development and
to measure the outcomes of the decisions
they make once the project is complete and
to share the results of these efforts with the
design and healthcare community. Pebble
Partners such as Bronson Methodist Hospi-
tal in Kalamazoo, Michigan, Clarian Meth-
odist Hospital, Indianapolis, Indiana and
St. Joseph’s Hospital, West Bend, Wisconsin
have been very successful in incorporating
evidence based design principles in their
processes. These hospitals as well as others
have received nationwide and international
recognition for their work. Also, these or-
ganisations have documented many positive
outcomes including increased patient and
staff satisfaction, reduced staff turnover and
many other organisational efficiencies*.
Some of the evidence-based design el-
ements that are being incorporated by the
Pebble Project Partners and other hospitals
in the United States, Europe and Asia and
the measured benefits of these designs for
the patients and staff as well as the health-
care providers are discussed here.
Single patient rooms with space
for families
Based on a large body of research evidence
as well as emerging information from Pebble
Partners and others, most healthcare pro-
viders in the United States are moving to-
wards providing all single bedrooms in their
facilities. Some of the documented benefits
of single bedrooms over double bedrooms
or open bays include lower nosocomial in-
fection rates, fewer patient transfers and as-
sociated medical errors, far less noise, much
better patient privacy and confidentiality,
*For more information please go to: http://www.healthde-
sign.org/research/pebble/data.php
12 Asian Hospital & Healthcare Management
Single patient rooms with
space for families
better communication from staff to pa-
tients and from patients to staff, superior
accommodation of family and consistently
higher satisfaction with overall quality of
care. This evidence is also reflected in the
2006 version of the AIA Guidelines for
Design and Construction of Health care
Facilities which recommends single bed-
rooms in all new hospitals under construc-
tion in the United States.
Acuity adaptable patient rooms
Patients are transferred from one room to
another as often as 3 to 6 times during their
short stay in the hospital in order to receive
the care that matches their level of acuity.
This process results in increased costs, re-
duced quality of care, reduced satisfaction,
medical errors, wastage of staff time and re-
duced staff productivity. The acuity adapt-
able model potentially addresses this prob-
lem by providing different levels of care in
a single room so as to minimise the need
to transfer patients as patients’ acuity level
changes. Acuity adaptable patient rooms
are single patient rooms with acuity adapt-
able headwalls—which are equipped with
the gases and equipment needed to provide
care as patient acuity changed. The impact
of a 56-bed acuity adaptable unit (28
rooms on two floors) at the Clarian Meth-
odist Hospital in Indianapolis on different
outcomes was measured by comparing two
years of baseline data (before the move)
and three years of data after the move. The
researchers (Hendrich et al., 2004) found
significant improvement post-move in
many key areas: patient transfers decreased
by 90%, medication errors by 70% and
there was also a drastic reduction in the
number of falls.
ISSUE-13 2007
Access to windows and light
There is strong evidence that light is criti-
cal to human functioning and can be ex-
tremely beneficial to patients as well as staff
in healthcare settings. Adequate lighting
conditions are essential for performance of
visual tasks by staff in hospitals, and poor
lighting conditions can result in errors.
There is also strong evidence that shows that
exposure to light helps in reducing depres-
sion, alleviating pain, and improving sleep
and circadian rhythms among patients and,
thus, supports the healing process. Studies
conducted among different populations
show a strong preference for daylight over
electric light. Building interiors are lit by a
combination of daylight and electric light-
ing. Daylight entering through windows
can be extremely beneficial to patients, pro-
vided there is no glare and it is possible to
control light levels. However, in addition to
natural light, electric light is needed in all
parts of the hospital, though the need for
artificial lighting can be reduced by efficient
utilisation of sunlight wherever possible.
Windows that let in natural light have
the additional benefit of providing views
to the outside that orient patients and staff
to the time of day as well as provide posi-
tive distraction. Ulrich (1984) found that
patients recovering from abdominal sur-
gery recovered faster, had better emotional
well-being, and required fewer strong pain
medications if they had bedside windows
with a nature view (looking out onto trees)
than if their windows looked out onto a
brick wall.
HEPA filtration
The importance of good air quality in con-
trolling and preventing airborne infections
in healthcare facilities cannot be overem-
phasised. Providing clean, filtered air and
effectively controlling indoor air pollution
through ventilation are two key aspects of
maintaining good air quality. Several stud-
ies show that high-efficiency particulate air
(HEPA) filters, in particular, are highly ef-
fective in filtering out harmful pathogens
and are strongly recommended in areas
housing immunocompromised patients.
Adequate ventilation rates and regular
cleaning and maintenance of the ventilation
system are critical for controlling the level of
pathogens in the air. Some special precau-
tions to prevent infection during periods of
construction and renovation include using
portable HEPA filters and installing barri-
ers between patient care and construction
areas.
High performing sound absorbing
ceiling tiles
Hospitals are extremely noisy, and noise
levels in most hospitals far exceed recom-
mended guidelines. The high ambient noise
levels, as well as peak noise levels in hos-
pitals, have serious impact on patient and
staff outcomes ranging from sleep loss and
elevated blood pressure among patients to
emotional exhaustion and burnout among
staff. Poorly designed acoustical environ-
ments can pose a serious threat to patient
confidentiality if private conversations be-
tween patients and staff or between staff
members can be overheard by unintended
listeners. At the same time, a poor acoustical
environment impedes effective communica-
tion between patients and staff and between
staff members by rendering speech and au-
ditory signals less intelligible or detectable.
Installing high-performance sound-absorb-
ing acoustical ceiling tiles results in shorter
reverberation times, reduced sound propa-
gation, and improved speech intelligibility.
Also, this design measure increases speech
privacy as less sound travels into adjoining
spaces. In addition, providing single bed-
rooms and removing noise sources from
the unit helps to reduce noise levels at the
patient’s bedside.
Ceiling lifts
Patient lifting is a major cause of injury
to healthcare workers. According to Fra-
gala and Bailey (2003), 44% of injuries to
nursing staff in hospitals that result in lost
workdays are strains and sprains (mostly of
the back), and 10.5% of back injuries in
the United States are associated with mov-
ing and assisting patients. Reducing injuries
that result from patient-lifting tasks can not
only result in significant economic benefit
(reduced cost of claims, staff lost workdays),
but also in reducing pain and suffering
among workers. Ergonomic programs, staff
education, a no-manual lift policy, and use
of mechanical lifts have been successful in
reducing back injuries that result from pa-
tient-handling tasks. When PeaceHealth in
Oregon, a Pebble Partner, installed ceiling
lifts in most patient rooms in their intensive
care unit and neurology unit, they found
Bringing natural light
that the number of staff injuries related to into the hospital
patient handling came down from 10 in the Estrella Medical Center,
two years preceeding lift installation to 2 in Phoenix, AZ
the three years after lift installation (Joseph
& Fritz, 2006). The annual cost of patient
handling injuries in these units was reduced
by 83% after the lifts were installed.
Decentralised work stations and
supplies
Nurses spend a lot of time walking – usually
to locate and gather supplies and equipment
or to track down other staff members. One
way to address this problem is to bring staff
and supplies physically and visually closer
to the patients. To take this idea further,
new designs are incorporating decentralised
nurses’ stations and alcoves outside patient
rooms so that staff is distributed around the
unit (as opposed to being in a single cen-
tral location), closer to the patient. In the
Clarian demonstration project described Decentralized alcoves
earlier, nursing stations with computer outside patient rooms
access and servers for supplies were decen- Clarian Methodist Hospital,
Indianapolis, IN
tralised. Further, additional workspace was
provided outside each patient room. Also,
to reduce time spent walking back and forth
to the nursing station, necessary supplies
were provided in each room. Hendrich and
colleagues (2004) assert that the efficient
unit design helped in reducing walking and
supply trips, such that nursing time signifi-
cantly increased allowing for a reduction in
budgeted staffing care hours while at the
same time increasing time spent in direct
patient care activities.
The evidence-based design elements
described here as well as others are quickly
becoming mainstream in the design of US
hospitals. Clearly, they are as applicable
and relevant to hospitals the world over.
One reason for their adoption is the fact
that these ideas are supported by a body of
evidence. The idea that the initial upfront
costs of construction can be recouped in
the long run through savings from fewer
falls, fewer nosocomial infections, fewer
medical errors, fewer staff injuries, in-
creased staff recruitment and retention,
improved patient satisfaction and increased
philanthropy makes a strong business case.
For access to additional information and free white-
papers on several of these topics, please visit The Center for
Health Design website at www.healthdesign.org or contact
the author at ajoseph@healthdesign.org.
w w w . a s i a n h h m . c o m 13
14 Asian Hospital & Healthcare Management ISSUE-13 2007

Improving
Patient Safety
Focussing on non-clinical skills
C
lose analysis of aircraft crashes
let NASA conclude in the late
1970s that many of these were
caused, or significantly influenced, by poor
non-technical skills. In other words, they
were not caused by technical failure of the
aircraft or the pilot not being sufficiently
trained to fly it. The type of non-techni-
cal skills referred to included communica-
tion, fixation on one thing so that other
important details were missed and confu-
sion. Then training commenced for these
skills—this was initially referred to as cock-
pit resource management but later this be-
came crew resource management with the
realisation that the whole crew (including
ground staff) were involved in avoiding
Rachel J Vickers
Consultant Anaesthetist
Queen’s Hospital
England
The aviation industry
has been aware of the
role of humans in safety,
specifically the possession
of non-technical skills.
As a result, these skills
are taught and assessed.
The healthcare profession
has only recognised the
corresponding role only
recently and training in
such skills is developing
accordingly.
H E A L T H C A R E M anagement
accidents. The issue of the hierarchy of the
flight team in particular and resulting in-
ability of crew to speak up when concerned
(empowerment) are now addressed. This
type of training is now mandatory on an
annual basis in the aviation industry and
assessments take place regularly and are as
important in allowing crew to continue
flying as assessments in technical skills.
The healthcare industry lags many
years behind aviation industry in this as-
pect of safety, despite many similarities
between the two, especially in acute hos-
pital medicine – such as working within
(often unfamiliar) teams in an environ-
ment in which emergency management of
the situation is crucial. The situations are
w w w . a s i a n h h m . c o m 15
 H E A L T H C A R E M anagement
commonly stressful and fatigue is also an
issue. At the beginning of the 21st century
awareness of the role of non-technical skills
in healthcare and specifically their role in
patient safety increased as a result of a num-
ber of publications and events. A report,
To Err is Human, published in 1999 in the
US drew attention to vast numbers of ad-
verse events (i.e. those caused by the teams
looking after these patients) occurring
within the healthcare environment. Many
studies since have confirmed this—ap-
proximately 10% of patients in hospitals
will suffer such an event.
The “Swiss cheese” model demonstrat-
ed that most adverse events do not happen
in isolation but as a result of many barriers
and defences being breached. A number of
high profile cases occurred in the UK (e.g.
the wrong kidney being taken out during
surgery, the wrong chemotherapy drug be-
ing injected into the spine). As a result of
the above, the profile of patient safety has
considerably increased and the comparison
with the aviation industry has led to aware-
ness of the role of non-technical skills in
healthcare.
Non-technical skills in healthcare are
similar to ones in aviation—those skills
which are neither based on knowledge nor
technical skills. They have been usefully
divided into two groups—those which
are individual and those which are social
or interactive skills required within a team
set up. Individual skills include planning,
prioritising, decision making and individ-
ual situation awareness. Interactive skills
include leadership, team working, empow-
erment issues and team situation aware-
ness. Communication skills feature heavily
within both groups.
A major challenge is how to improve
these skills both in an individual and with-
in a team. The following issues arise:
• Can these skills be taught? – The evi-
dence is that they can, although some
people naturally possess more than oth-
ers
• When should they be taught? – As early
as possible in training, so that the idea
of patient safety and management is in-
grained into staff
• Should they be taught separately from
technical skills? – Whilst problems with
non-technical skills should be addressed
within technical skills training, they
16 Asian Hospital & Healthcare Management
probably need separate teaching as well.
It has been acknowledged that they
need to be taught specifically within a
problem-based learning undergraduate
curriculum.
• Should they be taught to a multidisci-
plinary group? – Whilst the individual
skills could be taught to a specific group
of staff the social skills appear to require
multidisciplinary training—something
which does not commonly occur with-
in the healthcare environment.
• What teaching methods should be
used? – As with all teaching methods,
there are lots of appropriate differ-
ent approaches. The use of simulators
has been widely advocated and cer-
tainly communication, leadership and
teamwork are well demonstrated in a
simulated setting. Though there is an
increasing number of simulators avail-
able for healthcare teaching, access is
still limited. Small group workshop-
based teaching allows in-depth discus-
sion of subjects and a number of places,
including the hospital I work with, are
developing such courses. In the UK the
National Patient Safety Agency have
developed a course in association with
the Royal College of Physicians which
can be downloaded from the internet
and taught to small groups. It is aimed
at newly qualified doctors.
• Should non-technical skills be assessed?
– Some form of assessment should fol-
low all training, both of the trainees
and the trainers. The difficulty here is
how to assess the skills. Patient safety,
including competency in non-technical
skills, is a core component of the train-
ing programme for newly qualified doc-
tors in the UK. An assessment system
for anaesthetists has been developed but
we need to assess teams as well as indi-
viduals. However, these assessments take
place in the simulated settings and not
in real workplace settings. The real test
is whether the number of adverse events
occurring to patients is reduced. This is
a long term project because of the dif-
ficulty in measuring such events—there
is widespread underreporting of such
events. Increased awareness of the staff
about patient safety issues results in
an increased number of adverse events
reported.
ISSUE-13 2007
At Burton on Trent, a District General
Hospital in the Midlands in England, we
have set up such a course. The course idea
originated following an incident in the in-
tensive care unit in which it was clear from
retrospective analysis that the problem was
due the to failure of non-technical skills
and the difficulty nursing staff had in ques-
tioning the actions of a doctor, given the
traditional hierarchical structure within
the unit. Discussions about this with a
non-clinician who had experience of the
aviation industry highlighted the differing
approaches of the two industries.
The aim of the course is to give the
staff tools to recognise a risky situation and
act as required. The tools are termed “bea-
cons” in recognition of their role as “warn-
ings”. As increasing beacons are noted, the
situation is likely to be more risky and ex-
tra attention is required. The beacons are:
communication, confusion, policies and
procedures, fixation, trepidation, leader-
ship and team working and humanity.
Problems relating to these can be seen as
non-technical skills.
There are repeated references to car driv-
ing where similar non-technical skills are re-
quired and the concept of recognising and
acting on risk is understood by the partici-
pants. We also have developed a video about
a fictional character called Mildred, who is
followed on a patient journey through hos-
pital, encountering many different areas in
hospital and teams involved in her care.
Each scene portrays a different problem
relating to non-technical skills—situational
awareness, communication, leadership and
team work and empowerment. These form
the base for the workshops. We run a fol-
low up half day session following the course.
We ask the participants to go back to their
workplace and observe (and act on if re-
quired) situations from a safety perspective,
particularly with regard to non-technical
skills and the beacons.
In conclusion, whilst as stated above,
the healthcare industry lags considerably
behind aviation, general awareness of and
training in safety and specifically in the
subject of non-technical skills, recogni-
tion of the value of these in healthcare is
increasing. There would appear to be ac-
ceptance of the fact that these skills can be
learnt and many differing ways are being
used for the same.

Laparoscopic Repair
of Inguinal Hernia
A large series of randomised
controlled trials conducted
all around the world have
confirmed clearly the advantages
of endoscopic inguinal hernia
repair compared to the open
technique in terms of operative
complication, discomfort,
analgesic use and return to work.
Pradeep Chowbey
Chairman
Minimal Access & Bariatric Surgery Centre
Sir Ganga Ram Hospital
India
M
inimal access surgery has been
a surgical watershed which has
ushered in a new era of tech-
nology-enabled surgery. It has firmly estab-
lished itself in the armamentarium of most
surgeons. With the advancement in the
technology and instrumentation, minimal
access surgery has been successfully applied
to most surgical procedures with favour-
able outcomes. One of the procedures to
have benefited immensely from minimal
access surgery has been the repair of her-
nias, especially inguinal hernias.
Historical Background
The initial enthusiasm for endoscopic herni-
orrhaphy was driven by dissatisfaction with
the pain, disability and recurrence follow-
ing traditional anterior hernia repairs. The
first endoscopic approach to the problem of
groin hernia is credited to Ger who intraab-
dominally stapled the neck of a hernial sac
in 1982. Schwartz in 1990 described a plug
repair. Arregui had described the transperi-
toneal repair whereas Mckernan and Phillips
developed the totally extraperitoneal repair.
The intraperitoneal onlay mesh repair was
developed by Franklin and Rosenthal.
Principle of endoscopic repair
Over the past decade, endoscopic hernia re-
pair has changed from an operation in evo-
lution to several well-defined techniques
of transperitoneal or totally extraperito-
neal approaches. Almost all endoscopic
repairs are now based on the principle of
Stoppa’s repair. All accomplish a posterior
reinforcement of the myopectineal orifice
of Fruchaud with prosthetic material thus
taking care of existing and potential her-
nial sites (direct, indirect and femoral).
Effectiveness of this type of repair has been
well-established by the open operation of
Nyhus and Stoppa. The endoscopic ap-
proach mimics this and can be considered
as a new method of performing an old es-
tablished open operation.
There are two techniques available for
preperitoneal herniorrhaphy—the Total
extraperitoneal repair (TEP) and Trans-
abdominal preperitoneal repair (TAPP).
These two procedures differ in their ap-
proach to the preperitoneal space. In
TAPP approach, the preperitoneal space
is reached through the abdominal cavity
whereas TEP repair is carried out without
breaching the peritoneum.
SURGICAL SPECIALITY
Figure 1: Inguinal canal
Anatomy
The anatomy of the inguinal region is one
of the most difficult to master and it needs
to be relearned before embarking on endo-
scopic repair as the approach to the hernia
is from inside out, which is just the opposite
of what one learns in the anatomy class, i.e.
outside in. Hence, an overview.
The inguinal region is a bridge between
the abdomen and the thigh, allowing neces-
sary structures to traverse from one anatom-
ical region to the other while maintaining
the sanctity of each region. Transmission
of these structures creates potentially weak
spots in the otherwise uninterrupted three-
layered abdominal wall resulting in inguinal
and femoral hernias.
Endoscopic TEP hernia repair is per-
formed in the preperitoneal space of Nyhus,
which is a potential space created between
the fascia transversalis above and the peri-
toneum below. The lateral extent is from
one Anterior Superior Iliac Spine (ASIS) to
the other. This also includes the retropubic
space of Retzius and Bogros. The region,
which marks the inguinal and femoral
hernias, lies within a quadrangle known as
myopectineal orifice of Fruchaud (Figure 1)
w w w . a s i a n h h m . c o m 17
 SURGICAL SPECIALITY

which is bound medially by lateral border of
rectus abdominis, laterally by iliopsoas, su-
periorly by conjoint tendon and inferiorly
by the pectin pubis. The lateral limit of the
visible pubic bone marks the site of Coo-
per ligament (pectineal ligament), which
extends along the superior pubic ramus
lateral to the pubic tubercle. The iliopubic
tract (analogue to the inguinal ligament)
extends from the Cooper ligament to the
ASIS dividing the myopectineal orifice
into superior and inferior compartments.
The superior compartment has the inferior
epigastric artery which divides the inguinal
hernias into direct (medial) and Indirect
(lateral). Below the iliopubic tract lie the
external iliac vessels. The medial most com-
partment of the femoral sheath houses the
femoral canal which is a potential space oc-
cupied by a femoral hernia.
Endoscopic repair requires exposure of
the entire myopectineal orifice, from the
midline to the ASIS, so as to cover all the
potential sites of hernias with a single large
mesh.
infraumbilical 12 mm transverse incision.
After incising the rectus sheath, a space is
created between the rectus muscle and pos-
terior rectus sheath. We use our indigenous
balloon prepared using two fingerstalls of a
size 7.5 latex surgical glove for preperitoneal
dissection. A 10 mm Hasson cannula is in-
troduced in the preperitoneal tunnel. Two
working ports are placed in the preperito-
neal space in the midline (Figure 3,4). Dis-
section of the extraperitoneal space begins
in the midline. The aim is to identify the
pubic bone. Dissection then proceeds in-
feriorly and laterally and the Cooper’s liga-
ment is identified. The direct hernial sac is
visible immediately and is reduced by trac-
tion on the peritoneal extrusion and counter
traction on the abdominal wall. The ana-
tomical landmarks that would now become
visible are Cooper’s ligament, iliopubic
tract, femoral ring and the inferior epigas-
tric vessels.
An indirect hernial sac is identified as a
white glistening structure lying anterolateral
to the cord. An incomplete sac is dissected
off the cord and completely reduced. No
attempt should be made to reduce a com-
plete sac as excessive traction causes severe
postoperative testicular oedema and pain.
Such a sac should be separated from the
cord, transected and ligated using a catgut
endoloop. Complete reduction of the peri-
toneal extrusion is ensured by stripping
the peritoneum over the cord till it is no

Indications
Endoscopic hernia repair is the procedure of
choice in patients with bilateral and recur-
rent hernias.
Anterior repair of a recurrent hernia is a
technically demanding operation and is as-
sociated with a much higher risk of regional
nerve injury and testicular ischemia. Endo-
scopic herniorrhaphy provides a posterior
approach so that the previously dissected
tissue is avoided, thereby reducing the
chance of regional nerve injury and vascular
compromise of the testis.
Bilateral inguinal hernias are an ideal
indication for endoscopic repairs. The abil-
ity to avoid bilateral inguinal incisions,
dissection and postoperative disability is
a significant advantage that should not be
minimised.
Laparoscopic hernia repair is performed
for primary unilateral hernia as well.

Technique of TEP
Here we undertake to describe the technique
of TEP in brief followed at our institute.
The patient is positioned in supine position Figure 2: OT layout for TEP
with the surgeon and the assistant standing
as shown in (Figure.2). Repair can be done
in either regional or general anaesthesia. Ex-
traperitoneal access is achieved through an

18 Asian Hospital & Healthcare Management ISSUE-13 2007

 SURGICAL SPECIALITY

Figure 3 & 4: Port sites

more visible proximally. Adequate space has
to be created lateral to the cord structures as
the lateral extent of the mesh would lie in
this space. The inferior extent of dissection
in this space is the psoas muscle.
The minimum size of the polypropyl-
ene mesh to be used on either side should
not be less than 15 x 12 cm. The mesh is
laid from the midline and extended over
the cord structures till the lateral abdominal
wall. The free margin of the mesh is pushed
into the retropubic space medially and lies
over the psoas muscle laterally. The mesh is
then fixed at two places – the pubic bone
Figure 3
and Cooper ligament using a 5mm fixation
device, Protack TM (Autosuture). No fixa-
tion should be done laterally for fear of cu-
taneous nerve entrapment. The mesh is then
unrolled to lie within the extraperitoneal
space and CO2 is exsufflated ensuring that
none of the edges of the mesh is partially
rolled as this may lead to further rolling and
the likelihood of future recurrence.

Contraindications
The absolute contraindication is a stran-
gulated hernia. Patients with history of ex-
tensive intra-abdominal pelvic infections,
history of pelvic irradiation, surgery in the
space of Retzius are not suitable for lapa-
roscopic herniorrhaphy. Similarly, patients
with severe cardiopulmonary insufficiency
are not suitable for laparoscopic approach.
The relative contraindications based on
the experience of the surgeons are obstruct-
ed hernia, complete irreducible hernia, pa-
tients who are obese and those with a his-
tory of previous lower abdominal surgery.
TAPP vs TEP
The TAPP method is simpler to learn and
therefore more frequently performed. How-
ever, we do not agree in principle to a trans-
abdominal approach routinely for groin
hernia repair as it necessitates violation of
the peritoneal cavity. For over a decade we
have been following the TEP technique for
repair of groin hernias and a TAPP repair is
performed only in patients who have had ex-
tensive lower abdominal surgery. In a study
by Sergio Roll et al from Brazil comparing
TAPP and TEP, it was observed that TEP
repair was associated with the lowest risk of
intraoperative and postoperative complica-
tion related to the male genitalia. Similarly,
a study by Felix et al. has shown that TEP
has fewer complications and equivalent if
not superior recurrence rates.
TEP vs Conventional repairs
The TEP repairs began at a time when Li-
chtenstein repair had become the standard
of care with reported recurrence rates of less
than 1%. The advantages of laparoscopic
repair over open repair are:
1) Reduced postoperative incisional pain
and disability
2) The greater availability of space by the ex-
traperitoneal approach facilitates the inser-
tion of a much bigger mesh as compared to a
smaller mesh when performing an open repair
3) In recurrent hernia, the dissection pro-
ceeds through a virgin area which was not
previously operated upon thus reducing the
chances of nerve injury and vascular injury
4) The entire myopectineal orifice can
be inspected bilaterally and repaired.
The reported incidence of a contra
lateral hernia in a patient presenting
clinically with a unilateral hernia is up
to 50%. TEP approach presents a major
Figure 4
advantage in this regard as both sides can be
repaired with the same approach
A large series of randomised controlled
trials conducted all around the world have
confirmed clearly the advantages of endo-
scopic inguinal hernia repair compared to
the open technique in terms of operative
complication, discomfort, analgesic use and
return to work. In a study by Liem et al, us-
ing a validated quality of life measurement
instrument, the endoscopic patient group
was found to have a significantly improved
quality of life at 1 and 6 weeks after surgery.
Conclusion
Primary inguinal hernia is a heterogeneous
disease which with the increasing age of the
patient, shows a rising incidence and also a
tendency to bilaterality. The optimal surgi-
cal approach must be selected individually.
Though no true gold standard exists, the
TEP procedure is the main pillar of opera-
tive treatment which synergises the advan-
tages of minimal access surgery, tension free
mesh repair and the Stoppa’s repair.

w w w . a s i a n h h m . c o m 19
 DIAGNOSTICS
Rapid Diagnostics
Fighting emerging diseases
Hospitals must learn to incorporate new technologies for diagnosis for the simple reason
that vaccination, drug treatment and other containment efforts cannot be maximised unless
emerging diseases are quickly identified.
Albert Cheung-Hoi Yu
Chairman & CEO
Lok Ting Lau
COO & General Manager
Hai Kang Life Corporation
Hong Kong
D
espite impressive advances in the
field of antimicrobials and vacci-
nation, the world is still facing the
threat of emerging diseases. A new disease
makes headlines almost every year. Are we
witnessing more diseases now than any time
in the past?
From the plague to the 1918 influenza
pandemic, infectious diseases have always
played havoc. Several factors have played a
role in the rise of emerging diseases, includ-
ing genetic variation in hosts and pathogens,
environmental changes and population
pressures. Furthermore, air travel has com-
pounded the problem. People are traveling
more often and so are germs. Travellers may
be exposed to germs they do not have im-
munity to and hence have a higher chance
of contracting an infectious disease, bring-
ing it home and spreading to others. Dur-
ing the Severe Acute Respiratory Syndrome
(SARS) outbreak, infected travellers carried
SARS around China to Hong Kong, Singa-
pore, Vietnam and Canada. Therefore, every
serious infectious disease today is of global
importance, not restricted to the country of
origin.
Emerging diseases can also result from
re-emerging old infections, new infections
like SARS or infectious diseases which
20 Asian Hospital & Healthcare Management
become difficult to treat due to drug re-
sistance. More and more germs that were
once easily controlled now defy treatment.
This is due to the indiscriminate and exten-
sive use of treatments. Doctors cite diagnos-
tic uncertainty, time pressure on physicians
and patient demand as the main reasons for
over-prescription of antibiotic.
Southeast Asia has experienced several
emerging diseases in the past decade, e.g. the
avian flu (H5N1) in Hong Kong in 1997,
Nipah virus encephalitis in Malaysia in
1998, the SARS outbreak in Southern Chi-
na in 2002, dengue fever in India in 2005
followed by chickungunya outbreak in India
in 2006. Currently, H5N1 poses the greatest
danger to humans because of its increased
host range, rapid mutation, resistance to an-
tiviral drugs and absence of vaccination.
Dengue fever, first recognised in 1950s,
is the leading cause of childhood mortality
in South Asia. Before 1970, only nine coun-
tries had experienced dengue fever but by
1995, the number had increased four fold. It
is re-emerging in the tropics and had reached
epidemic levels in India last year. Rapid
growth of cities in tropical countries has led
to overcrowding and decrease in sanitation,
allowing more mosquitoes to live closer to
more people. Many of the affected countries
are some of the poorest.
The Nipah virus caused a severe out-
break of viral encephalitis in Malaysia in
1998-1999. It affects pigs and people. Large
scale production of live stock e.g high con-
centration of pigs in limited space, have lead
to the spread of Nipah virus. Recent out-
breaks have occurred in India in 2001.
Tackling the challenges
Hospital workers are at the frontline battling
ISSUE-13 2007
emerging diseases. They are at a high risk of
acquiring the infection because patients do
not display obvious symptoms or in most
cases, the symptoms are unknown. During
the first few weeks of the SARS outbreak,
Hong Kong, Singapore, Vietnam and Can-
ada witnessed a large number of healthcare
associated infections. Cases were either not
identified quickly due to vague respiratory
symptoms or inexperience in dealing with
known SARS cases. In Hong Kong, 25% of
patients with SARS were healthcare work-
ers. Consequently, rapid diagnostic tests are
of great importance for the management of
emerging diseases in the future.
Molecular diagnostic tools have been
around for years and are advancing with
time. They have allowed us to discover dis-
eases that may appear new but have been
loitering around for some time. One exam-
ple is Helicobacter pylori, the bacteria re-
sponsible for stomach ulcers. A few decades
ago, the very idea of bacteria causing ulcers
seemed far-fetched. But now, it is a proven
fact, thanks to diagnostic tools available to
test for Helicobacter pylori infection. The
infection has not changed, but the only
thing that has is our knowledge and percep-
tion of it.
Hospitals must learn to incorporate
new technologies for diagnosis for the
simple reason that vaccination, drug treat-
ment and other containment efforts cannot
be maximised unless emerging diseases are
quickly identified. Vaccination cannot pro-
tect against the rapidly changing viruses of
tomorrow and drug treatment cannot limit
the spread. In the case of bird flu, drug
treatment is effective only if administered
within 48 hours after the onset of the
symptoms.
w w w . a s i a n h h m . c o m 21
 DIAGNOSTICS
Conventional methods vs rapid molecular
diagnostics
Most traditional or conventional microbio-
logical and immunological approaches for
identifying diseases work best when high
concentrations of the pathogens are present,
i.e. when the patient is already critically ill.
They are also limited by the time required
to obtain a satisfactory answer. Even with
these concerns, they still remain as the most
widely used method for identifying a broad
range of biological agents. There are two
reasons for this. Firstly, people have become
accustomed to this method and are hesitant
to adopt any changes. Secondly, these are
well established methods and do not require
significant investment in new technology
or equipment and can be put into opera-
tion in a broad range of private and public
laboratories. However, traditional methods
tend to be labour and resource intensive and
require sufficient expertise.
Molecular diagnostics, on the other
hand, are sensitive, can be performed more
rapidly with high throughput and at a lower
cost. However, molecular diagnostic tests
are not commonly used and virus culture
still remains the method of choice. Also,
most technicians in developing countries are
not well trained to use molecular diagnostic
tests. At the moment, microarray technol-
ogy is developing rapidly but it still lacks the
sensitivity for direct application to clinical
specimens. Nevertheless, these new technol-
ogies are an option and through the avail-
ability of portable machines for conducting
tests, they may change the face of diagnosis
of emerging diseases in the future.
Routine methods in use today for
diagnosis of emerging diseases can be
divided into three categories:
1) Culture method, conventional method
2) Laboratory antigen detection tests, rap-
id test
3) Tests using Nucleic acid Amplification
Techniques (NATs), rapid test
Virus/bacterial culture is considered
as the ‘gold standard’ for identification of
viral/bacterial infections. However, in an
outbreak, time is the limiting factor and the
sooner the disease is diagnosed, sooner the
control measures can be put into place.
The second type of tests are the antigen
detection tests and they have to be carried
out in a laboratory. These include the Immu-
nofluorescence Assay and Enzyme-Linked
22 Asian Hospital & Healthcare Management
Immunosorbent Assay (ELISA). Although
these tests cost less, they are easy to operate
and provide results within hours, they are
prone to co-reactivity between proteins, af-
fecting results. These methods are also less
sensitive than Polymerase Chain Reaction
(PCR), described below, and their sensitivity
is inferior to virus/cultural isolation.
The third type of tests, NATs, give re-
sults within a few hours. This type of testing
helps provide convenient and fast automat-
ed result analysis, achieve higher sensitivity
as compared to virus isolation, and higher
specificity than the traditional immuno-
logical testing. NAT tests include PCR and
Nucleic Acid Sequence-Based Amplification
(NASBA). NASBA offers advantage over
other testing methods in that it requires no
expensive machines for the whole process.
Cost effectiveness of rapid
diagnosis of emerging diseases
Developed countries have the facilities to
conduct diagnosis but the on-going chal-
lenge is to bring cost-effective and efficient
diagnosis to highly affected developing re-
gions with minimal resources. Asia has been
the epicenter of many emerging diseases.
Considering that 60% of the world’s popu-
lation resides in Asia, emerging diseases are
an important cause of death in developing
countries, it is vital to make these rapid di-
agnostic tests available at rural healthcare
centres because the vast movement of people
between cities and rural areas will continue
to introduce emerging microbes.
Advantages of employing rapid diagnostic
methods
There are several clinical and financial ben-
efits of rapid diagnostic methods. They re-
duce the number of tests required and their
associated charges, reduce casual antibiotic
use, side effects, the length of stay in the
hospital, and increase appropriate antiviral
usage. They also allow community surveil-
lance by informing physicians quickly about
what agents are in the community. Rapid
diagnosis also prevents physicians from us-
ing drugs on wrong indications, possibly
delaying proper treatment of other infec-
tions and thus enabling doctors to prescribe
more effective drugs to patients.
Diagnostic laboratories in developing
countries are confronted with several chal-
lenges including financial constraints to
purchase equipment, supplies and reagents.
ISSUE-13 2007
They face problems in executing sample
collection schemes for disease surveillance.
Overall, the smaller hospitals have been
slow to adapt to new technologies due to
the lack of capital and clinicians' enthusi-
asm for them. It is important to support the
development of tests that are quick, sensi-
tive and inexpensive.
Peking University has initiated a low
cost project to help eliminate the need for
expensive machines for diagnosis in remote
areas. A mobile unit based on the NASBA
technology has been set up to conduct di-
agnosis on site. This saves time as it cancels
the need to send results to one of the few
designated laboratories for confirmation, in
case of an outbreak. The mobile unit will be
able to make the rounds of villages during
any season, facilitating early diagnosis and
treatment.
Prompt recognition and identification
is the first and vital step in confronting any
disease, regardless of whether it is a preva-
lent, a newly emerging one or deliberately
released. It is important to develop and im-
plement non-traditional methods for public
health surveillance and a system that allows
a wide and immediate dissemination of in-
formation.
BOOK Shelf
Medical Infrared Imaging
Authors : Nicholas A.
Diakides
Joseph D.
Bronzino
Year of Publication: 2007
Pages: 448
Description:
Medical Infrared Imaging presents many of
the new ideas, concepts, and technologies
that are key to the wider acceptance of
infrared imaging as a revolutionary new
standard. Beginning with the worldwide
advances and their medical applications
from a historical perspective, the book
provides detailed and comprehensive
information on the technology and
hardware resulting from these innovative
breakthroughs that will make currently
contributory infrared information even more
pertinent.
For more books, visit Knowledge Bank
section of www.asianhhm.com
 COVER STORY

The lab-to-market place transition of genomics seems to have begun. The whole healthcare continuum
is likely to be influenced by this. Genetic tests, personalised medicines, therapies, are all set to
change the way healthcare is provided. The unique combination of interviews and articles provide
unique perspectives on genetic testing and how personalised medicine can transform Cancer and
Cardiovascular care. The cover story also presents a perspective on the convergence in the life sciences
industry. This convergence is also most likely to be influenced by genomics in the future.

w w w . a s i a n h h m . c o m 23

Christopher McLeod, President of 454
Life Sciences was quoted as saying, "It's
the dawn of a new era when you can look
at not just all the genes, but all the ge-
netic information that an individual has.
We're just on the cusp of making that
economically feasible." Is the hype asso-
ciated with Genetic-testing justified?
To get started, we really have to define what
we mean by “all the genetic information
that an individual has.” While it is the case
that at some given cost, which is rapidly
dropping, individuals will be able to have
their genome sequenced in much the same
way that James Watson, co-discoverer of
the structure of DNA with Francis Crick
and Rosalind Franklin, recently did with
454 Life Sciences, a division of Roche. But
what is it that Dr. Watson really knows af-
ter his profiling? At the age of 78, he did
decide to exclude information that might
indicate a predisposition to Alzheimers, if
present, there was no real meaningful in-
tervention. This, however, is the crux of
24 Asian Hospital & Healthcare Management
Genetic Tests
All about interpreting
Profiling can be inherently valuable, but
we must keep it in the perspective of the
entire picture of a person’s health, lifestyle,
environmental factors, and the like.
Stephen M Sammut
Senior Fellow
Wharton Health Care Systems
University of Pennsylvania
and
Venture Partner
Burrill & Company
USA
the matter before us. At the present time
we really do not know the full range of
genetic markers that might suggest a
predisposition to Alzheimers.
What does “predisposition” really
means, or what factors will trigger onset
of the disease (if it ever presents itself at
all), and at what point will the disease, if
ever, appear. The implications of most
diseases are most grave when they ap-
pear in the presence of other diseases. In
the United States for example, according
to a study prepared by the Bloomberg
School of Public Health at Johns Hopkins
University, about two-thirds of all health-
care costs are absorbed by people with five
or more chronic diseases. Studies in Japan
have come up with similar results for their
society. This makes for a murky picture
and suggests that any genetic profile of a
person will require hundreds of statisti-
cally verifiable correlations before anyone
can draw a definitive conclusion. Moreo-
ver, some genetic factors in any given
ISSUE-13 2007
Interview
person may mitigate risk suggested by other
genetic factors.
Each of us is heir to the genetics of our
parents, grandparents and so forth, as well
as their health and intervention histories.
Profiling can be inherently valuable,
of course, but we must keep it in the per-
spective of the entire picture of a person’s
health, lifestyle, environmental factors, and
the like. So is it “hype?” I wouldn’t go that
far by any means. It is legitimate enthusi-
asm provided that scientists, clinicians and
people bear in mind the real limitations of
what we really understand in 2007, and
where we will inevitably go as we learn
more and integrate the knowledge with
preventive care and response to disease.
This is a highly knowledge-depend-
ent sector. With each company carry-
ing out its own research, will they be
ready to share their valuable knowl-
edge? If not, how will this affect the
industry?
You raise a critical issue here. There are
companies with proprietary instrumenta-
tion that allow for rapid reading, and pre-
sumably cheaper reading, of a sequence.
These companies can compete based on
what is unique to their own equipment
platform. There may be cases where they
mutually infringe some aspect of the
equipment. There may be cross-licensing
resolution of these issues, or even down
and dirty infringement suits. These are
generally engineering problems that can be

circumvented by clever scientists and en-
gineers. A good IP attorney doesn’t hurt,
either.
The real question with the interde-
pendence of knowledge has more to do
with “ownership” of genes, and we have
to be clear what “ownership” really means,
and the true limitations. This is still an
open area of intellectual property in the
United States at least, but I suspect that
we will converge on international princi-
ples related to genomic-related patents. At
the end of the day, however, some level of
proprietary rights will attach to the discov-
ery and description of the role of the gene,
that is to say, the role of proteins expressed
(in patent-speak, “utility”). Therein rests
the problem. In almost all diseases, there
will be multiple genes or mutations impli-
cated in either predisposition to a disease
or the disease itself. At the present time,
the portfolio of genes apparently related to
a disease condition are “owned” by many
parties. A company interested in develop-
ing the profiles as a business, and then pro-
viding interpretation, may have to contend
with an enormous patent thicket the reso-
lution of which will take many years and
significant layering of royalties. Regardless
of the engineering efficiency of given in-
strumentation, this will impact costs and
delay entry thus driving up the required
investment capital.
What could prove to be the hurdles to
the growth of the industry?
Beyond the IP issues that I’ve just outlined,
I suspect that the major challenges to the
industry will be a combination of clinical
and social issues. On the clinical side, we
have many unresolved problems in the
interpretation of results. For many years,
there has been testing available to counsel
aspiring parents as to risk for Tay-Sachs,
cystic fibrosis, sickle cell anemia and other
diseases. These are specific and testing of
the parents is generally a solid indicator
of risk for their offspring. In most cases,
the would-be parents are working under
a “hypothesis of risk” based on family
history or related factors. The results of
the testing can be interpreted by genetic
MEDICAL SCIENCES
counselors that can appraise the risk and
assist families in making decisions. This
long-standing clinical practice is not nec-
essarily analogous to the interpretation of
results for most diseases based on genomic
profiling, and certainly not in the case of
the enormous amount of data that will
have to be interpreted. Counselors will be
aided by software to be sure, but ultimately
advice will have to be rendered. There is, of
course, a business implication of interpre-
tation of the genome as a whole and com-
prehensive counseling based on that. The
implication is one of cost. Even supposing
that good engineering can get the cost of
a profile down to, say US$ 1000, it may
require many thousands beyond that to
derive an accurate interpretation and set of
recommendations. Myriad Genetics, how-
ever, has a business model that anticipates
these issues and focuses on specific diseases
and can provide a comprehensive set of
services, interpretations, recommenda-
tions and access to reimbursement. Their
approach may well be the best interim
business model.
w w w . a s i a n h h m . c o m 25
 The bigger issues, however, will be so-
cial and ethical. At the moment, I really
would not want a prospective employer
or insurer knowing (or thinking that they
know) something about my predisposi-
tion to a disease (Note “thinking that they
know”). As I submitted above, we really
are not knowledgeable enough yet to un-
derstand the full picture of disease impli-
cations. Drawing conclusions that might
result in discriminative action is clearly
not in the interest of society or people. In
times to come when we have a fuller un-
derstanding, viable interventions, privacy
safeguards, and the clinical care settings for
administration, then the testing will make
incontrovertible good sense. It is fair to say,
however, that for selected risks where we do
understand the genetic underpinnings of a
disease, that those patients with the emo-
tional and psychological make-up to han-
dle and act upon the information would be
better off having it. Again, of course, that
their privacy is protected.
One other area worth mentioning is
the role of genetic testing as it relates to the
testing or use of a particular pharmaceu-
tical agent during clinical trials or general
use. It is the case that roughly one-third
of all pharmaceuticals have no effect or
adverse effects on people. Genetic testing
may well identify those people who will
benefit and those who will not. The clini-
cal benefits of such technology are obvi-
ous. Genentech’s breast cancer products,
Herceptin and Her-2, are already a good
example of how a drug and diagnostic can
marry. This concept is one of the founda-
tions of “personalised medicine” which will
become a clinical reality rapidly.
In the interim, we will have to rely on
“early adopters” or pioneers to participate
in the testing and provide the social frame-
work for going forward.
How has been the initial response from
the medical community to genetic test-
ing products?
With respect to specific, well established
tests for specific diseases, testing has
largely been embraced by clinicians, es-
pecially when they know that they can
provide their patients with viable advice
or intervention. Let’s keep in mind that
this is a new area of medicine that will
demand an enormous amount of learning
26 Asian Hospital & Healthcare Management
by physicians as well as quality time with
their patients before and after the testing.
At least in the US, this is running coun-
ter to the trends in care over the last two
decades during which physicians have
been forced by reimbursement policies
to process patients through a gauntlet of
allied health professionals prior to spend-
ing ten or so minutes with their patients.
The industry is yet to come up with a
proper business model, are the ones be-
ing tried out by companies like Genomic
Testing, 23andMe and DeCode likely to
survive over the long run?
You’ve actually lumped three companies
with entirely different business models
together. I’ve already described Myriad
Genetics and their well-structured model.
DeCode’s primary business is discovery of
drug targets and interventions in collabo-
ration with academic health centers, such
as Massachusetts General Hospital, and
pharmaceutical companies. The model is
essentially sound, but the economic rents
that can be extracted for any given prod-
ucts or services that result from their data
are not clear to me. Nevertheless, when I
first learned of DeCode, I was enthusiastic
about their mission and approach and that
enthusiasm has not waned despite some
setbacks.
23andMe hypothetically addresses
some of the issues I identified previously.
Google, its investor, has other extraordi-
nary initiatives underway in knowledge
management and data mining, and ge-
nomic interpretation is an interesting
manifestation of their activity. The strategy
of 23andMe still begs the questions as to
sufficiency of data and reliable insight into
the relationship of specific genes or sets of
genes to disease, but the concept is based
on filling the interpretation gap.
With respect to the company
Genomic Testing, I would rather address
the model of companies doing genomic
testing (the lower case “g” and “t”) gener-
ally as opposed to this company specifical-
ly, Several companies have entered or will
enter the service area of running genomes,
especially as laboratory costs drop. These
are the companies that may have the big-
gest challenge operationally, especially in
marketing their services, assuring people of
confidentiality, and figuring out where they
ISSUE-13 2007
want to be along the spectrum of interpre-
tation. There is enormous liability risk for
these laboratories, not because they will get
the genome wrong, but they will inevitably
get the interpretation wrong more often
that getting it right. Clearly, they will have
to figure out where they can safely play in
the value chain.
How can the industry address issues re-
lated to Ethics and data security in the
future? Is it too early to start worrying?
It is not too early to start worrying, in fact
the debate started even before the Human
Genome Project was approved and under-
way. As I commented earlier, data security
will be a major hurdle for acceptance of
this technology. If insurance companies
pay for the testing, they will likely want
the results. To what extent can I trust a
lab or an organisation that does the inter-
pretation? Any company can establish a
sound protocol for patient protection, but
mistakes happen even under the most dili-
gent of circumstances, witness the recent
enormous breech of patient data in the
Japanese health care system.
How much longer is it likely to be before
it becomes economically feasible to pro-
vide genetic-tests?
Allow me to summarise a few of the points
that I’ve already made. The actual labora-
tory costs of testing are not the issue. They
will inevitably drop, even to the point
where the cost is trivial relative to other
costs in the healthcare system.
The fundamental economic issues are
the costs associated with interpretation,
the massive time-shifts that are likely to
result from how this data is communi-
cated to patients, and the paradigm shift
that will have to occur in changing medi-
cal care philosophy from one of reacting
to disease to preventing disease. For many
decades people have cavalierly said that
the medical community does not promote
preventive medicine because there is no
money in it for anyone, except perhaps the
nutritional supplement companies and the
manufacturers of exercise equipment. I am
deliberately cynical here in order to make a
point. Genomic testing performed to iden-
tify disease predisposition for the purpose
of early intervention will not be cheap. Yes,
sometimes it will be merely a matter of

exercise and better diets, but in most cases
the options will be expensive intervention
with life-long medicines, gene-therapy (yet
another set of issues), or frequent monitor-
ing, e.g., annual colonoscopy. Most of these
preventive measures will essentially shift
the cost from treating disease to prevent-
ing it. It is not simply a matter of “pay me
now or pay me later.” Unless our predictive
skills are near-perfect, we will spend scarce
money preventing diseases that might
never have occurred, and possibly doing so
over a life time. I have said elsewhere that
if a woman has a predisposition for breast
cancer, do you start intervention at pu-
berty, in her twenties, or after childbirth.
We will eventually know the answer. Per-
sonally, we are unanimously in favour of
prevention, but let’s not delude ourselves
to the economic implications. This will be
a new world of medicine and a new world
of healthcare costs.
What does the industry need to do to en-
sure that this happens?
Frankly, this goes beyond the capacity
of the industry to address directly. The
companies and their advocates—and the
advocates, including myself, are many
and include influential politicians, busi-
ness leaders and celebrities, many of
whom are “putting their money where
their mouths are”—have the challenge
of convincing the political and medi-
cal communities that despite the sea-
change that will follow in the costs and
practice of medicine that there is the
potential of revolutionary advance in
the progress of humankind. We all have
the moral obligation to assure that this
new care will not be an option for only
the “haves” to the exclusion of the “have
nots.” This worries me because most of
humanity is still awaiting access to essen-
tial medicines, vaccines and basic care.
Amidst all this, where do the patients/
consumers stand currently and what
does the future hold for them?
If consumers think the way I do, they are
also in a state of shock and awe. My com-
ments probably suggest that I might be
MEDICAL SCIENCES
over-thinking the issues. I would say in
response, so are a lot of people inside and
outside of medicine.
The direct benefits to consumers, i.e.,
an intervention for a specific predisposi-
tion, are not on the immediate horizon.
That is so reason not to move ahead with
alacrity. The potential mass of data—if
we solve the privacy issues—will be of
enormous benefit in the discovery of
drugs and other interventions to address
the very same predispositions that will
be found with a basis of confidence. And
the discoveries may come as fast as the
visionaries suggest.
Society and those of us in the busi-
ness of healthcare will, for the foresee-
able future, be in a period of vast ex-
perimentation seeking optimal modes of
the technology, the most productive and
sustainable business models, and sensible
approaches to integrating this unprec-
edented knowledge into healthcare and
our lifestyles. It is an interesting time to
be alive, and the younger among us may
live longer than ever imagined.
w w w . a s i a n h h m . c o m 27

Christopher McLeod, president of Con-
necticut-based 454 Life Sciences was
quoted as saying, "It's the dawn of a
new era when you can look at not just
all the genes, but all the genetic infor-
mation that an individual has. We're just
on the cusp of making that economically
feasible." Is the hype associated with Ge-
netic-testing justified?
There is some hype. The chance of seeing
any real commercially viable gene testing
in doctors' office or home kits in the next
two years is slim. But the future of testing
is very bright. As more diseases and condi-
tions are reliably correlated with predictive
accuracy and more information is obtained
about who will and will not respond well
to medications this field will become huge
in medicine. I think we are still five or six
years away however.
This is a highly knowledge-dependent
sector. With each company carrying out
its own research, will they be ready to
28 Asian Hospital & Healthcare Management
Genetic Testing
The ethics side
The industry should be addressing these issues
right now. Ethics is the biggest obstacle to the
future success of genetic testing.
Arthur Caplan
Emanuel & Robert Hart Professor of
Bioethics
Chair
Department of Medical Ethics
and
Director Center for Bioethics
University of Pennsylvania
USA
The information given
out must be accurate
and we don’t have good
international standards for
genetic testing.
share their valuable knowledge? If not,
how will this affect the growth of the in-
dustry?
Not much sharing likely in this highly
competitive industry. I think it will mean a
proliferation of tests, test kits and different
testing locations. Not sure how this will
all sort out but it will stand in the way of
efficient testing and may undermine con-
sumer interest if there are too many com-
petitors with small test niches.
ISSUE-13 2007
Interview
What could prove to be the hurdles to the
growth of the industry?
The information given out must be accurate
and we don’t have good international stand-
ards for genetic testing. Nor do we have agreed
upon standards for counselling consumers.
There will be liability issues surrounding false
negatives and positives as well as misunder-
standing by consumers of complex probabil-
istic information. There are also issues about
the need for privacy protection which is not
firmly in place and the handling of 'genetic
records'. The stigmatization of racial, ethnic
or family groups by testing is also a danger.
How can the industry address issues related
to Ethics and data security in the future? Is
it too early to start worrying?
The industry should be addressing these is-
sues right now. Ethics is the biggest obstacle
to the future success of genetic testing.
Amidst all this, where do the patients/con-
sumers stand currently and what does the
future hold for them?
Patients will in the short run rely on their
doctors for advice about all this, but direct to
consumer advertising will begin and then it
will be a free-for-all while the good drives the
bad out of the marketplace.
Any other comments?
See my book Smart Mice Not So Smart
People (Rowman Littlefield) which came out
six months ago for more on genetic testing
and ethics!
w w w . a s i a n h h m . c o m 29
 Interview
Genetic Testing
All set for growth

Julian Awad
CEO & Co-Founder
Smart Genetics LLC
HIVmirror LLC
USA

Photograph by William West

Technology and the worldwide coordination of efforts to
push discovery in genetics has exacerbated the growth
of opportunity in this sector.

What are your thoughts on the growth
potential of the sector?
We believe this sector has tremendous
growth potential and is poised to explode
over the next five to ten years. Technol-
ogy and the world wide coordination of
efforts to push discovery in genetics has
exacerbated the growth of opportunity in
this sector pushing market issues prema-
turely to the forefront. These issues may
be the factors that slow conversion of the
opportunities more than the technological
restrictions. Distribution and the after ef-
fects of the "disruption" to consumers
current access to personalised medical in-
formation are now driving ethical and ef-
ficiency questions.
This is a highly knowledge-dependent
sector. With each company carrying out
its own research, will they be ready to
share their valuable knowledge? If not,
how will this affect the growth of the in-
dustry?
Sharing of knowledge will become essen-
tial for industry at large but also for joint-
ventures where the big plays will happen in
a rapidly developing marketplace. If there
are multiple markers being developed for
risk scenarios of the same disease, the prod-
ucts independently will be competitive and
less effective than if the markers were com-
bined and used/sold collectively. Addition-
ally, the competitive marketing efforts will
confuse consumers and potentially reduce
uptake overall. What will be interesting is
to see if /how the patentability of genomic
information will remain unchallenged by
the world community at large.
What could prove to be the hurdles to
the growth of the industry?
End users (patients and consumers) of the
products and services will need to go through
a large learning curve. The information is

30 Asian Hospital & Healthcare Management ISSUE-13 2007


complex and must be diluted to the essen-
tial components and delivered in a man-
ner the end user can understand and value.
There are addition challenges with an in-
dustry that is constantly discovering, new
products (markers) are being discovered
on a regular basis. A new and potentially
more relevant marker could threaten cur-
rent products and all the capital invested
to develop and bring it to market.
How has been the initial response from
the medical community to genetic test-
ing products?
Mixed depending on the disease category
and the test. Some tests have been embraced
and others have been shunned. But as more
products become available more demand is
placed on front line clinicians to be aware
and incorporate genetic testing into their
practice. Our company has had numerous
calls from customers with very positive and
thankful feedback telling us that their doc-
tors have directed them to our site. Some
customers are being directed to us by ge-
neticists and hospital workers as well.
The industry is yet to come up with a
proper business model, are the ones be-
ing tried out by companies like Genomic
Testing, 23andMe and Decode likely to
survive over the long run?
I'm not aware that 23andMe's model has
been declared but they are consumer-fo-
cussed according to their website. Decode
is a research organisation. Both have differ-
ent models and are in different businesses.
It may be too early to make assumptions
on their survival. More interesting will be
their ability to adapt to how this sector will
be changing.
How can the industry address issues re-
lated to Ethics and data security in the
future? Is it too early to start worrying?
Ethics and data security should be ad-
dressed now and not later. Good standards,
industry best practices and guidance is
needed quickly to help new organisations
develop in this space. Organisations such
as the Genetic Alliance that Smart Genet-
ics is a member of acts as a focal point for
these types of issues.
MEDICAL SCIENCES
How much longer is it likely to be be-
fore it becomes economically feasible to
provide genetic tests?
We are already there. A subsidiary of
Smart Genetics, HIVmirror LLC offers
the HIVmirror genetic test for US$ 99.
Several of our customers have commented
they are shocked by how affordable our
tests are. Genetics test have been offered
for years.
8. Amidst all this, where do the pa-
tients/consumers stand currently and
what does the future hold for them?
Patients/Consumers will be forced to
become educated with the issues, ben-
efits and limitations of genetics. It will
have such a personal impact on each of
us in how we live our lives, how we are
treated for diseases and ailments (person-
alised medicine), and potentially to our
treatment of one another that we have to
embrace this change and quickly.
For more information, visit: www.smartgenetics.
com, www.hivmirror.com
w w w . a s i a n h h m . c o m 31
 Personalised Medicine
Future architecture
The standard “one size fits all” approach of treating many individuals may soon
become obsolete. More targeted approaches promise to improve outcomes while
reducing toxicity and medical costs.
Timothy Yeatman
Executive Vice President
Translational Research
H. Lee Moffitt Cancer Center & Research
Institute
University of South Florida
and
President & CSO
M2Gen
USA
C
ancer is a molecularly heterogeneous
disease. Simply put, not all cancers,
even when derived from an organ
site such as colon or lung, are alike. Despite
this recently determined finding, treatments
are assigned to tumour types primarily based
on their site of origin. Thus, while there may
be many different molecular subtypes of
lung cancer, all adenocarcinomas of the lung
are treated with the same chemotherapeutic
agents.
Cancer therapy as we know is effective
for some patients, but for others it can be tox-
ic and has no survival benefits. Despite many
therapeutic choices, still very few patients
with metastatic disease are cured. Couple this
fact with the clear reduction in the availability
of new drugs for testing and it becomes obvi-
ous that a radical change in the drug develop-
ment process is necessary in order to improve
outcomes. We believe the standard “one size
fits all” approach of treating many individu-
als may soon become obsolete. More targeted
approaches promise to improve outcomes
while reducing toxicity and medical costs.
We and others have answered the chal-
lenge that human tumours might be clas-
sified using a new molecular tool—the
microarray. With this tool, we are now
32 Asian Hospital & Healthcare Management
able to assess the expression of ~30,000
genes in a single day across numerous tu-
mours, a quantum leap in the technology of
mRNA-based gene expression profiling. This
technological advance has made it possible to
develop large data sets containing both gene
expression data as well as clinical outcome
and response data.
Initial studies clearly demonstrated the
potential to predict diagnosis and prognosis
for a number of tumour types more compre-
hensively than had been possible with previ-
ously available semi-quantitative immunohis-
tochemical tools. It has become clear that no
two tumours are precisely identical, with a
significant amount of biological heterogene-
ity between and within tumours. Correlative
studies at multiple sites have found that the
biological variability from one tumour to the
next exceeds the inherent variability or repro-
ducibility of the test. Moreover, the potential
to predict response or non-response to che-
motherapy has been recently demonstrated
by a number of investigators, suggesting that
there could be a clinical application for this
technology. Collectively, the data suggested
that there might be a long-term benefit in
evaluating every tumour possible using mi-
croarray technology (“one tumour, one chip”)
to fully characterise the tumours' individual
signatures.
It was then not a stretch to start to envi-
sion a data repository for tumour and clinical
data that might be useful for a host of op-
portunities from target and pathway iden-
tification, to signature generation. Think-
ing that a database might be more valuable
with data from both primary tumour and
metastases, we began to devise a mecha-
nism by which patients with metastatic dis-
eases might draw value from this project.
The concept of “population-based trial
ISSUE-13 2007
matching” was developed, which is a clear
departure from our standard means of iden-
tifying patients for therapeutic clinical trials.
With a large database composed of molecular
fingerprints from thousands of patients (with
metastatic disease), it was clear that it might
be feasible to match the right patient to the
right drug in an expedient fashion. And not
only would the trial be completed in record
time, we hypothesise the response rates will
climb due to the selective process for the iden-
tification of patient candidates. So, the future
of clinical trials will be much like organ trans-
plantation where large sophisticated comput-
erised data systems and networks are used to
find the right organ donor for the right trans-
plant recipient.
The H. Lee Moffitt Cancer Center has
begun to collaborate with multiple partners,
both in academia and in industry, to develop
a clinical and gene expression database for sci-
entific research and for translational research.
This database is part of a larger initiative at the
Moffitt Cancer Center called “Total Cancer
Care”. Total Cancer Care is a Center-wide
and State-wide initiative to improve the qual-
ity of medicine and the standard of care by
developing personalised approaches to cancer
care whereby the best therapeutics are deliv-
ered to the patients who might benefit the
most. In Total Cancer Care, we will scrutinise
outcomes and survivorship. We will try to de-
termine what barriers are there to clinical trial
accrual. We will also try to actually deliver
personalised cancer care back to the patient
through population-based trial matching.
This is truly an enterprise project that spans
the State of Florida and beyond, attempt-
ing to bring new value to the participating
patients, physicians and hospitals.
We have overlaid an all digital IT
approach to collecting and sorting the

clinical data that will be collected for the life
of the patient on top of a sophisticated data
warehouse that can collect, sort and relate
data from many different electronic feeds
and types. The data warehouse will contain
data from gene expression experiments
and will link this data by unique identifiers
to clinical outcomes data such as overall
survival and disease recurrence.
While initial pilot projects have been
successful, the real challenges lie ahead when
we begin to build the front end to the ware-
house that will enable patients, physicians
and basic researchers to access the data and
process it. Thus, the future of personalised
cancer care depends on our ability to opera-
tionalise a network of hospitals, physicians
and nurses to collect the tissues and associ-
ated clinical data longitudinally over time.
More importantly, our capacity to reach
out to the patients with metastatic disease
and align them with the best trial opportu-
nity through gene profiling is critical to the
success of this project.
There is more to the personalised medi-
cine project than gene expression data sets.
For example, because we plan to acquire
thousands of tumour and blood samples,
we will be able to interrogate these samples
with other novel technologies as they are
developed. We fully anticipate the potential
to evaluate thousands of tumour samples
for somatic gene mutations in the very near
future. This will permit the development
of new dimensions to the data warehouse,
ultimately allowing scientists to better un-
derstand the relationships between gene ex-
pression and the underlying genetic codes
and associated mutational flaws.
Beyond the development of a data
warehouse and trial matching capabili-
ties, we believe there is a great need to
develop molecular imaging technologies.
The capacity to image the metabolic activi-
ties in a tumour is now becoming a reality.
While currently we can examine the glu-
cose metabolism of a tumour using 64 slice
PET-CT scanners, we plan to develop im-
aging tools based on tumour biological end-
points such as apoptosis, proliferation, and
angiogenesis. This sort of technol-
ogy would permit, for the first time, the
MEDICAL SCIENCES
potential to measure the response of a
tumour to a drug or to radiotherapy
within minutes of delivery. This would
be a radical change from current prac-
tice where drug responses are evaluated
only after ~3 months of therapy using
Response Evaluation Criteria in Solid Tu-
mours (RECIST) that physically measure
tumour diameters with CT scans. Such an
approach, when integrated into a person-
alised medicine paradigm, might allow a
rapid, iterative, reevaluation/reassignment
of therapy following initial therapeutic
selection and delivery.
The path to personalised medicine is
neither short nor straight. We believe,
however, that we have outlined a rational
roadmap to deliver personalised cancer
care to patients within 5-10 years. This
roadmap requires precise execution of a large
translational research project we call “Total
Cancer Care”, that will build a research data
warehouse relating clinical and molecu-
lar data in a format useful to patients,
physicians and scientists.
w w w . a s i a n h h m . c o m 33
 Personalised Medicine
An idea whose time is approaching
DNA sequencing of human genes could provide the 21st century with the ultimate in
evidence-based medicine allowing us to tackle not only cardiovascular disease,
but many other life threatening diseases.
Robert Roberts
President & CEO & CSO
University of Ottawa Heart Institute
USA
I
n half a century, advances in cardiol-
ogy have revolutionised the approach
and treatment of the once-deadly dis-
eases. In the last 30 years, we have cut the
cardiac mortality rate in North America
by half. Cardiovascular disease remains
the No. 1 killer, however, and by 2010 it
will have earned that dubious distinction
worldwide.
DNA sequencing of human genes
could provide the 21st century with the ul-
timate in evidence-based medicine allowing
us to tackle not only cardiovascular disease,
but the many other life threatening diseases.
For the first time, we have the technology
and the basic science to personalise therapy
based on an individual’s genetic makeup
and variants. “Personalised Medicine,” com-
bined with prevention, offers us the chance
to defeat coronary artery disease.
We can, in large part, prevent coronary
artery disease by attacking its major risk
factors: hypercholesterolemia (elevated cho-
lesterol levels), obesity, hypertension and
diabetes. The advent of statin therapy and
the use of Angiotensin-Converting Enzyme
(ACE) inhibitors to treat heart failure have
reduced the mortality rate. However, not all
patients respond to treatment with statins.
All these risk factors have a genetic compo-
34 Asian Hospital & Healthcare Management
nent. We need to identify genetic risk factors
before we can implement a comprehensive
genetic screening and prevention program.
The evidence about genetics’ role in car-
diovascular disease is compelling. In a study
of premature Coronary Artery Disease
(CAD), only 38% of patients had abnormal
lipid values. It is reasonable to suspect that
the remainder of CAD patients were influ-
enced by family history, as several studies of
the Utah population suggest.
In the Framingham study, a family his-
tory of CAD, cerebral vascular accidents
or peripheral arterial disease was associ-
ated with 2.4-fold increased risk of CAD in
men, and 2.2 in women. More than 50% of
a person’s predisposition to coronary artery
disease is genetic, although the quantifica-
tion of the genetic versus environmental
component awaits more precise definition.
Until recently, it was not possible to
identify the genes involved in coronary
artery disease and other common multi-
gene disorders. The introduction, of 500K
DNA markers on a microarray chip and
the multi-slice Fast Computed Tomography
(CT), which permits non-invasive coronary
angiograms, has made it possible to search
for the responsible genes.
Current and future applications
In 2004, adverse drug reactions caused
more than 100,000 deaths and 2 million
hospitalisations in the United States. Our
increasing knowledge of pharmacogenet-
ics suggests that patients’ variable response
to drug therapy is, in large part, genetically
determined. Genetic screening for those
responses can eliminate such death and
morbidity. For example, 20% of people are
ISSUE-13 2007
resistant to aspirin. The dose of warfarin
required to be effective to prevent throm-
bosis in patients also varies markedly. It de-
pends upon the influence of the gene that
encodes for Vitamin K Epoxide Reductase,
responsible for 25% of the variation in the
dose. In the future, we will likely screen
patients for the 10 forms of this gene to
determine the effective dosage. Already,
genetic screening across ethnic groups has
led to the following recommendations:
African Americans require a high dose of
warfarin, Asian Americans a low dose and
European Americans a medium dose.
Genotyping is already an established
practice before administering chemo-
therapy for some forms of cancer. 20% of
breast cancer patients, for example, exhibit
the gene that encodes for HER2 protein.
Herceptin is given to block HER2 protein.
If the protein is not present, the therapy
will not be effective. The Food & Drug
Administration (FDA) is also convinced
of the importance of pharmacogenet-
ics; recently, the drug regulator approved
BiDil only for use in heart failure in African
Americans. The drug was shown to reduce
mortality and hospitalisation in African
Americans with heart failure by 43%, while
having no effect in the Caucasian popula-
tion.
Genetic screening: A prerequisite
for preventing Sudden Cardiac
Death
Below age 35, most Sudden Cardiac Death
(SCD) is attributable to familial diseases.
More than 40% of SCD is due to hypertro-
phic cardiomyopathy, followed by familial
arrhythmias such as long QT syndrome or

Brugada syndrome. Most individuals are
otherwise asymptomatic, and SCD occurs
without any warning. Approximately 5% of
the 13 million people with cardiovascular
disease in the United States are significantly
predisposed to SCD, which accounts for
more than 50% of deaths in patients with
heart failure. In patients over age 35, SCD
is predominantly due to coronary artery dis-
ease and usually occurs within the first 60
minutes of symptoms, often precluding the
availability of medical help.
Genetic screening and prevention
through therapy, such as the use of a defi-
brillator, is the only hope these individuals
have, because drug therapy for arrhythmias
is relatively ineffective. But cardiac defibril-
lators cost more than $75,000. If we can
determine through early screening which
patients have familial cardiomyopathies and
arrhythmias and so are vulnerable to SCD,
we could determine who would benefit
from a defibrillator.
Sudden Death phenotype exhibits
genetic predisposition
Hundreds of mutations have been identi-
fied in the sarcomeric proteins responsi-
ble for cardiomyopathies and SCD. The
increased risk associated with family history
provides a second indication of genetic in-
volvement. In cohorts of SCD, Friedlander
et al. and Jouvin et al. have shown there is a
1.6-1.8-fold increase in SCD susceptibility
among offspring of parents who died from
SCD. Although the sample size is small,
the relative risk in offspring from fami-
lies where both parents experienced SCD
increased by 9-fold. Thirdly, variations in
DNA sequences known as Single Nucle-
otide Polymorphisms, or SNPs, of the he-
patic P450 clearance pathways increase the
risk of ventricular (Torsades-de-pointes)
arrhythmias. Fourthly, a single SNP variant
in the SCN5A sodium channel gene found
in African Americans, affecting 4 million
people , is associated with an increased
incidence of arrhythmias, particularly in
individuals receiving proarrhythmic drugs
that prolong the QT interval. Over the
next 10 years, several predisposing SNPs
will likely be identified.
Research delayed in identifying
genes for CAD
The application of molecular genetics to
inherited cardiovascular disorders has been
successful largely in the field of single-gene
disorders, in which a single gene induces
the phenotype. It is estimated that there are
6,000 single-gene disorders, of which we
have identified more than 2,000. Hyper-
trophic cardiomyopathy was the first such
disorder identified in cardiology. There are
more than 1,200 mutations recognised as
responsible for single-gene disorders that
induce cardiovascular disease.
Multiple genes, however, confer sus-
ceptibility to CAD. We expect hundreds
of SNPs to contribute only 5% to 10% of
increased risk each. But in combination,
they are responsible for the phenotype.
In genome-wide studies, searching
for these SNPs would require a DNA
marker every 6,000 base pairs, amount-
ing to 500,000 markers that would need
to be genotyped for each DNA sample.
Such high-throughput genotyping has un-
til recently been prohibitively expensive.
A study would require samples from sev-
eral thousand individuals to detect a single
SNP.
New technology enables genome-
wide genotyping for case control
association studies
Case control association studies are the
most sensitive and appropriate mechanism
to identify genes for coronary artery dis-
ease. These studies collect samples from
thousands of unrelated individuals with
CAD and thousands of controls without
CAD. Then investigators compare the
SNP frequency in controls versus cases (af-
fected individuals).
Today, microarray chips contain-
ing 500,000 SNPs and 1 million SNPS
are available. They provide, on average, a
marker at intervals of 6,000 bps or 3,000
bps respectively. Studies by Hinds, et al.
and that of the International HapMap
project indicate a minimum of 375,000
properly placed markers to genotype an
American-European population.
Using the 500K microarray, in Au-
gust 2005 we initiated a study at the
University of Ottawa Heart Institute (the
Ottawa Heart Genomics Study). The
sample size was calculated assuming 90%
power, a gene frequency of ≥ 5%, odds ratio
of ≥ 1.3 and ≥ 0.2 size differences between
controls and cases.
MEDICAL SCIENCES
The initial population, estimated to
be 2,000 (1,000 affected individuals and
1,000 controls) was genotyped to detect
association having a p-value of 0.001 or
more significant. Those markers showing
an association in the initial population were
genotyped in a second independent popula-
tion to ascertain the degree of replication.
A second sample size of 12,000 (8,000
affected and 4,000 controls) would, we
estimated, detect SNPs showing a stronger
association at p-values such as 10-8 or great-
er. As far as we know, this is the first study
to utilise the 500K as a genome-wide scan
for CAD, with the latter documented by
coronary arteriography.
Results of Ottawa Heart Genomics
Study
At the Canadian Cardiovascular Genet-
ics Centre, established at the University of
Ottawa Heart Institute in 2004, we perform
more than 10,000 angiograms per year,
providing the necessary high-throughput
phenotyping. The Institute, which serves
1.8 million people, has more than 100,000
coronary angiograms available on patients.
To date, we have completed more than
900 million genotypes on 1,800 individuals.
We expect to complete Phase I (n = 2,000)
shortly. Unfiltered analysis of the first 500
controls and 500 affected cases indicates that
we have found several thousand SNPs with
p-values of 0.001 or greater, and more than
130 clusters with p-values ranging from 10-3
to 10-12. We will analyse the second popula-
tion (n = 12,000) to determine replication,
coupled with further customised SNP geno-
typing. We recognise that many of these as-
sociations are false positives. We don’t expect
to confirm them all.
Completing the initial phase, however,
provides us with a population with an all-in-
clusive set of SNPs exhibiting strong associa-
tions to the phenotype of CAD. We hope to
collaborate with investigators in Canada and
other countries to identify and analyse the
genes contributing the most risk for CAD.
It is a unique opportunity to provide
the armamentarium for comprehensive
genetic screening to help prevent this deadly
condition. Subsequent to completing the
replication studies, researchers can compare
these genes to those involved in specific risk
cohorts, such as hypertension, obesity or
hyperlipidemia.
w w w . a s i a n h h m . c o m 35
 Convergence
in the Life
Sciences Industry
Combination products
show the way

Driven by market forces, a need for new growth

avenues and an ever more conscious consumer,
medical device, pharma and diagnostics companies
are coming together to deliver innovative solutions.

Akhil Tandulwadikar
Healthcare Editorial Team

T
raditionally, the medical devices and pharmaceutical sectors have represent-
ed two different facets of the life sciences industry. Both the sectors have
charted their own paths to growth on a similar terrain. Therefore, ‘conver-
gence’ between the two never quite went beyond basic drug delivery instruments
such as injections. That was, of course, before the introduction of Drug Eluting
Stents (DESs)—the most successful combination product so far with a market size of
US$ 5.5 billion worldwide. Meant to treat coronary disease, the stents proved to
be a huge success as they allowed delivery of drugs directly and in low doses to
targeted areas unlike oral consumption that would require higher quantities to be
consumed. The DES had proved that combination products could play a major role
in improving patient care—and provide new areas of growth for the companies.
The early and huge success of DESs sparked a sort of frenzy in both the sec-
tors to collaborate and create a whole new line of products. This was evident from
the fact that the number of applications for combination products with the FDA
increased from less than 100 in 2003 to 275 by 2005. Today, this convergence
stretches across device makers, pharma, biotechs and diagnostics. This convergence
has already resulted in the creation of many combination products (Table 1) and
with further research and development, the horizon for combination products is
only likely to get wider. Market figures too indicate the same. According to Chris
Cramer, Principal, Life Sciences Practice, PRTM Management Consultants, the
market for combination products is currently estimated to be around US$ 40-50
billion and growing at 14% annually.
However, this area is still in its early stages. Several questions will have to be
answered and challenges that convergence presents will have to be overcome to
ensure that the products are innovative and safe. As products get smaller in size
and are implanted in the patient’s body to reach the targeted area, their safety will
be of utmost importance. Hence, regulatory agencies like the US Food and Drug
Administration (FDA) will play a crucial role in the development of the combina-
tion products market.

36 Asian Hospital & Healthcare Management ISSUE-13 2007


The need to converge
Both device and pharma companies are
looking for new avenues of growth. Phar-
ma is struggling to cope with pipeline
shortages, high R&D costs resulting in low
returns and increasing competition from
generics. The blockbuster model seems no
longer sustainable. For biotechs this con-
vergence brings in access to better funding
and sharing of resources. For device mak-
ers, integrating devices with drugs is help-
ing them develop new products, something
that was much needed given the fact that
they were finding it increasingly difficult
to come up with innovative products un-
til recently. The initial push for developing
combination products did therefore come
from them.
The diagnostics sector is perhaps the
best placed sector in terms of perform-
ance over the last few years thanks to the
emergence of in-vivo and in-vitro diagnos-
tics market size for the latter is expected to
reach US$ 40 billion by 2010 according to
a research report by Business Insights. As
a result, device manufacturers have shown
keen interest in diagnostics makers. A key
example of this being the big acquisition
of Bayer Diagnostics for US$ 5.7 bil-
lion by Siemens Healthcare and Abbott’s
diagnostics arm by GE Healthcare for
US$ 8.13 billion last year (although it was
recently). Diagnostics companies can gain
by collaborating in development of patient
monitoring equipment for chronic diseases
that have become highly prevalent around
the world among the ageing population.
In recent years, there has been a re-
markable improvement in the technologies
that support the R&D and manufacturing
processes in life sciences. As a result, sci-
entific advances such as genetic tests, stem
cells and genomics are helping companies
to develop better tests to identify and treat
diseases.
Apart from this, rising healthcare
costs and a more informed customer have
played their part as well. Aided by better
knowledge about the options available,
consumers are demanding better treatment
at lower costs. And it is safe to say that con-
vergence has enabled companies deliver
such solutions. In the case of patients with
diabetes, for example, blood glucose moni-
tors combined with implanted insulin
pumps offer round-the-clock monitoring
T E C H N O L O G Y, E Q U I P M E N T & D E V I C E S
Device – Drug
Drug-eluting stent that opens and prevents
restenosis in coronary and peripheral
arteries
Bone grafting scaffold/sponge coated
with a growth protein that promotes bone
regeneration
Implantable, programmable pump that
delivers a drug or biologic in small, timely
doses
Implantable polymer wafer that releases a
chemotherapy agent to a specific site
Implantable neuromodulator that enables
the targeted, regulated delivery of a drug or
electrical stimulation
Transdermal patch that transports drugs
locally and systematically through the skin
Pre-filled, metered dose syringe, injector
pen, or inhaler
Diagnostic – Drug
Screening test for the presence of a specific
gene or protein coupled with targeted drug
therapy
Use of passive pharmaceuticals and
radiopharmaceutical tracers as contrast
agents for positron emission tomography
(PET) scanners
Diagnostic – Device – Drug
Glucose monitor with an insulin pump
Source: Managing Pathways to Convergence in the Life
Sciences Industry, Deloitte Research
with timely, controlled release of insulin,
providing diabetes patients with a less in-
vasive and more effective treatment alter-
native, says Robert Go, Managing Direc-
tor, Global Life Sciences and Health Care,
Deloitte Touche Tohmatsu.
These factors have shown the way to
convergence within the life sciences in-
dustry. Cramer sums it up when he says,
“combining drugs, devices and biologics
appears to be the logical next step.”
All for the patient
The consumer is slowly but surely becom-
ing the centre of the healthcare universe
and as a result, treatments too are be-
coming patient-centric in nature. Ageing
population all over the world has meant
that technologies have to become more
patient-friendly, so that they not only help
in patient monitoring but also help the
doctors in taking the right decisions and
the hospitals to manage their operations
better. While companies might have their
own business motives behind this, the big-
gest beneficiary of this convergence will be
the patient. Says Go, “by bringing more
self-administered healthcare solutions to
the market and enabling remote patient
monitoring by physicians, convergence
may reduce the number of care visits that
are needed, potentially resulting in services
that are more cost-effective.” Combination
products are also helping to reduce the
side-effects that only add to the patient's
woes and expenses.
Several combination products have
received the FDA's nod in the recent past
(see box item). Further down the line,
these devices will get smaller in size, in-
novative and more effective. Says Cramer,
“Miniaturisation will change the way we
use medical devices as manufacturers will
be able to create implantable devices for
diagnostic and therapeutic delivery at the
micro to nano level.”
Regulation – The key
The coming together of hitherto mostly
independent industries presents a unique
challenge for the regulatory agencies like
the FDA. Medical devices typically take
shorter times to get approvals from FDA
than a drug which has to under go sev-
eral stages of trials and might take many
years. FDA was the first regulatory body to
recognise a need to develop guidelines to
regulate combination products. FDA’s Of-
fice of Combination Products was set up to
manage the review of these products. Cur-
rently, three centres of the FDA namely,
Center for Biologics Evaluation and Re-
search (CBER), Center Devices and Radi-
ological Health (CDRH) and Center Drug
Evaluation and Research (CDER) take care
of the regulatory function. Depending on
the primary mode of action the product is
allocated to the respective centre and will
be under its jurisdiction.
Defining the primary mode of action
for a product though is not that easy. If a
disagreement arises over this, it results in
lengthy disputes over who’ll get the juris-
diction over the product. Given the rate
at which the number of applications from
combination product makers for approval
is growing, this could prove to be a ma-
jor hurdle to the growth of the industry.
w w w . a s i a n h h m . c o m 37
 Opines Go, “regulators need to develop a
strong understanding of the technologies
that are involved and how exactly they are
integrated.”
It will be some time before a compre-
hensive approach to regulate combination
is in place. “Till then”, says Cramer, “com-
panies looking to bring new products to
market should take a proactive approach
to working with the FDA on pre-market
review/approvals”
Issues involved in converging
As attractive as the rewards might be, mak-
ing a convergence successful is easier said
than done. This will be a first time experi-
ence for many of the companies involved,
as they have never worked together. Says
Cramer, “most device manufacturers have
little or no experience working with the
drug that will be included in the device or
its coating. They not only have to decide
how to select, modify and incorporate the
drug into the product, but also demon-
strate its acceptable toxicity and shelf life
and characterise its release into the body.”
Finding a suitable convergence partner
could, itself, prove to be the biggest hurdle.
The companies need to identify specific op-
portunities with respect to each others ex-
pertise while making sure that technological
support needed to integrate the two or more
products exist and that the venture would
be profitable. They have to understand the
various risks that come along with the con-
vergence path they choose. While there is
a growing demand for combination prod-
ucts, industry dynamics make it tough for
the companies to make these decisions, and
when made, to stick to them and go the
distance.
Risks, of course, are not just external.
When coming together, companies need to
address issues related to knowledge sharing
and creating teams that will not just work
together but cooperate in all the aspects of
product development. In addition to this,
says Cramer, “the people aspect should not
be overlooked; i.e., the difficulty in bringing
together the various viewpoints, practices,
and experiences from the different worlds of
drug, biologic, and device development.”
Device companies have been the proac-
tive partners in this convergence—which
has been attributed to the fact that pharma
sector is many times bigger than the device
38 Asian Hospital & Healthcare Management
Recently approved combination products
Schwarz Bioscience’s transdermal patch
Neupro Patch, used for the treatment of symptoms of Parkinson's disease,
combines a new dopamine agonist, rotigotine, with the convenience of a
transdermal patch delivery system.
Medtronic’s absorbable collagen sponge with genetically
engineered human protein
INFUSE® Bone Graft used in the Anterior Lumbar Interbody Fusion (ALIF) surgical
procedure in combination with an interbody fusion device.
Orthovita Inc.’s biological product gel for surgical hemostasis
Vitagel™ Surgical Hemostat contains an enzyme that assists in the clotting of blood.
Vitagel is intended to assist in clotting when conventional means fail or are impractical.
Alza Corporation’s Iontophoretic transdermal system
IONSYS™ is a patient-controlled iontophoretic transdermal system providing on-
demand systemic delivery of fentanyl, an opioid agonist.
Shire US. Inc.’s transdermal patch for attention deficit
hyperactive disorder
Daytrana is a treatment containing the drug methylphenidate, a central nervous system
(CNS) stimulant for treating Attention Deficit Hyperactivity Disorder (ADHD) in children.
Somerset Pharmaceuticals, Inc.’s transdermal patch for
depression
Emsam transdermal patch used for treating major depression, delivers selegiline, a
monoamine oxidase inhibitor or MAOI, through the skin and into the bloodstream.
Pfizer’s inhaled insulin combination product for diabetes
Exubera is an inhaled powder form of recombinant human insulin (rDNA) for the
treatment of adult patients with type 1 and type 2 diabetes.
Source: FDA
sector and hence offers better opportunities. safety and efficacy issues that might arise.”
This has made several industry observers Therefore, initial convergence has occurred
doubt the interest level a pharma company at the later stages of product development.
would show in a convergence effort. “Gen- But this is changing, observes Go, “con-
erally speaking, pharma opportunities and vergence is now increasingly occurring at
therefore pharma deals tend to be much earlier stages of research and development,
larger than those of devices.” says David and companies in all sectors are forming
Cassak, Managing Partner at Windhover alliances and co-creating technologies and
Information, a healthcare industry analysis products from the earliest phases of R&D
firm based in the US. He further adds, “the through clinical validation, manufacturing,
whole drug-eluting stent market, which and product commercialisation.”
will be shared by a number of companies In conclusion, it is fair to say that the
is now pegged at around US$ 5-5.5 billion, convergence within the life sciences sector
which just about qualifies as one blockbust- presents a unique opportunity to all the
er drug and isn’t even the size of Plavix by players involved to develop solutions that
itself.” Thus, he says, a biotech firm would will have a long lasting impact on patient
see much bigger incentive in licensing its care, which in turn will provide growth in
products to a pharma company than a de- the long run. However, the key to this will
vice company. Further, device companies be innovation. And innovation can only re-
have tended to target existing drugs to be sult when companies work together. As Go
used in the combination products. By do- observers, “success will depend on the level
ing so, says Cassak, “device companies hope and intensity of participation from all the
to avoid their own extensive trials and the sectors of the life sciences industry.”
ISSUE-13 2007

Life Sciences
Industry
Converging for better care
What are the forces driving this
convergence?
Many factors are driving and influenc-
ing convergence in today’s life sciences
industry. Recent scientific advances and
improvements in enabling technologies
have opened new avenues for convergence
among drugs, diagnostics, and devices.
Aging populations and rising consum-
erism are increasing demand for health
care products that offer greater effective-
ness and convenience. Shifting industry
and market conditions are also creating
pressures and new opportunities.
Each of the life sciences sectors—phar-
ma, biotech, devices, and diagnos-
tics—faces somewhat different in-
dustry and market circumstances,
but convergence is presenting a new
avenue for business growth for all of them.
For instance, by acquiring and partner-
ing with firms in other life science sectors,
pharmaceutical firms are filling product
pipelines, extending product lifecycles,
and expanding product portfolios, while
device companies are achieving product
differentiation and expanding product
applications by developing platforms
that have multiple uses. Convergence is
reflected specifically in the develop-
ment of combination products, but also
T E C H N O L O G Y, E Q U I P M E N T & D E V I C E S
Combination products have the potential to respond
to the increase in patient needs in a way that may be
more affordable, easier to use, less expensive,
or more effective than current solutions.
Robert Go
Managing Director
Global Life Sciences and Health Care
Deloitte Touche Tohmatsu
USA
generally in the convergence between
industry sectors, particularly between
pharmaceutical and biotech sectors,
which are often now combined in a single
reference to “drugs” in spite of their funda-
mental scientific differences.
How is this convergence changing
patient care?
There is a general shift in patient needs as
a result of the overall demographic shift to-
ward older populations and larger popula-
tions of patients with one or more chronic
ailments that require regular monitoring,
prolonged treatment, and pain manage-
ment (cardiovascular conditions and dia-
betes, for instance). This shift is putting
upward pressure on health care costs and
increasing the demands on existing health-
care resources. Combination products
(ones that offer remote and continuous
monitoring, provide controlled drug thera-
py, are less invasive and painful, are simple
to use, and require minimal intervention
by healthcare providers) have the potential
to respond to the increase in patient needs
in a way that may be more affordable, eas-
ier to use, less expensive, or more effective
than current solutions. Also, by bringing
more self-administered healthcare solu-
tions to the market and enabling remote
Interview
patient monitoring by physicians, conver-
gence may reduce the number of care visits
that are needed, resulting in services that
are more cost-effective.
What are the legal ethical issues involved
in the convergence?
The regulation of combination products is
one of the biggest hurdles for both compa-
nies and regulators. This is largely because
drugs and devices are subject to different
regulatory requirements—when they are
combined, regulators must determine
which set or sets of regulations apply. To
provide guidance and ensure that combina-
tion products are tested and validated suffi-
ciently, regulators need to develop a strong
understanding of the technologies that are
involved and how exactly they are integrat-
ed. Companies may be able to facilitate the
validation and approval process and avoid
delays by working in close collaboration
with regulators during the R&D phase.
Variation in regulatory requirements across
different regions of the world also remains
an issue. Greater harmonisation of product
testing requirements, quality standards,
acceptance norms, technology protocols,
and certifications could lead to faster mar-
ket introduction of combination products.
Yet another issue may be the potential
increase in battles over the ownership of
intellectual property as convergence leads
to the formation of partnerships and alli-
ances. Companies will need to evolve new
models of licensing and profit sharing with
alliance partners.
w w w . a s i a n h h m . c o m 39
 Apart from the huge success of Drug
Eluting Stents, has the response to
other combination products been
good/satisfactory?
Drug eluting stents (DES) are, indeed, one
of the most prominent examples of con-
vergence. However, there are many other
combination products thriving in the mar-
ketplace today. Examples include spinal
cage fusion solutions and implantable drug
delivery devices that provide controlled
and timely release of chemotherapy agents
for the treatment of certain cancers.
Another category includes combina-
tions that integrate diagnostics with drugs.
Consider the example of positron emission
tomography (PET) scanners that are used
in combination with pharmaceutical con-
trast agents and radiopharmaceutical trac-
ers to be able to diagnose cancers at ear-
lier stages and less invasively than through
surgery. Similar is the case of Herceptin (a
genetically engineered humanized mono-
clonal antibody) which is used only for
breast cancer patients for whom a diag-
nostic test has detected the presence of a
40 Asian Hospital & Healthcare Management
specific protein - human epidermal growth
factor receptor-2 (HER2).
Examples for device-drug-diagnostic
combinations are also plentiful. Blood
glucose monitors, for example, when com-
bined with implanted insulin pumps, offer
round-the-clock monitoring with timely,
controlled release of insulin, and provides
diabetes patients with a less invasive and
more effective treatment alternative.
Are the two sectors doing enough to cre-
ate a platform for knowledge sharing that
would drive the innovations in the future?
Knowledge sharing occurs naturally hap-
pening during the convergence process.
Given that companies are not easily able
to create and commercialize a convergent
product alone, alliances and joint ventures
have become key paths to product crea-
tion. And, since the majority of alliances
require end-to-end participation from col-
laborating partners, the degree of knowl-
edge sharing may be quite high. Alliance
partners may not only be expected to be
involved jointly in R&D, but also to take
ISSUE-13 2007
part in the clinical validation and approval
processes together. This may help each gain
technology-product insights and speed up
clinical approvals. Similarly, alliances in
manufacturing may help companies un-
derstand the nuances of manufacturing in-
dividual products vs. converged solutions.
Any other comments you would like to
make?
There are two things that are vital for the
success of convergence in life sciences.
First, convergence is a cross-sector and in-
ter-disciplinary activity. Therefore, success
will depend on the level and intensity of
participation from all the sectors of the life
sciences industry. Second, convergence will
impact all the stakeholders of the health-
care industry – providers, regulators, gov-
ernments, payers and patients. They will
all have to work together, along with the
innovators, to facilitate the development,
introduction, and adoption of innovative
combination products.
For more information on convergence, please read
our new Deloitte Research report, Managing Pathways to
Convergence in the Life Sciences Industry.

What are the forces driving this
convergence?
Healthcare in general is moving away from
"one size fits all" / systemic approaches to
more targeted treatments. Patients are de-
manding better therapies with fewer side
effects, and combination products offer a
safe and effective solution.
Increasing competitive pressures are
playing a role in driving convergence too.
Until recently, the rate of innovation ap-
peared to be slowing in the medical device
and pharmaceutical industries. There were
a lot of incremental improvements, line
extensions, and "me-too" offerings, but
very few breakthroughs. Today, you see
more companies adopting an open innova-
tion model for developing products. They
are looking outside their organisation for
new ideas and partnership opportunities.
Combining drugs, devices, and biologics
appears to be the logical next step.
T E C H N O L O G Y, E Q U I P M E N T & D E V I C E S
Combination
Products
Enabling localised care
Combination products will enable healthcare
providers to treat diseases with localised
drug delivery and fewer side effects.
Chris Cramer
Principal
Life Sciences Practice
PRTM Management Consultants
USA
Finally, technology improvements
have fundamentally enabled this conver-
gence. Recently, drug-eluting coatings have
played a big role in cardiovascular stent-
ing and implantable orthopaedics. In the
future, we'll see more use of gene therapies,
human growth factors, and pharmaceuti-
cals where devices will serve as a vehicle
to deliver the therapeutic agent or as a
scaffold to encourage the body to actu-
ally heal itself. Miniaturisation will also
change the way we use medical devices as
manufacturers will be able to create
implantable devices for diagnostic and
therapeutic delivery at the micro to
nano level.
How is this convergence changing
patient care?
Simply put, the convergence is leading
to better products and better outcomes
for patients. To give you a few examples,
coronary stents and orthopaedic implants
have benefited from improved efficacy; the
former for the treatment of cardiovascular
artery disease and the latter for improved
acceptance of things like joint replace-
ments. Pacing leads and glucose sensors
could benefit from better biocompatibility
and a lower risk of inflammation and rejec-
tion. In cases such as cancer and diseases
Interview
of the retina, systemic treatments may be
ineffective or potentially harmful. Combi-
nation products will enable healthcare pro-
viders to treat diseases with localised drug
delivery and fewer/less severe side effects.
What are the legal, ethical issues
involved in the convergence?
As more combination products reach
the market, the difference between prod-
ucts may come down to the drug/bio-
logic component. As a result, I think,
you will begin to see new ways of market-
ing combination products. In the past,
devices were marketed exclusively to phy-
sician, surgeons and hospitals as surgical
tools. In the future, companies will look to
create consumer demand for their prod-
ucts. This will be especially true with drug-
delivery systems. Combination product
manufacturers will need to deal with the di-
rect to consumer marketing and patient edu-
cation issues that the pharma industry faced.
Apart from the huge success of Drug
Eluting Stents, has the response to other
combination products been good / sat-
isfactory?
Depending on whom you talk to, the
exact numbers may vary. But the overall
market for combination products is large
w w w . a s i a n h h m . c o m 41
 and growing. Initial estimates put the
total value in the range of US$ 40-50
billion and it’s growing at a rate of about
14% annually. This growth is being led
primarily by inhalation devices, includ-
ing intranasal and pulmonary systemic
therapies. Transdermal delivery will also
contribute significantly. Drug-enhanced
technologies—like stents, orthopedics,
and electrodes—are also expected to
contribute as well. It’s important to point
out that these numbers do not include
regenerative medicine products (wound
management, dermal substitutes, artificial
organs, etc.) that hold tremendous
potential.
Are the two sectors doing enough to cre-
ate a platform for knowledge sharing
that would drive the innovations in the
future?
A tremendous amount of learning
has taken place and the industry is
42 Asian Hospital & Healthcare Management
starting to pay attention to combination
products. For example, there are now
conferences focused exclusively on
combination products. Several large com-
panies have even created combination prod-
uct 'centers of excellence' to consolidate les-
sons-learned and to help match the needs of
combination product development
programs with the right resources and
expertise.
However, one of the biggest
challenges—and opportunities for
knowledge sharing—is in the regulatory
environment. There are still no specific
regulations or regulatory submissions
that are unique to combination products.
It would be great to see the leading
ISSUE-13 2007
industry players and regulatory bodies
work together to develop a consolidated
set of requirements and guidelines for
combination products.
Any other comments you would like to
make?
It’s good to see that the FDA is putting
more focus on combination products by
establishing the Office of Combination
Products (OCP). It is responsible for the
prompt assignment of a new combina-
tion product to the lead FDA agency (i.e.
- CDRH, CDER, or CBER) and coordi-
nating the cross-agency review process.
However, the regulatory oversight model
and requirements for combination prod-
ucts are still evolving. This trend is likely to
continue for the next few years. As a result,
companies looking to bring new products
to market should take a proactive approach
to working with the FDA on pre-market
review/approvals.

Operating Room of the Future
Emerging technologies
RFID, UIP and VoIP are technologies that will ultimately increase patient safety while
resulting in cost savings through improved workflow efficiency. However, careful
planning should take place prior to installation in order to avoid incompatibilities and
overload of existing local area networks.
Olivier Wenker
Professor of Anesthesiology
Division of Anesthesiology, Critical Care,
and Pain Medicine
and
Director of Technology Discovery
Office of Translational Research
M. D. Anderson Cancer Center
University of Texas
USA
T
he Operating Room of the Future
(ORF) or the Intensive Care Unit
of the Future (ICUF) are environ-
ments that are becoming more digitised,
complex and integrated into the overall
hospital operations. Tracking of patients,
staff and equipment on a real-time basis
will allow for better patient identification,
resource management and work flow im-
provements. Digitalisation of the work-
place will reduce time requirements for
charting, enable more accurate patient data
recording and archiving, provide better
imaging, allow integration between clini-
cal and administrative tasks, enable remote
monitoring, and result in reduced medical
errors by avoiding unreadable handwrit-
ing or incorrect patient identification. The
ultimate goal is to achieve enhanced pa-
tient safety and to obtain cost/time savings
through better work flows.
New technologies such as Radio
Frequency Identification (RFID) or Ul-
trasound Indoor Positioning Systems
(UIP) enable real-time location tracking
T E C H N O L O G Y, E Q U I P M E N T & D E V I C E S
(RTLS = Real-Time Location System) of
patients, staff and equipment. Voice over IP
(VoIP) takes advantage of existing wireless
networks in hospitals for delay-free commu-
nication within the institutions. An increas-
ing number of hospitals are now testing such
systems for various purposes. The following
overview will describe and compare some of
the emerging technologies and summarise
initial experiences.
RFID
It is known from other industries that
knowledge about location and movements
of relevant people and items can help maxi-
mise productivity. Over the past few years,
several hospitals around the world have
started to use RFID technology for real-
time tracking. The systems consist of tags,
readers, hospital local area networks (wired
or wireless), central computer/server and
software. Tags can be active (constantly or
almost constantly emitting signals) or pas-
sive (only emitting signal when activated by
reader). Depending on the task, the appro-
priate technology should be used. Some tags
have a hybrid function and act as active tags
until they pass a certain detector which then
Active vs Passive RFID
Active RFID
Tag Power Source Internal to Tag
Tag Battery Yes
Availability of Tag Power Continuous
Required Signal Strength from Low
Reader to Tag
Communication Range Long Range (100m or more)
Sensor Capability Continuously monitor and record
timestamp data
switches the tag mode to passive or vice ver-
sa. Active tags are more expensive, use more
bandwidth, and have shorter battery times.
Passive tags usually require special readers.
No electromagnetic interference with medi-
cal equipment has been reported to date
when using 2.4 GHz or 802.11 networks.
St. Vincent’s Hospital in Birmingham,
Alabama, conducted a pilot study on the
benefits of using an RFID indoor position-
ing solution in the hospital. They mainly
measured real-time patient location, and
by doing so, they were able to improve
admission, transfer, and discharge times by
85%. Discharges by noon, a key through-
put metric in many hospitals, could be
improved by 21%. Patient satisfaction im-
proved as a result of shorter waiting times,
improved resource availability, and faster
transport times. Staff satisfaction improved
because of decrease of unnecessary trips
and patient searches as well as a decrease in
answering pages.
An RFID tracking system was also in-
stalled in the “Operating room of the Fu-
ture” at Massachusetts General Hospital to
measure work flow efficiency in the operat-
ing room when combining the technology
Passive RFID
Energy Transferred from Reader
No
Only Within Proximity of Reader
High - Required to Power Tag
Short (3m or less)
Only able to read and transfer data when
tag is powered by reader
w w w . a s i a n h h m . c o m 43
 T E C H N O L O G Y, E Q U I P M E N T & D E V I C E S

with other work flow improvements. The
pilot study included 45 patients and the
results were impressive. Pre-surgical wait-
ing time could be reduced to 12.1 minutes
(vs. 29.9 minutes for standard OR times).
Emergence time was 8.3 minutes vs. 15.6
minutes prior to the changes. This allowed
for four additional cases per day in that
operating room. Additional benefits were
increased patient safety through positive
patient tracking and identification prior to
surgery.
Optimally, positive patient identifica-
tion should be combined with the display
of the patient’s photo on the display screens
of the appropriate pre-operative room and
operating room for absolute positive iden-
tification, with automatic opening of the
electronic patient chart on the appropriate
screens such as anaesthesia work station
and nursing station in the OR, and with
crosschecking of intended surgery and oth-
er relevant data such as preexisting medica-
tion and allergies.
UIP
Another technology enabling RTLS is
based on ultrasound. The system consists
of tags, detectors, hospital local area net-
works (wired or wireless), central com-
puter/server and some software. Small,
wireless transmission tags are attached to
objects such as equipment, patient charts,
staff, or patients. They can be tracked
via detectors using special digital signal
processing algorithms. The detector trans-
mits the data via the hospital network to a
central computer where the exact location
and movement of the objects are tracked
Ultrasound tags attached to patient charts
and displayed together with other relevant
information stored on the tags. Ultrasound
signals are confined to the room where
they originate and don’t “bleed” through
walls, floors and ceilings. Therefore, they
allow for room-level accuracy. Since ul-
trasound waves are not radiofrequency
dependent, they don’t interfere with sensi-
tive hospital instruments and equipment.
The bandwidth requirements are minimal
RFID versus ultrasound
(less than 200 bytes per signal) and local
area networks (wired or wireless) of hospi-
tals are not being overloaded with excess
transmission information.
The benefits of UIP are similar to the
ones of RFID and RTLS systems that
include:
• Enhanced patient safety due to bet-
ter patient identification, availability
of real-time patient data, and location
of items such as location of sponges
during surgery
• Time saving by real-time locating of
patients, charts, staff and equipment
Computer screen examples
• Reduced equipment shrinkage costs
• Better utilisation of staff and equip-
ment
• Improved patient flow with better uti-
lisation of resources
• Improved room, bed and staff manage-
ment
• Improved patient and staff satisfaction
• Better inventory management and
improved supply chain
• Overall cost reduction in the hospital
VoIP
At the 2003 annual meeting of American
Society of Anaesthesiologists (ASA) a survey

Comparison of various RFID tags

Technology Deployment Options Benefits Frequency Range Strengths Weaknesses

Passive RFID Passive Patient Tags Positive Patient 13.56 KHz or 900 MHz Low Cost, ease of Supports fixed reading only in
Identification deployment, flexible form line of sight usage model
factor
Active RFID (Non-802.11) Active Patient, Asset, Positive Patient 400 MHz//900MHz with Low Tag Cost, Long Requires additional network
Low Frequency Staff Tags Identification, Asset/ Infrared technology Battery Life, Lower (Access Point Infrastructure),
Person tracking frequency band Non-Standard proprietary
protocol
Active RFID (Non- Active Patient, Asset, Positive Patient 5751 - 7001 MHz Requires additional network
802.11) Ultra Wide Band Staff Tags Identification, Asset/ (Access Point Infrastructure),
Frequency Person tracking Non-Standard proprietary
protocol
Active RFID (802.11 Active Patient, Asset, Positive Patient 2.4 GHz Utilises existing 802.11 High Tag Cost , lower battery
Based) Staff Tags Identification, Asset/ infrastructure, aligned life for frequent real-time
Person tracking with general wireless tracking, additional 802.11
networking standards access points

44 Asian Hospital & Healthcare Management ISSUE-13 2007


was conducted. The five-question survey
polled the anaesthesiologists about modes
of communication in operating rooms,
ICUs, and hospitals in general. 65% of the
over 4,000 respondents indicated that pag-
er systems were their primary tool for com-
munication while 15% used their wireless
mobile phones. 20% used other tools such
as regular telephones or overhead systems
or had no preference for a single commu-
nication solution. 45% of the pager users
reported significant delays and 35% of
those had observed medical errors or inju-
ry as result of the delays. Only 31% of the
mobile phone users experienced significant
delays and 38% of those reported having
observed medical errors or injury. Mo-
bile telephone users were 1.6 times more
likely to report interference with medical
equipment, but this finding was not sig-
nificant. Overall, the results suggested that
the use of mobile telephones decreases the
risk of errors which needs to be weighed
against the potential risk of interference
with medical equipment. Most of the hos-
pitals prohibit or limit the use of mobile
T E C H N O L O G Y, E Q U I P M E N T & D E V I C E S
phones for staff and visitors alike. It can be
concluded that newer technologies could
decrease or eliminate unnecessary delays
in emergency-related communication
and therefore increase patient safety. Also,
direct communication without delays
could result in improved work efficiency
and cost savings.
A relatively new technology, VoIP
enables instant voice conversations
among team members, across groups, and
throughout an organisation of mobile
professionals. The systems are made up
of three elements: the wireless network
within an organisation, the system soft-
ware, and the communications badge.
One such commercially available solution
in the US runs on a standard Microsoft
Windows server and houses the central-
ised system intelligence: the call manager,
user manager and connection manager
programmes as well as speech recognition
software and various databases. The com-
munications badge is a wearable device that
weighs less than two ounces and can eas-
ily be clipped to a shirt pocket. It enables
instant two-way voice conversation without
the need to remember a phone number or
manipulate a handset. The badge is con-
trolled using natural spoken commands.
To initiate a conversation with Jim and
Mary, for example, the user would simply
say, "Conference Jim Anderson and Mary
Smith." In addition, when a live conver-
sation is not necessary, text messages and
alerts can be sent to the LCD screen on the
back of the Communications Badge.
It was shown that nursing groups in
hospital units can wait a total of 2,100
hours per year on the phone while trying
to reach physicians, pharmacists, or other
healthcare professionals. It is expected that
direct communication via VoIP can sig-
nificantly reduce these waiting times. This
was shown in Blacktown Hospital in Aus-
tralia. While past methods of locating staff
within hospitals including mobile phones,
pagers and physically searching were ineffi-
cient, the VoIP solution resulted in an esti-
mated 6,000 hours per year in time savings
for staff, leading to potential cost sav-
ings of more than US$ 105,000 per year.
w w w . a s i a n h h m . c o m 45
 T E C H N O L O G Y, E Q U I P M E N T & D E V I C E S

A pilot study in Regions Hospital, Min-

nesota, with about 100 staff members
across shifts in a trauma unit and a medi-
cal surgery unit supported expectations of
increased productivity of mobile personnel
and showed a decrease of overtime hours
by as much as 67% when using VoIP. Re-
cently, M. D. Anderson Cancer Center in
Houston, Texas, implemented the use of
VoIP as their primary tool for resuscitation
alarms and as the primary communication
tool amongst a selected group of healthcare
professionals within the hospital.

In summary
While most of the emerging technologies
are still being evaluated and implemented
as stand-alone tools, one can easily imag-
ine that they will soon be integrated in
overall solutions within the hospitals. As
more hospitals become wireless-enabled- while resulting in cost savings through Communication and coordination
enterprises combination of different tech- work flow efficiency improvements. Prior during planning and implementation be-
nologies will become reality and lead to to installing these systems, however, care- tween clinical operation, administration
“wireless convergence.” ful planning should take place in order to and information technology departments
RFID, UIP and VoIP are technologies avoid incompatibilities and overload of ex- are imperative in order to take full advan-
that will ultimately increase patient safety isting local area networks. tage of these new emerging technologies.

46 Asian Hospital & Healthcare Management ISSUE-13 2007


Medical Devices
Going the generic way
With the application of the generic pharmaceutical model to off-patent devices, the
availability of generic alternatives to branded medical devices presents an opportunity
for a drastic reduction in healthcare costs.
Richard Kuntz
President & CEO
Generic Medical Devices, Inc.
USA
O
ver the last two decades, tech-
nical improvements in the de-
velopment of medical devices
have helped create a thriving US$ 100 bil-
lion-a-year global industry. The expansion
of innovative and original medical device
manufacturing techniques has yielded re-
markable biotechnological progress that
has prolonged the life expectancy for
patients and provided access to new life-
saving procedures; but throughout this
growth, standard-of-care devices have
largely been ignored given their maturity
in the product life cycle. As a result, the
price of these devices has risen on pace
with the rest of the healthcare industry,
but without acquiring any new features
or improvements. Now, with the applica-
tion of the generic pharmaceutical model
to off-patent devices, the availability of
generic alternatives to branded medical de-
vices presents an opportunity for a drastic
reduction in healthcare costs in Asia and
internationally.
Generic pharmaceuticals––Laying
the groundwork for generic
devices
For years, consumers have widely used ge-
neric drugs offered by the pharmaceutical
industry. The idea is simple: once the patent
on a brand name drug expires (usually after
approximately 17 years), competitors are
allowed to develop, market and sell generic
T E C H N O L O G Y, E Q U I P M E N T & D E V I C E S
alternatives as long as they offer the same
safety and efficacy as their branded coun-
terparts. By introducing these lower cost
alternatives, drug manufacturers gravitate
towards innovation in healthcare for newer,
cutting edge pharmaceuticals.
Surprisingly, and despite the success of
generic pharmaceuticals across the globe,
the generic pharmaceuticals model has
never been applied to the burgeoning medi-
cal device market, where large manufactur-
ers continue to benefit from price increases
on patent-protected surgical devices. These
patents create barriers to entry for new com-
petitors, enabling prices to continue to rise
with little regulatory control and often with
few, if any, additional innovations or im-
provements on those devices. This, in turn,
creates financial problems for hospitals, am-
bulatory surgical centers and independent
physicians seeking to provide their patients
with the best in medical care; rising costs for
devices mean either a direct rise in costs to
healthcare systems, insurance providers and
patients in a privatised system, or else a re-
duction in the number of patients who can
gain access to care in socialised systems.
However, as patents expire, competi-
tors are allowed to enter markets originally
dominated by brand names. Generic Medi-
cal Devices (GMD), Inc. is the first such
company to capitalise on these allowances
by developing generic versions of standard-
of-care surgical products no longer under
patent protection. The first generic medical
devices are already available: the GMD Uni-
versal Surgical Mesh, a Class II, non-active
implantable medical device intended to sup-
port tissue growth in open or laparoscopic
procedures (common for hernia repair),
which has received 510(k) clearance for use
in the United States and been submitted for
CE-Marketing in Europe; and the GMD
Universal Circumcision Clamp, which has
been granted both FDA 510(k) clearance
and CE Marking. Several additional ge-
neric devices focussed on pelvic health are
in the product pipeline. Each generic medi-
cal device will be offered at approximately
two-thirds the cost of brand name devices,
providing enormous cost savings to purchas-
ers—which can translate into direct savings
for patients and healthcare systems.
To be clear, GMD is not setting its
sights on devices that are considered life-
critical, highly complex from a technology
stand point, consistently being improved
upon or regularly replaced by new itera-
tions. New medical devices that require
years of engineering and development are
not products for which generics should be
manufactured. Instead, GMD is focussed
on devices considered standard-of-care in
their respective categories, devices that have
undergone little, if any, innovation since
first being introduced to the market, and
devices which are easily replicated and for
which the company can dramatically reduce
costs. By some estimates, the first GMD
products could save the healthcare system
in excess of US$ 360 million per year in the
United States alone.
A new era of medical device
manufacturing
As more generic alternatives become avail-
able in 2007, the impact on Original Equip-
ment Manufacturers (OEMs)—and conse-
quently, the healthcare system—is likely to
be immediate and encompassing. By offer-
ing efficacious products costing significantly
less than brand name counterparts, the
w w w . a s i a n h h m . c o m 47
 T E C H N O L O G Y, E Q U I P M E N T & D E V I C E S
market for generic surgical devices is likely
to grow quickly and steadily.
Hospitals, surgical centres, and third-
party payers are limited in procurement
based on strict fiscal budgets. However,
with generic device prices estimated at ap-
proximately two-thirds of the current mar-
ket price, these organisations will now have
access to high-quality, lower cost alterna-
tives and benefit from an escalation in pur-
chasing power, allowing them greater access
to devices and the ability to provide services
to a wider number of patients—whether
through lowered direct costs or, in a so-
cialised environment, through the ability
to purchase more devices within the same
fixed budget.
As a result of the increased purchas-
ing power of hospitals, surgical centres,
and third-party payers, it is predicted that
OEMs will experience greater demand for
surgical devices and increasing production
quantity––in short, opening the door to a
new “generic” revenue stream influenced
and created by the demand from the health-
care system itself. Brand name companies
will face the greatest challenge in choosing
how to contend with this new competition.
To protect their market share, brand name,
manufacturers will need to respond by in-
troducing lower cost alternatives of their
own or adjusting to the new market prices.
Either way, the healthcare industry will
win as brand name companies compete to
match their generic counterparts and overall
prices on expensive, standard-of-care surgi-
cal devices drop.
Ideally, this will benefit Asian countries
in several ways; Asian countries are already
emerging as prime arenas for manufacturing
low-cost medical devices, so, not only will
hospitals and patients gain access to qual-
ity devices at lowered costs, but OEMs and
materials manufacturers based in China,
Singapore, Korea and elsewhere will expe-
rience a rise in the ability to partner with
American and international companies to
produce the devices.
The market for generic devices in
Asia
A 2001 United Nations population study
predicted that Asia’s over-65 population
will increase by 314% by 2050. With
one quarter of Asia’s population now over
the age of 55, the demand for lower cost
48 Asian Hospital & Healthcare Management
medical devices is ever-increasing. The
increase in elderly patients will necessar-
ily create a higher burden on the various
healthcare systems––many of which have
already ceased to provide sufficient govern-
mental support for the general population.
As a result of such conditions as widespread
deregulation in the healthcare sector in Ja-
pan and the fact that much of the cost for
healthcare falls to the individual in priva-
tised environments like China and Taiwan,
generic pharmaceuticals have been widely
accepted in Asia.
According to The Asia Generic Phar-
maceuticals Forecast Report published in
2006, Japan will be Asia's biggest branded
generics market by the end of the decade as
the government continues to cut drug costs
and make hospitals and consumers more
price-aware, and China's generics market
will continue to expand strongly, although
success will depend on brand strength as the
population remains reliant on basic drugs.
This trend demonstrates a willingness
among consumers and the healthcare in-
dustry to accept products that do not carry
a brand name––it is expected that generic
medical devices will follow suit.
This prediction is further supported by
the fact that many Asian countries, includ-
ing Taiwan, South Korea and Singapore,
import more than twice as much in medi-
cal devices as they export—in many cases,
Asian countries are importing more than
US$ 0.5 Billion in foreign medical devices
each year in order to serve their ageing and
expanding populations. With governmental
programmes in place urging reduction in
healthcare costs in several Southeast Asian
countries and a program directed at raising
the standards of medical devices and equip-
ment used in government-owned hospitals
in Malaysia, there is clearly a place for high-
quality generic medical devices in the Asian
market.
GMD: A market of one
Currently, GMD occupies an industry of
one, but with thousands of surgical devices
in production for which generic models
could be developed, there is considerable
room for emerging generic manufacturers
that could similarly benefit Asia and the
world. Ideally, each company would focus
on a unique device segment in order to best
meet increasing demand and maintain the
ISSUE-13 2007
highest levels of safety and efficacy. Sup-
ported by deregulation programs in coun-
tries such as Japan intended to increased fo-
cus on innovation and thus on partnerships
with foreign companies, GMD is beginning
to establish partnerships with manufactur-
ers and hospital customers throughout
Asia; the potential for widespread systemic
change and savings is immense.
Generic products will drive down the
cost of standard-of-care devices, make room
in a burdened global healthcare system for
innovation, and, most importantly, give
more patients access to cutting-edge treat-
ments by correcting decades of unregulated
price inflation worldwide. GMD’s entry into
the device industry has opened the doors to
a whole new market opportunity for OEMs
and new generic device manufactures––and
the potential impact on the market is just
now being defined. Ultimately, hospitals,
third-party payers and patients will drive
the industry shift by choosing brand name
quality at generic prices.
BOOK Shelf
Medical Devices and
Systems
Authors : Joseph D
Bronzino
Year of Publication: 2006
Pages: 1376
Description:
Over the last century, medicine has come
out of the "black bag" and emerged as one
of the most dynamic and advanced fields
of development in science and technology.
Today, biomedical engineering plays a
critical role in patient diagnosis, care, and
rehabilitation. More than ever, biomedical
engineers face the challenge of making
sure that medical devices and systems are
safe, effective, and cost-efficient. Offering
an overview of the tools of the biomedical
engineering trade, Medical Devices and
Systems reviews the currently available
technologies and lays a foundation for
the next generation of medical devices.
Beginning with biomedical signal analysis,
renowned experts from around the world
share their experience in imaging, sensing
technologies, medical instruments and
devices, clinical engineering, and ethics.
For more books, visit Knowledge Bank
section of www.asianhhm.com

Patient Safety
The next level
There is growing acceptance of the newer methods in
patient safety and a call to combine both retrospective
and prospective methods in order to gain a complete
picture of the patient safety challenge.
I
t has been seven years since patient
safety became recognised as a ma-
jor international healthcare issue.
Eisenberg’s analogy of patient safety having
the characteristics of an epidemic of world-
wide portions provides a framework of
examining patient safety with three stages.
• Identify the risks and hazards that cause
or have the potential to cause healthcare
associated injury or harm
• Design, implement and evaluate patient
safety practices that eliminate known
hazards, reduce the risk of injury to pa-
tients and create a positive safety culture
• Maintain vigilance to ensure that a safe
environment continues and patient safe-
ty cultures remain in place
For most of the past seven years patient
safety movement has focussed on stage one
in the epidemic cycle with the primary
FA C I L I T I E S & O P E R AT I O N S M A N A G E M E N T
action directed at the identification of risks
and hazards to patient from healthcare as-
sociated injury or harm. We are now just
beginning to actively move to stage two of
the cycle—the design and implementation
but we are no where near reaching stage
three. In examining new approaches to pa-
tient safety, it is important to review what
we have learned in the past seven years at
stage one to determine the directions for
stage two.
Stage One: Identification of risk
and hazards
Retrospective and prospective
Battles and Lilford noted that there are
three primary sources of identifying risks
and hazards that can be used 1) sponta-
neous active event reporting, 2) adminis-
trate data and 3) patient charts or records.
James B Battles
Senior Service Fellow
Patient Safety
Center for Quality Improvement and
Patient Safety (CQuIPS)
Agency for Healthcare Research and
Quality (AHRQ)
United States Department of Health &
Human Services
USA
Significant progress has been made at
implementing reporting systems at the
institutional, regional and even the na-
tional level. There is growing recognition
of the importance of using administra-
tive or billing data in patient safety. The
medical record continues to be a source
of patient safety information but chart
auditing is labour intensive. However
newer approaches that use triggers with
Electronic Health Records (EHR) are
showing promise. When it comes to iden-
tifying risks and hazards retrospectively,
we should apply a principle of maritime
navigation which states that you can never
truly know where you are without a three
point fix of your position. Thus all three
of these approaches are required to gain a
complete picture of risks and hazards to
patient safety.
w w w . a s i a n h h m . c o m 49
 FA C I L I T I E S & O P E R AT I O N S M A N A G E M E N T
Healthcare has relied almost exclusively
on retrospective methods for risk assess-
ment. This traditional epidemiologically
based approach has been useful; however
there is a growing need for more prospec-
tive or proactive approach to assessing risk
and hazards in patient safety. Proactive risk
assessment has been extensively used in a
number of high hazard industries such as
aerospace and nuclear power. The methods
include Root Cause Analysis (RCA), process
mapping, Failure Modes Effects Analysis
(FMEA) and Probabilistic Risk Assessment
(PRA). There is growing acceptance of the
newer methods in patient safety and a call
to combine both retrospective and prospec-
tive methods in order to gain a complete
picture of the patient safety challenge.
Sensemaking
In order for organisations to become learn-
ing organisations, they must make sense of
their environment and learn from safety
events. Sensemaking, as described by Weick,
literally means making sense of events. True
sensemaking in patient safety must use both
retrospective and prospective approach to
learning. Sensemaking is an essential part of
the design process leading to risk - informed
design. The results of these separate or com-
bined approaches are most effective when
end users in conversation-based meetings
add their expertise and knowledge to the
data produced by, FMEA, and/or PRA in
order to make sense of the risks and haz-
ards. Without ownership engendered by
such conversations, the possibility of effec-
tive action to eliminate or minimise them is
greatly reduced.
Safety culture assessment
Safety culture assessment is an essential ele-
ment at stage one of the epidemic cycle. Sig-
nificant progress has been made in health-
care in measuring the culture of safety at
the institutional and even the national level.
The results: safety culture assessment can
serve as a powerful starting point for organi-
sations to implement patient safety projects
in a positive atmosphere of improvement
as well as measure progress of patient safety
activities.
Stage two - Safety by design
The real challenge to patient safety is acting
on the information obtained once the risk
and hazards are identified. The design and
implementation of interventions that are
50 Asian Hospital & Healthcare Management
specially intended to eliminate or mitigate
known risks and hazards is the challenge
of stage two. Using the data collected in
stage one, we need to move to a more risk
- informed design approach to use proven
design methods involving a number of pro-
fessions outside of healthcare so that one
could actually design out system failure and
design in safety and quality of care.
Battles and Lilford have provided a
modification of the Donnabedian model
to serve patient safety which uses a nested
approach of structure surrounding process
with human behaviour at the core. This
framework of structure and process can help
determine what to design for the healthcare
system. Figure 1 is a graphic representation
of the nested model of the critical elements
of structure and process that must be de-
signed. This design model shares similar
characteristics with Ferlie and Shortell’s
model of the healthcare system and with
Morey’s onion model of human factors de-
sign elements.
Clinical work is increasingly being
supported and shaped by technology in
the form of tools, devices and Health In-
formation Technology (HIT). Technology
represents a range of sophistication from
automated laboratory testing and pharma-
ceutical dispensing equipment to robotic
surgery devices to simple mistake-proofing
devices. The fact is that the tools of work are
embedded into the process of care and are
connected directly to the built environment.
They must be designed in coordination with
both the built environment and work itself.
Automating broken work/clinical processes
can and often do make matters worse rather
than bring promised improvements.
The process of care can also be thought
of as clinical work systems. Clinical work is
an interaction of teams of healthcare pro-
viders working in micro systems within a
built environment, using tools, devices and
ISSUE-13 2007
The Nested Model of
Critical Design Elements of
Structure and Process
HIT to care for the object of the system i.e
the patient. The concept that work can be
designed is not new. In healthcare, there
has been a reluctance to shift away from
the myth of the independent professional
model of work to embrace the reality of in-
terconnected clinical work systems. Clinical
work can and should be designed for quality
and safety.
Ineffective teamwork and communica-
tions continue to be listed as the main under-
lying cause of failure in patient safety events.
This growing awareness of the importance
of team work has led to the development
of a number of successful programmes in
teamwork training designed to improve the
process of care. In addition to teamwork,
the use of simulation as an implementation
strategy that is showing great promise both
as an intervention strategy and as a means to
improve skills and performance across the
continuum of care.
Conclusion
There is no simple quick fix or easy solution
to the problems of patient safety. It requires
hard work and commitment by everyone.
There are a growing number of individual
advances in patient safety that are and will
continue to have an impact on the quality
and safety of care. These advances must be
looked at as a part of holistic or systems im-
provement rather than as a single solution
to a very complex interconnected problem.
Unless there is a shared ownership of the
risks and hazards associated with healthcare
little progress will be made. This shared
ownership of risk involves all levels of or-
ganisations from the Chief Executive Of-
ficers and the Board to all care givers and
even to the janitors. It also includes govern-
ment officials, those who pay for care and,
of course, patients. When risks are known
and fully understood, dealing with them is
possible in a culture of safety.

Cardiovascular Medicine
Integrating IT for better care
New interventions are urgently needed to update cardiovascular practice to the level of fast
pace in the other areas. The rapid and efficient cardiovascular services provided by these
new paradigms will improve standard of care and cut cost by eliminating communication
gaps, treatment errors and redundant diagnostic testing.
Ravi Komatireddy
Resident in Internal Medicine
Dartmouth-Hitchcock Medical School
Hanumanth K Reddy
Adjunct Clinical Professor
Medicine/Cardiology
University of Arkansas for Medical
Sciences
and
Clinical Professor
Medicine St. Louis University Medical
School
USA
I
n the last half a century, unprec-
edented cardiovascular progress has
occurred. With advances ranging
from the human genome project to heart
transplantation, cardiovascular medicine
has seen tremendous growth throughout
the spectrum of both basic research and
clinical practice. At the current pace, more
exciting advances such as prophylactic car-
diovascular vaccines, genetic and stem cell
treatments may soon be realised. Unfortu-
nately, there are still serious infrastructural
pitfalls in the coordination, communica-
tion and the delivery of medical care to
patients. With prompt and effective digital
communication, a well-coordinated and
comprehensive medical care could be of-
fered to patients. This approach would
mitigate medical errors and duplication of
medical testing and treatment saving lives
and money. Furthermore, efficiency of care
could be significantly improved.
Exchange of medical information
and medical education
Rapid transmission of patient information
and treatment strategies are critical to op-
timal disease management. To assure con-
sistent excellence of cardiovascular care, a
well-informed team approach is needed.
The team members need to believe in on-
going medical education. Unfortunately,
antiquated medical education systems exist
in many parts of the world.
Medical education at all levels must
undergo a significant change. We cannot
expect to demand excellence from our
peers when we are not given the tools or
any formal training on how to effectively
teach them critical information needed to
practice medicine ,
Perhaps one of the reasons we failed
to develop a consistent, evidence-based
model of medical education is that we
consider mastery of didactic knowledge
as “adequate.” However, the rapid change
of medical information makes this type of
“memorisation-recall” focused education
model increasingly futile as the growing
fund of medical knowledge grossly out-
weighs any one individual’s ability to suc-
cessfully recall it. Current guidelines for
recertification and CME are consistent
with this idea. Instead, we should focus on
giving physicians the skills to enable them
to seek out and integrate new medical
data as needed. Furthermore, and perhaps
more importantly, there is a large subset of
knowledge that is neither formally taught
I N F O R M AT I O N T E C H N O L O G Y
nor found in medical textbooks. This is
“experiential knowledge,” how to survive
and thrive in the medical environment,
how to anticipate problems, make tough
medical decisions based on scanty data,
etc. We sometimes refer to these as medi-
cal “pearls” of wisdom. Anyone who has
made the transition from medical school to
graduate medical training can attest to how
important this type of information can be
to successful patient care. Some of this
knowledge can only be learned through
experience, through trial and error; how-
ever, a significant portion is learned by
emulating our peers and superiors. This
knowledge is essential to the practice of
efficacious medicine and is just as valu-
able as factual knowledge. While we have
a plethora of electronic references that can
provide easily synthesised factual informa-
tion there are virtually no central clearing
houses of this experiential, “how to prac-
tice” class of information. By leveraging
the power of the internet and social net-
working, the creation of digital resources
that enable physicians to share this type of
information could prove to be a very pow-
erful tool towards preparing physicians to
practice more efficient and safe medicine.
Harnessing electronic power for
cardiovascular care
With the prompt availability of recent
developments and techniques via elec-
tronic media, prompt diagnosis and
treatment of cardiovascular problems are
expected in 2007. It is puzzling that the
cardiovascular field has not fully utilised
the power of networked technology and
w w w . a s i a n h h m . c o m 51
 I N F O R M AT I O N T E C H N O L O G Y
simulation to facilitate medical training as
fully as other industries such as the aero-
space industry. Practice simulations have
long been shown to increase efficiency, de-
crease response time and improve decision
making in various settings including ones
that require urgent decision-making.
With physical distance no longer a
limiting factor and intensive graphical and
computing availability to the general pub-
lic, the use of simulation software/hardware
or other complex tasks such as surgery,
ACLS, cardiac catheterisation, bronchos-
copy, etc. could be simulated by teams of
physicians working together connected via
internet. This would enable practice and
learning of new techniques as well as the
ability to simulate problems and compli-
cations periprocedure or intraprocedure
without any real world consequences to a
patient.
For surgical procedures this would act
as an additional, effective learning step
placed between reviewing a text book one
day, and expecting to perform in the OR
during the procedure the next day. While
several rudimentary simulation packages
are currently in use, especially for endo-
scopic technique, CPR and central venous
access, this technology has incredible room
to grow before it reaches its full potential as
a ubiquitous medical training tool.
Multidisciplinary education is also an
underutilised methodology for medical
education. Physicians spend a significant
portion of their lives working along side
other medical professionals whom they’ve
never met, know nothing about, and are
totally unfamiliar with in terms of the ex-
tent of their education. In light of this fact
the physician workplace demands a seam-
less integration with nurses, clinical re-
searchers, pharmacy etc. Working with or
learning about ancillary medical staff, even
briefly, during the process of medical edu-
cation may increase long-term efficiency in
the physician workplace. Medical schools
are at the beginning stages of incorporating
this type of interdisciplinary education, at
least on a small scale. And, there are several
examples of organised multidisciplinary
cooperation within specific hospital envi-
ronments i.e. intensive care units.
Another shifting pattern of practice is
becoming evident with the development of
growing demographics of the patients who
52 Asian Hospital & Healthcare Management
utilise various public databases of medical
information to learn about their illnesses.
This presents a very challenging situation
to physicians, as our role must evolve to
educate and reconcile often inaccurate and
incomplete medical information that is of-
ten gleaned from unreliable sources from
the Internet.
Information can also flow the other
direction, from doctor to patient as we
have the potential to leverage technol-
ogy in order to facilitate patient teaching;
this information, in the form of interac-
tive displays, distributable computer pro-
grams, or interactive simulations, can act
as supplementary material to face-to-face
doctor-patient discussion. This promises
to keep doctor-patient encounters more
informative for patients.
Medical Communication
Top-notch healthcare will always critically
depend upon an organised, efficient system
of communication between physicians, an-
cillary medical professionals and patients.
Unfortunately, the mostly outdated means
of technology currently used by the health-
care industry; phone, fax, etc., results in a
haphazard array of communication styles
that are inadequate to handle the workload
of a modern healthcare workplace. There is
no centrally accessible database or platform
for physicians in the United States to col-
laborate or communicate with each other
let alone with their patients. This problem
commonly manifests, with respect to doc-
tor-patient interaction, with the “lost to
follow up” phenomenon and has shown to
result in non-trivial mortality and morbid-
ity. Collaboration is not only essential to
medical practice, it is in fact intrinsic to it.
Medical care delivery depends upon
the combined efforts and analysis of mul-
tiple medical specialities; it would not be
unreasonable to see the development of
an internet based solutions to foster this
collaboration by networking physicians;
giving them a consistent and unified plat-
form to communicate and share data. An
internet based network that connects phy-
sicians opens doors to a staggering number
of possibilities for teaching physicians and
patients, collaboration, consultation, re-
search and healthcare delivery. The ability
to remotely view diagnostic data, in radiol-
ogy for example, are changing the system
ISSUE-13 2007
of healthcare delivery within that field.
We can expect to see similar changes to
other medical specialties where diagnostic
data can be acquired and sent for analysis
at remote locations via the internet (i.e.
echocardiography, cardiac catheterisation,
CT angiograms, EKG, EEG, colonoscopy,
etc.). Tele-medicine could easily be inte-
grated into such a platform. Although cur-
rent tele-medicine initiatives are being used
to showcase specific procedures or to treat
underserved areas in fields such as radiol-
ogy and dermatology, these tools are still
relatively in their infancy, the future holds
tremendous potential for these platforms to
evolve for real time healthcare delivery and
teaching. Imagine surgeons at several dif-
ferent locations working together on a case
using robotic surgical technology, or, rou-
tine on-demand video conferencing and
consultation from an underserved clinic
to medical specialists at larger academic
centres.
As such a system grows, it could po-
tentially foster patient-doctor, as well as
doctor-doctor communication. One pow-
erful result would be the ability to facilitate
patient triage by enabling the acquisition
of vital data or hemodynamic parameters
from home for a patient with a pacemaker
or special monitoring device, possibly given
to patients with advanced illness, thereby
helping to decide whether they will require
hospital admission or an adjustment of
their medication. This technology exists
in very early phases; patient’s can already
have their pacemakers interrogated over the
phone.
Several studies have examined the use
of internet based monitoring for children
with asthma. The hardware necessary for
this type of monitoring is in development,
“smart” clothing, apparel containing em-
bedded sensors that can measure vital signs
and transmit them to a remote site has
already reached the marketplace. With re-
spect to electronic networking, precedents
already exist outside the medical field in
the form of various “social networking
sites” which currently serve not only en-
tertainment purposes but also to foster
important communication between con-
tacts as well as facilitating the formation
of new contacts. The medical community
could readily adapt this existing technol-
ogy to at least create the initial version of a

physician network, thereby bringing social
networking to physicians. At the time of
this writing several companies are bringing
such networks to market. For example, in
a given geographic area of practice, all the
participating healthcare professionals can
sign in to a secure medical intranet.
The patients in the system are provided
with modern tools to appropriately com-
municate with their healthcare. All the
relevant information of these patients in-
cluding history and physical examination
as well as laboratory information should
automatically be sent to that intranet and
the concerned healthcare professionals
should be able access this through a secure
site on their hand held digital device and
laptop. If they desire, healthcare providers
may be alerted through their hand held or
their digital beepers.
Sick patients admitted to cardiac ICU
may be fitted with sensor laden health vests
so that cardiac ultrasound, ECG, oxygen
saturation and hemodynamic informa-
tion could be transmitted to the nurses
station or other monitoring stations via
wireless (Wi-FI, blue tooth etc) technol-
ogy. This information could be fed into a
pre-programmed computer (a computer
programmed with protocols, diagnos-
tic and therapeutic information gleaned
on line through world’s latest literature).
This computer would have artificial intel-
ligence and together with the information
provided as described above, will come up
promptly with the most appropriate care
plan for the patient and this plan could be
further altered by the patient’s physician as
deemed necessary.
With the development of comprehen-
sive medical records, there is no doubt that
they will become the dominant platform
for medical documentation and commu-
nication in the future. Current systems,
however, can vary in their power and abil-
ity to facilitate efficiency in the workplace.
In the near future, we can expect continu-
ing refinements to these systems that actu-
ally result in time savings, reduced redun-
dancy of documentation and improved
patient care.
Medical errors and adverse events
A great deal of research has been performed
over the least 20 years detailing the magni-
tude of medical errors in the United States.
As physician-patient load, clinical respon-
sibility and patient expectations of physi-
cian performance continue to increase,
medical errors will continue to be a topic at
the forefront of any conversation. In depth
analyses of these adverse medical events
always reveal a very complex sequence of
events that eventually lead to a bad out-
come. Clearly, current attitudes toward
medical adverse events must change; a fo-
cus on systems-based thinking and analysis
of events that lead to medical errors could
result in the streamlining of complex med-
ical systems, increased usability of current
medical technology by improving human-
machine interaction, and finding new roles
for technology to act as decision support
and fail safes within the medical environ-
ment. The potential to take “humans out
of the loop” for data gathering and phar-
maceutical drug delivery has the potential
to reduce human error in these areas that
could directly result in a significant de-
crease in patient harm. For example, some
electronic medical record systems and de-
cision support systems already warn practi-
tioners of potential adverse drug combina-
tions or wrong doses.
We currently know that the efficacy
of different medications depends upon an
individuals metabolic polymorphisms as
determined by his/her genes. In some cas-
es, whole drug classes work better within
certain ethnic populations for e.g., calcium
channel blockers and African Americans
with hypertension. The ability to custom-
tailor specific drugs to patients with specif-
ic metabolic patterns could greatly increase
the efficacy of our treatment regimes. Fu-
ture decision support systems could utilise
this data by recommending the most effica-
cious and appropriate class of medicine for
a specific patient.
Role of technology: Information
gathering vs. information analysis
The recurring theme of advances and new
paradigms within the context of medical
communication and education, as well as
diagnostic and therapeutic clinical medi-
cine, is the efficacious use of technology.
Effective healthcare delivery and prompt
medical decision-making depend upon an
ever-increasing burden of both objective
and subjective patient data. Traditionally,
the burden of collecting this data has fallen
I N F O R M AT I O N T E C H N O L O G Y
primarily upon physicians. However, with
efficient use of information technology to
collect and collate data such as history and
physical examination lab data, results of
studies, and by using non-invasive moni-
toring, remote monitoring, and decision
support tools, we can free our time to
focus on problem solving and analysis,
rather than information collection, there-
by potentially increasing our diagnostic
and therapeutic acumen. For this to occur,
however, requires a fundamental shift in
our attitudes toward the role of technology
in medicine. We must assuage fears of tech-
nology replacing the human touch, physi-
cian experience, or the ability to diagnose
and form therapeutic plans for patients.
This evolving role of technology in deci-
sion support and information collection
areas of medicine will represent one of the
greatest paradigm shifts in the medicine.
BOOK Shelf
Information Systems and
Healthcare Enterprises
Authors : Roy Rada
Year of Publication: 2007
Pages: 380
Description:
The healthcare industry in the United
States consumes roughly 20% of the
gross national product per year. This
huge expenditure not only represents a
large portion of the country's collective
interests, but also an enormous amount of
medical information. Information intensive
healthcare enterprises have unique issues
related to the collection, disbursement,
and integration of various data within the
healthcare system. Information Systems
and Healthcare Enterprises provides
insight on the challenges arising from the
adaptation of information systems to the
healthcare industry, including development,
design, usage, adoption, expansion, and
compliance with industry regulations.
Highlights the role of healthcare information
systems in fighting healthcare fraud and
the role of information technology and
vendors.
For more books, visit Knowledge Bank
section of www.asianhhm.com
w w w . a s i a n h h m . c o m 53
 I N F O R M AT I O N T E C H N O L O G Y
Connected Healthcare
What next?
Healthcare in the 21st century will require a much higher degree of connectedness and
mobility of information, knowledge, processes, devices and people.
Kevin Dean
Managing Director
Connected Health
Internet Business Solutions Group (IBSG)
Europe
Cisco Systems Inc.
UK
John Grant
Managing Director
Connected Health
Cisco Internet Business Solutions Group
(IBSG) Asia
Cisco Systems Inc.
Hong Kong
F
or many years, IT in healthcare has
been treated as a poor investment in
relation to other investments with
budgets frequently cut to fund treatments
or pay rises or increased demand for care.
However, there are emerging signs that the
value that IT can deliver in health & care
is being recognised, though the difference
between standalone “e” health applications
and those that support the patient’s jour-
ney through care is also being recognised,
and the value of truly Connected Health
solutions is becoming apparent. The con-
nections must bridge time, organisations,
clinical disciplines and the yawning gap be-
tween health and social care, especially for
ageing populations suffering from chronic
diseases. While healthcare industry is in
the process of recognising the potential
of IT, other factors are driving potentially
greater divisions in the patient’s journey—
for instance the fragmentation of medical
specialities as treatments become more
54 Asian Hospital & Healthcare Management
complex, the movement to care in non-
traditional environments like the home or
workplace, both introduce a risk of more
“unconnected” journeys. To make matters
worse, in the wider world outside health-
care, technological advances are accelerat-
ing, offering more opportunities and also
a greater need to coordinate and connect
processes, information, knowledge and
patient journeys.
The technology avalanche
The rate of technology advancements—
storage, processing, communications, and
connectedness of information—is exponen-
tial and will have a profound impact on the
way people work, live, learn and play in the
next 20 years. Consider the progress made
in wireless technology for example. In the
1980s, a mobile phone was considered in-
novative if it was smaller than a car battery.
In 2001, the first telephone call was made
from space when shuttle astronauts used a
Cisco® IP SoftPhone communications ap-
plication (a software programme used on a
PC or laptop) to call home instead of using
a radio. Today, phone calls are increasingly
made from computer devices for free over
the Internet.
The scale of the technology avalanche
is staggering. For instance, in 2003 alone
6.5 exabytes of data was created worldwide,
enough to fill the U.S Library of Congress
500,000 times over.
Profound implications for the world
of healthcare arise from the power of the
new communications enabled by advancing
storage, infrastructure and computing pow-
er. These new capabilities might be one of
the only ways in which we can collectively
deal with the rapidly growing demand for
ISSUE-13 2007
care generated by an ageing, chronically ill
population. Further, the power of the new
technological capabilities will enable new
ways of working rather than automating
current practices—changing the gover-
nance, control and distribution rules for
information and knowledge in healthcare.
The next generation of internet solu-
tions is enabling a “human network” to
evolve, rather than computer to computer
transactions.
The impact of the human network
on connected health
While healthcare is facing huge challenges
influenced by ageing populations increas-
ingly suffering from chronic disease, the
rules for interactions between organisa-
tions and especially between individuals are
changing dramatically. Traditional produc-
ers of content—from hospital performance
information to health knowledge—are fac-
ing new competition from sources that as
little as three years ago did not exist. Patients
now find it easy to create websites them-
selves (such as www.patientopinion.org.uk)
to capture information about a disease or a
hospital’s performance.
Such content usually has little of the
traditional quality-assurance process ap-
plied to it but is accessible and quickly up-
dated. Large organisations, especially those
in the public sector, can take years to cre-
ate a new service for patients, yet patients
or small private organisations can use in-
novative Internet tools to design online ser-
vices in a matter of days. “Mashups,” which
combine content from multiple sources,
are powerful examples of these new services
(see http://whoissick.org/sickness/). Simi-
larly, modes of distribution are being

multiplied by the increasing number of con-
nected devices, and by delivery technologies
such as WiMAX, YouTube, wikis and blogs.
These content avenues are making an abun-
dance of health information and services
widely and easily available to patients and
citizens. Yet, the very flexibility and freedom
that create these choices also make it hard to
assess the quality, competence and reliability
of such services and knowledge.
The impact of this technological
change, combined with healthcare’s need to
respond to sociological change with more
prevention, efficiency, higher-quality care,
and delivery of more complex treatments,
is leading to four emerging themes in many
healthcare systems:
e-health becomes connected health
The term “e-health” emerged in the late
1990s as healthcare organisations noticed
that the advent of Internet technologies
added new information technology tools for
sharing data and communications. E-health
is still very much a part of the healthcare
industry’s language and culture because it
helps ensure that important tools are periph-
eral to care, rather than intrinsic. Healthcare
in the 21st century, however, is evolving; it
is no longer just about e-health but more
about connecting healthcare—creating a
collaborative industry among clinicians
who have multiple specialties and cooperat-
ing across professional, organisational, and
budgetary boundaries. Unless a plan arises
for connected health, the opportunities cur-
rently available will pass, as will the benefits.
New tools are beginning to offer true con-
nected health capabilities, such as the Map
of Medicine (www.mapofmedicine.com),
developed in the United Kingdom, which
combines best practice patient journeys,
clinical evidence and public and private
health knowledge.
The divorce of health and care
As the world’s population ages and chronic
or long-term disease becomes more preva-
lent, traditional models of health and social
care will need to change. Today, all too often
the responsibilities for chronically ill people
moving in and out of hospitals are split
between local government, social care and
healthcare organisations. At the boundaries
of this infrastructure lie significant prob-
lems with continuity of care, funding, and
case management. For example, in Europe,
a hospital has discovered a way to support
patients at their homes using remote medi-
cal devices and video monitoring. Patients
leave the hospital up to 10 days earlier than
normal, but as soon as they are discharged,
the hospital ceases to be paid for the
patient’s treatment.
Furthermore, the healthcare system
will not be able to afford to treat all dis-
eases from which the ageing population
might suffer. Prevention must become the
norm—not only through preventive treat-
ments, but also through education to help
people change unhealthy lifestyles, such as
smoking, that lead to disease. These changes
are fundamental to the organisation of care
and to the information tools used to help
citizens take responsibility of their health.
Consumerisation
Increasingly, as we focus on health and pre-
vention, the degree to which individuals can
avoid disease will be driven by the services
available to them, or that they can afford.
In the future, more and more devices and
information-based services will become
available to help people avoid or manage
disease, including wearable or implantable
devices and smart clothing to monitor body
functions.
The availability of services to health
consumers will again change expectations
regarding service levels people should re-
ceive from their care organisations when
they move from health to care. This will dra-
matically increase the pool of available data
on which their care can be planned. There
will be far reaching implications, however,
for having so much information about an
individual’s health. For example, today, if
someone suffers a sudden heart attack on the
street, the ambulance and hospital do their
best, on very short notice, to treat and save
the patient. In the future, however, caregiv-
ers may have four to six hours notice of an
impending heart attack—and, as a result,
expectations of success will be significantly
higher. The systems for notification, coor-
dination of professionals, communications
with the patient, and liability for failure in
the care chain are still to be explored.
Virtualisation
A lack of young people to care for the el-
derly is a major concern among healthcare
organisations in much of the developed
world. This concern, combined with the
increasing cost of healthcare continues
to erode the gap that already exists for
I N F O R M AT I O N T E C H N O L O G Y
critical resources. In addition, finding the
right resources is also a significant challenge.
For example, paramedics and nurses sitting
in the back of an ambulance with a patient
showing unusual symptoms often have to
resort to paper-based lists of specialists and
phone numbers when calling for help. As an
example of how Connected Health might
address this problem, the Map of Medicine
is being further developed to contain an
Expert Network capability that will po-
tentially address both problems: locating
resources and scaling their expertise. The
Expert Network, accessed via the Map of
Medicine on PC or mobile device, has the
potential to link clinicians across organisa-
tions and professional boundaries so that the
right skills are available for a given patient at
the right time. Such developments will not
only improve access to care, but will also re-
duce the cost of care, stretching the impact
of skilled resources beyond the normal geo-
graphic or organisational boundaries.
The future potential of the human net-
work and Connected Health is vast. How-
ever, the biggest challenges will occur not
at a technical level, but in supporting the
process, cultural and behavioural changes
required to take advantage of these techno-
logical possibilities.
BOOK Shelf
Paper Kills - Transforming
Health and Healthcare with
Information Technology
Authors : David Merritt
Year of Publication: 2007
Pages: 150
Description:
Paper Kills addresses the most pressing
issues in the drive to modernize and
improve healthcare through health
information technology. This unique
book guides the reader on a tour of the
evolving health information technology
and health policy landscape, covering
topics from protecting privacy and
advancing research to building health
information exchanges and achieving
interoperability.
For more books, visit Knowledge Bank
section of www.asianhhm.com
w w w . a s i a n h h m . c o m 55
 I N F O R M AT I O N T E C H N O L O G Y

e-Health and
Healthcare Practice
The use of e-health can positively impact doctor-patient relationship promoting the mutual
participation model of medicine, which implies that, e-health can promote a shared
responsibility in decision making and problem solving.

Sisira Edirippulige
Coordinator e-Healthcare Programs

Anthony C Smith
Senior Research Fellow

Centre for Online Health

University of Queensland
Australia

H
ealth systems around the world
are facing numerous challenges,
including the rapid increase in
the prevalence of certain chronic diseases,
limited funds and the pressure of an ever-
ageing population. The shortage of health
professionals to provide essential services is
an important issue which both developed
and developing countries are struggling to
cope with. The rising costs of healthcare
makes the situation even more complicat-
ed. Governments and international organ- other spheres of the human society, such (pre-recorded). A common example of a
isations worldwide are seeking solutions. as online banking and online shopping real-time e-health application is commu-
Among others, e-health has been identified —the health sector has been slow to adopt nication via telephone. The use of the tel-
as one such solution that may help alleviate e-health. Nonetheless, hope for e-health ephone has become commonplace around
some of the challenges described. to play its role is still there. A number of the world and we can tend to forget the
In general terms, e-health may be used governments have implemented national value of it. Videoconferencing is another
to describe the delivery of healthcare and e-health strategies. National initiatives such example—however much more expen-
exchange of healthcare information across as National e-Health Transition Authority sive and generally less accessible than tel-
distances using Information and Com- (Australia), the Health and Human Servic- ephone services. Alternatively, e-health can
munication Technologies (ICT). Synony- es (United States) and the NHS Moderni- be achieved using pre-recorded techniques,
mous with e-health, other terms such as sation Program (United Kingdom) can be for example, the ordinary email. Whilst
telemedicine, telehealth and mobile health few such examples. It has been recognised considered a relatively inexpensive form of
are often used interchangeably. Despite the that the use of online communication e-health, this modality gives participants
high expectations raised in the early 1990s, techniques may be the key to improving the opportunity to access information and
e-health has not been widely adopted and quality, safety and patient outcomes. communicate at their own convenience.
integrated as a mainstream service interna- In principle, e-health can be catego- e-Health can be used for clinical,
tionally. Unlike the use of ‘e methods’ in rised as real-time and store-and-forward educational and administrative purposes.

56 Asian Hospital & Healthcare Management ISSUE-13 2007

 I N F O R M AT I O N T E C H N O L O G Y

For example, the access of clinical data at
distance can be useful for diagnoses and
making important decisions regarding
patient management. The growing use of
technology-enhanced learning (e-learn-
ing) in medical/health education is a good
example of e-health for educational pur-
poses. In terms of administrative value of
e-health, studies have shown that the use
of electronic tools and medium (for exam-
ple, computers, PDAs, Internet) can ease
the administrative process in healthcare
settings.
It may be argued that the use of e-
health can positively impact doctor-patient
relationship promoting the mutual partici-
pation model of medicine. This means e-
health can promote a shared responsibility
in decision making and problem solving.
In Australia, the integration of elec-
tronic technologies in routine clinical
practice has been most prominent in the
field of general practice. A recent survey re-
ported by the Australian Medical Associa-
tion (AMA) indicates that a well over 90%
of the Australian general practitioners are
utilising computer technologies such as
electronic prescribing and communica-
tions systems. Another area where e-health
has been making some progress is the use
of the Internet as a source of health infor-
mation. A number of web-based health in-
formation sites are growing rapidly, and so
too are the number of respective users.
to children who otherwise would have to
travel hundred or thousands of kilome-
tres to the specialist hospital. Paediatric
sub-specialities offered by the telepaediat-
ric service include post-acute burns care,
cardiology, diabetes, neurology, oncology,
orthopaedics, psychiatry and surgery. Both
patients and providers have reported high
levels of satisfaction with the service. Rou-
tine telepaediatric clinics are now sched-
uled 12 months in advance and managed
in a very similar way to the conventional
outpatient service.
An important factor in the success
of the telepaediatric service is the unique
referral model developed by the research
team. Firstly, a centralised referral centre
has been developed which gives selected
regional hospitals direct access to a telepae-
diatric coordinator via a dedicated toll-free
number. Staff in regional hospitals could
easily make a referral by contacting the
service instead of automatically sending
patients to Brisbane to see the special-
ist in person. Once a referral is made to
the telepaediatric service, a response is
guaranteed within 24hrs. Telepaediatric
coordinators liaise between the referer and
specialist, and coordinate the response
subject to the urgency of each case. It is
also the responsibility of the coordinator to
manage the technology during each con-
sultation. Upon the specialist’s arrival, the
coordinators ensure that an adequate (vid-
eoconference) link is made to the regional
site, that the sessions run smoothly and ac-
curate usage records are maintained.
Telepaediatric clinics are conducted
using standard videoconferencing equip-
ment available in the hospitals. Since the
service was established, project designers
have set up dedicated videoconferencing

Some success stories

Telepaediatrics
One of the successful e-health projects re-
ported in the literature is the telepaediatric
service in Queensland. The service com-
menced in November 2000 as a research
trial through the University of Queensland’s
Centre for Online Health (COH) in col-
laboration with the Royal Children’s Hos-
pital (RCH) in Brisbane, and in time has
emerged as a routine service. The telepae-
diatric service provides specialist consulta-
tions to children and their families living
in rural and remote areas of Queensland.
About 90% of telepaediatric consultations
provided through the service are done via
videoconference. More than 5000 consul-
tations have been conducted since the serv-
ice began, benefiting thousands of families
statewide. Specialists at the RCH are now
using this service to provide consultations

w w w . a s i a n h h m . c o m 57
 I N F O R M AT I O N T E C H N O L O G Y
rooms (studios) in selected remote sites.
The specialists use videoconference
studios at the COH. However, at both
regional and Brisbane sites, technology
handling of clinicians has been kept to a
minimum. Basic training is offered to all
clinicians, but the majority of responsi-
bility for operating the equipment is
maintained by the telepaediatric coordi-
nators. Videoconference calls are made
using digital telephone lines (ISDN) at
a preferred minimum bandwidth of 384
kbit/s.
The acceptance of this system from
both patients and clinicians has been
highly satisfactory. For patients, telepae-
diatric service has resulted in savings
for the family who are saved the incon-
venience and need for extensive visiters
to Brisbane for follow up consultations
with specialists. The telepaediatric serv-
ice has resulted in substantial cost sav-
ings for the health service in Queensland
which is responsible for subsidising a pa-
tient travel scheme. From the specialists’
perspective, it has become obvious that
a substantial proportion of sub-special-
ist outpatient appointments can be done
at a distance. One of the leading exam-
ples of telepaediatrics is in the area of
post-acute burns care where about 17%
of all outpatient services are now done
through the telepaediatric service.
58 Asian Hospital & Healthcare Management
In addition to standard studio-based
videoconferencing units, the telepaediatric
service has developed a mobile videocon-
ference system for use in the clinical areas.
In 2004, the COH introduced a videocon-
ferencing unit dressed up in the shape of a
robot in a regional hospital which lacked
a full-time paediatrician. “Roy the Robot”
(named after Royal Children’s Hospital) has
been used for ward rounds where specialist
paediatricians from Brisbane could offer re-
mote consultations directly at the bedside.
Roy has won the hearts and minds of the
children in the hospital while nurses and
doctors find him clinically useful. Indicat-
ing the success of this method, four new
robots are now being launched in different
distant sites in Queensland.
Low-cost telemedicine in developing countries
Technologies involved in e-health are not
always need to be expensive. A low cost e-
health project run by the COH in collabo-
ration with the Swinfen Charitable Trust
(SCT) has proven that inexpensive methods
such as email can be useful for the delivery
of health related services. This charitable
service provides free medical advice to doc-
tors in developing countries using ordinary
email and attached digital images where ap-
propriate. The SCT has been running for
eight years and has facilitated a specialist
response to more than 1000 clinical ques-
tions. More than 200 specialist consultants
ISSUE-13 2007
from around the world have volunteered to
provide advices. The growing use of this sys-
tem is an indication of the usefulness of an
email-based e-health application.
Health information
The use of the Internet for accessing health
and medical information has rapidly in-
creased for the last few years. Both clinicians
and health consumers are relying on the In-
ternet as a useful information source. For
example, in a survey conducted in 2002,
80% of adult Internet users, or almost half
of Americans over the age of 18 (about 93
million), said they have researched health
topics on the Internet. 30% of email users
have sent or received health-related email.
Online health information sources al-
low consumers to become informed about
diagnoses, surgery or health promoting be-
haviours, prepare for a visit to their doctor
or hospital, share information and give or
receive support. From the perspective of a
healthcare professional, the Internet may
be useful for continuing medical education,
conducting online peer review research and
access to the latest evidence-based informa-
tion. The Internet has also become useful
tool for health communication. Online
discussion lists and news groups, email chat
rooms are becoming popular tool for health
communication.
Conclusion
With the growing pressures on health serv-
ices around the world, there is potential for
e-health to be used more widely. Despite
predictions and high hopes that telehealth
(e-health) would become commonplace
in the 1990’s, evidence suggests that wide-
spread integration has not occurred. De-
spite this, the potential of e-health should
not be ignored. Instead, important lessons
(both successful and failed) should be con-
sidered before and during the development
of e-health within an organisation.
Further information
The Centre for Online Health (COH) is one of very few
research and teaching centres in the world which focus
on the evaluation of telehealth for the delivery of health
services. The COH is responsible for a broad range of col-
laborative projects which explore and evaluate innovative
methods of providing clinical services in metropolitan
and regional environments, including telehealth, health
information systems and health education.
Centre for Online Health, University of Queensland,
Australia
Web site: http://www.uq.edu.au/coh/

Intelligent Health Networking
Changing our way of healthcare
The fundamental reason for the healthcare IT gap, and the lack of impact of ICT
in healthcare relative to other industries, is that we are attempting to use an ICT
framework that is mismatched to the new models of care.
Michael Georgeff
CEO
Precedence Health Care
and
Director
e-Health Research Unit
Monash University
Australia
M
eeting the complex needs of
patients with chronic illness is
one of the greatest challenges
facing medical practice. If we are to im-
prove outcomes for these patients, the evi-
dence strongly suggests that we rethink our
approach to ambulatory care.
With better disease management, hos-
pital admissions for chronically ill patients
could be reduced by 50%, with consequen-
tial improvements in quality of care and re-
ductions in mortality and morbidity. Infor-
mation and Communications Technology
(ICT) focussed on better sharing and utili-
sation of knowledge is the key to achieving
this change.
In Australia, for example, it is estimated
that improved knowledge sharing and care
plan management for patients with chronic
disease would produce direct healthcare
savings of over US$ 1.5 billion a year. The
savings in non-healthcare costs (such as
travel, special foods and carer expenses) are
estimated to be the same order of magni-
tude. And increases in workforce participa-
tion and productivity could add a further
US$ 4 billion per year in benefits to the
economy.
However, while many healthcare pro-
viders now have clinical desktops and
other computer systems, these cannot
communicate with each other. Doc-
tors often do not know what medications
and tests have been given to patients by
other doctors, even when they are mem-
bers of the same care team. It is even more
difficult to bring relevant medical knowl-
edge to the point-of-care, to create integrated
care plans, to monitor a patient’s prog-
ress against the care plan, or to alert care
providers when a patient’s condition
requires intervention. The Economist has
referred to this as “Health Care’s Outrageous
IT Gap”.
My view is that the fundamental reason
for this gap, and the lack of impact of ICT
in healthcare relative to other industries, is
that we are attempting to use an ICT frame-
work that is mismatched to the new models
of care.
There are two key characteristics of
healthcare that should drive the type of
ICT solution we consider. First, we need to
take seriously that the fundamental busi-
ness of healthcare is knowledge: knowledge
of the patient, knowledge of medical treat-
ments and practice, knowledge of the health-
care system and knowledge of the prevailing
environment. This knowledge is extensive and
complex, is continuously changing, must be
shared among many providers and consumers,
and must be brought to bear at the right time,
in the right context, at the point-of-care. Sec-
ond, we need to be fully aware of the inherent
complexity of healthcare: it is composed of a
variety of participants, highly heterogeneous
systems and practices, highly autonomous
and independent agents, and highly
distributed information sources and services.
I N F O R M AT I O N T E C H N O L O G Y
In such a business environment, there
are three keys to success: (1) the knowledge
enterprise, (2) connectivity and (3) open
networks of businesses and users.
The knowledge enterprise
The knowledge enterprise is one in which
the key resource is knowledge, compared
to an industrial enterprise where the key
resources are physical assets and labour.
As is clear from the rapid emergence of
companies like Google and Amazon, and
the transformation of the music and retail
industries, knowledge enterprises are driv-
ing quite profound structural and qualita-
tive changes in the way we live and work.
However, despite the knowledge-in-
tensive nature of healthcare, the business
model we use in healthcare organisations
is still based on the industrial enterprise.
This is characterised by a focus on physical
components, big players to get economies
of scale, detailed planning, standardisa-
tion, stability, and locked-down, tightly
integrated computer systems.
The aim has largely been to move
from what is seen by many from an
inefficient “cottage industry” to a more
efficient industrial enterprise. This
approach may be suitable for running
hospitals but it will not work for manag-
ing and preventing chronic illness across
the continuum of care. Here, the organi-
sations and people involved use different
systems, different practices, different data
and different processes. The type of care is
also different: it requires continuous care
surveillance, with reminders and alerts
sent to the right people and followed
up with the right intervention at the
right time.
w w w . a s i a n h h m . c o m 59
 I N F O R M AT I O N T E C H N O L O G Y
The organisations and information
technologies used in healthcare must adapt
to match this business environment. Instead
of the industrial model, which may work
within a hospital setting, we need business
models and technologies that are typical
of knowledge enterprises such as Google,
Amazon and Skype.
These knowledge enterprises are char-
acterised by networked information, sup-
port for autonomy and personalisation, and
use of information systems that are open,
adaptive and distributed.
Not many are thinking this way in
healthcare. We are still planning, standardis-
ing, and “locking in” the big, centralised in-
formation systems. These kinds of systems,
such as being rolled out in the UK, require
massive investments between 5-10% of
annual healthcare expenditure.
Connectivity
The second key is connectivity. In the pe-
riod of the information economy (1970 to
1995), competitive advantage lay with in-
vesting in crunching power: large applica-
tions that could process Moore's Law: the
performance to price ratio of computing
doubles every eighteen months.
But for the knowledge economy (from
1995 forwards), raw computing power and
large monolithic applications are not the
keys to success. Here competitive advantage
accrues to those who invest in connecting
power: connecting to more people and
more systems to share knowledge faster and
farther. The prevailing law is Metcalf's Law:
the value of a computer is proportional to
the square of the number of connections it
makes. The key message: don’t spend time
getting agreement on the data, don’t spend
time ensuring all the systems conform—get
connected.
In businesses today, most high priority
and high volume communications are han-
dled electronically. Yet in healthcare, these
high importance communications—such
as referrals and hospital discharge summa-
ries—are usually transmitted using paper
and pen, fax, letter and hand delivery. This
state of affairs would be inconceivable in al-
most any other industry, let alone one that
rests so fundamentally on knowledge and its
sharing across the supply network.
Once connected, individual value
propositions will drive stakeholders towards
60 Asian Hospital & Healthcare Management
agreements and standards, continuously
increasing the value of the data in an evo-
lutionary way. The need to understand the
flow of information will drive faster adop-
tion of standards, in a virtuous cycle of in-
creased information flow, improving stan-
dards and increasing value.
However, this is not where we have fo-
cussed in healthcare. Instead, most invest-
ment has been directed at the development
of large, closed monolithic systems. The
Electronic Health Record (EHR) is almost
universally seen as the key to better knowl-
edge sharing in healthcare, but instead it is
the connectivity of the players that is the
key. It is the information flow that is impor-
tant, because from that everything else de-
rives. Without it—without the connectivity
to populate and to access health data—an
EHR is very difficult to build, maintain,
and operate.
Open networks
Thirdly, we need to design our systems to
accommodate the heterogeneity and in-
completeness of information, the distrib-
uted and diverse nature of the information
sources and users, and the various forms
of autonomous and governed institutions
and businesses that are part of healthcare.
Instead, the conventional approach in
healthcare can largely be characterised as an
attempt to remove the heterogeneity and
autonomy from the system, so that it can
better run like a well organised bank.
The prominent example of a system
built to accommodate heterogeneity and
autonomy is the Internet, and there are two
keys to its success: (1) connecting anything,
anybody, anywhere, and (2) divesting in-
vestment and control of the network (and
its services) from a central authority to sup-
pliers and users.
If we go back to the beginning of the
Internet, in the early 1990s, we see that
it was radically different from the prevail-
ing information systems at that time. As
Tim Berners Lee, the founding father of
the World Wide Web, said in 1991: “Its
universality is essential: the fact that a
hypertext link can point to anything, be
it personal, local or global, be it draft or
highly polished.” This was highly radical
at the time, where uniformity, accuracy
and completeness of information were
considered an essential part of computing.
ISSUE-13 2007
The Internet was also designed from
the beginning to have no central au-
thority and to operate “while in tatters”.
While initial government investment was
essential to provide the core infrastruc-
ture, the Internet’s huge growth has cost
the taxpayer little or nothing, as each
node is independent and has to manage
its own financing and its own technical
requirements. This allowed a mix of
government and private investment, new
applications and services to “plug in” and
add value, and new and innovative tech-
nologies and business models to rapidly
evolve.
These three key factors—the knowledge
enterprise, connectivity and open networks
of businesses and users—have transformed
the retail, finance and music industries,
and are starting to transform film and
television.
We need to do the same in health-
care. We can begin by connecting provid-
ers and consumers across the continuum
of care and making existing systems
interoperable using Internet technologies.
We can begin by sharing what we have.
We can begin by living with existing
business processes, without impinging
on the time or practices of healthcare
practitioners.
Once connected, and with the right
financial incentives in the right places, in-
dividual value propositions will then drive
greater electronic data entry, agreed data
models, and an increasing diversity of care
management and decision-support ser-
vices. Consumers, together with profes-
sional healthcare organisations, will drive
evidence-based care and practice change.
And this in turn will create new business
models and opportunities for hospitals, in-
surers, employers, healthcare providers and
businesses.
It will take money and partner-
ships between government and indus-
try to get started. It will take different
ways of collaborating with and building
on the conventional operational systems
of government-run health departments.
But with the right conceptual frame-
work—by taking seriously the knowl-
edge enterprise and the autonomy and
heterogeneity of care providers and consum-
ers—we can start to transform our health
practices.
w w w . a s i a n h h m . c o m 61
 I N F O R M AT I O N T E C H N O L O G Y

Interview
Healthcare
IT in India
This changing scenario of the healthcare industry
has drastically changed the IT requirements of
hospitals. There are clear challenges within the current
healthcare ecosystem that must be overcome before
the healthcare revolution is realised.

Ajay Shankar Sharma

CEO
Srishti Software Applications Pvt. Ltd.
India

Over the last few years, the Indian
healthcare sector has been rapidly evolv-
ing. How has this affected the software/
IT needs of hospitals?
Healthcare is undergoing a distinct move-
ment along a logical trajectory from its his-
torical focus on acute care i.e. dealing with
immediate and severe outbreaks of illness,
to chronic care, continuous care for long
term illness that may reduce acute cases to
preventive care, i.e. care focussed on early
detection and treatment of illness, includ-
ing immunisation, ultimately leading to
predictive care, i.e. not waiting for early
signs of illness but predicting and thwart-
ing it before the illness has the chance to
take root. This revolution would move us
away from a curative drug based healthcare
towards consulting/service based health-
care with focus on lifestyle, and adapting
behaviour to prevent and cut out the roots
of any instance of illness.
This changing scenario of the health-
care industry has drastically changed the
IT requirements of hospitals. There are
clear challenges within the current health-
care ecosystem that must be overcome
2. Chronic
Care
1. Acute 3. Preventive
Care Care
4. Predictive
Care
before the healthcare revolution is realised.
The challenges are:
• Low reach / inaccessibility as well as insuf-
ficiency (where available) of quality care
to the most economically backward areas
• Presence of specialist doctors is restrict-
ed to the metro and class-A cities
• High focus / risk of under-utilization of
capacity (beds, doctors, nurses)
• Fragmentation of isolated bits of patient
and medical know-how across entities
in the ecosystem
• Lack of a one-point complete patient
record
• High Cost / Low Productivity due to
bottom-up re-creation of diagnosis/
analysis for every instance
How have the suppliers handled this?
Business models are currently focussed on
Acute Care across healthcare ecosystem.
Models catering to Chronic, and more ad-
vanced Preventive care need to be explored
by insurance companies and healthcare
service providers alike.
The hospitals and the suppliers will
now have to start looking at the following:
1. Alternative delivery model to multiply
reach
2. Integrated health records - A complete, up-
dated / accurate one point patient database
3. Alternative transaction models
How have Indian hospitals fared in terms
of healthcare IT adoptation as compared
to other countries in Asia/Rest of the
world?
The structure within which healthcare
is carried out varies from country to
country—and sometimes even within
national boundaries.
The most fundamental property af-
fecting the Indian healthcare sector is the
multi-faceted demographic and socio-eco-
nomic profile of the country.
The emergence of corporate hospitals
on a larger scale is another important devel-
opment. The corporate entry into health-
care is important for the professionalism of
hospital management. Till recently, mod-
ern management systems had not penetrat-
ed most healthcare institutions, with some
notable exceptions. Most hospitals would
organise their resources and manpower
within structures that had evolved rather
than been designed. The processes would
be structured to ensure multiple points of
control rather than patient convenience.
Information capture would be rudimen-
tary and information rarely integrated be-
yond that required for reporting purposes,
because of which any data-based quality
control would not be possible.
With corporate entities entering the
healthcare sector, they are introducing man-
agerial practices and tools, which they had
been using for long, in the hospitals that
they are promoting. To understand the In-
dian hospital landscape, given below is the
classification of various types of hospitals:

62 Asian Hospital & Healthcare Management ISSUE-13 2007


Primary hospitals
These are the hospitals that are in the village
or the local locality level. The concept of
these hospitals is “Everything for Everybody”
Secondary hospitals
These are the hospitals that run on the con-
cept “Everything for Everybody, but at a
Higher Level”.
Tertiary care hospitals
These are the hospitals that give “Expert Care
for Everything”. These can be corporate or
Government. On the government side these
are the hospitals with the Medical Colleges.
Super speciality hospital (One speciality)
These are the hospitals where only one type
of vertical or speciality is handled.
An important and positive development
taking place in the Indian healthcare sec-
tor is the use of information technology for
purposes such as computerization of medical
records, networking of various departments
in a hospital, and providing of tele-medicine
services.
With advent of Information Technology
in Indian healthcare, disintermediation has
occurred in such a way that the primary &
secondary level hospitals can have a direct ac-
cess to the Super Speciality Hospitals, in a col-
laborative way. The new organisation model
not only removes the intermediate layers but
also provides a conducive atmosphere for pri-
mary level hospitals, to work symbiotically
with the Super Speciality hospitals. This will
be a win-win situation for both partners.
This graph depicts the ratio of number
of beds to number of patients of a few de-
veloped countries against that of India. As of
now India is very low on this ratio, with just
0.75 bed per 1000 population, as compared
to the other countries.
What developments are likely to occur
in the healthcare IT landscape in India
in the near future, how are you prepar-
ing for it?
The following developments will have to
necessarily take place in healthcare:
a. Alternative delivery model to multiply landscape in India?
reach
b. Integrated electronic patient record sys-
tem (EPR) - This helps in capturing of
information and maintaining continu-
ity and granularity.
c. Alternative transaction models
d. Remote diagnosis or Tele-medicine and
follow-up procedures
Care Beds / Population of 1000
8.00
Germany
7.00
6.00
5.00
France
4.00
3.00 USA Spain
2.00 UK
1.00
0.00
Srishti's integrated Healthcare solu-
tions provide the ability to support mod-
ern healthcare services, additionally future-
proofing initiatives, delivery models and
emerging trends that would soon domi-
nate this sector. Built on the philosophies
of integration of the entire spectrum of
healthcare technology enablers plus Srish-
ti's powerful tool-kit approach (that makes
healthcare services avoid constraints from
technology limitations), PARAS is the an-
swer to the need for a one-stop technology
for healthcare.
Srishti software offers a complete
healthcare information management sys-
tem (HIMS) which involves implementa-
tion of clinical system for managing EPR
and development of clinical care pathways.
This clinical system can be integrated
seamlessly with the hospital administra-
tion system
Integrated electronic patient record
system (EPR) - This gives the complete
demographic information of the patient
i.e. age, name, sex, etc., patient’s present
illness information which includes details
on present illness, history, medication,
consultant notes, etc.
PARAS toolkit facilitates remote diag-
nosis or tele-medicine. This separates point
of care and diagnostic resources, hence en-
abling healthcare providers to extend their
reach to geographies where such resources
are not available to patients.
How has IT changed the patient care
With the help of IT, patient care has im-
proved drastically. In IT enabled hospitals,
the bed turnaround ratio has increased by
as much as 10%, which is a big advantage.
Hence, the investment towards enabling
IT gets recovered in a few months.
Enumerated below are the advantages
of enabling IT in hospitals:
I N F O R M AT I O N T E C H N O L O G Y
2.50
Delhi
2.00
1.50
1.00 India
0.50
UP
India
0.00
1. The quality of service has gone up
and hospitals have turned more effi-
cient in terms of reach and delivery of
service.
2. Integrated electronic medical records
facilitate research as data is made
available in structured manner, which
helps in studying trends, identifying
disease outbreaks etc.
3. By means of creation of electronic
patient record, each patient’s blood
group, known allergies etc. would
be documented and available, hence,
preventing manual errors.
4. It also facilitates remote diagnosis of
patients. As a result, people in rural
areas can also have access to consulta-
tion from speciality doctors.
5. It has enabled Customer Relationship
Management (CRM), as this is a very
important facet for Speciality hospi-
tals and chain hospitals, in terms of
patient loyalty.
6. IT also helps patients move seam-
lessly across different geographical
locations.
7. IT provides the flexibility to procur-
ing and billing.
8. IT also provides accounting frame-
work hence help with entire billing,
inventory management, store man-
agement, laboratory management,
etc.
Thus IT helps in maximising returns on
every penny spent.
As a software company what are your
views on the potential of the health-
care IT sector in India?
Healthcare is an emerging industry
where the scope is unlimited. We have
a vision and that’s what we aim to sell.
Our differentiator lies in the fact that
we don’t just sell functionality, but func-
tionality with a vision.
w w w . a s i a n h h m . c o m 63
Products & Services

Company Page No. Company Page No.

Diagnostics Synthes Asia Pacific OBC OBC3

AsiaGen Corporation 31 Unomedical Pty Ltd. IBC2
Hanlab Co., Ltd. 46 ZOLL Medical Corporation 4
Inverness Medical Innovations, Inc. 21
Synthes Asia Pacific OBC3 Surgical Specialty
APS Medical 27
Facilities & Operations Management Shimadzu (Asia Pacific) Pte Ltd. 29
APS Medical 27 Synthes Asia Pacific OBC3
Synthes Asia Pacific OBC3
Unomedical Pty Ltd. IBC2 Technology, Equipment & Devices
APS Medical 27
Healthcare Management AsiaGen Corporation 31
1st India Health Summit 14 Bloodline SpA 25
B. E. Smith 10 Electrolux Professional 2
Hospital India 40 Fotona d.d. IFC1
Gouri Engineering Pvt. Ltd. 45
Information Technology
Hanlab Co., Ltd. 46
ZOLL Medical Corporation 4
Hospital India 40
Medical Sciences Inverness Medical Innovations, Inc. 21
APS Medical 27 Monomedi Korea Co. Ltd. 42
AsiaGen Corporation 31 Shimadzu (Asia Pacific) Pte Ltd. 29
Bloodline SpA 25 Synthes Asia Pacific OBC3
Mediaid (Singapore) Pte Ltd. 33 Unomedical Pty Ltd. IBC2
Shimadzu (Asia Pacific) Pte Ltd. 29 ZOLL Medical Corporation 4

Suppliers Guide
Company Page No. Company Page No.

1st India Health Summit 14 Hospital India 40

www.ihs.in www.hospital-india.com
APS Medical 27 Inverness Medical Innovations, Inc. 21
www.apsmedical.com.au
www.determinetest.com/print
AsiaGen Corporation 31
www.asiagen.com.tw Monomedi Korea Co. Ltd. 42
www.monomedi.com
B. E. Smith, Inc. 10
www.besmith.com Mediaid (Singapore) Pte Ltd. 33
Bloodline S.p.A. 25 www.optosystems.com.sg
www.bloodline.it Shimadzu (Asia Pacific) Pte Ltd. 29
Electrolux Professional 2 www.shimadzu.com
www.electrolux.com
Synthes Asia Pacific OBC3
Fotona d.d. IFC1 www.synthes.com
www.fotona.si
Unomedical Pty Ltd. IBC2
Gouri Engineering Pvt. Ltd. 45
www.gouriengg.com www.unomedical.com

Hanlab 46 ZOLL Medical Corporation 4

www.hanlab.co.kr www.zoll.com

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1. IFC: Inside Front Cover 2. IBC: Inside Back Cover 3. OBC: Outside Back cover

64 Asian Hospital & Healthcare Management ISSUE-13 2007

65 Asian Hospital & Healthcare Management ISSUE-13 2007
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