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Issue 18 2009 £12 €18 $25 Rs.300 www.asianhhm.com

Interoperability robots e - h e a lt h a c c r e d i t i n g h e a lt h i n f o r m at i c s

Importance of Lean in MR Diffusion

Traditional Medicine Primary Care and Perfusion
In the age of technology Sustaining transformation Can they replace PET?

From possibilities to reality
In 2008, healthcare continued to struggle with the adaptation
of Information Technology. Will 2009 be any different?
A
recent New York Times article highlighted the
adaptation of Information Technology (IT) by
the Wisconsin, US-based Marshfield Clinic.
Considered to be one of the pioneers in adapting IT,
Marshfield introduced mandatory Electronic Health
Records (EHRs) way back in 1994. Today, 795 doctors
working with the Clinic use Tablet PCs and it has all but
done away with paper charts for patients. This could be
termed as the ideal scenario where IT has completely
transformed the way healthcare is provided. Unfortunately,
while this is true for Marshfield and a few other provid-
ers, the same cannot be said about the rest of the US
healthcare system. This is true for healthcare systems
around the world, including the ones in Asia. Investments
IT is still considered to be a privilege by many providers
who prefer to manage records on paper and insist on
the patient visiting the doctor or the hospital. In such
a scenario it’s difficult to imagine a healthcare system
that leverages the benefits of IT to the full.
Efforts by the governments and policy makers to
resolve this situation cannot be doubted. Countries
around the world are busy working on developing
their own solutions for integrated healthcare delivery
and it won’t be wrong to say that incorporating IT (or
Telemedicine) is considered as one of their top priorities.
However, success stories are yet to come to the fore.
Notable advancements have been made in countries
like Singapore and Australia. While the former has set
aggressive goals with regards to EMRs, the latter is
focussing on e-Health. Developing countries like India
and China face problems at a much basic level. The
governments here are focussing on increasing access to
healthcare for the masses. This is a reasonable goal, but
incorporating IT into this framework in the initial stage
Foreword
itself could prove to be beneficial in the long-term. For
example, Telemedicine is the best way of reaching rural
areas and investing in developing the infrastructure for
this would be ideal.
One of the exciting developments of the year gone
by was the introduction of online Personal Health Record
(PHR). At a time when healthcare technology providers
are grappling with the problem of interoperability for
sharing data across healthcare IT systems, the Internet
could prove to be the best possible solution to this
problem, thanks to its ubiquity. Another important benefit
of providing patients’ health records online is that it
places the onus of maintaining health information on
the patient, thereby making them an integral part of the
healthcare system.
As healthcare continues to move slowly, but steadily,
towards a more IT-oriented framework, possibilities
abound. It will be interesting to see how things workout
over the next one year.
The anniversary issue of Asian Hospital & Healthcare
Management has a special focus on Healthcare IT with
a spread of insightful interviews, articles and features. I,
along with Prasanthi Potluri, would like to thank all our
authors over the years for helping us bring out four issues
of the magazine successfully. We hope to carry forward
this endeavour with many more issues of the magazine
as we track the changing landscape of healthcare.
Akhil Tandulwadikar
Editor
 al
eci

Contents
Sp
IT

52 Ready for Transformation

Pradeep chowbey, Sir Ganga Ram Hospital, India

53 Learning from the Global Experience

Asia
Steven Yeo, HIMSS Asia Pacific, Singapore

54 Start with the Basics

Peter Gross, Hackensack University Medical Center, USA

Australia
55 Driven by e-Health
Sisira Edirippulige, University of Queensland, Australia

60 An Optimistic Outlook

India
Krishna Ganapathy, Telemedicine Society of India, India

62 An Innovative Transformation

UAE
John R Hawkins, Abu Dhabi Health Service Company (SEHA), UAE

64 Interoperability - Healthcare IT’s big challenge

David W Bates, Brigham and Women’s Hospital, USA and

66 Interoperability - Banking on market demand

Gerard Anthony Dass, Nortel Asia, Australia

Healthcare Management Medical sciences

06 Commissioning for Improved Patient Safety 20 Importance of Traditional Medicine
Rise of a new era In the age of technology
Martin McShane, NHS Lincolnshire – Commissioning, UK Beverly A Jensen, UAE University, UAE

09 Lean in Primary Care 23 Contrast Echocardiography

Sustaining transformation Current indications
John A Bibby, Beverley Slater Robert Olszewski, Military Medical Instytut, Poland
Improvement Foundation, UK Harald Becher, Oxford University, UK

12 Emergency Services in India

Counting on betterment
Prasanthi Potluri, Asian Hospital & Healthcare Management
Surgical Speciality
28 Heart Valve Surgeries
16 Personalised Healthcare Innovations and new developments
A transformational opportunity Timothy Gardner, Christiana Care’s Center for Heart & Vascular Health, USA
LiHui Xu, Henry Zheng, Steven G Gabbe, Clay B Marsh
The Ohio State University Medical Center, USA

Diagnostics
28 76 20 32 MR Diffusion and Perfusion
Can they replace PET?
Marco Essig, German Cancer Research Center, Germany

36 Cardiac Computed Tomography

Emerging cardiac devices and technologies
Jeffrey M Schussler, Baylor University Medical Center, USA

 A s ia n H o s p i ta l & H ea lt hcare M a nage ment ISS Ue - 18 2009

68 Adoption in Asia Pacific
Sourabh Kankhar, Frost & Sullivan, Singapore

70 A Look into the Future

Ian Neild, BT, UK

76 Enhancing Self-Management of Chronic Low Back Pain

Role of a patient-centred website
Sara Rubinelli, Maria Caiata Zufferey, Peter J Schulz
University of Lugano, Switzerland

78 Benchmarking and Accrediting in Health Informatics

Driving up quality and reducing risk
Di Millen, NHS Connecting for Health, UK

82 Patient Proxies in Decision-Making

What computers can’t capture
Anne Croker, Franziska Trede, Joy Higgs
Charles Sturt University, Australia

85 IT Bookshelf
F e at u r e s

86 Industry Reports
88 Featured Healthcare IT Articles from 2008
90 Happenings in 2008
90 Profiles of IT Companies

40 The Innovator’s Prescription

How Asia can disrupt the global healthcare
Alexandra Leichtman, Jason Hwang, Clayton M Christensen
Innosight LLC, USA

Technology, Equipment &

Devices
44 Orthopedic Medical Devices
Emerging technologies and trends
Frost & Sulllivan

Facilities & operations

management
46 In and Out of the Emergency Room
Streamlined design of patient flow
James W Harrell, GBBN Architects, USA

92 Featured Non - IT Articles from 2008

Features

92 Techno Trends
95 Healthcare projects

www.asianhhm.com 
Advisory Board
Editors
Akhil Tandulwadikar
Prasanthi Potluri

Language Editor
G Srinivas Reddy

Copy Editor
Prity Jaiswal

Art Director
M A Hannan

Visualiser
Sk Mastan Sharief

Designer
Ayodhya Pendem

Sales Manager
Rajkiran Boda

Sales Associates
Sylas Makam
Murali Manohar
John E Adler Savita Devi
Professor
Asst. Manager, Compliance
Neurosurgery and Director Radiosurgery and P Bhavani Prasad
Stereotactic Suregery
Stanford University School of Medicine, USA CRM
Yahiya Sultan
Vijay Kumar Gaddam

Subscriptions Head
Sasidhar Kasina

IT Team
Sandy Lutz Ifthakhar Mohammed
Director Azeemuddin Mohammed
PricewaterhouseCoopers Sankar Kodali
Health Reseach Institute, USA Thirupathi Botla
N Saritha

Finance
A Bhasker Reddy
Chandra Shekar Inguva
Malcom J Underwood
Chief Managing Director
Division of Cardiothoracic Surgery, Ashok Nair
Department of Surgery
The Chinese University of Hong Kong CEO
Vijay Chintamaneni
Prince of Wales Hospital, Hong Kong

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www.asianhhm.com 
Healthcare Management
Commissioning
for Improved Patient Safety
Rise of a new era
T
Ensuring the delivery of he end of the 20th century may
well be seen as marking the
healthcare as safely as
decline of one era in health-
possible has become care and the rise of a new era in which
top priority for the NHS. excellent commissioning is required to
The commissioners meet the challenges of increasing life
have an important role expectancy, changing patterns in disease
and developments in treatments and
to play in planning and
technology. Advances in treatment and
monitoring services on technology together with the increasing
the basis of quality and expectation of society mean that health-
outcomes to restore care costs are being driven relentlessly
primum non nocere (first, upwards. A larger proportion of GDP is
being consumed by healthcare worldwide
do no harm)as a policy
and the UK faces the same challenge
to its rightful place in the as numerous other countries. How to
health system. But how make the best use of the resources being
should commissioners committed to improve health services and
set about their task? health outcomes for its citizens.
The need for effective use of resources
is coupled with a greater desire for qual-
Martin McShane
Director of Strategic Planning and ity. The ‘information society’ is reject-
Health Outcomes ing the paternalism of the 20th century
NHS Lincolnshire – Commissioning, UK health system and increasingly arming
itself with readily accessible insights and
knowledge from the World Wide Web
as to what constitutes not only effective
but also safe, high quality care.
In these circumstances, as societies
change and people’s expectations rise,
health systems must adapt and evolve
to meet these changing needs and new
challenges.
The publication of To Err is Human
in 2000 by the Institute of Medicine
and An Organisation with a Memory
 A s ia n H o s p i ta l & H ea lt hcare M a nage ment ISS Ue - 18 2009
in the same year by the Department of
Health in the UK marked increasing
awareness of the importance of and need
to address safety in modern, complex
health systems. Momentum has grown
following these publications, spreading
understanding of the important need to
address safety in healthcare throughout
the professions and public. The National
Patient Safety Forum, set up following
the publication of Safety First, jointly
chaired by the Chief Executive of the
NHS in England and the Chief Medical
Officer, signals the highest leadership
and priority the NHS is giving safety
for patients.
Fundamental to improving safety is
the realisation that it is not, predomi-
nantly, the responsibility of an individual.
Neither is it solely attributable to a team.
Both, of course, do have responsibility
for safety: in a complex and demanding
environment, excellent team work will
improve safety. However, there is abun-
dant evidence to demonstrate that the
best way to drive improvements in safety
is through ensuring that the systems and
processes being used by organisations
make safety a priority. How can that be
engendered? What will ensure a focus
on safe systems and processes?
In any industry, regulation has a vital
role to play. Alongside an increased aware-
ness of the need to design health systems
that are safe, there has been an increase
in regulation as well. In the UK, the

Commission for Health Improvement was
replaced by the Healthcare Commission,
which is shortly due to be replaced by the
Care Quality Commission. Each reor-
ganisation has expanded the reach of the
regulator. However, regulation alone will
not deliver a safe system. There is an old
saying that ‘he who pays the piper calls
the tune’. Commissioners who finance
the system, alongside regulators, have a
critical role in improving patient safety
as well as securing the most effective use
of resources.
The need for better commissioning
has been recognised in the UK and the
Department of Health in England has
launched an ambitious programme to
develop ‘World Class Commissioning’.
For the first time, a vision and defined
set of competencies have been clearly
articulated for commissioners.
Several of these competencies have
direct relevance to improving patient
safety, for example:
Recognised as leaders of the local health
system.
As leaders of the health system, commis-
sioners have a vital role in signalling their
intention to prioritise and value safety;
to embed and ensure Primum non nocere
(First, do no harm). Organisations move
in the direction of the questions asked
of them. Commissioners need to ask
the right questions throughout their
planning, procurement and perform-
ance management of the health system.
Healthcare Management
Patients have another powerful and
often underutilised role which commis-
sioners could and should harness. The
importance of the patient story has
been used by Sir Liam Donaldson,
Chief Medical Officer, very effectively
to illustrate and engage the public and
professionals in safety. The National
Patient Safety Agency through its work
on encouraging reporting of incidents
from organisations, staff and the public,
is alerting the health system to issues
that need addressing. Commissioners
need to be friendly with patients and
proactively seek out their views and also
make sure that the systems are in place
This is a cultural shift in what has, tradi- to receive their complaints.
tionally, been a provider-led system. Lead continuous and meaningful engage-
Commissioners must develop skills to ment with clinicians to inform strategy,
lead the health system and it is well and drive quality, service design and
established that leaders who champion resource allocation.
safety will improve safety. Professor Chris Ham from the Health
Proactively seek and build continuous Services Management Centre at
and meaningful engagement with the Birmingham University in England
public and patients, to shape services and describes an ‘inverted pyramid of power’
improve health. which exists in any health system due to
Shaping health services that deliver the important role that clinicians play
safe care inevitably demands changes, in decision-making and committing
which, unless set in context, commu- resources. Doctors, nurses and allied
nicated and explained, may well be professionals, with their close contacts
opposed by communities and indi- with patients, could help commission-
viduals. Parties with vested interests ers in effectively implementing the
will also oppose change that threat- safety procedures. Hence, commis-
ens them and may seek to manipulate sioners should work in close coordi-
public opinion. Commissioners need nation with clinicians and ensure that
to understand this and ally themselves they are committed to improve safety.
with the public and patients they serve; Commissioners need to work with and
otherwise, reconfigurations for safer align the decisions they make with
services may be delayed or prevented, professional values and insights, to stim-
leading to avoidable harm. ulate a cycle of continuous improvement.
World class commissioning vision
Better health and well-being for all
• People live healthier and longer lives
• Health inequalities are dramatically reduced
Better care for all
• Services are evidence based, and of the best quality
• People have choice and control over the services they use, so they become more personalised
Better value for all
• Investment decisions are made in an informed and considered way, ensuring that
improvements are delivered within available resources
• Commissioners work with others to optimise effective care
www.asianhhm.com 
Healthcare Management
World-class
commissioning
competencies
1. Are recognised as the local leader
of the NHS
2. Work collaboratively with community
partners to commission services that
optimise health gains and reductions
in health inequalities
3. Proactively seek and build continuous
and meaningful engagement with the
public and patients, to shape services
and improve health
4. Lead continuous and meaningful
engagement with clinicians to inform
strategy, and drive quality, service
design and resource utilisation
5. Manage knowledge and undertake
robust and regular needs assessments
that establish a full understanding of
current and future local health needs
and requirements
6. Prioritise investment according to
local needs, service requirements and
the values to the NHS
7. Effectively stimulate the market to
meet demand and secure required
clinical, and health and well-being
outcomes
8. Promote and specify continuous
improvements in quality and outcomes
through clinical and provider innovation
and configuration
9. Secure procurement skills that
ensure robust and viable contracts
10. Effectively manage systems and
work in partnership with providers
to ensure contact compliance and
continuous improvements in quality
and outcomes
11. Make sound financial investments
to ensure sustainable development
and value for money
10 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
This bottom-up approach to influence
commissioning has been exemplified
by the recent review of the NHS in
England led by Lord Ara Darzi, who
is not only a health minister but also a
practising surgeon.
Effectively manage systems and work
in partnership with providers to ensure
contract compliance and continu-
ous improvements in quality and
outcomes.
In order to improve patient safety,
commissioners should work closely with
their providers. World class commis-
sioning is unlikely to be of any use
unless it supports world class provision.
Commissioners must work collabora-
tively with their provider organisations
to understand barriers which need to be
overcome and incentives and sanctions
required to manage the health system
appropriately and safely. To do this well
requires effective use of information.
Quality improvement is nourished by
information but that information needs
to be compelling—the sort of infor-
mation which will stimulate change in
systems and behaviour. Astonishingly,
the NHS spends one hundred times
more on research than it does on audit.
Feedback in the form of case studies,
significant event reviews, audit or
the other established methodologies
for quality improvement needs to be
valued and supported by commissioners.
Embedding them within the contracting
process and working with clinicians to
identify which measurements will drive
improvement must be integral to decid-
ing how to invest, another important
competency.
Making sound financial investments
to ensure sustainable development and
value for money.
Martin McShane has had over 20 years of frontline clinical experi-
A u t h o r
ence. Supported by the NHS, he developed an interest in commis-
sioning. He is currently working for NHS Lincolnshire which com-
missions services for 750,000 people with a budget of £1 billion.
He is a member of the NHS National Patient Safety Forum.
ISS Ue - 18 20 09
Ultimately, commissioners have to create
an understanding that safer, better qual-
ity care is also cost-effective care.
Information alone does not provide
answers but helps the right questions to
be asked. The work being done nation-
ally in the UK by the NHS Institute
for Innovation and Improvement is
providing commissioners with a wealth
of information. The question is; how is
such information to be used? Surely it
means collecting and using information
for improvement rather than for judge-
ment. This is perhaps the most difficult
and biggest challenge to commissioners
as there is constant fear among organisa-
tions and professionals that this informa-
tion may be misused. There appears to
be a predominant culture in many health
systems to simply use information for
judgement in an adverse and confron-
tational way. This needs to change.
Therefore, commissioners should support
a system that is not driven by fear but
by a continuous drive to improve safety
and outcomes.
Crossing the Quality Chasm (Institute
of Medicine 2001) has an appendix
entitled Redesigning Health Care with
Insights from the Science of Complex
Adaptive Systems.
Commissioners need to become adroit
at using their levers and those exerted
by other agencies in order to compe-
tently influence the complexities of the
healthcare system they are shaping, to
obtain safe and effective services, deliver-
ing the best possible outcomes for their
customers.
Providers who understand this new
context and rise to the challenge of work-
ing collaboratively with commissioners
will flourish and prosper and, most
important of all, patients will benefit.

Lean in
Primary Care
Sustaining transformation
Lean approaches have
been widely adopted by
hospitals, but application
in the primary care setting
has received less attention.
Primary care can use a
Lean approach to structure
and sustain quality
improvement work but, as
with all quality improvement
approaches, needs energy
and committed leadership.
John A Bibby
Clinical Advisor
Beverley Slater
National Knowledge Management Lead
Improvement Foundation, UK
P
rimary care has altogether a differ-
ent quality improvement environ-
ment and a different organisational
and management structure compared to
a hospital care setting. It reflects a differ-
ent role, purpose and a different organi-
sational culture. See Table 1 for charac-
teristics of primary care general practice
in England.
A hospital has many specialist teams
within the same organisation (and under
the same management), each delivering
a limited range of patient pathways. In
contrast, each primary care team is a small
independently managed hub that links
to a huge range of potential pathways
and onward referral points.
The quality improvement strategy,
managed and practiced in primary care
on a day-to-day basis is necessarily differ-
ent from the approaches that are taken
in a hospital setting.
In particular, a hospital that is imple-
menting a quality improvement strategy
is in a position to provide dedicated
improvement support and expertise. Some
commentators (Westwood and Silvester,
2007) argue that this sort of support is
essential. But for small primary care teams,
this is less likely to be available, and there
is greater emphasis on the quality of the
leadership from within the primary care
practice itself.
What do patients really want?
Over the recent years there has been
an increase in attempts being made to
Healthcare Management
find out what patients value the most.
This links to a policy in the UK to focus
directly on improving patient experience.
The methods used may involve paper
questionnaires, real-time electronic
data collection, various focus groups or
patient participation groups. A useful
development was the use of discovery
interviews (a technique of in-depth
interviews with patients to inspire qual-
ity improvement) and more recently
the model of experience-based design
(Bate & Robert, 2006) where patients
record episodes of emotional importance
by either using video, audio or written
media. These emotional ‘touch points’
are then discussed in a facilitated meeting
between the patient and care provider.
This process has led to a greater under-
standing by clinicians of what is valuable
to their patients.
These insights are then the basis for
eliminating waste and confidently direct-
ing resources towards what increases value
to patients (see Table 2 for a summary of
Lean principles applied to healthcare).
Increasing patient value in
primary care
Delays in the patient journey (at all stages
from presentation, through diagnosis, to
treatment and aftercare) are the most
significant ‘non-value adding’ challenges
to any healthcare system, as they increase
the risk of adverse outcomes and errors
being associated with significant incon-
venience and cost. The following examples
www.asianhhm.com 11
Healthcare Management

of increasing patient value and reducing

waste are taken from the author’s own Development of quality improvement
experience in primary care practice. Many shared tools but differences of emphasis
Example 1: Helping GP appointments to
run on time
1920s W Shewhart—Statistical process control
An example of the 5 Ss (sort, simplify, shine,
standardise, sustain)
1950s W E Deming—System of profound knowledge
Recently, a local peer support system
has been set up for GPs to see how
Toyota Taichi Ohno Juran
colleagues manage their appointment
times without getting late. A significant 6 Sigma Goldratt
learning from this has been the finding Toyota production system
(‘Lean thinking’)
that those doctors that run on time have
their consulting rooms in order, with all Theory of TQM
2008 Service lean ‘Lean Six Sigma’ constraints BPR
forms and equipment handy and with
very little need for the doctor to leave
the room during the consultation for
equipment or patient details.
Characteristics of primary care general practice in England
Example 2: Streamlining processes with
suppliers Practices run by generalist doctors (general practitioners) in independent teams
An example of managing the value Structure with nurses Contracted to provide NHS services free at point of service Small
stream organisations, independently owned and managed (5-50 staff)
The practice has developed an arrange-
Diagnosis and gate-keeping of referrals to specialists Primary care management of
ment with the pathology laboratory that Role and purpose chronic conditions Coordination and continuity of care to patients on the practice
if a haemoglobin test is low the labora- list Commissioning of specialist and community services
tory will automatically undertake a B12 Table 1
/ foliate and ferritin assay without the
need for a further blood test. Previously, Lean principles and quality improvement tools
either all these blood tests were ordered
Similar or related
on suspicion of anaemia (wasteful order- 5 Lean principles
Lean principles applied to
Lean tools / concepts quality improvement
ing of tests), or just a Hb was ordered healthcare
tools
and the patient was asked to return for 1. Identify customer Identify value to the patient Value stream mapping Experience-based
further blood tests when the low Hb was value design Emotional
discovered (wasteful of patients’ time and mapping
introducing delay). In addition, electronic 2. Manage value Manage the patient journey 5 Ss (workplace Process mapping
links enable the GP to see the results stream organisation) Capacity and demand
within minutes of having been processed 7 wastes analysis
3. Align processes to Facilitate the smooth flow
Visual workplace
by logging into the hospital pathology facilitate flow of patients and information
Distance walked
system.
4. Introduce pull Introduce pull in the patient Pull systems Advanced access
Example 3: Patients getting appointments between steps journey
on the day they need
5. Pursue perfection—continuously reducing waste Rapid improvement Whole system
An example of a pull system by developing and amending processes events (incorporating redesign initiative and
Traditionally, general practice has suffered all of the above) collaborative using
due to appointment systems that appeared rapid change cycles
to be designed to control a perceived high Table 2
demand. Many different approaches to one of an overall lack of capacity for the oped by the Improvement Foundation,
the problem were taken but all had a basic demand (If this was the case, then the and now employed by many practices
flaw. In order to protect ‘today’s’ appoint- waiting list would continue to increase). in NHS primary care (Improvement
ments, various sanctions or ‘carve outs’ The problem is one of a mismatch between Foundation, 2008). This involves:
were imposed, hence reducing routine capacity and demand on a daily basis. Lean 1. Carefully measuring daily demand over
appointments and pushing work onto principles have been used in the ‘Advanced a period of weeks to see how this varies
subsequent days. The problem is not really Access’ approach, supported and devel- from day to day

12 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09

 Healthcare Management

2. Removing the backlog of appoint-
ments by a one-off concerted increase
in capacity
3. Re-shaping demand by providing
different types of consultation (using
nurses, providing telephone or email
consultations)
4. Matching capacity to the calculated
demand on a daily basis
5. Monitoring the system daily and having
contingency plans in place for situ-
ations where capacity could fall (for
example, doctors’ holidays)
Instead of postponing work to another
day, the work will be completed on the
same day. The calculated demand (both
type and volume) from patients acts as a
trigger to ‘pull’ the correct capacity into
place. The result is that patients are seen
on the day they want to be seen, staff
are less stressed and there is less waste
in the appointment system.
Example 4: Streamlining clinical commu-
nication across boundaries
An example of managing the value
stream
In the author’s practice, recent improve-
ments in the electronic patient record
have meant that if an opinion is required
from a renal consultation at the local
hospital, then instead of taking several
weeks, (sending a referral letter, then the
patient attending the hospital, and the
consultant sending a letter back to the
GP) the system has been redesigned by
removing many intermediate stages so
that when a GP has a query about what
to do next, he sends an electronic message
to the consultant and gives the consultant
access rights for a few days to look at the
patient’s electronic record. The consult-
ant reviews the problem with access to
the complete patient record including all
previous investigations and medications.
Sustaining Lean in primary care
The fifth Lean principle is to pursue
perfection, continuously, reducing waste
by developing and amending processes
(Table 2). This then is the challenge:
how to make improvement a habit and
a continuous process?
Applying a set of Lean tools or using
a one-off Kaizen Blitz (rapid improve-
ment event) will not in itself deliver
Model for Improvement
What are we trying to accomplish?
How will we know that a change
is an improvement?
What change can we make that will
result in an improvement?
Act Plan
Study
Do
Source: Langley et. al. (1996) The Improvement
Guide. San Francisco: Jossey Bass
Figure 1
sustainable continuous improvement.
For sustainable quality improvement in
primary care, there is a key requirement
for someone within the practice who is
able to lead, encourage and develop an
improvement culture. This may be a
John A Bibby is the Senior Partner in a primary care practice in
Shipley, West Yorkshire. He is also clinical lead for the Improvement
Foundation, a body that facilitates service redesign within the health
and public services, throughout the UK, Australia and Canada.
A u t h o r s
clinician or a manager, anyone with a
passion for quality improvement. The
leader’s task is to set the environment
for learning, communicate the benefits
of continuous improvement, provide the
right support and demonstrate how to
learn.
Hines and colleagues’ 2004 review
of Lean thinking shows how Lean has
evolved from its narrow origins in 1950s
car manufacturing to the extended
application in service industries (such
as health) today. Real understanding of
the customer value stream was developed
during the 1990s. With this understand-
ing now driving business processes, rather
than relying on a mechanistic application
of specific Lean tools, present day Lean
draws on a range of tools from diverse
management approaches.
One such quality improvement tool
that has great value in setting a learning
culture and sustaining improvement in
primary care is the improvement model,
with the ‘three questions’ followed by
Plan-Do-Study-Act (PDSA) rapid change
cycles (Figure 1).
Conclusions
Lean in primary care is more likely about
applying ‘Lean thinking’ flexibly rather
than a programmatic step-by-step appli-
cation of Lean tools. The Lean approach
can be used by primary care to structure
and sustain quality improvement work
but, as with all quality improvement
approaches, needs energy and commit-
ted leadership.

He then types directly into the primary

care record from his office in the hospital
and an electronic message is sent to the Beverley Slater is National Knowledge Management Lead for the
GP informing him of the opinion. The Improvement Foundation, where her role focusses on generating
and disseminating knowledge about improvement. She has eight
consultant’s access to the record is then years of experience in leading quality improvement initiatives in lo-
terminated. This process adds value to cal healthcare systems, including the UK Primary Care Collaborative
the patient, saves time and saves patients and the international US-led Pursuing Perfection initiative.
from travelling to the hospital

www.asianhhm.com 13
 I
t is terms like ‘The Golden Hour’ Globally prearranged emergency lance service available in the metros and
and the ‘Platinum Ten Minutes’ that services is expanding it to the rural areas.
typify the importance of Emergency Emergencies typically occur in cases like The prearranged emergency services
Medical Services (EMS) all over the road accidents, cardiac problems, convul- currently operate via an emergency services
world. It is a well-accepted fact that sions and so on. Trained technicians or contact system with dedicated telephone
a patient who receives basic care from paramedics provide first aid to the patient numbers.
trained professionals and is transported i.e. pre-hospital care and shift the patient
to the nearest healthcare facility within to an appropriate facility. EMS can be Medical
Country
15-20 minutes of an emergency has the provided in two forms—treatment to emergency no.
greatest chance of survival. EMS is an in-patients and pre-hospital services. UK 999
essential part of the overall healthcare Pre-hospital medical services include Ireland 999
system as it saves lives by providing care ambulatory services, transportation of Poland 999
immediately. It’s this recognition that the patients to or from places of treat- Hong Kong 999
has led to research and development in ment and acute medical care (also called
Malaysia 999
EMS. Over the years several advance- first aid). Ambulance services were largely
ments have been made and research unregulated prior to the 1970s. But over China 119
is underway to create services that the last 2-3 decades, a largely regulated Japan 119
provide medical assistance to patients system has emerged around the world. Republic of Korea 119
at the earliest. However, the state of Earlier, emergency services were being Singapore 995
EMS varies drastically from developed provided only with the means of road
UAE 998 or 999
to developing countries like India. In transport through hammocks and automo-
The most common 112
spite of the development in the health- bile. In 1972, a modern emergency medi-
European countries
care sector over the past decade, India cal helicopter transport—air ambulance
Australia 000
is yet to create a single, comprehensive was introduced in the US. Later, more
EMS that can be accessed throughout standards were formed to make services USA 911
the country. better. India also has a helicopter ambu- Canada 911

14 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09


Emergency Services
in India
Counting on betterment
Scenario in India
As compared to developed countries with
proper emergency systems in place, there
is no single system which could play
a major role in managing emergency
medical services in India. There is a frag-
mented system in place to attend the
emergencies in the country. 102 is the
emergency telephone number for ambu-
lance in parts of India. There are different
emergency numbers in India’s 28 states
and seven Union Territories. Hospitals in
the country provide different telephone
numbers for ambulance services. Clearly,
India is in need for proper emergency
medical service that can be accessed from
anywhere in the country. The existing
fragmented system falls terribly short
of meeting the demand.
Trauma continues to be one of the
major causes of death in India. To avoid
preventable deaths and disabilities, India
has planned to have a common effective
system that could provide emergency care
with equity of access. In a bid to address
this problem, The Centralised Accidents
Healthcare Management
India requires a better
emergency medical service
to meet the growing number
of emergencies. What ex-
ists currently in the form of
fragmented services across
the country falls way short
of meeting the requirement.
and Trauma Services (CATS) was set up
by the Delhi Government in the early
1990s. This service was later expanded
throughout the country. Unfortunately,
it didn’t succeed despite having a toll free
number (102) that was made available
through various media.
More recently, NGOs and hospitals
have come forward to provide their own
EMSs. There have been considerable Prasanthi Potluri
efforts by states across India to develop Editor
emergency services. Organisations like Asian Hospital &
Emergency Management and Research Healthcare Management
Institute (EMRI) and American
Association of Physicians of Indian
Origin (AAPI)’s EMS are banned by
corporates. EMRI is an exception in the
otherwise struggling EMS system.
EMRI was founded in 2005. To
begin with, its operations were limited
to Hyderabad and Andhra Pradesh with a
vision of responding to 30 million emer-
gencies and saving 1 million lives a year.
EMRI handles medical, police and fire
emergencies through its 108 emergency
service. Satyam is the technology partner
www.asianhhm.com 15
Healthcare Management
of EMRI. EMRI has also entered into
PPP with Indian Emergency Number
Authority, National Emergency Number
Association, American Association of
Physicians of Indian Origin (AAPI),
Shock Trauma Centre, Stanford
University USA, Singapore Health
Services, City of Austin in Texas, USA
and Government of Andhra Pradesh.
EMRI also comprises a research
institute, which does medical research,
systems research and operations research.
Through this, EMRI provides research
papers for prevention and management
of emergencies. EMRI’s other services
includes free medical advice on phone on
another toll free number 104 with access
to more than 200 medical doctors and
several more paramedics. It has entered
into a partnership with Stanford Hospital,
the School of Medicine for training 150
paramedics and 30 paramedic instructors
over a two-year period in India. Though
a positive, this is unlikely to meet the
demand for paramedics in the country.
“So far neither of these two services in
Mumbai (AAPI) or Hyderabad (EMRI)
have the kind of human resources and
massive training programmes needed”,
concurs Dr N Bhaskara Rao, Chairman,
Centre for Media Studies, New Delhi.
In 2007, with the extension of
Ambulance Access for All (AAA)’s serv-
ices, American Association of Physicians
of Indian Origin (AAPI) founded
Emergency Medical Service (EMS) for
Mumbai. AAPI
16 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
has collaborated with the Confederation
of Indian Industries (CII) and signed
an MoU to endorse the growth of the
healthcare sector in India, especially in
rural areas. This agreement is to provide
knowledge and technology transfer and
provide EMSs to develop healthcare
facilities in India.
Another such facility, Life Support
Ambulance Service (LSAS) operating in
Mumbai for three years in association
with London Ambulance Service, UK,
has now made inroads into Kerala and
has 500 ambulances that can be reached
on a toll free number 1298.
Recently, the Gujarat state govern-
ment set up the Gujarat Emergency
Medical Services Authority (GEMSA).
Institute of Kidney Diseases and Research
Centre (IKDRC), U.N. Mehta Institute
of Cardiology and Research Centre,
Gujarat Cancer Research Institute
(GCRI), EMRI and Public Health
Institute, Gandhinagar have entered into
several other PPP projects to improve the
emergency services in the state.
But these examples are far and few
in a largely fragmented system. The lack
of a common emergency number across
the country is a major hurdle in creating
a reliable emergency service. The fact
that there isn’t clarity in the Ministry
of Health about the importance of a
common EMS does not help either. Says
Dr Rao, “The Ministry does not have
basic data on ambulances for emergency
medical services in the country. This is
despite the state-wise studies on
‘health infrastructure’ that
were conducted recently.”
Clearly, there is an urgent
need to appraise the
situation and imple-
ment corrective
measures that
can help put in
place the
required
infra-
structure
as soon as
possible.
ISS Ue - 18 20 09
Meeting the demand?
In spite of the work going on in the area
of EMS, the question still remains: is it
meeting the requirements? The answer is
no. Though there has been a considerable
improvement in emergency services in
India, but there is still a long way to go
before a comprehensive EMS is imple-
mented across the country. “Available
emergency services are not sufficient to
meet the demand as one ambulance is
needed to cover a population of 50,000
to 100,000,” says Mr Venkat Changavalli,
CEO, EMRI. Still numerous deficiencies
exist in the emergency services across the
country. “India should have far more
accessible and reliable emergency medi-
cal services irrespective of geographical
factors,” says Dr Rao.
Another important component
missing in the current system, and
one that will be needed in the long-
run, is a body to regulate the EMS in
the country. “LSAS in Mumbai claims
that it had saved 22,000 lives in three
years while EMRI in Hyderabad claims
saving 55,000 lives in one year,” says
Dr Rao, but there is no way to validate
these claims and introduce corrective
measures.
Awareness
Awareness of the available services and
preparedness are mandatory among the
general public for the success of an EMS
service. People also need to take initia-
tive in knowing about the services being
provided by available EMS. Indeed, an
EMS that people are not aware of is as
good as non-existent. One of the reasons
for the success of EMRI is that 108 is
widely recognised and has a great recall
among citizens. “People’s participation
is as important as blood donation and
such cooperation is an important aspect
of emergency medical relief service,” says
Dr Rao. In 2006, American Academy for
Emergency Medicine in India (AAEMI)
made efforts to educate, impart knowl-
edge and expertise to emergency care
workers in Indian hospitals. It was aimed
to increase the awareness and importance

Helicopter Ambulance Service
One ambulance per 100,000 people norm for
‘pre-hospital emergency medical response
services’ is what the Chief Minister of Delhi
had recently talked about. The traffic system
being what it is and how it is worsening in
most cities of India, it is high time that we
start experimenting with helicopter services
for emergency medical services in metro
cities. Hindustan Aeronotics Limited (HAL)
could be approached to design a helicopter
with medical relief facilities including oxygen
storage to accommodate more people and
other paraphernalia and with maneuverability
of Emergency Medicine. But this and
other similar programmes are restricted
to a few regions. Thus arose a need for
an awareness creation programme across
the nation that filled this gap.
Legislation for emergency services
The demand for legislation for EMS has
been rising steadily in India. Supporters
of such legislation opine that it would
mandate a common access number,
formation of an EMS council, trained
paramedics, gradation of ambulance and
hospitals, network of hospitals and define
physical and human resources needed for
the service. This could help save lives by
making access easy for all the patients.
Methods, technology, personal skills
need to be standardised with formation
of legislation in emergency services to
provide protection for the providers.
Associations like Society of
Emergency Medicine-India (SEMI)
and American Association of Physicians
of Indian Origin (AAPI) have submit-
ted proposals for EMS legislation to
the Central Government and State
Government of Gujarat, Maharashtra and
Andhra Pradesh. A word of caution comes
from Dr Rao as he says “making emer-
Healthcare Management
to land and take off easily even from
urban ghettos. We already have medical
relief rail and compartments for massive
emergency situations. As more and more
road accidents often involving groups of
people get reported, the present architecture
of ambulance services will not be able to
cope with and cater to even as mere patient
transport vehicle. And then the number of
disasters are on the increase—floods, fires,
earthquakes, etc and then now terrorist
attacks, communal conflicts besides
increasing road accidents.
N Bhaskara Rao
gency medical service legally compulsory
without ground level preparedness will
not be enough.” He adds that people
need to be aware of their responsibilities
towards fellow citizens—insist on and
be aware of the best emergency service
available.
Conclusion
The importance of a reliable EMS cannot
be overemphasised, especially in India
where the government has the respon-
sibility of caring for a majority of the
population. It can be argued that a nation
of a billion people has been deprived of
a decent EMS for too long now and it is
high time the government takes defini-
tive action. The success of a few services
is evident enough of the need for EMS
and what it will take to ensure that it
works as expected. In a healthcare system
that is sprouting and experiencing the
benefits of involving private players, a
public-private partnership framework
could be the right way forward for policy-
makers. At a time when the emphasis on
preventing damage is greater than ever,
the provision of pre-hospital care will be
the key to ensure that lives are not lost
due to avoidable circumstances.
www.asianhhm.com 17
Healthcare Management
Personalised Healthcare
A transformational opportunity
I
Despite increasing ncreases in healthcare spending
appear to be a global concern. For
healthcare costs,
example, the rising costs in Asia
healthcare suffers from are being driven by many of the same
suboptimal quality and factors that have triggered the spiralling
inefficiency. Personalised of medical costs in developed countries.
Healthcare offers Factors include ageing societies with more
chronic disease, rising technology costs;
the transformational
high patient expectations of care; and
opportunity. This article more frequent coverage by third-party
discusses the science, payers such as insurers or employers.
enabling technologies, However, the quality of healthcare does
opportunities and not necessarily correlate with the total
spending. Take US as an example, total
challenges of
healthcare costs in the US were US$ 2.2
moving Personalised trillion in 2007, representing 16 per cent
Healthcare forward. of the Gross Domestic Product (GDP), an
amount expected to reach US$ 4.2 trillion
LiHui Xu in 2016. Despite this vast spending, our
Program Director healthcare system suffers from suboptimal
Henry Zheng quality and inefficiency, as evidenced by
Director the World Health Organization (WHO)
Operations
ranking healthcare in the US 37/191
Steven G Gabbe
Senior Vice President
countries in performance. Furthermore,
Health Sciences studies show that prescription drugs are
Clay B Marsh effective in fewer than 60 per cent of
Professor treated US patients. The current trend is
Center for Personalised Healthcare unsustainable and ineffective, emphasis-
The Ohio State University Medical ing the need for transformational change
Center, USA to create value-based, patient-centric
healthcare.
Reversal of this trend will require
Personalised Healthcare. It incorporates
individual genetic, behavioural and envi-
ronmental information to define indi-
vidual prescriptions for health mainte-
nance, disease prediction, prevention, and
tailored therapy. In addition, it considers
individual environments, health-related
behaviours, cultures and values. This
approach is revolutionary and will funda-
mentally transition medical practice from
illness to wellness. Equally important is
18 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09
patients’ control over their own health
by their personal prescription for health,
incorporating approaches for their unique
risk of disease.
Scientific advances are leading the
way to Personalised Healthcare
Rapid advances in platform technologies,
such as Single Nucleotide Polymorphism
(SNP) analysis, the ‘-omics’ such as
genomics, microRNA (miRNA) analysis
and systems biology and network analysis,
offer the potential for revolutionary change
in the practice of medicine. Landmark
projects, such as the Human Genome
Project completed in 2003, have laid the
groundwork for researchers to identify
genetic causes and genetic contributions
to complex human diseases.
For example, genome-wide association
studies have uncovered new genes linked
with common diseases, including coro-
nary heart disease, type 1 diabetes, type
2 diabetes, rheumatoid arthritis, Crohn’s
disease, bipolar disorder and hypertension.
Identification of disease-specific genes
could lead to clinical interventions to
improve outcome. In addition to genetic
research, ‘-omics’ technologies, such as
transcriptomics, proteomics and metabo-
lomics have grown rapidly. These powerful
tools allow researchers to link phenotype
with dynamic protein production, gene-
protein and protein-protein interactions
to identify markers and molecular targets
in health and disease.
Beyond gene and protein activation
as disease triggers, underlying regulatory
genetic events have drawn significant
attention. For instance, miRNAs, small
non-coding RNAs of 21-23 nucleotides
that bind complementary sequences in
target genes and cause mRNA degradation
 Healthcare Management

or inhibition of target protein production,
are involved in the regulation of gene
expression in cell proliferation, differ-
entiation, and apoptosis. miRNAs are
implicated in tumorigenesis through regu-
lating the expression of tumour suppressor
genes and oncogenes. miRNA expression
is abnormal in chronic lymphocytic leuke-
mia, solid organ tumours like lung cancer,
and non-tumour diseased tissues. A recent
study suggests miRNAs mediate cancer
chemoresistance or sensitivity. These tools
may revolutionise disease classification,
diagnosis, monitoring, prognosis, and
potential treatments to drive personal-
ised care. Similarly, miRNAs also regulate
epigenetic regulation of gene transcrip-
tion, another actively explored regulatory
process in the genetic underpinnings of
complex human disease.
Mainstream research focusses on iden-
tifying individual gene(s), molecule(s),
or pathway(s) that lead to disease. The
rise of systems biology tools facilitates
dissecting the organisation, regulation
and structure of complex systems, such
as dynamic gene and protein networks
that underlie human health and disease.
This approach has great potential in bring-
ing predictive and preventive medicine
to reality.
Information technology and biomedi-
cal informatics are key enablers of
Personalised Healthcare. Electronic and
personal health records make complete
and current patient information avail-
able when and where it is needed.
Electronic patient phenotyping provides
the opportunity to interface genetic and
‘–omic’ information with patient-specific
outcomes to create novel approaches to
promote health and prevent disease. These
tools support clinical decision-making
by clinicians and healthcare providers,
thus delivering the best individualised
care for each patient. Equally important
is that Personalised Healthcare promises
to place information technology in the
hands of consumers / patients empower-
ing them to take control of their health
and managing wellness.
Personalised Healthcare is already
happening, but at a slow pace
The rise of personalised medicine is the
result of unprecedented advances in
biomedical research and technologies,
such as DNA sequencing and ultra-high
throughput screening. Technological
breakthroughs have dropped the price

Global perspectives on Personalised healthcare

The US Department of Health and Human Services (HHS) plays
a leading role in advancing Personalised Healthcare. In particular,
the HHS has issued two reports with the first one released in
October 2007 and the second in November 2008, demonstrating a
strong focus and commitment to delivering the best care possible
to each patient. Michael Leavitt, Secretary of HHS, stated that
Personalised Healthcare is not a niche concern. Its promise is
central to the future of healthcare. Under the HHS leadership,
National Institutes of Health and the Food and Drug Administration
have both embarked on the journey to Personalised Healthcare.
The NIH roadmap and FDA critical path are all part of the efforts
for this initiative.
Inspired by the vision, both academia and industry are
advancing Personalised Healthcare research, education and
clinical practice. Among many of the academic centres, The Ohio
State University is committed to developing and creating the future
of medicine by improving people’s lives through Personalised
Healthcare. Our commitment is to help people maintain healthier,
happier, and productive lives. To do so, we are implementing
an innovative programme to promote the active participation of
individuals in their own ‘personalised’ health maintenance and
to use genetic tests and health markers to predict and prevent
disease. In addition, Ohio State is developing a general patient
informed consent to prospectively collect patient’s biologic
specimens and DNA samples for medical research. This biobank
will be linked with the patient clinical database to make it highly
useful for translational research, such as human cancer genetics,
individualised cancer therapy, advanced lung disease and sepsis,
cardiovascular diseases, women’s health, pharmacogenomics
and diabetes mellitus. The data generated by these research
programmes will then be incorporated into the electronic medical
record to support clinical decisions.
Personalised Healthcare or Personalised Medicine has become
a global initiative. Other countries, such as the UK and Canada,
have also embarked on this exciting initiative. Furthermore,
countries in Asia, such as China and Japan, have played a critical
role in the international HapMap project. The goal of the project is
to develop a haplotype map of the human genome, the HapMap,
and provide researchers around world with free access to the data
to find genes affecting health, disease, and responses to drugs
and environmental factors. Combined phase I and phase II projects
have identified over 3 million SNPs in 269 individuals, including
Han Chinese, Japanese, Nigerian, and European. The data will
provide important information to guide genome wide association
studies and to identify genetic variations in different ethnic groups.
Finally, as part of the 1000 Genomes initiative, Asian countries,
such as China, are playing an increasing role in funding genomic
research and technologies. Given the low cost of labour and their
intellectual prowess, China and India are on the rise to develop
research powerhouses. However, science and technology have
always outpaced public policy, regulation and clinical medicine.
Integrating genetics / genomics into clinical practice will be at
slower pace than we wish, especially in the developing countries,
given the disparity of their healthcare system.

www.asianhhm.com 19
Healthcare Management
from US$ 3 billion to sequence the entire
human genome to US$ 60,000. Several
countries and commercial entities are
investing in technology to reduce the
cost of sequencing a person’s complete
genome to US$ 1,000. Price reduction in
this technology will enable each person to
obtain a blueprint of their genetic code
in the near future.
Moving towards the goal of indi-
vidualised predictive, preventive and
personalised care, researchers have devel-
oped genetic tests that can be utilised to
diagnose, predict and identify carriers of
genetic disease and also determine the
risk of adverse medication reaction. Over
1,000 genetic tests are currently available
and more are being developed. A current
example is testing for BRCA1/2 mutations
in women with a family history of breast
cancer or ovarian cancer. If a women tests
positive for BRCA1/2 mutations, she has
an estimated lifetime risk of 36-85 per
cent for developing breast cancer, a 16-60
per cent for ovarian cancer, and should be
closely monitored for these diseases.
In addition, companies such as
23andMe, Navigenics, and deCODE
Me, continue to develop tools for genetic
analysis marketed directly to consum-
ers and physicians. These tests allow
consumers to evaluate their genetic risk
of disease and genes defining personal
traits. Consumers can take control of
their own health by understanding their
predisposition to disease and modify their
lifestyle accordingly, providing potential
long-term benefit.
Pharmacogenomics / genetics is a
promising area for Personalised
Healthcare, translating scientific discovery
into clinical application. Pharmacogenetic
testing presupposes the availability of
validated genetic tests, with data link-
ing the presence or absence of specific
variants with a specific outcome, such
as improved therapeutic response or
reduction in adverse events. A topical
example is the genotyping of CYP2C9
and VKORC1 in guiding the titration
of the anti-coagulant warfarin towards
the optimal maintenance dose.
20 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Despite decades of experience and
careful monitoring, the adverse events
of warfarin are still among the highest
of all commonly prescribed drugs. The
challenge of administering warfarin is due
to the wide (20-fold) inter-individual vari-
ation in dose requirements, the narrow
therapeutic range, and the risk of serious
bleeding from overtreatment, or risk of
repeat thrombosis from under-treatment.
Studies show that age, gender, sex, race,
body mass index, smoking, diet, and drug
interactions, have a significant impact on
warfarin sensitivity. Variability in warfarin
response can result from polymorphisms
in vitamin K epoxide reductase subunit
1 (VKORC1), the pharmacologic target
of warfarin. In addition, patients with
genetic variants of CYP2C9, involved
The rise of Personalised
medicine is the result of
unprecedented advances
in biomedical research
and technologies, such
as DNA sequencing and
ultra-high throughput
screening.
in warfarin metabolism, require lower
doses of warfarin because of reduced
drug clearance. By applying genotype
biomarkers at the beginning of warfarin
treatment, one can shorten the time to
reach the proper warfarin dosage, thereby
reducing adverse drug reactions (ADRs).
Based on these findings, the US Food
and Drug Administration changed the
labelling information for warfarin to
recommend genetic testing of CYP2C9
and / or VKORC1 genes.
Increasing the awareness
As research in Personalised Healthcare
advances, educating healthcare provid-
ers and consumers is the key to improve
healthcare delivery. There is a lack of
knowledge and utilisation of clinical
ISS Ue - 18 20 09
genetics, genetic testing and genetic
counselling in the medical community
and the public. Therefore, it is critical to
develop Personalised Healthcare-related
educational programmes through contin-
ued medical education and integrate this
curriculum into medical education for
medical students, residents and physi-
cians.
Personalised Healthcare promises to be
a predictive, preventive and participatory,
and personalised—‘P4’—medicine. To
be truly participatory and personalised,
seamless and logical information technol-
ogy interfaces and tools are essential. The
development and application of these tools
and education targeted to Personalised
Healthcare is lacking.
The power of Personalised Healthcare
in improving people’s health and saving
cost rests on transforming medicine
to disease prediction, prevention, and
wellness. This will require re-engineer-
ing current healthcare reimbursements
and delivery to bring healthcare to each
home and community on demand. It is
not just the right medicine at the right
time, but more importantly, a health
and wellness intervention strategy that
prevents the onset of diseases. This strategy
will not work without key public-private
partnerships to create the tools to start a
social epidemic of change in healthcare
delivery.
Issues and challenges
Although Personalised Healthcare offers
a transformational opportunity to change
the current healthcare system, many issues
or challenges must be addressed before
it can become a reality, including lack of
public policy, regulation, reimbursement,
education, standardisation of healthcare
information technology such as elec-
tronic medical records, clinical valida-
tion, adequate funding for research, and
privacy concerns.
Each of these challenges must be
dealt with by all of the stakeholders,
including physicians, scientists, health-
care organisations such as hospitals and
health networks, private insurers, public

insurance providers such as Medicare and
Medicaid, pharmaceutical and diagnos-
tic companies, state governments, the
federal government, and, most impor-
tantly, patients.
Summary
Personalised Healthcare holds the promise
of transforming the current healthcare
delivery into a value-based and patient-
A u t h o r s
centric healthcare. While advances in
science and technology continues at a
dramatic pace, other areas such as public
policy, regulation, reimbursement, educa-
tion and clinical validation will continue
at a measured pace. This will require all
stakeholders in the healthcare arena to
work together in years to come to over-
come these hurdles and challenges before
Personalised Healthcare can become a
reality.
References are available at
http://www.asianhhm.com/magazine
Healthcare Management
LiHui Xu is currently the program director at the Ohio State
University Center for Personalized Healthcare. Prior to that, Xu was
the Chief Operating Officer of a biopharmaceutical company. From
1989-2001, she was a postdoctoral fellow and a research assistant
professor at University of North Carolina at Chapel Hill.
Henry Zheng is the director of operations at The Ohio State University
Center for Personalized Healthcare. Zheng has served in numerous
leadership positions since joining OSU in 1997, as senior planning
manager, business performance officer, director of Technology and
Commercialization Partnerships and director of Data Analysis and
Information Services.
Steven Gabbe recently joined the Ohio State University as senior
vice president for Health Sciences and Chief Executive Officer of the
OSU Medical Center. Prior to that, Gabbe was Dean of the Vanderbilt
University School of Medicine. From 1987-1996, he was professor
and chair of Obstetrics and Gynecology at OSU.
Clay Marsh came to The Ohio State University in 1985. He is cur-
rently professor and vice chair for research of Internal Medicine,
director of the Center for Critical Care, and director of Pulmonary,
Allergy, Critical Care and Sleep Medicine.
www.asianhhm.com 21
Medical sciences

Importance
of Traditional
Medicine
In the age of technology

Most nations, except the US,

have natural medicine traditions
known and widely practised by
the populace. With the increasing
availability of Western techno-
centred medicine, there’s a
seduction in favour of ‘modern’
medicine over traditional
treatments. Health outcomes
in the US indicate the risks on
this path and the importance
of staying patient-centred.

Beverly A Jensen
Associate Professor
Communications
UAE University, UAE

22 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09


T
he purchase and installation of
new technology in any environ-
ment generates excitement—
whether it’s in the office, school, hospital
or home. Owning the latest technology
is exciting.
There is a certain seduction in owning
the ‘latest and greatest’ technology. And
for decades, the sales departments of
manufacturers have played the ‘status’
card in their persuasive sales pitches. In
the education field, school storerooms
around the globe are filled with equip-
ment that no one on site was trained to
use properly, and no one was trained to
maintain or repair.
Over the last 50 years a revolution
has occurred in healthcare with pacemak-
ers, artificial joints, organ transplants,
and now, a whole new horizon is open-
ing with stem cell research. However,
just as in education, many developing
countries find themselves flooded with
sophisticated medical equipment they
can neither fully utilise nor maintain.
The technology salesmen have sold
medical equipment even to the nations
in which the local health issues do not
warrant such expenditure, As a result,
technology sales usurp the resources that
are available for basic healthcare. This
misallocation of resources happens not
only in the US but also in every other
nation.
Healthcare in Asia
will be most successful if
the traditions of Ayurveda,
Chinese medicine, and
other tried-and-tested
indigenous medical
treatments remain at the
forefront in medical care.
The development of national
Health Information Technology (HIT)
programmes, on the other hand, could
help to reduce healthcare costs and
improve safety in delivery to patients.
Others nations’ experiences in develop-
ing national HIT provide immediate
and salient lessons for organisations and
nations just beginning the process.
Still, the implementation of any tech-
nology carries the risk of diminished
attention to the patient’s well-being. The
evolution of medical care in the US over
the past 60 to 70 years is a demonstration
of myopia brought on by focussing on
the wonders of technology.
Until the mid-1930s the American
Medical Association coexisted fairly well
with naturopaths and other health prac-
titioners. Many MDs incorporated forms
of natural healing into their practices,
such as herbs, baths, breathing and exer-
cise programmes. As the chemist labs
cranked up in the 1930s, MDs began
prescribing pharmaceutical drugs instead
Medical sciences
of homeopathic or herbal remedies.
Between the two world wars, great strides
were made in surgical techniques.
Advances in surgery and the develop-
ment of pharmaceutical drugs combined
to sweep mainstream medicine towards a
more technological approach to health-
care. By the end of the 20th century the
consequences have grown dire.
Deadly reliance on pharmaceuticals
Americans, who are only 4 per cent of
the world’s population, consume about
50 per cent of the world’s pharmaceutical
drugs. A study of US hospital emergency
room visits published in 2006 showed
that 700,000 ER visits annually are due
to interactions or contraindications of
pharmaceuticals. Since most ER admis-
sions are undiagnosed or misdiagnosed,
the authors of the article in JAMA (18
October, 2006) suspect this number is
an underestimation.
Add to the 700,000 visits to ERs,
100,000 deaths annually from phar-
maceuticals. So, every year nearly one
million Americans are killed or seriously
injured due to use of pharmaceuticals,
but you won’t read this in the mainstream
American media. The public’s health has
become secondary to business interests:
pharmaceutical advertising is a major
revenue source for broadcasters and
print media since 1998, and American
media are almost entirely owned by
conglomerates.
The loss of other medical models
With American medical education heav-
ily supported by the pharmaceutical
companies and medical students learning
no other forms of treatment but ‘pills
and scalpels’ common sense, non-tech
treatments and traditional treatments
for health are being forgotten.
www.asianhhm.com 23
Medical sciences
At a health conference in September
2008, an executive of the Robert Wood
Johnson Foundation told the 700 in atten-
dance a story of his patient whose stool
tests indicated possible cancerous cells.
He was advised to have a colonoscopy,
but he had limited funds, and Medicare
wouldn’t cover the full cost. Unable to
obtain an estimate of his personal costs
for the test from area hospitals, he chose
instead to buy a much-needed furnace for
his home instead of getting the test.
Apparently the MDs couldn’t recom-
mend any other courses of action, other
than a colonoscopy and chemotherapy, so
the patient died of colon cancer within
two years.
Health practitioners trained in
natural, non-tech treatments (as well as
educated consumers / patients) would
have advised the above patient to do a
colon cleanse. Herbal colon cleansing
has been known to flush out cancerous
cells. In any case, the outcome couldn’t
have been worse than that from the AMA
route, which was death.
The price of technological
health solutions
The cost of medical testing points to
another major reason to keep one’s
perspective on use of technology—esca-
lating costs. In 2003, US spending per
capita was US$ 5,635, two-and-a-half
times the median for other industrialised
nations (the OECD members). As a per
centage of the gross domestic product,
the US spends nearly twice the expen-
ditures of other nations (15 per cent vs.
8 per cent).
With all these expenditures, up to 60
million Americans do not have enough
or no health coverage at all or during
the year. These were the figures before
the financial crisis which is putting
millions more out of work, and health
insurance in the US is tied to employ-
ment. Over 80 per cent of Americans
told the Commonwealth Fund in 2008
that the US healthcare system needs a
major overhaul, and two-thirds of the
population has problems in paying
24 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Integrate techno-model with traditional medicine
The great majority of Americans know only of the techno-model of medicine for three
generations now. Most are ignorant of any other means of taking care of themselves
except chemical medicines, but the expenses and painful outcomes are causing a slow-
stirring revolt.
Asia is fortunate to have several traditions in health treatments that have been
successful for thousands of years. Healthcare in Asia will be most successful if the
traditions of Ayurveda, Chinese medicine, and other tried-and-tested indigenous medi-
cal treatments remain at the forefront in medical care. Technology is best regarded as
a supplement, an aid in diagnosing and treatment but not the centre of healthcare. A
holistic view of the patient should remain at the centre.
Keeping the patients responsible for their own health will improve health outcomes.
Contributing to the diagnosis and jointly making decisions with their doctors aids patients
in their recovery. An actively involved patient is a faster-healing patient. Asia has the
tradition of taking charge of one’s own health. That must not be lost in a technology-
centred health system.
medical bills or they don’t seek medical US by putting more emphasis on devel-
services due to costs. opment of medical specialities than on
primary healthcare.
American model – This Gulf nation is restructuring
Unhealthy outcomes its healthcare system—with legions of
For all this technology and money spent, advisors from Harvard Medical School,
the outcomes of American healthcare are Cleveland Clinic, and Johns Hopkins
so poor that the US is not even ranked University. Dr Roberts told the Gulf
among other industrialised nations. The News, “The UAE is making the same
WHO ranked the US 37th in the last mistakes as the US, listening to (the likes
survey, two notches above Cuba. of ) Harvard and Cleveland Clinic. It’s
Like many US universities, American like a nuclear arms race. Everybody will
medical schools are setting up campuses be trying to top everybody with their
overseas. And the American medical insti- special this and special that.”
tutions are leading their foreign clients The warning regarding medical
right down the same path that has put specialisation is part of the technology
US healthcare where it is now—no longer domain. Primary care or family medi-
ranking among industrialised nations. cine physicians are trained to consider
The World Organization of Family the whole person. I have compared the
Doctors met in Dubai in February 2008. medical specialists to blind men trying
Dr Richard Roberts, a Wisconsin physi- to describe an elephant—they can only
cian and president-elect of the organisa- ‘see’ that area that is their speciality and
tion, told the Gulf News that the UAE have no comprehension on how the whole
risks making the same mistakes as the system works.
Beverly A Jensen is the founder of www.WomensMedicineBowl.com.
A u t h o r
She has worked as a communications strategist and program
manager in development projects in Africa, the Middle East and
Eastern Europe since 1993. Currently she teaches strategic
communication and health promotion in the UAE.
ISS Ue - 18 20 09

Contrast
Echocardiography
Current indications
Contrast agents have been
shown to be useful to
improve the image quality
in echocardiography.
The development of new
ultrasound contrast agents
and imaging techniques
has enabled the bedside
assessment of myocardial
function and perfusion.
Robert Olszewski
Consultant Cardiologist
Military Medical Instytut Warsaw, Poland
Harald Becher
Professor
Cardiac Ultrasound
Oxford University, UK
F
or almost 40 years, Cardiac ultra-
sound has been demonstrated to
be a promising diagnostic tool to
evaluate patients with pericardial, valvular
heart disease and patients with ischemic
heart disease. However, inadequate endo-
cardial visualisation occurs in up to 20
per cent of cases during echocardiogra-
phy and it fails to produce diagnostically
useful images. Contrast agents have been
shown to be useful to improve the image
quality (endocardial definition) in 2D
and 3D echocardiography. This problem
is even greater in patients referred for
stress echocardiography when subjective
assessment of regional wall motion is
dependent on the quality of the images
recorded. In stress echocardiography opti-
mal endocardial border delineation is
needed in all segments. Images are worse
during stress because of cardiac move-
ment and also hyperventilation. Although
image quality has been improved with
the introduction of harmonic imaging,
the quality of many studies still remains
inadequate. To improve the quality of
images, millions of contrast agent appli-
cations have already been given to the
patients since 90s.
Available contrast agents in
echocardiography
At present, three contrast agents
are licensed for left ventricular (LV)
opacification and endocardial defini-
tion: SonoVue (Bracco Diagnostics
Inc, US), Luminity (Lantheus Medical
Imaging; trade name Definity in US) and
Optison (GE Healthcare, US). The latter
Medical sciences
is currently not available. All these agents
provide intensive opacification of the
left heart chambers when administered
intravenously. Although infusions are
preferred for assessment of myocardial
perfusion, bolus injections of agents
may be satisfactory for left ventricular
opacification in many cases. All agents
are suspensions of microsheres filled with
a perfluorocarbon gas and have a similar
size as red blood cells. The dosages of
contrast needed for LV opacification are
minimal (0.1-0.3 ml) compared to those
in other imaging modalities, such as X-
ray for instance. These small dosages are
possible because of very sensitive contrast
specific imaging technologies, which have
been implemented in all state-of-the-art
ultrasound systems.
Assessment of myocardial
opacification – An integral part of
contrast echocardiography
Ultrasound contrast agents have been
licensed for improvement of endocardial
border definition by left ventricular opaci-
fication. But left ventricular opacification
is inevitably associated with myocardial
opacification—in particular when the
newer contrast specific imaging modali-
ties are used. Assessment of myocardial
opacification provides very important
information on top of the evaluation
of the wall motion. Questionable find-
ings of wall motion can be clarified by
assessing left ventricular opacification
and vice versa.
Homogeneous myocardial and quick
opacification of the myocardial vessels
www.asianhhm.com 25
Medical sciences
after LV ventricular opacification indicate
normal myocardial perfusion and provide
further confirmation of a normal wall
motion study. This is particularly help-
ful in stress echocardiography. Reduced
opacification in the subendocardial layers
usually indicates reduced perfusion and
is often easier and earlier to appreciate
than a new wall motion abnormality. For
rest echocardiography, the assessment
of myocardial opacification is also very
helpful. In an akinetic segment, lack of
myocardial opacification indicates viabil-
ity. Thrombi can be distinguished from
tumours due its lack of opacification.
Contrast application is only useful,
if it alters patient management
The threshold for ultrasound examina-
tions is usually very low and the results
of the examinations do not always affect
the patient management. Considering the
extra time, additional costs and small risk
of intolerance, contrast echocardiogra-
phy needs a more disciplined approach.
There are a lot of patients, in whom
echocardiographic images are not opti-
mal due to factors such as obesity, lung
disease, recent thoracic surgery or posi-
tive-pressure ventilation. Nevertheless,
echocardiography still gives the correct
answers to the clinical questions.
According to the guidelines of the
American Society of Echocardiography,
there is an indication for contrast
echocardiography when the endocar-
dial border definition in two or more
segments is poor. In some patients
poor visualisation of two myocardial
segments may change management,
in others Stress examinations present
altogether different situation. For this
kind of examination, image quality is
crucial; suboptimal images of the LV
cannot be accepted.
The complexity of protocol and the
risks of ischaemia can only be justified
if the test is diagnostic. Therefore, high
image quality is vital. In these patients,
contrast administration is of great impor-
tance in delineating the endocardial
border in all segments, thus changing the
26 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
way patient is managed. These consid-
erations are reflected in the most recent
published guidelines of European Society
of Cardiology (ESC), British Society
of Echocardiography (BSE) and the
American Society of Echocardiography
(ASE) for the clinical application of stress
echocardiography. Therefore, the use of
contrast agents is highest in stress echo
departments—at the John Radcliffe
hospital about 60 per cent of all stress
echocardiograms are performed with
contrast.
In the rest, contrast echocardiogra-
phy is useful when minor changes of LV
volumes and ejection fraction change
management. Many studies have demon-
strated that contrast-enhanced assessment
of LV volumes and LV ejection fraction
compares favourably with the accepted
gold standard of cardiac magnetic reso-
nance imaging. Monitoring of LV func-
tion during treatment with cardiotoxic
drugs like Herceptin is a good example
for the need of accurate assessment of LV
function. In patients with poor acoustic
windows, the reproducibility of contrast-
enhanced studies is comparable to MRI
recordings.
Safety of contrast
echocardiography
For ultrasound, side effects have been
reported in contrast agents, but they
are usually mild. However, rare allergic,
potentially life-threatening reactions may
occur and the investigators have to be
prepared for such an event.
In April 2008, the US Food and Drug
Administration (FDA) performed a safety
review of the US approved perflutren
microsphere contrast agents (Definity
and Optison) and revised a previous black
box warning. The new contraindications
are much less restrictive than the previous
contraindications and satisfy the needs
of clinical echocardiography.
The FDA revised the benefit / risk
assessment for patients with unstable
conditions and acknowledged that some
of the fatal events may be coincidental
and not related to the contrast media.
ISS Ue - 18 20 09
Only four fatal events with Definity
occurred within 30 minutes after the
application of contrast in a total of 2
million vials used.
But even if we assume that all four
cases are related to the ultrasound
contrast agent, the fatal event rate would
be only one in 500,000 for Definity
and zero for Optison. This rate is far
less than the fatal event rate in exercise
and Dobutamine stress echocardiogra-
phy. Meanwhile, several studies were
conducted on more than 20,000 patients
demonstrating the safety of ultrasound
contrast agents during stress echocar-
diography and myocardial perfusion
imaging using the flash-replenishment
technique.
Available
imaging techniques
Harmonic imaging has been developed
primarily as a contrast specific imaging
modality that can be used with a transmit
power (mechanical index <0.6) lower
than that used for non-contrast imaging
(mechanical index >1.0). Harmonic imag-
ing has become the standard imaging tech-
nique for native echocardiography. For clini-
cal contrast echocardiographic studies, the
contrast specific imaging modalities should
be used (see next paragraph). Harmonic
imaging may be used only if they are not
available. In order to use it for contrast
studies one has to reduce the transmit
power. However, the transmit power is

Data collected during Post-Marketing
Surveillance referred to more than
200,000 of SonoVue vials used, indi-
cate that serious adverse events (SAE)
are rare (0.01 per cent). The signs and
symptoms of most of these SAEs indi-
cate an underlying allergy-like mecha-
nism and they were considered by the
European Medicines Agency (EMEA) in
the context of idiosyncratic, hypersen-
sitivity reactions. This kind of reactions
(allergy-like) is well known from wide
reports in literature to occur with other
medical imaging agents such as X ray
or MRI contrast media.
Risk / benefit considerations
Assessment of risk / benefit means to
Improved endocardial delineation
following SonoVue infusion:
4, 2 chamber (top left and right),
short axis view and multiple
plane view bottom right and 3D
reconstruction left, obtained from
a native real-time contrast 3D
dataset. The stress recordings
show perfusion defects (arrows).
Notice the excellent delineation of
the endocardial borders.
still relatively high and can cause destruc-
tion of the contrast in the near field of the
transducer as well as tissue signals of the
myocardium, which impair the delineation
of the endocardium.
Latest developments, such as Power
Modulation and Power Pulse Inversion,
which use very low non-destructive trans-
mit power techniques (mechanical index
<0.2), allow for real-time imaging without
the limitations of harmonic imaging. As
tissue returns are not displayed, unlike with
high powered techniques, they are ideal
for accurately delineating the left ventricu-
lar borders. Low power-contrast specific
techniques display the contrast within the
cavities and the myocardial blood within
the intra-myocardial vessels. The blood
compare the risks of the procedure—here
contrast echocardiography—with the
risks of an incorrect diagnosis when not
using the contrast agent. If, for instance,
a new wall motion abnormality is not
detected in stress echocardiogram because
the wall is not adequately imaged, the
diagnosis may be inaccurate and subse-
quent management of the patient may
be wrong. Although it appears to be very
convincing that patients with a missed
diagnosis of coronary artery disease have
an unfavourable outcome, there is only
limited data to quantify the extent to
which this might happen.
It appears to be easier to assess the
risk / benefit when we consider false
positive studies. Usually coronary angi-
Figure 1
volume within the myocardial vessels
makes up only 7 per cent of the myocardial
tissue. Therefore, the myocardial opacifi-
cation is always much less intensive than
the cavity opacification and provides an
excellent contrast for endocardial delinea-
tion (Figure 1). The myocardial contrast is
also very useful for assessing thickening of
the myocardium and myocardial perfusion.
Whenever available, low power contrast
specific imaging techniques should be the
first choice. These contrast specific imag-
ing modalities are available in all state-of-
the-art ultrasound machines.
The settings of the ultrasound scanners and
the contrast dosages are well standardised
and make contrast echocardiography an
easy to use technique.
Medical sciences
ography is requested in the case of a false
positive stress echocardiogram. This will
expose the patient to significant radiation
and there is a procedural risk, which
certainly exceeds the risk of an adverse
event when using an ultrasound contrast
agent.
Therefore, it is very important to
take a decision whether to continue in a
study, which has suboptimal images or do
other kind of choice considering all the
possibilities in the context of ensuring to
the patient the most adequate medical
treatment. Even when the risk of serious
adverse events is very low, there should
be a clear benefit from the application
of the contrast agent to justify its use. In
patients undergoing stress echocardiogra-
phy, the benefit of using a contrast agent
certainly overweighs the small risks—in
particular when the current contraindi-
cations are not ignored.
Contrast echo closes the gap between
native echo and cardiac MRI in patients
with poor acoustic windows.
Comparison with other imaging
technologies
There are three aspects, when different
imaging technologies are compared: the
accuracy, the risk / benefit and the costs
/ effectiveness (Table 1). Cardiac MRI,
CT and nuclear methods are known to
be considerably more expensive than
contrast echocardiography. Several
multicentre, and numerous single centre
trials as well as series of case reports have
demonstrated the accuracy of contrast
echocardiography for assessment of LV
volumes and ejection fraction (overview
in 6) . The reproducibility of contrast
enhanced echocardiography is as good
as that of MRI. For assessment of global
and regional LV function, controlled
large trials are conducted on a large
number of patients. The accuracy of
stress echocardiography is not worse
compared to myocardial scintigraphy.
Multi-slice CT is a new technology and
a better option to display the coronary
arteries compared to myocardial ischemia.
There is an ongoing debate whether
www.asianhhm.com 27
Medical sciences
non-invasive coronary angiography is
really providing the best information
for the patient management. But there
is consensus that functional assessment
of coronary stenoses with a stress tests
cannot be given up.
Contrast echocardiography could
hardly be advocated if there is an imag-
ing technology for the same indication
with similar accuracy but a better risk /
benefit ratio. There are immediate risks
in using contrast agents during MRI,
CT and SPECT examinations and long-
term risks from the radiation by SPECT
and cardiac CT. The latter may become
important, if repeated examinations are
necessary. For single test, however, the
incidence of side effects appears to be
very low for all imaging technologies.
Therefore, it is difficult to establish a
significant superiority of one method
over another concerning safety.
Echocardiography is the method of choice for
repetitive cardiac imaging
In many patients the clinical course
requires several appointments for cardiac
imaging. Radiation dosages become an
issue in patients, who need coronary
angiography and coronary interventions.
This has to be taken into account, when
the patients need functional imaging.
MRI and echocardiography should rather
be used instead of nuclear methods.
Contrast application can close the gap
between MRI and echocardiography in
those patients with suboptimal images.
Moreover, contrast echocardiography
remains a very cost-effective test and
can be easily integrated into the work-
flow of an outpatient appointment of
the treatment on a ward.
Cost-effectiveness of contrast
echocardiography
Cost-effectiveness of contrast echocar-
diography has been demonstrated
in patients with difficult acoustic
windows.
Appropriate use of contrast for image
enhancement is cost-effective because it
substantially improves the image quality
(and helps to avoid false-positive and
28 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Indications for contrast echocardiography –
Suboptimal image quality of native recordings
Clinical question Competing imaging method
LV volumes Cardiac MRI, blood pool scintigraphy, cardiac CT
LV ejection fraction Cardiac MRI, blood pool scintigraphy, cardiac CT
LV masses/thrombi Cardiac MRI, cardiac CT
LV hypertrophy Cardiac MRI, cardiac CT
Regional LV function (rest) Cardiac MRI, gated SPECT
Regional LV function (stress) Severity of CAD SPECT, stress MRI, cardiac CT
Viable myocardium PET, Cardiac MRI, gated SPECT
Aortic stenosis-severity TEE, cardiac MRI, cardiac CT
CAD = coronary artery disease, CT = computed tomography, LV = left ventricle, MRI = magnetic resonance
imaging, SPECT = single photon emission computed tomography, TEE = transesophageal echocardiography,
PET = Positron Emission Tomography
Table 1
negative findings) and favourably impacts cost and has the potential of additional
the practice of performing additional cost savings through the elimination of
tests for the same clinical indication. further diagnostic tests.
Thanigaraj et. al. estimated savings of TTE is frequently used in patients
US$ 238.00 / patient undergoing contrast who are in ICU to assess LV function.
enhanced stress echocardiography when However, if TTE is not possible (or diag-
baseline images are suboptimal. nostic) in these patients a time-consum-
This raises the question whether ing and expensive TEE is usually needed.
contrast agents should be used in all Yong et. al. demonstrated that the use
patients referred for stress echocardiog- of contrast in technically very difficult
raphy. However, the use of contrast in all studies improves visualisation of the
patients who were analysed with a model ventricular endocardium and increases
based on previously published patient the accuracy of interpretation of regional
outcomes was not cost-effective. and global LV function. Contrast echo
Tardif et. al. demonstrated that was cost-effective compared to TEE
contrast echocardiography has a simi- in determining regional and global
lar success rate compared to nuclear ventricular function, with a cost saving of
perfusion imaging in diagnosis CAD, but 3 per cent and 17 per cent, (US$ 43 and
has a 28 per cent (~US$ 170 Can) lower US$ 423) respectively.
Robert Olszewski is a Consultant Cardiologist at Military Medical
Instytut Warsaw, and Honorary Trust Doctor at the John Radcliffe
Hospital in Oxford. His research has involved the development of
echocardiographic phantoms and techniques such as Doppler
A u t h o r s
Tissue Imaging, stress and contrast echocardiography and tissue
specle tracking.
Harald Becher is Professor of Cardiac Ultrasound at Oxford
University and consultant cardiologist at the John Radcliffe Hospital
Oxford, UK. He is member of writing committee of the American
Society of Echocardiography for “A Consensus Statement on the
Use of Ultrasonic Contrast in Echocardiography 2008”.
ISS Ue - 18 20 09
www.asianhhm.com 29
Surgical speciality
Heart Valve
Surgeries
Innovations and
new developments
Operation through a smaller incision makes
valve surgery easier on the patient. Because
of improved durability, more tissue valves are
implanted compared to mechanical valves. The
latest development is percutaneous replacement
of aortic valves and repair of mitral valves.
Timothy J Gardner
Medical Director
Christiana Care’s Center for Heart & Vascular Health, USA
S
urgery directed at valvular heart
conditions dates back almost 80
years when the first efforts were
made to relieve mitral valve stenosis.
Rheumatic fever was a common disease
worldwide and frequently resulted in
mitral stenosis. The scarred two-leaflet
mitral valve appeared to be an easy target
for simple division of the fused valve leaf-
lets along the closure plane of the valve.
A few daring attempts by brave surgical
pioneers to open the obstructed valve
while the heart was beating and pump-
ing blood throughout the body almost
always ended in failure and the death of
the patient. But occasional by such mitral
commissurotomy was successful and, as
predicted, when the obstruction to blood
flow through the valve was relieved, heart
function improved considerably.
Arrival of the heart-lung machine
Despite those rare attempts at direct valve
repair, it was not until the heart-lung
30 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
pump with a blood oxygenator became
available that heart valve surgery became
widely practised. In the early 1960s, ‘open
heart’ surgery became feasible and rela-
tively safe with the development of cardi-
opulmonary bypass. Surgeons continued
to treat the still common condition of
mitral stenosis, including many who
persisted in using ‘closed heart’ approaches
to performing mitral commissurotomy.
The major attention in the early days of
open heart surgery, however, was directed
to the aortic valve which required that
the patient be on full cardiopulmonary
bypass support in order to work in a
bloodless field.
The development of heart valve
prostheses
The other requirement for successful
treatment of a diseased or deformed
aortic valve was a valve substitute, or
prosthesis, that could be used to replace
the diseased native valve. Heart valve
ISS Ue - 18 20 09
prostheses, both mechanical and those
fashioned from biological material and
usually derived from pig or cow heart
tissue, have undergone multiple itera-
tions over the 50 years of heart valve
replacement. Currently available heart
valve prostheses represent excellent refine-
ments of earlier devices, but there have
been few major innovations in design or
manufacture of heart valve prostheses over
the past 20 years. Current innovations
in heart valve surgery have been directed
more toward refinements to the operative
approaches and technical aspects of valve
surgery itself.
Repair, don’t replace,
a leaking mitral valve
Today’s heart valve surgical innovators
are a relatively small group of heart
surgeons, representing, perhaps, fewer
than 20 per cent of practising cardiac
surgeons. Although heart valve surgery
and surgery for the treatment of congenital

heart defects were the most commonly
performed procedures during the first two
decades of open heart surgery, coronary
artery bypass surgery has dominated the
field since the late 1970s. Most currently
practising heart surgeons are expert coro-
nary bypass surgeons, but their experience
with heart valve surgery may be quite
limited. This is an especially important
consideration today since the most
important ‘innovation’ in heart valve
surgery over the past two decades has
been the successful evolution of mitral
valve repair surgery for the treatment of
mitral valve insufficiency. In the Western
world, with the dramatic decline in
rheumatic fever, mitral stenosis is much
less common. At the same time, mitral
insufficiency, due either to structural
deterioration of the valve or secondary
to changes in left ventricular geometry
from chronic ischemic heart disease, has
become a common indication for heart
valve surgery.
Structural repair of the leaking
mitral valve whenever possible, rather
than replacement of the valve with an
artificial prosthesis, has been shown to be
decidedly better in virtually all important
respects, with fewer perioperative deaths
and better late outcomes. Some estimate
that as many as 80 per cent of leaking
mitral valves are amenable to successful
repair. Despite compelling outcomes,
and data favouring repair rather than
replacement, fewer than 50 per cent of
patients with mitral valve insufficiency
undergo valve repair, but have mitral valve
replacement instead. This disappointing
statistic has resulted from the fact that
many cardiac surgeons have not mastered
the technical challenges of valve repair.
The clear advantage of mitral repair over
replacement with either a mechanical or
biological prosthesis has been established
by multiple surgical series, making repair
rather than replacement mandatory when-
ever feasible. Since many practising cardiac
surgeons are not comfortable attempting
mitral valve repair, the referring physi-
cian should select for referral of a patient
with mitral valve insufficiency only to a
surgeon who is capable of and willing
to repair the incompetent mitral valve
whenever anatomically feasible.
Minimally invasive or limited
incision heart operations
The other important innovation in heart
valve surgery over the past decade has been
the successful development of alternate,
and often less invasive, surgical incisions
for valve repair or replacement surgery.
The standard and most common incisional
approach used by heart surgeons over
many years is the median sternotomy
incision. This operative approach entails a
midline incision from the base of the neck
to the upper abdominal wall, exposing
the sternum which is then completely
divided using a bone saw. For most
cardiac surgical procedures performed
on cardiopulmonary bypass, full expo-
sure of the heart and great vessels within
the pericardium and adjacent mediasti-
num facilitates the necessary operative
manoeuvres, provides the surgeon with
full exposure of the heart to deal with
any unexpected problems, and is in fact
necessary to allow for full exposure of
the posterior or inferior aspects of the
heart. Some negative physiological conse-
quences of a full sternotomy incision,
especially when combined with entry
into one or both pleural spaces, include
respiratory insufficiency, increased post-
Technical innovations in
handling diseased valves
Preferential repair of a leaking mitral
valve instead of replacement with a
prosthesis
Valve-sparing replacement of a dilated
or dissecting aneurysm of the ascending
aorta instead of replacement
Routine repair of a leaking tricuspid
valve rather than valve replacement with
a prosthesis
Repair of selected leaking tricuspid
and bicuspid aortic valves instead of
replacement with a prosthesis
Direct-vision commissurotomy of
stenotic mitral valves
Surgical speciality
surgery wound inflammation and greater
blood loss. Patients with these extensive
surgical incisions experience slow recov-
ery and long convalescence. While many
surgeons have eschewed the challenge of
minimally invasive approaches, complain-
ing that smaller incisions restrict their
procedural options and add unnecessary
risk for the patient, operations performed
through smaller incisions generally result
in less discomfort, less blood loss and
corresponding reduction in the need for
transfusion, more rapid recovery and few
wound complications.
The hemi-sternotomy incision
The partial sternotomy approach, some-
times referred to as a hemi-sternotomy
incision, represents an important inno-
vation for heart valve surgery. The most
common application of a hemi-ster-
notomy incision in heart valve surgery
has been the upper partial sternotomy
approach for aortic valve repair or replace-
ment. The sternum is divided from the
suprasternal notch and may be carried
laterally for a short distance into the 3rd
or 4th intercostal space. For an aortic valve
procedure, this ‘J’ incision, as it is often
referred to, may be directed medially to
the left or laterally to the right, depending
upon the patient’s unique anatomy. If the
mitral valve is the target of procedure,
the partial upper sternotomy is generally
carried laterally into the 3rd intercostal
space. Less commonly used is the lower
partial sternotomy incision that some
surgeons have employed for mitral valve
procedures. The primary disadvantage
of the lower partial sternotomy is poor
exposure of and access to the ascending
aorta for cannulation and cross clamp-
ing. If the lower sternotomy approach is
used for a mitral valve procedure, arte-
rial access for cardiopulmonary bypass
is usually obtained via the femoral artery
and the aorta is not cross-clamped. An
additional disadvantage of any hemi-ster-
notomy incision that is carried medially
or laterally into an intercostal space is the
need to sacrifice the internal mammary
artery on that side.
www.asianhhm.com 31
Surgical speciality
Mitral valve surgery through a right
chest wall incision
Although some have used a partial lower
sternotomy incision to expose the mitral
valve for repair or replacement, the more
commonly used ‘less invasive’ incisional
approach for a mitral valve procedure is a
right lateral thoracotomy incision via the
4th intercostal space. Chest wall muscle
sparing and careful rib spreading will
minimise chest wall trauma and gener-
ally will provide for excellent exposure
of the left atrium and mitral valve along
with adequate exposure of the ascending
aorta. Depending on individual anatomic
variations, however, the ascending aorta
Innovative operative approaches
in heart valve surgery
• Greater use of smaller incisions to
expose the valve (“limited incision”
or “minimally invasive” heart valve
surgery)
• Upper or lower “hemi-sternotomy”
approaches for isolated aortic or
mitral valve procedures instead the
traditional full median sternotomy
incision
• Right lateral thoracotomy approach to
the mitral valve
• Increasing use of peripheral
cannulation (femoral or iliac artery,
internal jugular and/or femoral vein)
for cardiopulmonary support when
using a very small chest incision to
expose the targeted area of the heart
• Use of full Port Access approach
for mitral valve repair via a 10cm or
smaller right thoracotomy incision,
including femoral or iliac artery
cannulation and internal jugular
and/or femoral vein cannulation to
establish cardiopulmonary bypass
support, use of a percutaneous
endo-clamp catheter to arrest
the heart, remote and magnified
visualisation of the surgical site, and
use of elongated surgical instruments
including scalpel, scissors, suture
needle driver and knot tying tools,
all of which allow for extra-thoracic
instrumentation of the valve repair.
32 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
may not be accessible for cannulation or
even cross-clamping from right chest inci-
sion. Despite the procedural challenges,
the right thoracotomy approach through a
small incision has been mastered by many
skilled cardiac surgeons and has been
shown to be well tolerated by patients
as well as hastening postoperative conva-
lescence and full recovery.
Another incisional approach that has
been used by some is the right paraster-
nal incision, made over the 2nd to 4th
intercostal spaces. It is necessary to incise
the corresponding costal cartilage tissue
that often resulted in a chest wall defect
and lung herniation. For this reason,
the right parasternal approach has been
largely abandoned. While the upper
partial sternotomy can be reliably used
for exposure of the aortic or mitral valves,
this incision is not suitable if the patient
requires concomitant coronary artery
bypass grafting.
As is the case with mitral valve repair
versus the technically easier mitral valve
replacement option, undertaking an aortic
or mitral valve procedure through a smaller
surgical incision is generally more tech-
nically challenging and may, in fact, be
riskier. When working on the aortic valve
through a partial upper sternotomy, deair-
ing of the left heart chambers may be more
difficult, and accessing a tear or disruption
on the posterior or lateral aspects of the
aorta or adjacent pulmonary artery may
be very difficult. Conversion to a full
sternotomy incision under such circum-
stances may be necessary. The dilemma
that the surgeon faces when pondering a
smaller incision is whether to perform a
procedure that will be easier on the patient
but technically more challenging for the
surgeon. The other important considera-
tion is whether any added risk related to
limited surgical field exposure is worth
the benefit of the smaller incision and
reduced surgical trauma. The referring
physician bears some responsibility for
determining the appropriateness of the
procedure: is surgery indicated and is this
the right time for the patient to undergo
the operation. The referring doctor must
ISS Ue - 18 20 09
Trends and improvements in
heart valve prostheses
• Improved durability of bioprostheses
(tissue valve substitutes), resulting
from improvements in harvest,
preservation and production
techniques
• With improved durability of
bioprostheses, the proportion
of mechanical valve prostheses
implanted is declining compared to
use of bioprostheses
• Availability of multiple mitral valve
annuloplasty rings for varied
anatomical conditions for use in
mitral valve repair
• Recent availability of self-monitoring
devices for prothrombin time
calculation greatly facilitates daily
warfarin dosing for patients with
mechanical heart valve prostheses.
also take into consideration the capability
of the surgical team, especially when the
procedure involves additional technical
challenges related to valve-sparing repairs
and smaller incisions.
Heart valve repair and replacement
performed without surgery
The most important current innova-
tion in heart valve surgery has been the
development of transcatheter techniques
for repair or replacement of heart valves.
Just as has been the case with percutane-
ous transcatheter treatment of coronary
artery disease, catheter delivery of valve
prostheses for valve replacement is now
a reality. In addition, percutaneous cath-
eter techniques have been developed to
reduce mitral valve insufficiency. To treat
aortic valve stenosis, two transcatheter
devices have been implanted successfully
in hundreds of patients with excellent
results in terms of safety and efficacy. Both
are bioprostheses mounted on a balloon
catheter. In the more common approach,
the catheter is threaded into place in the
aortic root retrograde through the aorta
via a trans-femoral or iliac artery inser-
tion site. Alternately, the catheter with
 Surgical speciality

the collapsed valve prosthesis is inserted
through the left ventricular apex into the
aortic root. The balloon is then inflated,
compressing the native aortic valve,
followed by deployment and expansion
of the valve prosthesis snugly into place
in the aortic annulus.
For transcatheter mitral valve repair,
two options have been used successfully
over the past several years. The technique
referred to as transcatheter mitral annu-
loplasty involves insertion of a semi-rigid
device into the coronary sinus directly
adjacent to the posterior aspect of the
mitral valve. With successful sizing of this
annuloplasty device, the dilated posterior
mitral annulus is compressed or shortened
by the device, reducing the dilation of
clip is deployed in such a way as to attach
the central leading edges of both mitral
leaflets. With this technique, a billowing
and incompetent mitral valve is converted
from a single leaking orifice to a more
effectively closing double-orifice valve.
While many patients have been
successfully treated with transcatheter
mitral repair devices or have had transcath-
eter aortic valve replacement, the longterm
durability, especially of the mitral repairs,
remains to be demonstrated. Regardless,
these innovations have been transform-
ing. In the case of transcatheter aortic
valve replacement, many people in need
Timothy J Gardner is a noted heart surgeon and leader in car-
A u t h o r
of relief from progressive aortic stenosis
who may not have tolerated surgical valve
replacement have, and will be, success-
fully treated. As we have experienced with
percutaneous stent therapy for obstructive
coronary artery disease, the availability of
percutaneous techniques for heart valve
disease will greatly increase the number of
those benefitting for heart valve therapy. It
is remarkable to reflect on the progress in
heart valve surgery over the past 80 years.
Who could have predicted the success of
heart valve surgery or the development
of transcatheter heart valve repair and
replacement!

the annulus and rendering the valve more
functional and less insufficient. The other
technique involves apical septal puncture
and placement of a catheter into the left
atrium. Using fluoroscopic and echocar-
diovascular medicine in the US. He is Medical Director of Christiana
Care’s Center for Heart & Vascular Health. He was chief of the Division
of Cardiothoracic Surgery for the University of Pennsylvania Health
System from 1993-2003. He has lectured extensively both nationally
and abroad and he is the author of nearly 200 scientific papers and
has edited or contributed to many texts on cardiac surgery.

diographic imaging of the valve leaflets, a

www.asianhhm.com 33
Diagnostics
MR Diffusion and Perfusion
Can they replace PET?
Functional Magnetic oped in the past years that provide new
resonance imaging tools insights into the physiology of tissues
and the pathophysiology, for example, of
have now become widely tumours. These techniques include MR-
available and allow viewing spectroscopy, perfusion MR imaging,
beyond the morphology of dynamic contrast-enhanced MRI and
physiologic and pathologic diffusion tensor MR.
tissue. Using innovative The provocative question, if these meth-
ods may one day replace PET in oncologi-
sequence design and cal imaging, needs to be discussed.
modern MR contrast media, Today, the combined PET-CT acqui-
most methods can be easily sition is becoming the standard in the
integrated into the standard assessment of focal and systemic cancer.
#MRI protocols and make PET-CT provides a n excellent combi-
nation of morphological and metabolic
a combined assessment in imaging and identifies tumorous lesions
one single exam possible. that are at least 5mm in diameter with
Although MR is still less the uptake of e.g. fluorine-18 FDG.
sensitive than PET imaging, With the use of a combined system one
functional MRI tools has the possibility to locate those lesions
with a high precision. PET-CT, however
end up as a comparator with its limited spatial resolution, fails to
using to some of the detect lesions smaller than 5mm reliably.
assessments, e.g. perfusion Therefore, MRI could perhaps aim to
imaging or diffusion compete by realising its high-resolution
MRI, even the same potential.
Whilst FDG-PET is the standard
modelling strategies of the tracer method in most cancer types,
imaging data are used. alternative tracer methods with a more
specific uptake are investigated and may
Marco Essig allow for a better imaging of anti-tumour
Professor effects involving angiogenesis, apoptosis
Radiology, Department of Radiology
German Cancer Research Center and reporter gene expression.
Germany But if the advocates of both of these
modalities view each other as rivals, how
can they help each other? Instead they
should answer following questions: What
can functional MRI learn from PET and
W
hile in the past, MRI was vice versa? How and when can MRI be
praised mainly for its superb used instead of PET? These questions
anatomic display and tissue can form key for panel discussions for
contrast, a number of advanced, non- the radiological community.
enhanced and contrast-enhanced MR Proton magnetic resonance spectroscopy
imaging techniques have been devel- of Chemical Shift Imaging (CSI) is becom-
34 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09
ing a common clinical tool because it can
add to the diagnostic accuracy of MR
imaging. In neurooncology it has been
shown that MRS, especially if combined
with the later described MR perfusion, is
able to increase the sensitivity and posi-
tive predictive value in the determina-
tion of the glioma grade when compared
with conventional MR imaging. The use
of modern scanner technology further
allows to measure spectroscopic data from
a single voxel. Two or three dimensional
MR spectroscopy (2D or 3D CSI) help to
acquire multiple small voxels which give
better information about the heterogeneity
of a lesion. The voxel information can be
used to calculate metabolite ratios which
can be colour-coded and overlayed on the
anatomic images to better visualise, for
example, hot spots within the tumour.
Follow-up assessment of tumours is
another promising field for MR spec-
troscopy. Increase in size and contrast
enhancement are typical findings in
tumour progression but they also reflect
therapy-induced changes. The same is
true for postoperative changes. Magnetic
Resonance Spectroscopy (MRS) provides,
beside the definition of extent of changes,
the metabolic fingerprint of a lesion which
can be further enhanced by the analysis of
the quantitative ratio of tissue metabolites
such as N-acetylaspartate (NAA), creatine,
choline and lactate.
Perfusion-weighted imaging (PWI) is
a new tool which provides information
about the hemodynamics of anatomic
tissue or lesions and is mainly used in the
assessment of disturbed cerebral hemo-
dynamics, e.g. in stroke MRI. In brain
tumours, the method showed benefits for
three major fields: differential diagnosis,
biopsy planning, and treatment monitor-
ing. MRI can now provide quantitative

information of the underlying pathologi-
cal tissue with the help of PWI. It can
also provide better metabolic informa-
tion about brain tumour biology with
the help of MRS. PWI in neurooncology
is mostly performed on the basis of T2+
weighted dynamic susceptibility contrast-
enhanced (DSC) MR echo-planar imag-
ing approaches. Newer perfusion imaging
approaches, which do not need extrinsic
contrast media application, use the blood
as intrinsic contrast media.
Dynamic Contrast-Enhanced Magnetic
Resonance Imaging (DCE-MRI) describes
the acquisition of serial T1 weighted
images before, during and after the
appearance of extracellular low-molecular
weighted MR contrast media in the tissue.
The resulting signal intensity measure-
ments of the tumour reflect a composite of
tumour perfusion, vessel permeability, and
the extravascular-extracellular space.
DCE-MRI has been used in quite a
large variety of clinical oncologic applica-
tions including body cancer detection (e.g.
The DCE-MRI). It allows to measure the
vascular permeability and its aberrations,
while the microvascular density (MVD)
describes the histopathologically partial
picture of the tissue microvasculature.
Furthermore, MVD is also a heterogene-
ous property of tumours and is limited by
histopathologic sampling and are gener-
ally hotspot values. The measurement of
the tumour microvascularity using the
DCE-MRI method has found to be well
correlated with prognostic factors such
as tumour grading, angiogenic factors,
e.g the vascular endothelial growth factor
expression (VEGF) and with the risk of
recurrence or simple survival outcome
measurements.
Dealing with modern chemotherapeu-
tic approaches, the use of DCE-MRI in
follow-up studies is becoming more and
more important. Since the anti-angiogenic
therapies focus on the measured DCE
parameters, the method may play an
important role as a predictive marker.
Diffusion weighted MRI is used
routinely in the assessment of cerebral
infarction and infectious diseases. Both
diffusion weighted and Diffusion Tensor
Imaging (DTI) also play an important role
in the diagnostic workup and monitoring
of patients with cerebral tumours.
Another promising field is diffusion
weighted imaging in the assessment of
lymph node metastases. DTI is a promis-
ing new methodology which allows insight
into the integrity of tissue of the brain.
Lymph node imaging and prostate cancer
DSC (A) MRI DCE (B) MRI
DSC acquires a series of EPI images after a
bolus injection ofcontrast media and using
the indicator dilution theory for quantification
of blood flowand volume. DCE MRI
acquires a series of GRE images after slow
contrast mediainfusion for quantification of
tumor vascularity and vessel permeability.
Histology proved the presence of low
grade and high grade areas with different
vascularity and molecular vascular profiling
within the same tumor and in good
correlation to the imaging findings.
Figure 1
are good examples in the description of
tumour infiltration potentiality by this
method.
All methods can be integrated in
the treatment monitoring in anti-cancer
therapy. As at initiation, tumours in a
pre-vascular phase are supplied by oxygen
and nutrients that diffuse from pre-exist-
ing normal vessels, ischemia leads to the
secretion of angiogenic factors when the
tumour reaches a critical size. Angiogenic
markers, such as VEGF, are responsible
for the recruitment and maintenance of
Marco Essig is a Professor of Radiology in Heidelberg Medical
A u t h o r
School and Assistant Medical Director in Department of Radiology,
Head of MRI and Neuroradiology, German Cancer Research Center,
Heidelberg, Germany. He was Professor of Radiology, Heidelberg
Medical School.
Diagnostics
tumour vessels, which exhibit increased
blood volume and permeability compared
with normal vessels. MR-based techniques
like dynamic susceptibility weighted
(DSC) MRI or dynamic contrast enhanced
(DCE) MRI can be used to measure the
blood volume, the vascularity, the size of
the vascular space within designated areas,
and the behaviour of contrast within those
vessels. DCE-MRI has been used in a
variety of tumour entities and oncological
applications including cancer detection,
diagnosis, staging and assessment of treat-
ment response. Tumour microvascular
measurements by DCE and DSC-MRI
have been found to correlate with prog-
nostic factors such as tumour grade,
microvessel density (MVD), and vascu-
lar endothelial growth factor expression
(VEGF) and with recurrence and survival
outcomes (Figure 1).
A group of researchers from the
University in Munich are evaluating the
role of perfusion MRI to monitor the
efficacy of anti-angiogenic treatment in
kidney cancer. This type of cancer has been
shown to respond well to anti-angiogenic
drugs. Functional measurements related to
the tumour blood supply should provide
a surrogate marker of whether the treat-
ment strategy is working. This may not
be obvious from measurements of the
tumour size or morphology.
Work to standardise and to quantify
diffusion and perfusion MRI procedures is
just beginning. This will be most essential
if multi-centric trials are to be conducted
to be used for follow-up assessments and
in clinical trials. However, it should be
taken into account that for absolute quan-
tification both diffusion and perfusion
MRI require specifically tuned sequences
and an extensive and time-consuming
post-processing.
www.asianhhm.com 35
 When
the future is
uncertain
and the
going is
tough

Choose very carefully

Hospitals-Management.com is the online platform of choice for
hospitals & healthcare industry decision makers seeking to create
fruitful partnerships and stay abreast of the day-to-day developments
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w w w. h o s p i t a l s - m a n a g e m e n t . c o m
Diagnostics

Cardiac Computed
Tomography
Emerging cardiac devices and technologies

O
Recent studies have ver the last five years, the Prior to the advent of 16 slice scan-
confirmed that non-invasive speed and resolution of muti- ners, it was difficult to evaluate the heart,
slice Computed Tomography much less the coronary arteries, due to
coronary imaging using
(CT) has advanced to the point where the constant motion of the beating heart.
Computed Tomographic it can now be used for accurate cardiac With a 16-slice scan, patients would typi-
Coronary Angiography evaluation. Calcium scoring, a popu- cally have to hold their breath for 25
(CTCA) is exceptionally lar method of cardiac evaluation using to 30 seconds for the entire heart to
accurate and at the same Electron Beam CT technology (EBCT), be imaged. This was difficult for some
has been re-evaluated using spiral CT patients to do, and there was accelera-
time, compared with its
technology, and has been validated for tion of heart rates towards the end of
invasive counterpart, is risk assessment of patients’ long-term the scan. In addition, it was difficult for
faster, cheaper and safer. cardiovascular outcomes and in varied
patient ethnicities. Calcium scoring, a
Jeffrey M Schussler gated non-contrast examination of the
Medical Director heart using cardiac CT, is a quick and
Cardiac Intensive Care Unit safe way of evaluating for the presence of
Baylor University Medical Center, USA
calcified atherosclerotic coronary plaque.
The largest drawback of calcium score
is that while a positive test confirms the
process of atherosclerosis, a negative
score does not completely rule out the LAD
disease. While high calcium scores can
assess general risk of coronary events,
they cannot accurately predict individual
coronary stenosis (Figure 1).
Multislice Computed Tomographic
Coronary Angiography (CTCA), unlike
calcium scoring, allows for the evaluation
Calcium score of a 45 year old
of the soft as well as the calcific plaque asymptomatic man with strong family
within the coronaries. The technique is history of coronary disease. Calcified
similar, but the addition of iodinated plaque (arrow) is demonstrated in the
proximal left anterior descending (LAD).
contrast during the scan, and higher
This amount of plaque in a young man
resolution imaging allows for more places him in the highest per centile risk for
anatomic evaluation of the coronary future cardiac events compared to men of
structures and the surrounding cardiac the same age without detectable plaque.
anatomy (Figure 2). Figure 1

38 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09


the patient to remain movement free for
such a long time.
Sixty-four slice scanners, which were
largely available starting in 2006, allowed
for acquisition of heart scans in only few
seconds, and at higher heart rates than
were previously possible. With the larger
(approximately 4 cm) arrays in 64-slice
scanners, the heart could typically be
scanned in its entirety within five or six
heart beats. This eliminated almost all
of the problems with breath holding,
and there was a much shorter time that
patients needed to remain motionless.
The additional benefit was that a wider
range of heart rates were acceptable for
scanning.
There has been a great deal of publica-
tion on 64-slice scanners with regards to
accuracy of the evaluation of coronary
disease, as well as its utility in evaluating
the larger structures of the heart. The
majority of recent evaluations suggest
that the sensitivity and specificity for
64-slice scanners is exceptionally high,
typically in the 90-95% range. Currently,
most research and clinical trials are being
performed on 64-slice technology, and
the majority of scans being performed
clinically are using this technology.
From a patient’s perspective, having
a CTCA or calcium score is a relatively
simple and painless process. Calcium
scoring is slightly less involved than a
CTCA, since no contrast is used, and no
intravenous access is necessary. ECG leads
are placed on the patient’s chest, and a
2.5 to 3mm thickness scan is performed
through the level of the heart, gated to the
patient’s heart beat. There is no post-imag-
ing recovery time, and the patients are
able to leave immediately. A preliminary
report is often given to the patients before
they are discharged. The final report is
generated only after the review of the
final images by the reading physician.
Images are sent to a workstation for initial
processing by the imaging technologist
and then reviewed by the reading cardi-
ologist or radiologist. For patients, the
total time this process takes, including
paperwork, is less than 30 minutes.
Diagnostics
A 64-slice computed tomographic
For patients receiving a CTCA, cardiac scan in a 50 year old woman
the process is similar. Outpatients are with chest pain and risk factors for
coronary disease.
typically given oral beta blockers two to
three days prior to and on the day of
A
the scan. They are asked not to eat six
A 3D reconstruction
hours prior to scan. Once in the imaging (panel A) demonstrates
suite, an intravenous line is placed in an the coronary arteries
antecubital vein. Telemetry is connected and the larger
to ECG leads which are placed on the structures of the heart.
chest, but as lateral as possible to avoid
interference with the scan. Patients who
have significant renal insufficiency are
typically not candidates for this test,
B
although a mild amount of renal insuf- A maximum intensity
ficiency is not enough to disqualify them. pixel projection (panel
With 64-slice scanners, there is less of an B) highlights areas of
issue related to heart rate, and patients calcific plaque.
with heart rates up to 80 bpm are still
able to be imaged with excellent image
quality. Patients with irregular heart rates
(e.g. atrial fibrillation or a large amount C
of ectopy) are not good candidates for The left anterior
coronary imaging, although it is still descending (panel C)
is free of disease.
feasible to evaluate the larger structures
of the heart.
The CTCA scan itself consists of a
series of pictures including an optional
initial calcium score. A scout scan it D
used to localise the borders of the heart, A close-up of the left
Aa
and then a test bolus (typically 20 cc main and proximal
of contrast material) is used to localise left-sided arteries (panel
D) highlights a small
the left main coronary and estimate the area of non-obstructive
transit time of the contrast from the IV calcification in the ostium
to the coronary arteries. The full bolus of the left main (arrow).
(typically 80 cc of contrast material) is
injected at a rate of 3 to 5 cc / second. E
The patient is asked to hold their breath The left circumflex
(panel E, arrow) is
for the duration of the scan, which lasts free of disease, as
5 to 10 seconds, depending of the area is the right coronary
of the scan. Once the scan is complete, artery (panel F).
the patient is allowed to leave. Images
are sent to the reading workstation, and
the reading physician evaluates the raw
data, reconstructed images, and generates F
a final report. For patients, the process Curved reformatted
(including paperwork) takes less than images (panels C-F)
allow the visualisation
one hour. of the lumen of
In comparison with its invasive individual arteries.
counterpart, CTCA is much safer. The
only risks are related to the contrast
dye, which is potentially toxic to the
This patient was treated with aggressive medical
kidneys, and the theoretical risk of the
therapy, as no flow limiting disease was seen. No
invasive angiogram was indicated.
Figure 2
www.asianhhm.com 39
Diagnostics
A coronaries is mostly done to the patients
B invasive angiogram it is deemed overly
C of evaluation is currently not being
Invasive cardiac catheterisation
(panel A), 3D reconstruction
(Panel B) and axial image (Panel
C) of a patient with a single
coronary artery arising from the
right coronary cusp. The left main
(arrow) is noted to be traversing
between the aorta and pulmonary
artery, which has been associated
with sudden cardiac death.
Figure 3
dose of ionising radiation. For patients
with normal renal function, the contrast
load is very safe. Only about 100 to 120
cc of contrast is given during a typical
cardiac CT. The radiation is variable,
but typically ranges from 10 to 16 mSv
for a gated study.
The application for multislice cardiac
CT generally falls into two categories:
Evaluation of the coronaries and eval-
uation of the non-coronary cardiac
40 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
structures (Table 1). The evaluation of
who suffer from chest pain and have a
low to moderate risk of flow limiting
coronary disease. It is always better to
send patient for an invasive angiogram
if there is a very high pre-test probability
of significant coronary disease. Many
patients sent for CTCA have had a prior
stress test which was thought equivocal
or negative, but in patients who had an
aggressive. In this subset of patients,
CTCA can define those patients in whom
it is unnecessary to proceed with further
testing.
In high-risk asymptomatic patients,
there is still potential use for CT to iden-
tify patients who have very premature
or sub-clinical atherosclerosis. This type
reimbursed by insurance companies,
and is often paid for by patients out-
of-pocket.
Coronary anomalies, while uncom-
mon, are potentially lethal. Certain
subsets of these patients are at high
risk for sudden cardiac death, and so
it is helpful to evaluate the course of
the anomalous arteries (image-anomaly
Figure 3) CTCA is considered the gold
standard for the evaluation of the coro-
nary tree for the presence of anomalous
coronaries. While this is its strongest
indication, these patients represent a
much smaller group than the patients
who are suspected of having flow-limit-
ing coronary disease.
A large group of patients are now
receiving cardiac scans as part of the
preoperative evaluation for electrophysi-
ology procedures such as pulmonary vein
ablations for atrial fibrillation (Figure
4). In our centre, as with many others,
this is becoming the standard of care
prior to this type of invasive treatment.
A growing number of patients in whom
re-operative coronary artery bypass is
being contemplated are receiving CTCA
to evaluate patency and location of grafts
(both readily determined utilising CT)
prior to repeat median sternotomy. Some
ISS Ue - 18 20 09
patients are now receiving CTCA instead
of invasive angiography prior to non-
coronary cardiac surgery in whom the
pre-test probability of disease is relatively
low. The most significant change from
16 to 64-slice scanners was the reduction
of acquisition time, while the resolution
of the scans was essentially unchanged.
Beta blockers, which are less necessary
with 64-slice scanners, are still typically
used as they improve the overall image
quality and allow for larger radiation
dose modulation.
Recently, there has been an increase
in the awareness of the potential dangers
of radiation, and in particular those theo-
retical dangers associated with ionising
radiation from the increase in utilisa-
tion of computed tomography. While
the dosage of CTCA is higher than that
of a typical invasive angiogram, the one-
time dosage of a CTCA is negligible in
the total impact of clinical incidence
of cancer.
Current Indications for Cardiac
Computed Tomography
• Chest pain in patients with moderate
risk for flow limiting coronary disease
• Chest pain in patients with equivocal
stress testing
• Coronary anomalies
• Cardiac evaluation prior to pulmonary
vein ablation
• Post coronary bypass evaluation of
graft patency
Possible Future Indications for Cardiac
Computed Tomography
• Screening for early presence of
asymptomatic coronary disease
• Pre-operative coronary evaluation for
non-coronary cardiac surgery
• Pre-operative coronary evaluation for
coronary bypass
• Pre-operative coronary evaluation for
non-cardiac surgery
• Post-PCI evaluation of coronary stent
patency
Table 1
 Diagnostics

There have been advances in reduc- A B C

LPV LSPV RSPV
ing the amount of radiation by reducing
the amount of peak radiation during
those parts of the cardiac cycle which is
less useful to image (e.g. systole). Dose
modulation has been available for several LAA
years, but the most recent generation of
software and hardware allows a signifi- LIPV LAA
RPV RIPV
cant dosage reduction.
New hardwares have focussed on two
areas: array size and spatial resolution.
Internal view (panel A) and external views (panels B and C) of the left atrium of a patient prior to
Several companies have produced scan-
pulmonary vein ablation for atrial fibrillation. The ostiae of the left sided pulmonary veins (LPV)
ners with larger physical arrays, which as well as the left atrial appendage (LAA) and right sided pulmonary veins (RPV) are clearly
can theoretically image the heart in a seen (panel A). This type of imaging facilitates the operator’s choice of catheters, as well as
single heart beat. Some of the early litera- allows planning for ablative procedures. External views allow for the determination of the number
and location of the pulmonary veins. LSPV – left superior pulmonary vein. LIPV – left inferior
ture suggests that utilising a higher-slice
pulmonary vein. RIPV – right inferior pulmonary vein. RSPV – right superior pulmonary vein. LAA
scanner would allow for faster acquisi- – left atrial appendage.
tion and reduction of additional dose Figure 4

and gathering more data in less time.

There is almost no clinical data out on
the 320-slice version of these scanners
and at present, only a handful of clinical
sites are in operation. It is likely that
with the quicker acquisition times, it
will be easier to scan patients whose
heart rates are higher, and possible that
patients with irregular heart rhythms
may be imaged more successfully.
Other companies have focussed on
improving detector quality and resolu-
tion, keeping the physical size of their
detectors unchanged. These efforts will
further improve the evaluation of plaque
distribution, lumen size, and their poten-
tial ability to determine ‘at risk’ or ‘unsta-
ble’ plaque characteristics. For example,
arterial collaterals, which have previously
been too small to define, are potentially
visible through this technology.
With these evolutionary advances in
technology, there will be expansion of
applications which will be seen in the
coming years. One of the areas which
may benefit immensely from this tech-
nology is the emergency department.
Recent studies have shown that chest
Calcium scoring may be supplanted
by CTCA once technology to reduce
overall radiation dosage is adopted. It
is not too farfetched to foresee a time
when an ‘at-risk’ individual will receive
a screening CTCA at age 40, much in
the way that certain individuals receive
a screening colonoscopy.
Once the resolution of CTCA
approaches that of invasive heart cath-
eterisation (approximately 0.2 mm), there
may be far fewer diagnostic procedures
performed. Besides preoperative scans
performed in patients with low-risk for
flow limiting coronary disease, it may
become feasible to scan individuals who
are high-risk for left main and multivessel
disease, sending them to coronary bypass
without having an invasive catheterisa-
tion. It will also be more feasible to
visualise post-stent patients to evaluate
for in-stent restenosis. If this becomes
the norm, there may be shift in training
programmes away from producing ‘inva-
Jeffrey M Schussler is the Medical Director of the Cardiovascular
ICU, one of the assistant Fellowship Directors for the Cardiovascular
A u t h o r
sive’ cardiologist who do not perform
interventions. Resource utilisation may
change, with a greater focus on outpa-
tient diagnostic imaging with a larger
percentage of patients being referred
directly for intervention or surgery.
Overall, the future of cardiac
computed tomography looks bright.
There is a strong advocacy for the adop-
tion of this technology. Active train-
ing programmes are being conducted
throughout the world, with the first
board certification in 2008. The tech-
nology is proven even in its infancy,
and appears to be here to stay. Cardiac
computed tomography, which has
advanced quickly in only a few years,
stands poised for more evolutionary leaps
over the next decade, as it is incorpo-
rated into our cardiovascular treatment
algorithms.
References are available at
http://www.asianhhm.com/magazine

pain triage is feasible and potentially Disease Fellowship, and is the Vice-Chair of the Institutional Review
cost-reducing in the emergency setting. Board at Baylor University Medical Center . Schussler’s research and
It is notable that several hurdles (includ- publications have involved both invasive and noninvasive coronary
angiography and the use of multi-slice CT for cardiac imaging. He
ing rigorous patient selection) need to has written chapters for several current textbooks on CT cardiac
be addressed before this technology is imaging.
utilised in a wider clinical setting.

www.asianhhm.com 41
Diagnostics

The Innovator’s Prescription

How Asia can disrupt the global healthcare

Asian innovators have ties in access to care and in the ability
the opportunity to design of patients to afford it.
systems and services Asian systems are facing similar pres-
sures. As developing nations become more
that are profitable and urban and affluent, patients will inevita-
sustainable, yet affordable bly transition from sporadic reliance on
and accessible to everyone. local healthcare providers to a model of
As they do so, they can healthcare consumption that attempts to
make major contributions to mirror the systems found in developed
countries. Industry players will be increas-
solve the global healthcare ingly tempted to compete by developing
crisis by collaborating with cutting-edge, centralised and high-cost
colleagues in other regions infrastructure. However, the outcome of
to adapt and export those this model in western systems suggests
new models of care. that this impulse should be questioned,
and, concerted effort should be made to
avoid the traps in which those systems
Alexandra Leichtman
Manager
now find themselves. Improved healthcare
Jason Hwang
should not come at the expense of creating
Senior Strategist innovative, convenient, low-cost models
Healthcare Practice that are accessible to everyone.
Clayton M Christensen Based on 20 years of research at the
Co-founder Harvard Business School as well as field
Innosight LLC, USA work designing and deploying innova-
tions, we have observed the transformation
of industry after industry when compli-
cated, expensive products and services are
replaced by affordable, accessible alter-
are familiar, particularly in developing
economies that face the natural challenge
of serving low- and rising-income consum-
ers. Healthcare is an industry ripe for
disruption worldwide, and it is possible
that Asia will lead a wave of disruption
there as well.
A more comprehensive discussion of
disruptive innovation in healthcare can
be found in The Innovator’s Prescription:
A Disruptive Solution for Health Care
(available January 1, 2009) and at the
book’s website.
Enabling technology
Technological enablers in healthcare often
take the form of innovations that precisely
diagnose the underlying causes of patients’
conditions. They replace the historical
process of trial-and-error treatment of
symptoms followed by post-hoc diagno-
sis. Precision medicine involves applying
therapies that are predictably effective
for precisely-diagnosed diseases, and this
rules-based work can be standardised to
facilitate treatment by a wider range of
caregivers and in a wider range of settings
than previously possible. This transition

T
oday’s healthcare systems are in a
critical state of distress in nearly
every nation around the world.
In developing countries, the prevailing
model equates to adequate care for
the wealthy and little for the masses.
Nationalised, single-payer models like
the systems in the UK and Canada face
long waiting lists and spiralling costs.
The notoriously dysfunctional US system
combines the follies of each: escalating
costs that threaten to swamp public
payers and employers, together with
impending workforce shortages in
critical areas—fostering both inequali-
natives. This agent of transformation,
disruptive innovation, has a rich history
of success in Asia. Cellular telephony
catapulted Southeast Asian countries
past stages of expensive infrastructure
development. The advent of compact and
inexpensive automobiles, first in Japan
and more recently in India and China,
has upended the global auto industry.
Consumer products targeting the bottom
of the pyramid have found early traction
in Asian markets. Indeed, innovations in
Asia have often presaged transformations
in the US and Europe. In Asian markets,
themes of affordability and accessibility
enables broader access and reduces over-
all system costs in two ways: Procedures
can migrate from specialists to generalist
physicians, nurses, family members and
patients themselves. Additionally, the site
of care can shift to local hospitals, outpa-
tient clinics, offices, and retail locations.
Avoiding the use of centralised hospitals
populated by highly-trained specialists
eliminate major drivers of healthcare
costs.
Singapore’s Economic Development
Board, via its healthcare venture capital
arm Bio*One Capital, has a good grasp
of the concept of technological enablers,

42 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09

www.asianhhm.com 43
Diagnostics

investing in a portfolio of disruptive ultimately shrink in the long run, the same specialised services. The fee-for-service
companies. Building upon the Singapore model can be applied to serve remote or model is appropriate for these problems
government’s investments in medical sparsely-populated communities. With the and is likely to persist in dedicated solu-
research, Bio*One formed Dx Assays, a advent of simple, low-cost, portable imag- tion shops.
joint venture with a European biotech ers and the increasing video capabilities VAP businesses, by contrast, focus
firm. The focus is developing molecular of general telecommunications tools like on transforming incomplete or broken
diagnostic assays to facilitate cost-effec- mobile phones, the telemedicine model things into higher-value outputs. For unre-
tive drug development by identifying may allow health systems in developing fined crude oil, the treatment process to
appropriate candidates for trials based economies to provide widely-accessible transform it into petrol is consistent and
on genetic factors and precise disease diag- quality care without the 30-40 year cycle known. Therefore, the petroleum refining
nosis. On the treatment side, Bio*One of infrastructure development. business conforms to the VAP model.
has also funded ventures aimed at expand- Many medical procedures are likewise
ing access through accurate, simple to Business model innovations suitable for VAP hospitals and clinics,
deploy therapies that would preclude The US and European healthcare systems which take a narrowly-defined slice of
intervention by a professional. One port- have been particularly resistant to business customers with similar needs and apply
folio company, ReVance Therapeutics, is model innovations, with strong inertia due standardised, efficient care—often at a
exploring novel technologies to deliver to entrenched fee-for-service accounting fraction of the cost of a solution shop or
large active molecules through the skin. and payment models and a century-old conflated model. Aravind Eye Hospital
One lead application in clinical trials focus on hospital- and physician-directed in India, a pioneer in the VAP hospital
is delivery of botulinum toxin type A, delivery. The result has been a system in movement, is now the world’s largest and
which, in addition to cosmetic appli- which healthcare providers are economi- most productive eye care facility. From the
cations, can be used to treat a variety cally incentivised to create or inflate outset, Aravind’s founders were committed
of muscular disorders, regulate certain demand for their services. to providing free eye care for the poor,
glandular functions, and possibly treat Generically, there are three distinct creating a powerful incentive to develop
very common conditions like prostate business models: solution shops, value- innovative low-cost treatment models.
hyperplasia and migraines. The technology adding process (VAP) businesses and facili- By some measures, Aravind is more than
also shows promise for delivering insulin, tated networks. In healthcare, these are five times as productive as the average
antibody-derived therapies and non-ster- often conflated in a single organisation, ophthalmologic hospital in India.
oidal anti-inflammatory drugs. creating a complex, confused institution Expanding their reach beyond their
Telecommunications, too, has an that is unable to accurately allocate costs local markets, VAP hospitals like Aravind
important role to play in enabling and drive efficiency and productivity. can serve as models for the emerging trend
healthcare disruptions. Remote care Segregating these business models through of medical tourism. While some early
networks in Asia have been entrusted the creation of single-purpose institutions entrants in medical tourism have simply
with outsourced diagnostic work for is the most promising avenue to increased re-created the high-cost model of solution
years. Using state-of-the-art telecom- access and affordability. shop general hospitals, the savings based
munications technology, Teleradiology Solution shops, like the general hospi- on wage and cost differentials alone are
Solutions, a Mumbai-based radiology tals that excel at diagnosing and solving not a durable advantage. Innovative busi-
services provider, leverages wage and time- unstructured problems, will necessarily ness models like Aravind have a greater
zone differentials to allow hospitals in the have high-cost business models, and the chance of remaining relevant even as wages
US and Singapore to better meet growing payment systems they employ should rise, because unlike solution shops, VAP
demand. Though wage disparities may compensate them sufficiently for their businesses present a more attractive value
proposition by charging fixed prices for
their outcomes—often guaranteeing the
The mechanism of disruptive innovation
results. Because of this output orientation,
VAP hospitals can significantly reduce
• Enabling technologies that simplify and routinise formerly complex and unstructured processes
(e.g. precise diagnostic technologies, telecommunications)
the total system costs.
A final model, facilitated networks,
• Business model innovations that allow companies to profitably deliver affordable, accessible holds promise for treating chronic illnesses
solutions to consumers (e.g. targeted and efficient providers, facilitated user networks)
requiring behaviour changes, coordinating
• Value networks of companies that have mutually compatible economic models which together the response of caregivers and patients to
provide the underlying commercial infrastructure (e.g. drug and device suppliers aligned with
integrated payer-providers and a health information system).
disease outbreaks, and filling persistent
infrastructure and logistical gaps in the

44 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09

 Diagnostics

challenges of delivering comprehensive,

Value networks accessible and affordable healthcare.
However, many are not yet encum-
The final element of disruptive innovation, value networks, is often the most difficult in indus- bered by the legacy cost structures and
tries like healthcare in which system participants have evolved to develop mutually-incompat- patient expectations that impede inno-
ible economic incentives. As a result, the commercial infrastructure is resistant to change, even
when it optimises overall outcomes, and the system remains deadlocked. One model for untying vation elsewhere. The patterns we have
this Gordian Knot is integrating the payer, provider, and physician models as some nationalised seen in healthcare and other industries
systems have done. Though Singapore has focussed considerable effort in this direction, the suggest that innovation paths need not
model may not be widely replicable as it requires significant control and alignment of multiple be linear or predetermined. Emulating
stakeholders.
the established healthcare models already
In the absence of government-controlled reform, innovative businesses should explore
models for creating integrated systems of their own. In the US, Kaiser Permanente created a
found elsewhere will guarantee that Asian
system in which it owns hospitals, employs doctors, and provides services to consumers for a systems will always remain behind. But
fixed annual fee. Aravind, the Indian eye hospital, has also had success integrating critical parts the central message of disruption is that
of its commercial infrastructure. Given its volume of eye patients, Aravind was able to set up a innovations can come from unexpected
manufacturing facility to produce intraocular lenses of comparable quality to imports at less than
15 per cent of the cost. Its value network has also evolved to include facilities to train and house
and counterintuitive sources.
doctors and nurses, ensuring a supply of quality practitioners. By experimenting with new healthcare
models, Asian innovators have the oppor-
tunity to design systems and services that
medical landscape. Examples of facilitated SMS messaging to sign up donors, post are profitable and sustainable, yet afford-
networks in healthcare include communi- requests, and coordinate donations. Using able and accessible to everyone. As they do
ties targeted to specific chronic conditions Rs 2 lakh of his own money and with- so, they can make major contributions to
like dLife.com, which focusses on Type out the assistance of the government or solve the global healthcare crisis by collab-
1 and 2 diabetics, whose daily healthcare NGOs, Kushroo Pocha has created the orating with colleagues in other regions
questions and needs cannot be conven- largest blood donor database in India. to adapt and export those new models of
iently, efficiently, and profitably served Networks like these can help accom- care. Meanwhile, developed economies
by traditional healthcare providers. plish the same individual and public health in Asia can foster innovation by funding
Facilitated networks played an outcomes that formerly required constant and facilitating technologies and business
important role in containing the 2003 reliance on skilled health workers or the models that enable the rehabilitation of
SARS outbreak in China. ESRI China, a building of high-cost infrastructure and their healthcare systems. With deliberate
geographical information software firm, organisational capacity. management and foresight, Asian health-
created the SARS Mapping Website care systems can pioneer innovations that
that used data from government health Conclusion: The last shall be first? not only serve their populations, but also
authorities to produce accurate maps of Asian systems at every stage of devel- provide the models the rest of the world
affected areas that even included details opment are being confronted by the is so desperately seeking.
about specific buildings. Public health
officials, health workers, the media and
individual citizens could get up-to-date Alexandra Leichtman is a Manager at Innosight LLC, an innovation
and strategy consulting firm in Watertown, Massachusetts, USA.
reports on suspected, actual, and recovered
cases to inform their activities. The same
model could easily be adapted to create
an effective H5N1 influenza surveillance
and response network.
A u t h o r s

Jason Hwang is Senior Strategist for the Healthcare Practice

Facilitated networks have also helped at Innosight LLC; Executive Director of Healthcare at Innosight
Institute, a non-profit social innovation think tank in Watertown,
coordinate blood donations in India, Massachusetts, USA; and the author of The Innovator’s Prescription:
which faces chronic blood shortages. In A Disruptive Solution for Healthcare.
the absence of comprehensive munici-
pal or national blood banks, the burden Clayton M Christensen is the Robert and Jane Cizik Professor of
of finding lifesaving units of blood Business Administration at Harvard Business School and co-founder
often falls to the patient or his family. of Innosight LLC and Innosight Institute. He is the bestselling author
of six books, including The Innovator’s Prescription: A Disruptive
Indianblooddonors.com is a network Solution for Healthcare.
that connects patients and potential
blood donors using the Internet and

www.asianhhm.com 45
Technology, Equipment & Devices
Orthopedic Medical Devices
Emerging technologies and trends
Scope and Segmentation
Research is looking beyond using implants,
screws, metallic cages, to incorporating
biologic bone substitutes with regenerative
potential to address orthopedic conditions.
For example, Medtronic Sofamor Danek of
Memphis licensed the growth factor rhBMP-2
developed by Wyeth and this powerful bone
stimulant has been coupled with their LT-
CAGE Lumbar Tapered Fusion Device.
However, A biologic substitute can be
any material that dynamically alters and
affects the surrounding environment to
proceed in an active biological manner,
which manifests as cellular activity, growth,
and differentiation. For instance, orthopedic
surgery required surgeons to use biocom-
patible specifically designed metal implants
to structurally support a fractured bone or in
some cases to fuse bones in spinal condi-
tions. Now surgeons are looking towards a
biologic component incorporated with the
metal implant so that the latter serves to
regenerate living bone tissue while the metal
implant functions in a structural manner. Defi-
nitely, the next stages of technology develop-
ment would reduce the amount of metal in
implants and use biodegradable scaffolds for
the structural function.
An ideal biologic bone substitute is
required to have either or all of the follow-
ing--osteogenic, osteoconductive, and oste-
oinductive properties. Steady progress in
biologic material sciences assures that the
future treatment of injury and tissue loss will
be altered and more biologically correct.
The objective of this research service
is to analyse and report new and emerging
orthopedic biologic substitutes; advances in
research and development (R&D) and prod-
uct development in the orthopedics arena.
The research service plans to identify key
players (with contact information)--those in
the forefront of technology development and
commercialisation pertinent to this market
and end-user information. The scope has
been sketched to include bone substitutes or
biologics that fill voids, support and enhance
the repair of biological defects.
46 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
The first chapter gives an introduction to
orthopedics, followed by an overview of the
technology developments observed in ortho-
pedics till date. The scope and segmentation
of the study and the methodology adopted for
it are also discussed here.
A technology primer of the different kind
of biologic substitutes--allografts, demineral-
ized bone matrix (DBM), synthetics, factors
and stem cells are discussed in the second
chapter. A heads-up of the trends in the
orthopedics industry and important clinical
trials has also been included under relevant
headings.
Developments in technology, products,
and research studies in orthopedic biologic
substitutes that have osteogenic, osteocon-
ductive and osteoinductive potential consti-
tute the third chapter. Challenges faced by
the industry participants, and the drivers to
the biologics industry are discussed under
relevant heads in the fourth chapter. This
chapter also comprises an analysis of the
impact of the biologic substitutes (allografts/
DBM, synthetics and factors/cells) on differ-
ent orthopedic applications.
The factors include funding, partnerships,
intellectual property (IP) portfolio, regulatory
impact, biocompatibility, and scalability.
Patents and the contact details of
company officials and university faculty
members who have participated in the study
are listed in the fifth chapter. (Patents are
listed by area and contacts are listed sepa-
rately for companies and universities).
Decision support database tables form
the sixth chapter of this study. Frost & Sulli-
van’s healthcare decision support database
service offers a valuable collection of tables
that provide historic and forecast data for
medical devices.
Methodology
To provide a thorough analysis of each topic,
Technical Insights’ analysts perform a review
of patents to become familiar with the major
developers and commercial players and their
processes. Building on the patent search,
the analysts review abstracts to identify key
ISS Ue - 18 20 09
Industry
report
Frost & Sullivan
scientific and technical papers that provide
insights into key industry participants and the
technical processes on which they work.
The analysts then create a detailed ques-
tionnaire with content created to address the
research objectives of the study, which func-
tions as a guide during the interview process.
While the analysts use structured question-
naires to guarantee coverage of all the desired
issues, they also conduct interviews in a
conversational style. This approach results
in a more thorough exchange of views with
the respondents, and offers greater insight
into the relevant issues than more structured
interviews may provide.
The analysts conduct primary research
with the key industry participants and tech-
nology developers to obtain the required
content. Interviews are completed with
sources located throughout the world, in
universities, national laboratories, govern-
mental and regulatory bodies, trade associa-
tions, and enduser companies, among other
key organisations.
Our analysts contact the major commer-
cial players to find out about the advantages
and disadvantages of processes, and the
drivers and challenges behind technologies
and applications. Our analysts talk to the
principal developers, researchers, engineers,
business developers, analysts, strategic
planners, and marketing experts, among
other professionals.
The project management and research
team reviews and analyses the research data
that are gathered and adds its recommenda-
tions to the draft of the final study. Having
conducted both published studies and
custom proprietary research covering many
types of new and emerging technology activi-
ties as well as worldwide industry analysis,
the management and research team adds
its perspective and experience to provide an
accurate, timely analysis.
The analysts then prepare written final
reports for each project and sometimes
present key findings in analyst briefings to
clients.
www.asianhhm.com 47
 In and Out of the
Emergency Room
Streamlined design of patient flow
Many factors influence
T
he Emergency Department (ED)
the patient throughput in has become the ‘Front Door’ to
the hospital. Many institutions
and out of the Emergency report that 50 per cent or more of their
Department. Clarity in admissions come through the ED. Yet in
layout and simplicity many hospitals the flow to and through
in operations are keys the ED is fraught with bottlenecks, with
to streamlined flow. confusing and conflicting messages circu-
lating to and within the ED. Hospitals
with only one or poorly placed dual
James W Harrell
Design Leader
entrances experience the chaos of co-
Healthcare Group mingling of self-arriving patients with
GBBN Architects, USA those coming in emergency vehicles.
Many EDs have poorly conceived first
encounter systems. For instance, triage
stations that are too small or too few
result in patients lining up to be seen,
in effect, diluting or even negating the
concept of priority screening. Or, queu-
ing can also build up if distinct patient
registration stations are adjacent to the
waiting room. Poorly designed treatment
areas inhibit efficient clinical operations.
48 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09
There are many examples of layouts that
require excessive walking to fetch supplies,
to get patients to an x-ray room, or to
simply manage the patient record. These
conditions lead to delays in treatment and
increased length of stay within the depart-
ment, which in turn lead to the build-
up of stress in patients and staff alike.
Poor and inefficient patient throughput
results in costly, error-prone operations
and patient dissatisfaction.
Arrival
There are two ways to come to the
ED. Most of us envision going to the
‘Emergency Room (ER)’ as that dramatic,
frenetic trip we see depicted in movies and
on television in an ambulance with the
siren blaring. The by far more common
occurrence is to be brought by family,
friends or come alone. We distinguish
these two arrivals as ambulance and
ambulatory or self-arrival.

Initially, the ‘ER’ had but one entry.
The ambulance arrivals and the ambu-
latory patients alike came in this way.
Of course, as the hospital’s emergency
services grew, more and more people
began to access the service and this
entry became highly congested, chaotic
and, quite simply, unsafe. Fundamental
change in the layout of the ED began to
manifest separate entrances for the two
types of traffic. These entrances were
generally side-by-side, and indeed, many
instances of this arrangement are in use
today. Having these in close proximity,
however, still creates an opportunity
for confusion and uncertainty for the
self-arrival patient as to which is the
correct place. The optimal layout is to
have distinct pathways for the ambu-
lance apart from the ambulatory. This
separation should begin at the arrival to
the campus and continue to each entry.
Ideally, the ambulance entrance should
be located so as not to be in sight from
those coming to the ambulatory entry.
Signage and directions to the Emergency
Facilities & operations management
Department should point only to the
Ambulatory Entrance—ambulance driv-
ers and emergency medical technicians
are familiar with the route and don’t
require such directions. This arrange-
ment eliminates the need for the self-
arriving patient to make choices regard-
ing which entry may be correct.
The Ambulatory Entrance should
be unmistakably obvious and have a
system to shelter arriving patients from
the elements. Doorways should have
hands-free operation and a supply of
wheelchairs should be readily acces-
sible. There should be someone from
the hospital available at this point to
assist the patient into the hospital. This
is often done by security personnel.
Electronic health record
The advent and utilisation of the elec-
tronic health record brings a significant
opportunity to streamline and improve
patient flow. When a ‘paper’ chart is
used, the patient record must remain
in close proximity to the unit clerk,
who manages the upkeep of the record.
Since doctors, nurses and ancillary care-
givers must access this same, unique,
singular set of documents, there are
frequent occasions when the location of
the chart is difficult to determine and
much time is wasted by care-givers look-
ing for it. The electronic record allows
data to be entered anywhere within the
unit, especially at the patient bedside.
Multiple, simultaneous access permits
faster entry and retrieval of data from
within the unit and from remote diag-
nostic services such as the lab.
Strategic supply placement
An axiom of the workplace holds that
worker efficiency has direct relationship
with the placement and availability of
supplies. The same holds true in the
healthcare environment, especially in
the ED, where patient throughput is
impacted by the nurses’ ability to get
needed supplies at the bedside. It is
clear that if much walking is required
to fetch supplies from centralised
www.asianhhm.com 49
Facilities & operations management

Traditional intake flow First encounter

Patient Patient Patient Patient Immediately upon arrival, the ambulatory patient must be

Registrar
acknowledged and given the opportunity to state his problem.
Greeter

Triage

Bed
This is done by a non-clinical “greeter” who conducts ‘quick reg’
(registration)—a basic set of identifiers to register the patient into
the hospital’s record system. This should take but a few minutes.
When beds are available, the patient is placed immediately therein.
High impact intake flow The registration process can be completed at the bedside.
Patient Patient
But, what to do when the beds are all full? After the quick reg,
Quick reg

Registrar
Bed the patient is given an initial assessment by a clinician—generally
a nurse in a triage station. This triage will determine the severity
of the patient’s condition and allow the emergency personnel to
establish the priority to provide care. The patient, and in many
cases with family members or escorts, is then shown to an ‘inner
Contemporary emergency department waiting area’ in the treatment zone. The patients can be watched
and reprioritised, thereby getting the right patients into a bed more
Ambulatory Entrance quickly. The traditional concept of a main waiting room is altered.
Distributed Imaging Since patients and some family members are waiting within the
treatment areas, the main waiting room can be much smaller, as
Ambulance it will be serving family and visitors who shouldn’t be or prefer not
Entrance to be accompanying the patient.
To improve patient flow, a scheme for treating patients with
low-risk problems such as sprains and lacerations should be
Low acuity Inner waiting developed. This notion of a ‘fast-track’ should be incorporated
"fast track" Acute care within the context of the total treatment area. All beds should be
Critcal care capable of severing any acuity level. The fast track patients can
Inner waiting be clustered in one area of the overall department not isolated in
a discreet or separate unit. This will permit flexibility in assigning
patients to rooms based upon the variation in volumes throughout
Swing spaces Inner waiting Distributed the day.
Imaging
Ambulance patients have a different track into the ED. The
Acute care condition of these patients is generally communicated to the
Distributed
Imaging
ED by the ambulance personnel—paramedics or emergency
medicine technicians. Their arrival is then anticipated and care
protocol can be promptly implemented. However, there are occa-
sions when multiple arrivals occur at essentially the same time.
When this happens, a triage of these incoming patients becomes
necessary. In high-volume EDs, especially trauma centres, plan-
ning for an ambulance triage station will afford appropriate space
to handle this traffic.

Figure 1

clean supply and utility rooms, more which includes items like procedure Diagnostics
time will elapse in the patient visit. trays, IV fluids, assorted catheters etc., Getting diagnostic information in a
Moreover, evidence now shows that is essential to this concept. These items timely manner has significant impact
when nurses spend a lot of time walking, must be located within just a few steps upon patient flow through the ED. A
this can result in increased stress and from the patient bedside. An often used high per centage of patients require x-
concomitantly decreased effectiveness configuration is to have the second rays. Sending the patient to the Radiology
in direct patient care. When supplies tier supply in carts or cabinets at the Department has become too onerous in
are decentralised and evenly distributed perimeter of the nurse and doctor terms of time—transport time, queuing in
throughout the department, walking work area that is in the centre of an the department, waiting for a radiologist’s
distances are reduced and access time array of exam rooms or patient care reading and so on. The quest to improve
is improved. A three-tier supply system stations. A central storage room, the patient throughput has resulted in plac-
has proven to be highly successful in third tier supply system, is located on ing medical imaging within the ED. The
supporting improved throughput. The the unit out of the area of direct care. volume of patients seen in the department
first tier system includes items common This is where infrequently used items will, of course, determine the number
to each bedside, alcohol wipes, blood and backup supplies for Tier 1 and of radiographic devices required, but in
draw tubes etc. The second tier system, Tier 2 are kept. high volume EDs, multiple devices can be

50 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09

www.asianhhm.com 51
Facilities & operations management

Supply system configuration

expected. As in the case of decentralised
supplies, the same benefit of improved Tier 1
throughput will accrue from decentrali- Supplies
sation of diagnostic tools, especially if @ bedside
digital radiographic devices are used.
Since digital medical imaging is filmless,
multiple devices need not be clustered
for operational efficiency. Placing a DR
in proximity to the ‘fast-track’ zone will
greatly increase turnaround time for image
acquisition and result in quicker diag-
noses. A second DR can then be placed
conveniently to serve the more acute
patient. Placing a CT scanner adjacent
to trauma bays saves critical time in deal-
ing with life-threatening situations.
Tier 2 Nurse / Physician
Supplies in close proximity work area Figure 1
Discharge process
After medical clearance by the emergency
medicine physician, the patient and his occupy space that could be used to treat The disposition of inpatient beds is a
family / escort is either given discharge the next incoming patient and in effect complex issue, but it is imperative that
instructions and is released to leave the reduce the number of beds available to do the hospital be committed to a policy
hospital or is admitted to the hospital. so. Just a few unexpected ‘boarders’ can of timely bed availability for those in
If the patient is admitted, several steps choke an organised flow through the ED. need.
must be taken to place the patient in a
bed. The timeliness of moving the patient
out of the ED and into this bed will James W Harrell has over 40 years of experience in planning,
A u t h o r

design and construction of healthcare facilities. His interest in

greatly affect the overall patient flow in the improving the environments in which healthcare is provided has led
department. If location and assignment him to be involved at the national level in the development of design
of beds is slowed or beds can’t be found, standards for adult critical care units, newborn intensive care units
and women’s healthcare environments.
these admitted patients become ‘board-
ers’ in the ED. Boarded patients then

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52 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09

 IT continues to evolve in an industry characterised
by slow adaptation and other challenges that vary
from country to another. Asian countries would have
to transform their systems so as to integrate with
the rest of the world. In this scenario, e-Health and
the Internet seem to be the way forward.

www.asianhhm.com 53
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IT

Ready for
A s i a

Transformation What are your views on Asian healthcare

Pradeep chowbey
Chairman
Minimal Access, Metabolic and Bariatric
Surgery Centre, Sir Ganga Ram Hospital
India
In your experience, how has IT helped
improve patient care, what are your
expectations from it in the coming
years?
Yes, healthcare IT has definitely helped
us in improving patient care. It provides
us with complete and accurate history,
timely alert, medical knowledge to
patient and doctors, communica-
tions with other points of care, greater
ease and speed of recovery of patient
data.
In future there might be:
a) More training provided to health care
providers
b) Development in the field of telemedi-
cine and telesurgery
c) Establishment of e-library where all
the articles can be accessed through
Internet.
Considering that a majority of Asian
countries are still developing, do you
think Asia is ready for the rapid tech-
nological changes shaping healthcare
globally?
In my opinion Asia is ready for rapid
technological changes happening in
health care globally. More over, in country
like India with such a vast population it
might benefit the most.
How do you see the adoption of PHRs
and EMRs in Asia? Do you think Asian
hospitals are prepared to shift toward
the trend?
Electronic Medical Records (EMR) is
being utilised in various hospitals in
Asia but Personal Health Record (PHR)
system has to go a long way before its
implementation due to its vast popula-
tion size, cost and limited knowledge
in this field to health care provider.
What are the areas of Healthcare
IT that you think need to be further
developed?
Areas in which I think healthcare IT
can be further developed:
a) Personnel heath record system
b) Centralised e-library
c) Better training to healthcare
providers
d)Development of improved and
specialty software for medical data
archiving and retrieval.
e) Uniformity of data recorder to improve
data analysis
IT sector?
The most important issue facing the
healthcare IT sector in Asia is to ensure
that quality of care is achieved through
effective diagnosis, patient compliance
and avoiding medical errors. In addi-
tion, the Asian healthcare IT sector
must improve access to care in remote
communities, or emerging and under-
developed economies, with enough
hospitals and care professionals to
meet healthcare demands.
With an ageing population across
the globe and especially in the Asia
Pacific region, the healthcare sector
will need to focus on reducing patient
care and administrative costs for the
healthcare system.
Thus, it is imperative that healthcare
organisations recognise these issues
and respond with effective processes
and technologies for delivering supe-
rior care. This includes the widespread
adoption of healthcare IT systems to
deliver improvements in the quality and
accessibility of care, while also lower-
ing costs.
As the region is home to more than
half of the world’s population, and with
the Age Wave, (fast forward into the next
15 to 20 years)—there are 3 distinct
markets for Health IT to address:
• The first is Chronic Diseases / Ageing
management (Personal Health
Records / PHR
• The second is Modernizing the Point
of Care (Electronic Medical Records
/ EMR)
• And the third is Population Health and
Bio Surveillance (Electronic Health
Recrods / EHR).
These pose the following threats as well
as opportunities:
• Incredible healthcare demand is
certain
• Healthcare Infrastructure cannot be
built fast enough

54 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09

Learning from the
Global Experience
• The only way out of system failure
is increased efficiency—this can be
achieved through the growth of the
Healthcare Information Technology
adoption.
Do you think Asia is ready to accept
the changes in technology?
Developed countries in Asia are under-
taking national initiatives to develop
national EHR policies, with hospitals
focussing on digital integration and
operational efficiency. These initiatives
are being undertaken with the ultimate
goal of improving productivity and qual-
ity of care, while also helping to reduce
overall healthcare costs.
As for the developing economies in
Asia, they are also working on healthcare
reform and are building their infrastructure
to meet the needs of the new demands
in healthcare. Some of these economies,
such as China, may eventually leap-frog
the rest of the world through the adop-
tion of new technologies.
What is the scenario in Asia?
Different countries in Asia are facing
different challenges and will need to
respond accordingly.
For example, due to their rapidly
ageing populations, countries such
as Australia, Japan and Singapore are
already placing a focus on the ‘silver
industry’, which is potentially one of
the fastest growing markets. In such
countries, PHRs and home-care initia-
tives are part of the national focus to
empower patients to have the same
level of care at home, while bringing
down costs and improving the quality
of care beyond the hospital itself.
A s i a
The scenario for China is slightly
different. The country is likely to leap-
frog the rest of the world in healthcare
IT adoption if they are able to do the
following:
• Learning quickly from the interna-
tional / global experience
• Overcoming the resistance to
change
• Knowing how to manage change
• Developing more expertise in these
areas of need.
Other countries like Malaysia and
Thailand are focussing on Telehealth
and improving primary care by providing
accessibility to remote communities and
building healthcare infrastructure.
How do you see the adoption of PHRs
and EMRs in Asia? Do you think Asian
hospitals are self sufficient to shift
Steven Yeo
toward the trend? Vice President and Executive Director
EMRs and PHRs are still at a very early HIMSS Asia Pacific, Singapore
stage of adoption both globally as well
as in Asia.
Asian hospitals can learn from
international HCO experiences through to measure Access to Care, Workflow
successful EMR implementation. They Optimisation, Employee Productivity and
will also need to work with national Patient Satisfaction are also important
health authorities on policies and EHR contributing factors to the success of
/EMR plans pertaining to legal, stan- Healthcare IT adoption in a hospital
dards and infrastructure matters. environment.
Events such as HIMSS AsiaPac09,
What are the areas of Healthcare IT happening from 24–27 February 09 in
in which do you think improvement is Kuala Lumpur, provides health IT stake-
required? holders with a platform to connect and
It depends to a great extent on the goal exchange ideas in order to help advance
and plan of each hospital. Having said quality healthcare delivery through
that, hospitals should focus on manag- the use of IT. It is a place for intensive
ing change, and measure the busi- learning and knowledge exchange and
ness value that Healthcare IT brings networking with leaders from healthcare,
to its operations. Developing KPI(s) government and IT.
w
wwww
w .. aa ss ii aa nn hh hh m
m .. cc oo m
m 55
55
 al
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IT

A s i a

Peter Gross
Senior Vice President and
Chief Medical Officer
Hackensack University
Medical Center, USA

Start
with the
Basics
In your experience, how has IT helped
improve patient care, what are your
expectations from it in the coming
years?
IT when properly implemented in an
orderly fashion should improve patient
safety, facilitate compliance with perfor-
mance measures, reduce costs, and
improve physician and nurse satisfac-
tion with their jobs and their health
care institution.
Considering that a majority of Asian
countries are still developing, do you
think Asia is ready for the rapid tech-
nological changes shaping healthcare
globally?
I think you need to start with the
basics. Automate laboratory and
radiology results reporting, then follow
up with a pharmacy system that helps
manage physician orders. Build in some
clinical decision support to help reduce
errors from medication ordering. Putting
transcripts of history and physical dicta-
tions and those of operative notes
online could come next. Add electronic
signatures. Nursing documentation and
the electronic medical administration
record can follow. This approach is
reviewed in Gross and Bates. JAMIA
2007;14:25-28.
How do you see the adoption of PHRs
and EMRs in Asia? Do you think Asian
hospitals are prepared to shift toward
the trend?
PHRs and EMRs are inevitable to
accomplish what was described in the
first question. They also will be the
basis for a country wide RHIO (Regional
Health Information Organization) or HIE
(Health Information Exchange) which
will permit doctors and patients wher-
ever they are in that country to access
there medical information.
What are the areas of Healthcare IT
that you think need to be further devel-
oped?
Virtually all areas of Healthcare IT need
further development. In fact, they will
be in a state of evolution for a long
time.

56 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09


Sisira Edirippulige
Coordinator
e-Healthcare Programme
Centre for Online Health
University of Queensland
Australia
In your experience, how has IT helped
improve patient care, what are your
expectations from it in the coming
years?
It is not an overstatement that new
information and communication tech-
nologies (ICT) have revolutionised
the way people access information
and communicate with each other.
All spheres of human society have
impacted by these developments.
Undoubtedly, the impact of ICT devel-
opments on health sector and medi-
cine has been significant. However, the
changes prompted by ICT in health care
are limited compared to other areas
such as trade, banking or media. The
influence of ICT can be seen in clinical
practice, administration, education and
research. The use of the Internet by
patients and practitioners to access
health information has tremendously
increased in recent years. The Internet
also has become a powerful media of
Driven by
e-Health
public health and education. Disciplines
such as teleradiology and telepsychiatry
have proven being efficient and cost
effective in delivering care. In general,
a large number of research studies
have shown the effectiveness of tele-
health / telemedicine applications in
providing improved care, particularly
to communities otherwise are deprived
of such services. These include rural
and remote communities and popula-
tions in developing countries. Evidence
suggests that the use of ICT in health,
i.e. e-health / telehealth / telemedi-
cine has a potential to address critical
problems in the health sector. There is
a growing awareness in health profes-
sionals, policy makers and business
communities that ICT has a major role
to play in health sector. These factors
will facilitate the use of e-health in the
future.
Considering that a majority of Asian
countries are still developing, do you
think Asia is ready for the rapid tech-
nological changes shaping healthcare
globally?
The irony is that despite its limited
use, e-health is better suited to
address critical problems in devel-
oping countries. e-Health can be
helpful to support limited (and often
isolated) health professionals by provid-
ing better education, information and
AUS T RA L IA
peer-support. E-health can also provide
alternative ways of care delivery to
meet needs of patients. But the main
problem in developing countries has
been the lack necessary infrastructure,
funding and expertise to establish and
sustain e-health. This is true with a
substantial number of countries in Asia
which fall into the category of develop-
ing countries. The level of ICT use in
the health sector of these countries is
limited. The barriers mentioned above
will prevent these countries benefiting
from this new tool.
Another reason for slow progress
in e-health in Asia can be the magni-
tude of health problems themselves.
Countries like India and China—world’s
most populous countries—have enor-
mous challenges in terms of health
care provision. Restructuring health
systems in these countries is an enor-
mous task. However, the good news
is that the rapid economic growth and
the technological development have
already begun to re-shape the health
sector in these countries.
Meanwhile, it is worth mentioning
that there are some good examples
in Asia where progress in e-health
has been substantial. South Korea,
Singapore, and Taiwan, for example,
have been able to use modern tech-
nological developments to advance
their health systems.
www.asianhhm.com 57
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scenario in australia
The level of success in e-health in Australia, like in many other coun-
tries has been mixed. There have been some success stories in imple-
mentation and sustained use of e-health while others have shown
disappointing results. In general, there is a rapid increase in the use of
computers and the Internet within health care sector. A recent survey
revealed that 94 per cent of GPs nationwide are computerised, 90 per
cent GPs use clinical software packages and nearly 80 per cent use
broadband connection. The growth of ICT use can be seen in both
public and private health sectors.
As mentioned, the use of e-health in Australia is patchy. There
are number of different research projects underway to investigate the
effectiveness of ICT use in improving health care provision. Some
e-health projects are initiated and funded by federal and state govern-
ments while others by business partners. However, the majority of
these initiatives are run as research projects, but few have been inte-
grated to mainstream care provision.
One key feature of the current state of e-health in Australia is a
clear lack of coordination. This is probably due to the absence of an
authorised body to oversee and coordinate e-health activities. It is
expected that the National e-Helath Transition Authority (NEHTA)—
nation’s peak e-health body—is to play a key role in Australia’s frag-
mented e-health fabric.
Having said that, a number of e-health projects have shown the
potential to be feasible, cost- effective and sustainable. One good
example is the telepaediatric service managed through the Centre
for Online Health (website http://www.uq.edu.au/coh/) at the Royal
Children’s Hospital in Brisbane which provides services to rural and
remote communities in Queensland. It is estimated that some 15 per
cent of all burns consultations are now done via telehealth.
Attempts are being made to use telehealth applications to improve
the health services in the indigenous communities in Australia. If
successful, these models can be used to in similar contexts in other
parts of the world, particularly in developing countries.
Australian government’s emphasis on expanding broadband
coverage and funding IT education will have an impact on the growth
of e-health. At the same time, Federal Government has also shown
interest in supporting e-health.

How do you see the adoption of PHRs
and EMRs in Asia? Do you think Asian
hospitals are prepared to shift toward
the trend?
Electronic storage and access of
patients’ data has been a topic of
the day in many parts of the world.
Progress in electronic health records in
Asia has been slow due to understand-
able reasons, such as lack of funding,
infrastructure and expertise. Unlike
European Union (EU) or some other
industrialised nations, Asian countries
have not been able to invest heavily
into electronic health records. However,
there are some impressive examples
in Asia; for example to certain extent,
Singapore, Taiwan and South Korea
have made headway in implement-
ing electronic health records. These
examples show the trend in Asia. The
transition from paper based patient
records to electronic health records
has not been an easy and smooth
process even in industrialised coun-
tries. Continuing economic and social
progress along with the technological
advancement are the key for Asia to
achieve this goal.
What are the areas of Healthcare IT
that you think need to be further devel-
oped?
When you look at the global scenario,
you can see that the key emphasis in
ICT use in health has been on adminis-
tration and education. A limited atten-
tion has been put on the use of ICT
in clinical practice. I think it is vital to
explore new ways of using technol-
ogy for clinical practice and for better
clinical outcomes.
It is also important to explore
ways to use low cost technology as
opposed to expensive technologies.
There is some good evidence that
simple and inexpensive technologies
can be effectively used in providing
quality health care. One such example
can be email.
I strongly believe that technology
must NOT be the focus of e-health /
telehealth. While technology is impor-
tant, the primary focus of e-health
must be on the clinical need. Evidence
shows that technology driven prac-
tices are doomed to fail. Technology
must be a tool to address the need.
Therefore, e-health practitioners must
adopt a ‘techno-skeptical approach’
to treat technology as a tool to serve
the purpose.
Any other comments?
I think there is a critical need for a
global governing body for e-health.
Setting up such an organisation with
appropriate legal and regulatory rights
should be a priority. While this peak
body would have authority relating to
e-health across the world, it should also
have the necessary financial capability
to fund its activities.
The importance of e-health educa-
tion has so far been overlooked.
Evidence shows that access to system-
atic education in e-health is limited
in both industrialised and develop-
ing countries. Systematic education
in e-health for health professionals
must be at the heart of the strategy
to promote e-health. It is important
to increase funding for post-graduate
studies in e-health/health informatics.
The accreditation of e-health qualifica-
tions is another way to attract health
professionals and help address the
critical skills shortage.

58 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09

www.asianhhm.com 59
 Wipro Healthcare Offers
Hospital Information System
in the “Pay Per Use” Mode
Offering the Software as a Service(SaaS)
P
atients’ data in hospitals must be timely,
accurate and reliable as it could make the
difference between life and death. The benefits
of Information Technology can effectively address the
challenges faced by healthcare providers.
Wipro HealthCare IT (Wipro HCIT) is a dedicated
Health Informatics Company and is part of Wipro
Ltd ,which is the World’s first CMMi Level 5 certified
software services company and the first outside USA to
receive the IEEE Software Process Award.Wipro HCIT
has a talent pool of over one hundred professionals
with healthcare domain, Information Technology and
management expertise. There are more than 50 satisfied
global healthcare customers who have successfully
implemented the healthcare information systems in
private and government hospitals, clinics, pharmacies
and diagnostic centres.
Wipro has recently launched SaaS model called as
“Pay per use” or the “Utility Computing Model”
of Hospital Information System in India. Especially
designed for medium and small sized hospitals and
clinics who work on very low IT maturity and shy away
from automation.
Software as a service (SaaS, typically pronounced
‘sass’) is a model of software deployment where an
application is hosted as a service provided to customers
across the Internet. By eliminating the need to install and
run the application on the customer’s own computer,
SaaS alleviates the customer’s burden of software
maintenance, ongoing operation, and support. SaaS
has the potential to transform the way information-
technology (IT) departments relate to and even think
about their role as providers of computing services to
the rest of the enterprise.
Simply put, SaaS can be defined as “software
deployed as a hosted service and accessed over
the Internet.”
Today, SaaS applications are expected to take
advantage of the benefits of centralisation through a
single-instance, multi-tenant architecture, and to provide
a feature-rich experience competitive with comparable
on-premise applications.
60 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Key characteristics…
The key characteristics of SaaS software, includes:
• network-based access to, and management of,
commercially available software
• activities that are managed from central locations rather
than at each customer’s site, enabling customers to
access applications remotely via the web
• application delivery that typically is closer to a one-to-
many model (single instance, multi-tenant architecture)
than to a one-to-one model, including architecture,
pricing, partnering, and management characteristics
• centralised feature updating, which obviates the need
for downloadable patches and upgrades
SaaS applications are generally priced on a per-
user basis, sometimes with a relatively small minimum
number of users and often with additional fees for extra
band width and storage.
Managing the Risks of Software Acquisition
In a small hospital or nursing home setup it may-not be
viable to install, run and maintain an application and the
hardware infrastructure by the hospital team. Not only
does it require a substantial commitment of financial
resources , it also requires space , manpower, power,
air-conditioning etc. With this there is always the fear
of the initiative not being successful and hence the risk
of failure. Hence in a smaller setup the management is
looking for a risk free software acquisition where the cost
of sunk investment is low. SaaS is a perfect solution for
this since it is on a monthly rental model with no upfront
investment in either the software or hardware or AMC.
SaaS model of hospital information system doesn’t
require the deployment of a large infrastructure at the
hospital location, which eliminates or drastically reduces
the upfront commitment of resources.
Managing IT Focus
With SaaS, the job of deploying the hospital information
system and keeping it running from day to day—testing
and installing patches, managing upgrades, monitoring
performance, ensuring high availability, and so
forth—is handled by the provider ie Wipro.
ISS Ue - 18 20 09
By transferring the responsibility for these ‘overhead’ Front Office
activities to a third party, the hospital management • Registration
can focus more on high-value activities that • Patient search and information
align with and support the business goals of the • Doctors information
hospital. • Package and tariff information
• Appointment scheduling
Considerations for Embracing SaaS OP Billing
However there are certain considerations when adopting • OPD Consultation billing
the SaaS model. Having a strong internet connectivity • Pathology/Laboratory billing
is an essential as all transactions will happen over the • Radiology and other services billing
internet. Also here the server and data is residing at Admission,Discharge and IP Billing
a third party through it is essential that all data has to • IP admissions
be secure and safe with the provider and for that the • Bed availability information
vendor has to sign all legal non disclosure agreements • Locate patient- bedwise- wardwise
with the hospital. The datacenter has to follow all • Collection of advances
norms of physical and virtual security to ensure that the • IP bill on discharge
data is secure and non accessible by anybody other • Discharge summary
than the hospital itself. Thirdly SaaS model proposes • Cancel discharge
standardization of solution for all hospitals. Hence the Consumption Module
software is fairly standard across all hospitals who use • Service consumption by patients during inpatient stay
the hospital information system and individualization • OT and all procedures tracking
or customization of processes and workflows is not • Equipment utilisation
encouraged in this model. • Medicines
• Automatic updation of bill
What is WIPRO offering in SaaS Laboratory and Pathology and Radiology
A secured datacenter which will host and run your • Billing
software • Result printing
• Complete maintenance and running of the software • Result dispatch tracking
on Wipro’s infrastructure Contract Management and TPAs
• Customer access the software over a remote • Package deal designer
broadband online real-time 24x7 • TPA data management
• Wipro experts will train clients people in using the • Insurance claim and handling TPA patients
software. This will be done onsite. • Tracking payables from TPAs
• Maintenance of hardware, backups, security, bug • Outstandings
fixing, database maintenance and application Reports and MIS
maintenance is Wipro’s responsibility • Analysis on new patient registrations
• There is no capital expenditure from Customers side, • Collection summary daily, department wise, doctor
apart from a monthly fee based on usage. wise
The advantages of offering SaaS to the customers are: • Profitability of each department
1.No upfront investment in hardware or software • Outstanding position and ageing analysis
2.Only monthly rental fee plus one time setup and • Admissions analysis
training fee • Clinical data analysis
3.No investment in IT staff and manpower. No headache Wipro aims to provide software solutions that are well
of retaining them and looking for replacement once thought-out, heavily tested and reasonably priced and,
they leave ensures reliability and consistency in the performace
4.No fear of virus or any other form of security attack of the hospital information system by furnishing it with
5.No challenges of server downtime or breakdowns a comfortable and user-friendly interface, elaborate
6.No worries on data backups documentation, and technical support.
7.No space cost for setting up a server room
9.Monthly recurring cost of air-conditioning the server Bottom Line…
room. You concentrate on running the hospital efficiently

The Product–Modules offered are Wipro will be your partner and take care of your IT and
The modules and functionality are as foll. automation needs.
Advertorial

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IT
In your experience, how has IT helped
improve patient care, what are your
expectations from it in the coming
years?
It was Rudyard Kipling who once
remarked “What do they know of
England, who only England know”. In
the 21st century this aphorism could
be replaced thus “What do they know
of healthcare who only medicine know”.
21st Century is the age of informatics.
Today’s doctor needs to be as well
versed in the basics of Information
Technology as he/she is in anatomy,
physiology and pharmacology No man
is an island unto himself. In the 21st
century the physician or surgeon is
only a member of a multi disciplinary
healthcare team which necessarily must
include experts from various domains.
Information Technology should neces-
sarily be an integral part of any modern
healthcare system. Having been trained
in the BC era (before Computers and
Before Christ are essentially one and
the same!!). It has been my good
fortune, to have witnessed the growth
and development of medical care in
the last 35 years in India including
the gradually increasing use of HIT.
It would be no exaggeration to state
that IT has made, is making and will
62 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
An
Optimistic
Outlook
Krishna Ganapathy
Co-founder
Telemedicine Society of India, India
continue to make a significant differ-
ence in patient care. Whether it be in
the field of diagnosis, investigations,
treatment, documentation, retrieval of
information, access to state of the art
knowledge, medical instrumentation,
teaching, research etc IT has made a
major difference.
IT in healthcare will level the playing
field. It will bridge the gap between the
haves and the have nots. In spite of
the obvious short term and long term
benefits it is a matter of deep concern
that the use of IT in the healthcare
industry is far less than its use in bank-
ing, commerce, travel, automobile or
almost any other industry. Less than 2
per cent of gross revenues are set apart
for deployment of ICT, compared to 5
to 8 per cent in most other industries.
IT improves patient care, by enabling
processes and systems to be intro-
duced and repeatedly monitored.
Standard operating procedures and
audit processes can be introduced in
almost every aspect of healthcare.
Viewing healthcare as an industry
and attempting to achieve a sigma six
though improbable is not impossible.
Using ICT should not be viewed as a
dehumanising process. IT should be
viewed as a tool to achieve an end. Not
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IN D IA
an end by itself. IT has improved patient
care in many, many ways. Providing real
time appropriate relevant information
to every stakeholder in the healthcare
industry makes all the difference. Well
informed patients and doctors can
make a significant differences in the
standard of healthcare. Rapid increase
in computing power is accompanied
by exponential reduction in costs.
Though the healthcare IT market in
India has grown 200—300 per cent
in the last 10 years, it is accepted that
the healthcare sector has to be more
IT-oriented. Studies indicate that the
use of IT in healthcare has enormous
benefits—short term and long term for
all stake holders, for e.g. a patient’s
hospital stay could be reduced by up to
39 per cent with improved use of IT.
Considering that a majority of Asian
countries are still developing, do you
think Asia is ready for the rapid tech-
nological changes shaping healthcare
globally?
A major advantage that developing
countries in Asia have, with regards
to being ready for the rapid techno-
logical changes shaping healthcare
globally, is the fact that they have no
colonial legacy to ‘disinherit’ in the field
 scenario in India
India is indeed a paradox. While we have world-class hospitals of excel-
lence, these are few and far between. They are like oasis in a desert,
confined to the urban elite and the well to do. We are in a position to
offer state of the art healthcare, to those who come to us from other
countries but are unable to do so for the 700 million Indians living in
suburban and rural India. The picture, however, is not totally bleak. It is
reassuring to see that the central government and several state govern-
ments have accepted Telemedicine as a means to provide healthcare.
We are optimistic that the present digital divide in healthcare, existing
between the haves and the have nots, will gradually shrink.
The formation of the Telemedicine Society of India, the Medical
Informatics Society of India, the publishing of several journals
dedicated to e-Health etc. all augur well for the future though we
have a long way to go, but then so do scores of other countries.
The Government of India has launched the Health Management
Information System (HMIS) portal to convert local health data into
real time useful information, management indicators and trends
which could be displayed graphically in reports.
Real time data provided by web-enabled technologies will
strengthen monitoring, enabling policy makers, to make better deci-
sions for public health delivery. Enhancing the information flow at
various levels and providing useful and timely inputs for programme
development and monitoring. And midcourse interventions in poli-
cies would be a direct spin-off. Several multinational companies like
GE Healthcare, Intel, Hewlett Packard, Cisco Systems, Qualcomm,
Microsoft, Google, IBM, Computer Sciences Corporation (CSC),
Perot Systems, TCS, HCL and Satyam, to name a few, have all
entered the health space.
These new healthcare models initiated by the IT companies,
while delivering quality care will explore the possibility of innovative
new technology that are simple to use, cost effective, portable and
power independent. Challenges in integrating IT into the healthcare
system in India are many. They include lack of Standards, lack of
in-house IT expertise, reluctance of medical, nursing and other staff
to change, fear of technology failing (paper systems appeared more
reliable), poor support from vendors, reluctance of vendor to make
changes in software when requested. These can be addressed by
leadership and strong message from the top , ownership by the
departments and long term vision, Health Administration acting as
facilitator and recognising IT as a felt need in health, recognising
champions among the health personnel, customising IT solution
to needs of the users, confidence building, good co-ordination and
communication between vendors and users. Reasons for rela-
tive failure in IT implementation initiatives in Indian hospitals are
many. They include customisation of software used to computerise
manual processes without proper refinement in policies and proce-
dures; lack of proper implementation methodologies (detailed proc-
ess study and refinement strategy). To make the management aware
about time and efforts required for successful computerisation and
not using standard inter operable, scalable software.

of modern healthcare; for example, they
do not have to ‘unwire’ to introduce
mHealth. One does not have to undo to
keep up with technology simply because
e-Health is still not a reality. We do not
have to follow the advanced countries.
We do not have to piggy back. We can
leap frog. The apparent lack of progress
in the field of healthcare during the last
few decades is not a deterrent. It can
actually be viewed as an incentive so far
as introduction of e-Health is concerned.
We may not have achieved ‘health for all
by 2000’ but the target e-health for all by
2020 is not impossible. The exponential
growth in mobile telephony and in ICT
in India clearly shows that we are more
than ready to embrace technology. While
it is a matter of justifiable pride that e-
Governance is slowly being introduced
and that mBanking and mCommerce
has also commenced it is a matter of
deep concern that the use of ICT in
the healthcare industry is considerably
lagging behind.
How do you see the adoption of PHRs
and EMRs in Asia? Do you think Asian
hospitals are prepared to shift toward
the trend?
Universal adoption of Personal Health
Records (PHRs) and Electronic Medical
Records (EMRs) is a challenging and
daunting task even in the most advanced
countries. The very fact that we have
started talking about it in India is itself a
good sign. It was Confucius who once
remarked “a journey of a thousand
miles begins with the first step”. The
concept of Personal Health Records
(PHR) continues to gather steam as
several healthcare and insurance
providers established connectivity with
PHR platforms like Google Health and
Microsoft HealthVault, which allows their
members to access and store personal
health information online. Microsoft also
continued with its strong strategic alli-
ance plans to promote several of its
healthcare offerings. The development
of a common strategy and roadmap
for e-health standards development,
to support interoperability and the
adoption of electronic patient records
is crucial. One of the barriers in the
adoption of international e-health
standards in hospitals, is the priority
given to internal process functionality.
Standardisation of data and processes
across hospitals will go a long way in
enforcing the use of PHR, EMR etc.
A Hospital Information Management
System (HIMS) should essentially inter-
connect all departments of the hospital
seamlessly and attempt to minimise
operations on paper. No doubt it will
take a long, long time before PHRs and
EMRs become a reality in India, but it
will certainly happen.

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What are the areas of Healthcare
IT that you think need to be further
developed?
With the exponential increase in mobile
telephony and the imminent deploy-
ment of 3G, it is imperative that broad
band wireless technology be exploited
and used to develop mHealth. While
mBanking, mCommerce, mEntertain-
ment is becoming a reality we need
to develop mHealth. Pilot studies
carried out by Apollo Telemedicine
Networking Foundation in conjunction
with Erricson in Tamil Nadu, Bhutan
and Bangladesh have shown that
mHealth can be a reality in India. The
number of ‘Hospital on Wheels’ are
very few. This needs to be considerably
increased, with facilities for real time
two way audio video contact with a
tertiary center. Virtual skills laboratories
where a large number of medical and
surgical procedures are simulated on
virtual patients are now a reality in
advanced countries. We need to have
such learning centres. To achieve all
this, IT should be a part of the medical
curriculum. Similarly, Applications of
IT in Healthcare should be taught to
all IT students.
Any other comments?
HIT strategy should be driven broadly
by business, clinical and societal
requirements. Business needs are
around administrative work, finan-
cial and procurement. Clinical and
social needs are quite specific. For
example, patients need to access their
health records, get reminders and be
advised by doctors even when mobile.
Data needs to be captured at source,
whether from doctor’s written/spoken
word or from equipment or even at
patients’ home. On the output end,
portable health information should be
disseminated to patients’ families and
their general physicians.
Many hospitals are committed
to the use of innovative technology.
Apollo Hospitals is working on a proj-
ect with Tata Consultancy Services
that would give each of its patients
a Universal Hospital Identification
Number (UHIN), thereby providing
access to the entire medical records
of the patient. The medical data will

UAE An Innovative
Transformation
John R Hawkins
Director
Information and Technology Services
Abu Dhabi Health Service Company (SEHA), UAE

In your experience, how has IT helped
improve patient care, what are your
expectations from it in the coming
years?
Health Information Technologies are
streamlining patient care and provid-
ing data to foster improved and
faster clinical decision making. The
SEHA ecosystem is implementing an
Electronic Medical Record which will
be seamless across 14 hospitals and
65 clinics. Patient Data will be acces-
sible throughout our ecosystem which
will drive efficiencies and reduce dupli-
cate procedures. I expect that HIT will
continue to drive efficiencies at the
clinical level, and that researchers will
begin to drive population based disease
management initiatives which will drive
continuous healthcare improvements
for the citizens of Abu Dhabi. Last, I
expect that social networking tools like
Facebook will flourish to launch online
communities focused around diseases
or conditions to improve patient aware-
ness and information sharing.
Considering that a majority of Asian
countries are still developing, do you
think Asia is ready for the rapid tech-
nological changes shaping healthcare
globally?
Asia and the Middle East are uniquely
positioned to harness and implement

64
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be stored for life. Any doctor anywhere
in the world will be able to access
the patient’s medical history using
the number. Apollo has been at the
forefront of technology adoption for
healthcare in India. The complex issues
in healthcare arising due to non-adop-
tion of technology, in managing data,
burgeoning manpower cost, quality
costs etc. and its impact has been
understood. HealthHiway is an Apollo
Hospitals and industry initiative to
build and provide a comprehensive
National Health Data Network ensur-
ing global best practices in healthcare
processes and solutions HealthHiway
will ensure efficiency in day to
day processes in a healthcare
system, thereby impacting the key
new technologies during this period
of rapid growth and development. In
addition, these emerging markets can
learn from legacy markets to harvest the
best of bread for hardware, software,
and communication tools.
What is the scenario in United Arab
Emirates (UAE)?
Healthcare in the UAE is undergoing
innovative transformation to better meet
the needs of the current as well as the
anticipated population growth. Brand
new state-of-the-art hospitals are being
designed and built. Insurance reforms
are shifting the healthcare economic
risk from a government funded model to
a more traditional managed care model.
The UAE Health Authority (HAAD) is
defining health data standards to ensure
that providers and insurers are reporting
data consistently; HAAD is leveraging
this empirical data to drive popula-
tion based healthcare reforms and
healthy lifestyle initiatives. Hospitals
are investing in new healthcare tech-
nologies, albeit, Software Based, or
Therapeutic based. These innovative
performance indicators—patient
services, clinical outcome and financial
health of user companies. This will
help the companies in creating satis-
fied patients and create knowledge
for the community. Reduced process
and process time will deliver enhanced
patient care, lowering operational
costs. In the long term, HealthHiway
will deliver a National Health Data
Network which will create an
interoperable, standards based
healthcare network that will enable
the healthcare community to inter-
act and share data in an efficient
and secure environment, with the
patient in the center of the universe.
According to Ashvani who spearheads
the HealthHiway initiative, “Easy to
initiatives are transforming healthcare
in the UAE.
How do you see the adoption of PHRs
and EMRs in Asia? Do you think Asian
hospitals are prepared to shift toward
the trend?
There is a convergence of consumers,
technologies, and providers that are
driving the adoption of PHRs and EMRs.
Consumers are demanding PHRs to
facilitate ownership of their healthcare,
to become smarter consumers, and live
healthier lives. Technology companies
are providing the hardware, software,
security, and communication tools to
integrate disparate data elements to
create the PHRs and EMRs. Providers,
regardless of structure: government
funded, for-profit, or non-profit, are driv-
ing the deployment of EMR to foster
improved and more efficient clinical
decision making. The convergence
of these three vectors—the consum-
ers who are demanding it, technology
companies who are supplying it, and
the providers who are leveraging it are
all driving the adoption of the PHR and
deploy, Easy to use and Easy to pay”
best describes the project. Revenue
Management, Learning Management
and CME, Performance Management,
including Decision Support and
Knowledge Management, and Clinical
Information Systems form the core of
the system
While several pilot projects and
proof of concept validation studies
have been carried out, confirming how
IT in healthcare can make a significant
difference, these need to be scaled
up. A solution is not a solution unless
it is universally available. The time is
now ripe to go all out and make sure
that in the next decade India will be in
the forefront of e-Health. Improbable?
Perhaps. Imposible? No.
EMR. Asian hospitals, and the commu-
nity are well prepared to shift towards
this trend.
What are the areas of Healthcare IT
(HIT) that you think need to be further
developed?
I am excited about extending the HIT
footprint beyond the clinical walls and
into the patients home. This extension
will be fueled by the development of
integrated technologies traditionally
found in the clinic, e.g. blood pressure,
blood sugar or wound management
tools that are connected electronically
to the PHR or EMR. Imagine a patient
living in a digital home, where the blood
sugar is measured and tracked elec-
tronically which is correlated to the diet
and the exercise program all connected
electronically through components like
the smart refrigerator and work-out
equipment. Extending the HIT foot-
print into the home will foster patients
owning their own healthcare, to allow
patients to see the benefits of healthier
lifestyle choices, and to avoid costly
hospitalisations.
w
wwww
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What is your take on the issue of
interoperability in healthcare IT?
The inability to move clinical data
from place to place—that is to say,
the lack of interoperability—clearly
hinders delivery of good care around
the world. It also imposes barriers to
move between healthcare systems.
Work done by our group at the Center
for Information Technology Leadership
has estimated that the US could save
US$ 77.8 billion annually if interop-
erability were in place. Another key
finding that emerged from this analysis
66 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
was the importance of standards for
addressing this issue—if standards are
not in place, and data are exchanged
for example in PDF format, most of
the savings would not be realised. We
did a further evaluation for Australia,
and found that Australia could save
approximately $ 4 billion (AU) annually,
if interoperability can be implemented
there.
What is currently being done to over-
come this issue?
Relatively little is being done with
ISS Ue - 18 20 09
David W Bates
Chief
Division of General Internal
Medicine, Brigham and
Women’s Hospital, USA
respect to regulation in the US to
promote clinical data exchange. Most
of the emphasis has been placed on
what we call regional health informa-
tion organisations, or RHIOs. In early
2007 we surveyed 145 regional health
information organisations (RHIOs), and
published the results in Health Affairs
in 2008. The key findings were that
nearly one in four was defunct, and
only twenty were of at least modest
size and exchanging clinical data. With
respect to what was being exchanged,
most successes related to exchange
of test results, and few prescriptions
or referrals or notes were exchanged.
The RHIOs are expected to support
themselves, but struggled to do so:
thirteen RHIOs received regular fees
from participating organisations,
but eight were heavily dependent
on grants. These data suggest that
the business model for clinical data
exchange may be problematic, and
federal support may be needed.
Other countries are using a much
more centralised approach. For exam-
ple, Australia has implemented data
exchange in several regions. The UK
has a national approach, and “the
spine” will eventually allow exchange
of a core of clinical data for all citizens
in England.
Clearly standards play a key role in
facilitating this. In the US, the federal
government and quasi-governmental
entities have established standards for
most of the key types of clinical data,
but the problem has been that there
Healthcare IT’s
Big Challenge
are costs to convert, and few users
have demanded conversion, so that
even though they exist they aren’t yet
widely implemented. Other countries
like the UK are much further along in
this regard. Much more work needs to
be done internationally so that stan-
dards become accepted.
In the far east, Singapore has been
a leader in this area, as has Australia
and Hong Kong for example has estab-
lished data exchange within the Health
Authority.
Issues with privacy and security
also represent an important concern,
and a small but vocal minority in many
countries has substantial concerns.
One way of dealing with this is to use
an ‘opt-in’ as opposed to an ‘opt-out’
or mandatory approach toward having
one’s data included in the clinical data
exchange.
What, according to you, could be the
panacea for interoperability?
I think that panacea is too strong a
word, but one key will be to repre-
sent data in standard format and then
actually to implement data exchange.
Any time you start with data exchange,
you identify issues which need to be
worked out. Many of the key standards
are not fully mature—for example, just
because a message is represented as
HL7 version 3 doesn’t mean that it will be
possible to read it on the other side.
Another key issue is the archi-
tecture of the data exchange. All the
exchanges that have worked well to
date have used some sort of central
repository structure. The alternative
approach has been to use a feder-
ated approach, and only to extract
data on a ‘need-to-know’ basis. One
of the biggest issues with the latter
approach has been speed, which is
central in clinical care.
How are vendors responding towards
this trend?
Vendors are clearly interested and
paying close attention, but they are
also waiting to be pushed by their
clients to be asked to use key stan-
dards and to set up the portals to
facilitate data exchange. This makes
good business sense, as being a ‘first
mover’ in this area carries significant
risk, but on the other hand will be
very problematic for vendors to be
laggards in this area.
How is interoperability affecting patient
care?
Many predictions have been made
about how interoperability will affect
patient care, but relatively few empiric
data are available regarding this.
But it can be expected that
patient safety will improve, that it
will be possible to decrease redun-
dancy for example with respect to
tests, and that the quality of care will
improve. We are evaluating the impact
of clinical data exchange that has been
established in three communities in
Massachusetts, and will be looking
at these and other issues.
In our own network, we have
achieved interoperability, and it
has been very helpful clinically in
my own practice to be able to look
at lab results from anywhere in the
network. Before this, it would often
take a long time to get results from
some other site by lab or fax, and
this often represented a big enough
barrier that it was easier to just repeat
the test. Furthermore, another effect
has been that the pool of specialists I
am comfortable working with is much
larger, as I can now see data from
several thousand specialists.
What could be the role of Internet in
overcoming interoperability?
Clearly, the Internet provides a plat-
form that makes it easy to exchange
information at low cost. There are
issues at the same time with secu-
rity, but these should be manageable
with techniques like the use of virtual
private networks.
Any other comments?
Overall, clinical data exchange has
the potential to dramatically improve
care, and reduce costs. That being
said, there are many practical hurdles
to be overcome. Some of the biggest
are better defining the business case,
actually using key standards so that
they become more mature and the
kinks get worked out, and then
dealing with the inevitable privacy
and security concerns that will
arise.
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What is your take on the issue of interop-
erability in healthcare IT?
I believe there is still a lot of room for
improvement for interoperability in
healthcare. We still see issues in solu-
tions that are not able to be integrated,
which costs healthcare institutions a lot
of money to fix and causes delays to the
implementation of critical solutions.
What is currently being done (in terms
of regulations and standards) to over-
come this issue?
User groups have been formed around
the region to look into this issue, but with
so many vendors providing solutions
to the healthcare market, it will take
some time to see any change. The main
driver for change would be the cost of
customizing the solutions.
What is the interoperability scenario
with respect to Asia?
In Asia, the problem with interoperability
is the same as in North America and
Europe. Healthcare institutions are still
faced with the challenges of integrating
solutions. Hospitals are currently spend-
ing a lot of money to fix issues as we
see with the NHS project in the UK.
What, according to you, could be the
panacea to health IT systems interop-
erability?
I think if key stakeholders in the health-
care market demand something to be
done, then the interoperability issue will
68 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Banking on
Market Demand
Gerard Anthony Dass
Leader
Healthcare Solutions, Nortel Asia, Australia
see a significant change. While we don’t seamless flow between all the solutions,
see this happening in the next one to we will see a significant time savings
two years, there are already forums in patient care.
and user groups that come together
to work out a common ground for all What could be the role of Internet in
solutions to co-exist and operate in an overcoming interoperability?
eco-system. More industry players are starting to
adopt web 2.0 in the healthcare industry.
How are vendors responding towards With Web 2.0 technology, the belief is
this trend? that we will fix some of the issues that
The key challenge is cost. Vendors are are creating the current bottle neck with
taking steps to address this issue but healthcare applications.
it’s moving at a slow pace.
Are the existing standards enough to
How is it affecting patient care? support healthcare data exchange?
As hospitals spend more money to fix I think the current standards need to
the issues of interoperability, the cost be reevaluated to take into account the
is passed to the patients. We also see current technology trends in the health-
delays with patients being discharged care market. This is already being looked
from a hospital or for a patient to get at and we hope to see some changes
his/her medical records. Once there is a in the next 12 to 24 months.
New technologies, powered by unified communications, are also now being implemented
within healthcare, ensuring the right information is available at the right time, regardless of
location. A range of wireless communications are in already in use, such as mobile PDAs
or tablets that allow practitioners to make bedside care decisions more quickly. When
equipped with mobile devices, they can connect with doctors or specialists at other loca-
tions for an immediate consultation or quickly access information from a facility’s digital
files without losing valuable time running back to the central nursing station on the floor.
Doctors can also now share medical imaging files with distant colleagues for an
immediate second opinion and can receive real-time alerts wherever they are, from the
moment a patient’s condition worsens and needs attention.
For example, Kyushu University Hospital in Japan upgraded its current IT system to
a new medical service infrastructure to enable information to be more efficiently stored,
managed, retrieved and shared amongst physicians and medical staff. Built on the hospital’s
vision to offer patient-oriented, one-stop medical services, the new clinical grade next-gener-
ation network provides anywhere, anytime, quick access to information such as diagnosis
data, X-ray and ultrasound imaging - and real-time readings of patient vital signs and operat-
ing theater monitoring. Real-time access to this important information creates an environ-
ment for primary physicians, specialists and medical staff to collaborate more efficiently for
remote consultations, diagnosis and patient care. The network from Nortel is an example
of how technology can improve quality healthcare services and patients’ quality of life by
simplifying the complexity for medical providers to access and share information.
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Adoption
in Asia Pacific
Challenges such as
W
e have seen the influence
rising healthcare costs, of Information Technology
(IT) in many different
demand for better sectors such as banking, finance and
quality of healthcare, education but healthcare is one sector
increasing labour where the impact of IT has not been so
shortage and fragmented conspicuous. Healthcare organisations
healthcare system are have been slow adopters of IT solutions
in the past. However, they presently
making it imperative for aggressive in adopting IT solutions due
healthcare organisation to various challenges to healthcare deliv-
to integrate IT solutions ery. In Asia Pacific (APAC), Singapore,
in their administrative Japan, South Korea and Australia have
and clinical workflow. been at the forefront of technology adop-
tion in the healthcare sector whereas
China, India, Malaysia and Thailand
Sourabh Kankhar
Consulting Analyst
are the emerging markets.
Frost & Sullivan, Singapore
Factors driving the adoption of HIT
in Asia Pacific
Strong government support for HIT initiatives
In Australia, the state and federal
government are supporting state-wide
and country-wide HIT initiatives. A few
examples of such initiatives in the past
are HealthSmart, a four-year technol-
ogy programme in the state of Victoria
and HealthConnect, the nationwide
electronic health records programme
Impact of clinical IT solutions on the challenges to healthcare delivery
Challenges Clinical IT solution
by the federal government. At present,
the State of South Australia is developing
Australia’s first fully integrated state-wide
electronic health record system through
its careconnect.sa programme. In
Western Australia, eHealthWA is a major
reform programme designed to provide
a modern and integrated platform of
Information and Communications
Technology (ICT) for public health
care services in the state.
Globally, countries are trying to
achieve an integrated healthcare delivery
structure in their quest to improve the
quality of patient care. Singapore has
been successful in its progress towards
a well-integrated quality healthcare
service. This success can be attributed
to the country’s focus on achieving
immediate HIT goals rather than holis-
tic ones along with the recognition of
the importance of integrating IT into
health system by the hospital admin-
istrators and clinicians. In 2003, the
country’s health minister identified the
use of information technology as one
of his priorities with the aim of ‘One
Singaporean, One EMR.’ With the
announcement of the Intelligent Nation
Outcome

Medication Better access

e-Prescribing
errors to information

Fragmented Integration
EHR, Telehealth
healthcare delivery of agencies

Rising cost Improved

PACS, EMR
of healthcare efficiency

Increasing Workflow management

Staff retention
labour shortage solutions

Source: Frost & Sullivan Figure 2

70 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09

 Roadmap to integrated healthcare delivery in Singapore
• Acute care hospitals, speciality centres and primary
care polyclinics restructured into two vertically
integrated clusters: the National Healthcare Group • One EMR for every patient
• Harmonisation of the financial,
(NHG) and Singapore Health Services (SingHealth) • Electronic personal health records
materials and patient management
• Exensive implementation of administrative and processes across all the NHG • Clinical decision support systems
clinical IT systems by the NHG and SingHealth institutions by an integrated • Home monitoring systems
clusters. information system. • Clinical databases to support research

1999 - Restructuring
By2003 - Single EMR 2003 - NHG's project
of healthcare facilities 2004 - EMRX program Future - iN2015 plan
system in SingHealth Naut1cus
into two clusters

• SingHealth had a single • Government rolls out the EMR Exchange (EMRX)
EMR system for the entire cluster. initiative to share electronic medical records
• NHG institutions had different EMR across all the public hospitals and polyclinics.
systems linked through a Cluster • Plan to extend EMRX initiative to the private
Patient Record Sharing system. sector healthcare agencies in the future

Source: NBR Center for Health and Aging / NHG Annual reports Figure 1

2015 (iN2015) plan, the government
has accentuated that HIT will always
be a priority for them.
Challenges to healthcare delivery
drives investment in HIT
Healthcare facilities are facing daunt-
ing challenges such as rising health-
care costs, demand for better quality
of healthcare, increasing labour short-
age and fragmented healthcare system.
There will be a huge rise in demand
for healthcare services in the future
due to ageing of population, lifestyle
changes and increasing incidence of
chronic diseases.
For example, Japan has the fastest
ageing population in the world. Today,
one in five Japanese people are over the
age of 60. The population aged 60 years
and above is estimated to be around 28
per cent in 2025. From around 13 per
cent of the total population in 2006,
the population aged 65 years and over
in Australia is projected to be around
28 per cent in 2056. Today, one out
of every 12 Singaporeans is aged 65 or
above. By 2030, this ratio will become
one out of five.
Challenges to adoption in APAC
Under-investment in healthcare IT
In many APAC countries, there has been
an under-investment in healthcare IT
in the past. Even now, healthcare agen-
cies in APAC are spending considerably
lower on IT initiatives as compared to
their counterparts in Europe and North
America. In countries such as India
and China, the government funding
for healthcare IT initiatives is limited
and there has not been a strong push
from the government regarding HIT
initiatives.
Economic slowdown
The present economic slowdown is
bound to have an impact on the IT
budgets of healthcare agencies in APAC.
The Chief Information Officers (CIO)
in majority of the hospitals will react
to the economic slowdown by cutting
down on their overall IT budgets.
Legacy systems
The lack of awareness of the right
systems and limited budgets has led
to the installation of legacy systems in
many healthcare facilities in APAC,
A u t h o r
especially in countries such as India,
China and Australia. These systems lack
industry standards as well as pose a big
challenge in the integration with new
modules. In Australia, the state health
departments are currently spending
millions of dollars in replacing these
legacy systems with solutions that are
based on industry standards.
Conclusion
There has been a successful imple-
mentation and wide use of IT solu-
tions in administrative workflow of
healthcare organisations in Japan,
Singapore, Australia and South. The
focus in these countries will now be on
clinical IT solutions such as Electronic
Medical Records (EMR), Electronic
Health Records (EHR) and decision
supports systems. Countries such as
India and China will concentrate on
the implementation of administrative
solutions. Clinical IT solutions will play
a major role in developing an efficient
and patient-centric healthcare delivery
structure in the future.

These challenges are making it Sourabh Kankhar is a Consulting Analyst with the Frost & Sullivan
imperative for healthcare providers to Asia Pacific Healthcare Practice. He focusses on monitoring and
analysing emerging trends, technologies and market dynamics in the
integrate IT solutions in their adminis-
Medical Technologies Group in Australia.
trative and clinical workflow to bridge
the gap between the demand and supply
for health services.

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72 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09

A
t the start of 2009, it is interest-
ing to look further forward and
see just what may be coming in
the next 10 years.
Many of the people alive today are
going to live longer than their ances-
tors and as medical technologies and
our understanding improve, there are
more things we can fix. This adds up
to a lot of problems for health services
around the world; there are not enough
doctors, surgeons, nurses and healthcare
is getting increasingly expensive. Medical
tourism will increasingly drive patients
around the world but ultimately there
will always be a shortage. Can machine
intelligence, sensors and robotics offer
some of the services we get from doctors,
dentists and surgeons? Can we do this
in the home?
Chips that are good for you
We are already starting to see the prom-
ise of ‘lab on chip’ sensors (or Micro
Total Analysis Systems (µTAS)), where a
single drop of blood can be scanned for
a whole range of problems. Though still
in development, the promise of a reduc-
tion in the time and cost to do point-
of-presence tests has many advantages
(rapid results, smaller samples required
and no supply chain required for sending
samples, though aerial delivery (discussed
later) offers an alternative for this).
If ‘lab on chip’ sensors are proven
successful, it will have a big impact on the
way healthcare is provided; near constant
monitoring would become cost-effective.
Smart toilets have been touted as the
obvious place to do testing, and the toilet
does have a provenance in spotting early
signs of parasitic infection. More modern
variants could soon be analysing what
we flush for more subtle indications of
changes to our bodies before they become
apparent to us and, with diabetes on the
increase, it may be crucial in allowing us
the chance to change our lifestyle before
we need medicine. This, however, raises
issues. If a smart toilet can detect traces
of drugs, alcohol, sexually transmitted
diseases or pregnancy then who should
be allowed to see the information, just
the person who flushes the toilet, or the
owner of the toilet?

The ‘Hippocratic Oath’

mentions the teaching of

A look into the

knowledge and leaving
jobs to professionals; in

Future
the future, the professional
may be a robot. Historically,
technological changes have
come at a manageable
pace; today, the potential
danger is that a lot of
new technologies are
emerging very quickly.
We, therefore, need to
look forward to what may
happen in order to be better
prepared for the future.

Ian Neild, Disruptive Futurist, BT, UK

w
wwww
w .. aa ss ii aa nn hh hh m
m .. cc oo m
m 73
73
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Have a heart, or at least print me one

Research is underway to print replacement body parts and whilst
the whole femur may not be replaced it may be possible to create
replacement bone, which can be grafted onto existing bone. This
rapid prototyping is already available for objects and will have
many uses in the medical world, where accurate scans are readily
shot available. Artificial organs are also a possibility, with modified
A snap sim Figure
2
printers already able to print human cells in precise patterns. Rat
of per io
hearts have also been rebuilt using donor hearts; the donor heart
1 ting
Figure
n t s m anipulaclass is first partly ‘dissolved’, which eaves a ‘skeleton’ framework and
Stude OM files in then a DNA soup from the host is used to rebuild the heart using
DIC
the existing framework. This method creates an organ that the
body does not reject since it is made from its own DNA.

teaching and consultation. Disect systems procedures, in order to do well in the

The doctor can see more now
Augmented reality (mixing computer
generated images with real life) and haptic
interfaces (controls which give feedback)
could aid in the training of medical profes-
sionals. ‘Periosim’ from the University
of Illinois is a training tool for dentists.
Students see a computer-generated view
of a mouth from any angle (see Figure
1) and then, using haptic controls, are
able to practice many procedures with-
out going near a patient. This has lots
of benefits as machines can monitor the
students’ progress to ensure that future
tooth work is as pain-free as possible and
require less return visits. The students can
be set dentistry homework and can also
watch how procedures should be done.
The haptics allow the students to
judge just how deep those instruments
have to be and how much pressure is
needed. If the machine can recognise what
would cause pain, then each procedure
could score like a computer game. This
is starting to become much more feasible
as graphics, processing and networking
costs have plummeted, while the sending
and viewing of extremely large medical
files such as DICOM allows for better
have already performed trials of this with
2D and 3D images being viewed remotely.
Students in the class (see Figure 2) access
radiology files and annotate the images.
A mentor can also work on the same files
looking over their ‘virtual’ shoulder.
As this is network-based, the students
do not have to be in the same classroom
and the best teachers / mentors can influ-
ence students around the world and expert
assistance can be found during normal
working hours somewhere on the planet.
If operations are recorded along with the
haptic data, the computer-generated
images used in applications like Periosim
can be replaced with real images and a
large database of previous procedures
stored for future training. We may even
see a league table of medical professionals
/ hospitals and patients may get to know
just how good the surgeon or dentist really
is. As these leagues would be global, the
idea of ‘tele-doctoring’ gets even more
promising. If such a league existed, it
may be tempting to only carry out certain
United States flu activity
2008-2009 Past years
Jun Jul Aug Sep Oct
league. So, would such a league influence
the procedures that were carried out? This
is entirely feasible but it would be very
visible; if each procedure was ranked in
terms of complexity by the profession,
then any professional or institution that
only carried out low-risk or simple proce-
dures may find themselves performing
these simple procedures. In the future,
as robot surgeons such as the Da Vinci
improve. Those who limit their work to
simple procedures will find themselves
replaced by machines, like modern day
luddites.
So, soon patients could upload X-
rays of their teeth and body scans onto
a medical YouTube (it really would be
you) and ask the medical professionals to
show how they would operate and how
this compares to a robotic system.
With robots doing the simple surgery,
the highly skilled people are able to focus
on more complex procedures, though they
may be programming the robot to do
the task rather than holding the tools
Minimal Low Moderate High Intense
Nov Dec Jan Feb Mar Apr May
Figure 3

74 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09


directly. To many medical professionals,
this may seem an abomination of their
skills, but is it really so when you consider
that they are just linking their eyes, brain
and hands to a different tool?
Would you be happy letting a machine
operate on you? Machines make cars more
efficiently than humans do as the parts
are all the same, whereas the human body
is built to the same specification, every
one is unique. With the right scanners,
does a machine have better vision than
a human? Surgeons performing close-up
work wear ‘microscopes’ to let them see in
finer detail; they may use micro manipula-
tors to allow them to do finer movements.
So, in one way, the machines are already
operating on us; they just have a human
at the wheel. Just 10-20 years ago, this
was science fiction and absurd; today,
machines have started to carry out the
operations, these machines won’t grow
old and as they perform more operations,
their cumulative knowledge will exceed
that of a human.
Robotic pigeon post delivery
Robots may also help in drug delivery;
visiting a pharmacy for drugs is common-
place in the developed world but are we
ready for drugs delivered by air autono-
mously? Unmanned aerial vehicles (UAV)
have already been shown as capable of
travelling between distant points, there-
fore, they could be used to deliver drugs
and transport blood samples. Flight times
would be short and so problems with
temperature control would be reduced.
A central refrigerated drug store could
deliver drugs over a very wide area and
blood samples could be flown to central
labs efficiently for testing.
There is no argument that self-help forums are
extremely important but with increasing access
to information on disease, a growing number of
people are suffering from Cyberchondria.
Improving the patient awareness
As health authorities shift the first line of
care to web and telephone-based systems,
an increasing number of people have
already turned to the Internet and self-help
groups for information on their condition.
In the past, the medical profession had
access to all the knowledge and the patient
had none. Today, that balance is shifting
as patients have access to a wide range of
information. A medical professional has
to know a lot about many things whereas
a patient wants to know everything about
the specific ailment or condition they may
have. So today, when a patient meets a
health professional, they may be in the
strange situation of having spent more
time reading about a condition than the
professional. But where is this information
coming from, is the information correct
and well balanced or biased and based
on some other unknown factors? There
is no argument that self-help forums are
extremely important but with increasing
access to information on disease, a grow-
ing number of people are suffering from
Cyberchondria.
Cyberchondria is a recognised
phenomenon based on hypochondria,
when people read about symptoms
they think they have the same condi-
tion; with so much access to information
on ailments, these people are going to be
able to pseudo-suffer with a new condi-
tion every hour.
As users search Internt to know
of pandemics etc. In an attempt to self-
diagnose, the population is flagging up
potential health problems (see Figure 3). If
enough people enter the same symptoms,
it may be the first sign of a problem that
needs to be acted upon. As the Internet
address has a fixed location, this may even
be broken down into areas. This is also
the case if a supermarket or pharmacy
notices a sudden increase in the sale of
certain medicines, which may indicate a
problem. If these sales could be tied to
a user’s location or previous sales then
it may even be able to pinpoint that a
certain restaurant may need a visit from
the health inspector.
Flu like search terms used in
Google show a rise in searches around
February.
Wrap up
The ‘Hippocratic Oath’ mentions the
teaching of knowledge and leaving jobs to
professionals; new technology will play an
important part of this in the future as the
world changes. Historically, these changes
have come at a manageable pace; today,
the potential danger is that a lot of new
technologies are emerging very quickly.
We, therefore, need to look forward to
what may happen in order to be better
prepared for the future.
I work in BT Innovate; it is the future looking part of BT;
my company’s strategy is to enable our customers to thrive
in an ever changing world. http://www.btplc.com/

what their ailments are, the search References are available at

Let’s play your notes
Multimedia patient records would be
a useful addition to patients’ notes as
cameras and microphones could record
engines could be used for the first sign http://www.asianhhm.com/magazine
Ian Neild is a disruptive futurist who presents on technology trends
A u t h o r

how visual and audible conditions have
changed over time. Instead of subjective
measurements, it would be possible to
see (or hear) how a treatment is actually
working.
and social / business impacts. He writes the BT technology timeline,
which lists possible technology changes and their impact. Currently
he is working on an area dubbed the ‘Internet of Things’ within BTs
foresight team and working on his doctorate.

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Enhancing
self-management of
chronic
low back pain
Role of a patient-centred website
C
hronic pain can have a profound
impact on sufferers’ lives, and
it is often associated with a loss
of confidence and self-esteem. While
the majority of cases of low back pain is
self-limiting and resolve on their own,
the risk of recurrence and development
of chronic disease is significant.
The Internet is praised in the
literature for its potential of enhanc-
ing patients’ coping with conditions.
Yet online websites on back pain are for
the most part affected by a main limita-
tion: Due to their mainly informative
nature, websites provide generic advice
that often does not spark users’ interest
and does not meet their expectations.
The comprehensiveness of generic
material is based on the assumption
that, as people have different informa-
tional needs, individuals will select the
content that is relevant to them and
sift out what does not apply to them.
Despite the avalanche of advice on how
to prevent or manage low back pain,
there exists an information gap between
76 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
general knowledge of back pain and the
application of this knowledge to amelio-
rate the individual’s condition.
Between June 2006 and October
2008 the Institute of Communication
and Health of the University of Lugano
conducted a project to explore to what
extent an interactive website, that
provides tailored information to patients
affected by chronic low back pain, is a
proper response to enhance their self-
management of this condition.
The conceptual framework behind
ONESELF is based on the notion of
health literacy. Most recently health
literacy—as the cognitive and social skills
which determine the ability of individu-
als to gain access to, understand and
use information in ways which promote
and maintain good health—has been
given increasing attention in attempts
to understand people’s health promot-
ing capacities. Patients’ health literacy
is a competence that integrates factors
working at three main levels. On the first
level, health literacy is made up of the
ISS Ue - 18 20 09
kind of knowledge technically labelled
declarative. This is the ‘knowledge of
the what’ that patients have or develop
when they hear / read and understand
certain medical-related statements, e.g.
diagnoses, explanations of what certain
conditions are and of what the benefits
/ side effects of treatments and drugs
are. On the second level, another type
of knowledge plays a key role in the
development of health literacy, namely
procedural knowledge. This term refers to
the ‘knowledge of the how’. Procedural
knowledge is knowledge directly applied
to a task, e.g. to treat a certain disease. It
tends to be less general than declarative
knowledge and results in the ability of
doing specific activities, e.g. to follow
a certain treatment, to take a certain
drug or to do a specific exercise. Above
these two types of knowledge, health
literacy includes, on a third level, a set
of skills derived from patients’ ability to
integrate their knowledge and all sorts
of information received in the context
of their own existence and goals.
There exists, from the patients’
point-of-view, an information gap
between general knowledge
about treatment and prevention,
and capacities to change
behaviours. Often, delivered
information does not address
specific difficulties of the patients.

Sara Rubinelli
Senior Researcher
Maria Caiata Zufferey
Senior Researcher
Peter J Schulz
Director
Institute of Communication and Health
University of Lugano, Switzerland

In the outcome, the website includes

the Library and the Gym, where users
can find texts and videos of exercises to
increase their declarative and procedural
knowledge, as well as a Forum and a
Chat-room where they can meet and
interact with both other patients and
a group of health professionals that are
part of the project team. These are the
sections where patients can ask for a
contextualisation of their knowledge
towards the development of more criti-
cal skills to manage their disease.
ONESELF is currently used by
approximately 900 patients who live
in Ticino (the Italian speaking part
of Switzerland) and who have been
recruited by health professionals and
mass-media channels. Among them,
112 patients agreed on taking part in tion. Qualitative interviews were also asked in the post-use survey. More
the study, where they were asked to conducted with a sample of 18 patients specifically, 25 per cent reported
navigate on the website for 12 months. selected depending on the total time that ONESELF contributed much to
The patients filled an online question- they spent online. increasing their knowledge about back
naire at the beginning of navigation, Generally, many users reported pain, and an additional 58 per cent said
and responded in a post questionnaire benefits of using ONESELF in their ONESELF had contributed sufficiently
distributed at the end of the interven- answers to five different questions to knowledge. Users also acknowledge

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in majority ONESELF’s contribution
to managing their back pain: 12 per
cent said the site had contributed much,
and 57 per cent said it had contrib-
uted sufficiently to managing pain.
The next most frequently acknowl-
edged benefits were improvement of
communication with doctors (56 per
cent) and family and colleagues (55
per cent). A majority of users (55 per
cent) also reported that their search
for information had decreased (includ-
ing decidedly decreased) as far as other
websites are concerned, and 45 per cent
reported the same of other sources of
information. Roughly one in three users
reported they exercised more (including
decidedly more) since starting to use
ONESELF, while just 2 per cent said
they exercised less since then.
Results from the qualitative study
highlight additional information on the
way patients used the website. The partic-
ipants mentioned several positive effects
of the use of the website on attitudes and
behaviours related to self-management.
In the following section we reported the
main effects recorded, namely:
Self-comprehension: The interviewed
sample considered ONESELF very
useful to build an individualised under-
standing of their situation: the richness
and trustworthiness of the information,
the possibility to interact with health
professionals to obtain specific answers
and the stability of the material helped
them to construct their personal frame
of reference about the nature and the
course of their cLBP.
Improvement of argumentative abilities:
ONESELF helped people in learning
how to speak about their health condi-
tion. Users could improve their capacity
to frame and explain their situation in a
way that people—and especially health
professionals—could comprehend and
assess correctly.
Orientation: ONESELF provided
users with basic information on how
to behave towards cLBP. For example,
people could learn new exercises or
brush up on old ones.
78 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Development of self-confidence: ONESELF for the consultation on more urgent
helped people to acquire confidence in matters; second, ONESELF could help
their ability to manage cLBP. Some users screening requests from patients that
felt reassured because they had a trust- do not need face-to-face encounters
worthy place where they could address to be answered.
concerns. Overall, the conceptual model
From the point of view of the health of ONESELF proves its potential
professionals’ daily practice, the project in improving techniques of self-care
ONESELF appeared to be succesful through new technologies. Effective
in the creation of a bridge between self-management of chronic low back
clinic-based methods for treating back pain can reduce healthcare costs and
pain and the humanistic approach from increase worker productivity because
communication sciences. There were of fewer work-related absences. Beyond
several difficulties linked to the amount the simple financial savings, ONESELF
of time that health professionals can has the potential of improving substan-
devote to projects of medical websites. tially the quality of life of patients
ONESELF has minimised the risk of who suffer from back pain and from
overloading health professionals by chronic conditions that require similar
sub-dividing their tasks and schedul- management.
ing exactly when each of them had to The authors wish to thank the
enter the website and answer patients’ National Research Programme NRP 53
requests. Despite their initial concerns, ‘Musculoskeletal Health – Chronic Pain’
the health professionals involved in of the Swiss National Science Foundation
this project became more and more for the financial support of this study
interested in conducting online inter- (project 405340–104841/1), as well as
actions with users. From the point of the Lega Ticinese per la Lotta contro
view of their daily practice, ONESELF il Reumatismo, which has enabled its
has helped them in at least two ways: feasibility.
First, by referring patients to ONESELF
for general background, health profes- References are available at
sionals could focus the time at disposal http://www.asianhhm.com/magazine
Sara Rubinelli holds a PhD from the University of Leeds (UK) in the
areas of ancient logic, argumentation theory and rhetoric. She is a
Senior Researcher at the Institute of Communication and Health of
the University of Lugano (CH), where she collaborates in national and
international research projects in the field of health.
A u t h o r
Maria Caiata Zufferey holds a PhD in social science from the
University of Friburg (CH). She is currently Senior Researcher at the
Institute of Communication and Health of the University of Lugano
(CH). She currently works, on a qualitative basis, on doctor-patient
communication in the information era.
Peter J Schulz is a Professor of Semiotics and Health Communication
at the School of Communication Sciences and Director of the Institute
of Communication and Health of the University of Lugano (CH).
He currently holds several project grants from the Swiss National
Science Foundation in the area of health communication.
ISS Ue - 18 20 09
Healthcare Information Exchange
On the Internet
I
n a nation like India, where population multiplies in
leaps and bounds, delivery of healthcare involves
numerous challenges and barriers. This is not
just because of the lack of infrastructure and skilled
resources but also because of the unavailability of the
patient’s medical records to provide the right treatment
at the right time. Though, India being a strong and
preferred destination in Information Technology, the
penetration of IT into healthcare sector is much below
the supposed mark. Whereas in countries like Australia,
Canada, US and many European countries, most of the
hospitals and group-practitioners are using integrated
healthcare solutions like Hospital Information Systems
(HIS), Electronic Medical Records (EMR), Electronic
Health Records (EHR) etc. to substantially reduce
medical errors and treatment costs besides focusing on
the quality of healthcare delivered to the patients.
Reasons for lagging behind
Although there are numerous benefits associated when
adopted to healthcare IT systems, the acceptance rate
is not high in the Indian healthcare sector both in the
public and private sectors. There are many reasons for
slow adoption rates, but the major reasons include, the
bare minimum spending by hospitals, lack of technical
expertise and lack of common standards. Apart from
the above, the lack of awareness about the benefits
associated in adapting to these systems both among
the healthcare providers and people is also one of the
important reasons.
Need for a unique solution
Realizing the fact that Internet along with recent
innovations in open source technologies can be
combined to deliver a cost effective comprehensive
healthcare solution, the Hyderabad based company
eMedReport has launched an integrated web based
solution eMedReport.com. This cost effective and
feature-rich solution ensures flawless communication
among all the healthcare providers and patients for
exchange of health information.
The solution ensures unlimited and secured storage
of patient’s health records, along with other benefits
such as sending prescriptions to pharmacies and test
requests to pathological labs and diagnostic centers.
Patients can create a free health account which would
help them access their health records, prescriptions, test
reports and radiological images “Anywhere-Anytime”.
Patients can also search for doctors in a specific area
and request appointments which would save time and
money to a large extent. All the above features ensure
that the patient gets the right treatment at the right time-
All this happens with a single click at eMedReport.com
Doctors can manage their calendar, view patient
appointments, previous health records, review notes,
prescriptions and test reports which would help them in
providing a better patient care. In addition, doctors can
also refer a patient to other doctor for a second opinion
with all the previous health records of the patient. All
this critical information is stored in a secured doctor’s
account that no one else has access to.
eMedReport also offers SMS alerts and system
reminders to patients, doctors and other healthcare
providers about appointments, prescriptions, test
requests and test reports.
eMedReport offers inexpensive subscriptions for the
web solution for a period of 3 months, 6 months and 1
year.
For more information
Please logon to www.emedreport.com or
send an email to info@emedireport.com
Advertorial
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Benchmarking
and Accrediting in
Health Informatics
Driving up quality and reducing risk
I
Quality assurance and nformation has always been at the
heart of healthcare delivery. Today,
continuous development new information systems and tech-
of health information and nologies are becoming ubiquitous in
IT services in healthcare health and give rise to new opportu-
is a key patient safety and nities and challenges to the ways care
business issue. A part of is delivered and the way professionals
work. Information sharing between
this is the need to assure professionals, care providers and sectors;
the professionalism of and patient access to and management
individual practitioners of their own records are driving changes
as well as the services in inter-professional relationships and
themselves. care delivery processes.
So, information and information
systems underpinned by technology are
Di Millen
Head
increasingly impacting directly on patient
Informatics Development experiences of healthcare delivery and
NHS Connecting for Health, UK on their treatment and on the outcomes
of their care. There is, as a result, an
increasingly vocal group of profession-
als in health who would argue that if
information, information systems and
IT can positively impact upon patient
care, then the converse must also be true.
The UK Council for Health Informatics
Professions (UKCHIP) has collected a
catalogue of examples of healthcare
delivery failures where information and
IT systems are implicated in errors and
even loss of life.
Our information and IT systems,
therefore, need to be safe; and the profes-
sionals—individuals and teams, who
design, implement, support, manage
and develop these systems must also
be assured, as far as possible, as safe
to practice.
80 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09
In an increasingly litigious world,
is this an issue healthcare delivery
organisations can continue to
ignore?
Further, commercial pressures, whether
in State—funded healthcare services
which exists in the UK or private or
insurance-based services (or indeed
a mixed health economy)—have an
obligation to deliver best value, high
quality services that demonstrably use
accepted standards and be committed to
the principles of continuous improve-
ment. Commissioners of services want
to know they are buying a quality, value
for money service; and service deliverers
want a competitive edge in an increas-
ingly pressured free market.
In England, a further driver in the
push for benchmarking and accreditation
of both informatics practitioners and
services and teams has been a continuing
concern that recruitment and retention
in informatics in health is problematic
and that we just don’t have access to
the right people with the right skills.
When we find and appoint staff, the
employment package is not sufficiently
attractive to retain the best. Whilst there
is a perception that pay is not as high
in the public sector as it might be in
the private sector, it is actually lack of
status and lack of opportunities for career
progression that drive staff out into the
more lucrative private sector.
The adoption of standards and
the accreditation of people and
services / teams are seen to be at the
heart of all of addressing these issues—at
national and local levels.
In the UK, UKCHIP now holds
a professional register of some 700+
individuals and is in the process of
applying for accreditation by the UK
Accreditation Service which will author-
ise it to certify professional status. This
will require a revision of existing stand-
ards for and levels of registration and
further contribute to driving up quality
and providing assurance to employers
that staff are safe to practice having not
only met the requisite standards but
agreed to abide by a code of profes-
sional conduct and created a planned
programme of continuous professional
development.
IT and informatics are relatively
young professions and are in the forma-
tive stages of development. They are
sometimes criticised for not making
faster progress but recent developments
in English national informatics strategy
indicate that the tide may be chang-
ing. There are a number of actions that
could speed up progress, foremost of
which are:
1. Giving informatics a place on Executive
boards with a CIO type post reporting
directly to the CEO
2. Organisations should expect profes-
sional accreditation/registration and
include this in job descriptions and
person specification
Developing an approach to
benchmarking and accreditation of
health informatics services
Let us move away from discussing the
accreditation of informatics practitioners
as individuals, to consider a range of issues
associated with the benchmarking of
health informatics services and teams.
Benchmarking or accreditation?
The nature of the political environment
and the strategic drivers for a scheme
will influence decisions about whether
either benchmarking or accreditation,
or both, are required. Benchmarking
may well be the first stage of a process
Benefit recipient Description of benefit
Health Informatics • Reputation enhancement
Service Provider • Competitive edge
• Marketing tool
• Staff morale
• Recruitment and retention
• Reduced risk of litigation
Purchasers / Commissioners • Assurance through third party attestation
• Increased confidence in supplier’s ability to deliver to agreed plan
and to agreed standards
• Opportunity to influence nature and quality of service
• Aid to procurement
• Know what to expect
Table 1
of accreditation, enabling teams and again a potentially contentious issue
services to assess themselves against a for some of the reasons set out above.
set of measures and metrics in a non- It may well be the case however from
threatening environment; and to share the perspectives of both commission-
the outcomes only with selected peers ers / purchasers of services and service
and colleagues; or more widely in an providers themselves that a requirement
anonymised or pseunomynised form. to go through a process of assessment is
This implies that outcomes may not desirable in the interests of patient safety
routinely be shared with commission- and continuous improvement; but this
ers and purchasers of services and may is not the same as saying that a scheme
arguably have limited value from these should be mandatory and that services
perspectives. will be classified according to an agreed
scoring system. The implication of the
latter is that a service or team might be
deemed unfit for purpose or ‘unsafe’ and
The nature of the accordingly lose its ‘licence to trade’.
political environment and Again, the political and commercial
the strategic drivers for drivers for the scheme will dictate the
preferred approach. Experience from
a scheme will influence
other UK public sector approaches to
decisions about whether accreditation in healthcare undertaken
either benchmarking or by organisations such as the English
accreditation, or both, NHS’ Healthcare Commission suggests
are required. that an incremental approach to scheme
implementation and development are
more likely to receive the support of
participating organisations and, there-
With benchmarking there is gener- fore, more likely to achieve scheme
ally no ‘pass or fail’ and the process may, objectives.
therefore, be seen more developmen- A generally well-respected and well
tal and less threatening than a formal received scheme in England has been
accreditation scheme. the Pathology Accreditation Scheme
Table 1 summarises the high level which combines an accreditation
business benefits of an accreditation scheme with integral peer review and
scheme to both providers and commis- support for improvement through a
sioners / purchasers of services. programme of action learning to support
Voluntary or mandatory? service modernisation and continuous
Whether an accreditation scheme improvement, and the establishment of
should be mandatory or voluntary is pathology (people) networks.
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Existing standards; measures and metrics?

Researching existing approaches to
benchmarking and accreditation in
the chosen domain is essential in the
interests of time and resources. Avoiding

Str long
at e t e
duplication is essential.

gic rm
Four critical
Checking out what standards,

ing suc
success factors

red ces
measures and metrics already exist will •Leadership

ien s
•Governance
not only save time and ensure appro-

ts f
•Strategic development plan

or
priate links and connections are made •Long term resource framework
with other complementary schemes; but
will make the task of scheme members
less burdensome. If an organisation Balanced scorecard for

Tac of p
already has been through a process of effective informatics services

tica rior
Delivery of services

l ev itie
accreditation to, for example, ISO 9000, Meeting user expectations

alu s
any accreditation scheme comprising Benefitting care delivery

atio
Positive effect on informatics staff

n
a comparable standard should accept
a statement of compliance (to be
supported by evidence if required) as Functional descriptions for each IM&T service component

Op eckpo
ch
Best practice service delivery models

era in
sufficient for its purpose. Reference to Options for deployment and management

tion ts
existing standards either as guides to Potential for standardisation and critical mass

good practice or as required evidence
of quality should be built into a scheme
and references to sources of information
and support be made available within
the scheme.
Measures and metrics should also be
both clearly defined and meaningful to
stakeholders. In designing any assessment
tool, stakeholders—service providers
and service purchasers / commission-
ers—should be involved and the tool
tested in a robust way to ensure sense,
appropriate use of language and ease
of use. A simple glossary to help define
terms might help avoid misunderstand-
ings and a loss of credibility for the
scheme and its content further down
the line; as will testing and piloting in
a cross section of organisation types and
environments.
A high level description of the tool
developed in England is provided below.
Behind the framework is an online tool
comprising 300+ measures and metrics.
It started life as a complex and macro-
Benchmarks and success criteria
information management and training
and development) to those delivering
just some of the possible elements of
service.
Conclusion
Quality improvement and value for
money, together with large scale invest-
ment in health informatics systems, are
at the heart of the need to ensure effec-
tive, efficient and safe health informat-
ics services available to support clinical
professionals twenty-four hours a day,
seven days a week, 52 weeks of the year.
The accreditation of individual practi-
tioners, teams and services to agreed
national / international standards are
themselves at the core of service improve-
ment goals.
A u t h o r
al
Figure 1
In the English NHS, a Health
Informatics Service Benchmarking
Club has been established with support
from NHS Connecting for Health but
owned and managed by the constituent
members (over 100 services have joined
the Club at the time of writing). The
next phase of the development, during
early 2009 will be to appraise a number
of modes and models of accreditation
already in existence and to consult
service commissioners and providers
on the business benefits and merits of
a national accreditation scheme. If such
scheme is supported and there is opti-
mism that this will be the case a service
provider will be procured during 2009
with a view to the scheme becoming
live in 2010.

rich MS Excel spreadsheet and is in the Di Millen has worked in the area of informatics education, training
final stages (early 2009) of conversion and development and workforce and service development for more
that fifteen years at local, regional and national levels.
into a web-based tool flexible enough to
support the assessment of services and
teams, from those delivering the full
range of informatics services (including

82 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09

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Patient Proxies in
Decision-Making
What computers can't capture
Healthcare policy makers
M
any technological, human,
face the challenging task of economic and knowledge
accessibility factors are making
balancing managements’ healthcare increasingly complex for provid-
requirements for quantified ers and consumers alike. This complexity
information with the often requires a form of decision-making that
unmeasurable realities balances the collection and use of techni-
of clinical decision- cal, rational information for cost-effective
evidence-based care and accountability,
making. Decision-making and consideration of patients’ interests
and healthcare policies and their wish to participate in clinical
need to be responsive decision-making. Alongside these chang-
to biomedical, personal, ing patient attitudes, health profession-
cultural, as well as als are increasingly taking on the roles
of patient advocate and proxy through
economic needs. patient-centred inter-professional deci-
sion-making.
Anne Croker
Research Associate
Different worlds and competing
Franziska Trede interests
Senior Lecturer
The worlds of health management and
Joy Higgs
Director patients collide on many accounts. Policy
makers and managers may look at patients
The Education for Practice Institute
Charles Sturt University, Australia
from the-point-of-view of a diagnosis that
needs to fit into particular groupings, a
body occupying bed days and a number
that needs to meet benchmarking targets.
However, there is a risk that care plans that
are developed without fully understanding
the patient’s situation are ineffective and
inefficient. Patients bring hopes, fears and
at times unreflected expectations to their
hospital stays. Health management inter-
ests may concentrate on measurable data
and efficient patient flow, whereas patients
want to be respected, listened to and well
cared for. A one-sided focus on electronic,
codified information may impede and
marginalise the complexity of professional
practice as well as silence the voices of
84 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09
patients. The challenge for stakeholders of
hospitals and other healthcare services lies
in providing balanced policies that enable
both worlds to blend to achieve acceptable
processes and outcomes for all.
Complexity of professional practice
There is a solid body of evidence-based
knowledge that guides best clinical prac-
tice of decision-making from biomedical
perspectives; however, this perspective is
only one amongst many. Other perspec-
tives include professional values and ethics
of healthcare professionals, cultural beliefs
of patients and their carers, staffing levels,
and economic perspectives of hospital
management. For example, we can under-
stand a young doctor’s recommendation
to a geriatric patient to start living in
institutionalised care in order to be safe.
We can also understand the reluctance
and resistance of patients to comply with
such a recommendation because they want
to remain in their home environment.
Delaying such a patient’s discharge can
be seen as an uneconomical approach to
hospital bed occupancy once all biomedi-
cal aspects of the patient’s care needs have
been addressed. Instead, providing oppor-
tunities for adequate discussions with
patients and their families, responding to
their concerns and searching for the most
suitable accommodation for individual
patients can be seen as a duty-of-care
approach to hospital bed occupancy.
Valuing patients’ voices and proxies
in team decision-making
Sharing patient stories may not fit comfort-
ably with the ‘body focus’ biomedical
model and procedural concepts of efficient
team meetings. While many team members
interviewed in the research valued the role
of storytelling for developing shared under-
standings of patients and their rehabilita-
tion directions, some were significantly
time pressured and preferred quicker meet-
ings. However, if teams routinely shorten
their case conferences there is a risk of
marginalising patients’ voices and proxies.
Health professionals’ contributions could
be reduced to discipline-centred reports of
progress, and teams’ foci could be narrowed
to collecting and recording information
for procedural purposes. In short, such
an approach to case conferencing would
thwart the incorporation of patient prox-
ies in shared decision-making. Critical
opportunities for building networks of
understandings about patients would be
missed.
Can we value what computers
can’t capture and policy makers
don’t see?
Accountability and reporting to other
team members are important aspects of
being a professional. However, account-
ability extends to patients and also to self,
not just the technical tasks of healthcare.
Deficiencies in procedural accountabil-
ity are often obvious, for example inad-
equate documentation can be identified
through monitoring of adverse events.
The situation is different for patients’
voices and proxies at team meetings.
While audible during meetings, these
voices then merge into decisions and
rehabilitation directions, and often disap-
pear. Once they become part of teams’
decisions there may be no evidence that
they were ever there.
Valuing what cannot be seen and
counted can be difficult. While policy
makers’ requirements for quantified infor-
mation from clinicians are not disputed,
the value of the often invisible informal
sharing at case conferences should not be
discounted. An unequal focus on techni-
cal rational information over patient-
centred narratives relies on the caring
attitudes of health professionals and the
Hearing patients’ voices and proxies in team decision-making
One area where complexities of professional practice are evident is the inter-professional
discussions that occur at case conferences or team meetings about patient care. These
meetings provide regular forums for doctors, nurses and allied health staff to discuss
patients. Members of the different professional disciplines bring their own perspectives
and understandings of their patients’ problems, abilities and contexts. As patients may
not be present during these discussions, there could be a risk that their perspectives and
wishes are obscured or sidelined within the milieu of health professionals’ contributions.
However, a recent qualitative research project exploring the experiences of collaboration
in rehabilitation teams found that patients’ voices and proxies were brought informally
to case conferences through the stories and anecdotes that health professionals shared
with each other (Croker, Higgs and Trede 2008). These overlapping conversational-
style interactions were interspersed between the formal sequences of contributions in
case conferences observed in this research. Team members shared stories describ-
ing patients’ conditions and situations, gave examples of insights and concerns, and
relayed extracts of their conversations with patients and families. These contributions
often stimulated responses from others and triggered recall of other incidents.
The patient’s voice became evident in these overlapping discussions, particularly
when team members repeated verbatim patients’ words in ‘she said’ or ‘he said’ types
of contributions. From these spontaneous and seemingly disordered interactions,
shared understandings of patients’ situations, aspirations and directions emerged.
These shared understandings often influenced team decisions. The following scenario
gives an example of how team decisions can be influenced by a patient’s proxy.
“He said he wants to go home on the weekend”: Following a stroke, Duncan was
admitted to a rehabilitation unit 250 kilometres from home. His wife Peg was torn between
spending time with Duncan and returning home to be with her elderly mother. Duncan
still required extensive assistance with everyday activities. When he initially expressed a
wish to return home with his wife for a weekend visit, the team were sceptical about the
feasibility of this. However, when they heard about how keen he was to see his friends,
sleep in his own bed for a weekend and take the pressure off his wife’s concerns about
her mother, they decided to work with his local health service, family and friends to
ensure that his visit would be adequately supported. His local health department provided
a shower chair, his builder friend put in a toilet rail, and his neighbours ensured that
someone was with him when his wife was visiting her mother. The visit went well and
Duncan returned to the unit with a new understanding about the progress required to
regain independence at home and renewed enthusiasm for rehabilitation.
Opportunities to relay patients’ hopes, fears, perspectives and aspirations through
the sharing of stories and anecdotes provided informal ways of bring their proxies to
meetings. However, in highlighting the contributions patient proxies make to patient-
centred clinical decision-making, this research also raises an important question: How
can a balance be achieved between the time taken to incorporate patients’ voices and
the need for team members to be responsive to work time pressures?
professional culture they create with each and anecdotes. While this may sound
other to bring patients’ voices and prox- obvious and mundane, there is a danger
ies to team decision-making. Adequate of overlooking such basic concepts when
time for case conferences, stability of team meetings are rushed or common
team membership, team social events and practice removes the patient’s voice from
sharing food during meetings are some the debate.
ways of creating suitable atmospheres in If patients’ needs and expectations are
which team members in this research feel to be valued alongside hospital procedures
encouraged to contribute their stories and documentation structures, policy
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makers need to not only appreciate but
actively support the notion that there
is more to healthcare than what can be
captured by computers and quantified
reports. With this awareness and lead-
ership, health managers can play a key
role in enabling and nurturing complex
professional practice. Key questions that
should be posed to scrutinise all policies
are: “Does this policy impede patient-
centred practice?” and “Where is the
patient in this policy?”
Conclusion
A patient-centred orientation to clinical
decision-making that includes patients’
hopes and fears can assist interprofessional
teams in making relevant and meaningful
decisions. Management can play a role
in supporting this by appreciating and
actively supporting a professional prac-
tice that is responsive to the complex
and human world of people in search
of improved health.
86 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
References
Croker A, Higgs J, Trede F, (2008) Shared decision making in rehabilitation teams: the role of
patient-directed proxy. International Conference on Communication in Healthcare, 2-5 September,
Oslo, Norway.
Anne Croker initially worked as a physiotherapist in the area of re-
habilitation, and then subsequently worked with teams of individuals
from different professional and consumer groups in an area of public
health. These experiences led to her current PhD research interest in
how members of rehabilitation teams collaborate with each other.
A u t h o r
Franziska Trede has extensive experience as a, university lecturer,
clinical physiotherapist, health communication researcher and hos-
pital policy adviser. She researches in the area of complexity, cultural
diversity, uncertainty and communication in clinical practice. She is
interested in exploring values, bias and practice philosophies that
shape the way clinician practise.
Joy Higgs is the Strategic Research Professor in Professional
Practice at Charles Sturt University. She has published widely, in-
cluding 14 books, in her fields of expertise in professional practice,
knowledge and education. In 2008 she published the third edition of
Clinical Reasoning in the Health Professions with Mark Jones and
colleagues.
ISS Ue - 18 20 09

Understanding
Healthcare Information
Product Description
In an age of internet resource guides,
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overall understanding of healthcare
information within the information society.
Author: Lyn Robinson The contents cover the domain of
Pages: 256 healthcare information; its organisational
Year of Publication: 2009 structures and history, and the nature of
its resources and the factors affecting
them. It looks at examples of healthcare
information resources from the perspective
e-Business in Healthcare
From eProcurement to Supply Chain
Management
Product Description
eProcurement in Healthcare is a book
that aggregates 5 years of experience
of three successive R and D projects
(ELCH, GetTogether, GROPIS) covering
technical and organizational issues of
eProcurement. The projects, which were
funded partly by the government and
partly by industry and hospitals, looked
at the characteristics of procurement
processes and at standard technologies.
Authors:
Two of the projects included case studies
D Karagiannis
(ELCH, GROPIS), the third project
N LeMaster
focused on the development of standard
Ursula Hübner
business objects for eProcurement in
Marc A Elmhorst
healthcare (GetTogether). Together they
Pages: 328 pages
form a rich source of information worth
Year of Publication: 2007
communicating to a large audience of
experts and newcomers alike. Results
from the projects are supplemented
it bookshelf
of different user groups, including
healthcare professionals and consumers
and goes on to highlight areas of research
into healthcare information, including
evaluation studies, user studies, impact,
bibliometrics, metadata and web 2.0. This
title features themes such as: healthcare
information background, nature and
drivers for change; healthcare information
resources, users and services; and,
healthcare information research. This book
would be of interest to anyone working
in the field of library and information
science wishing to understand healthcare
information, especially public librarians,
who are increasingly called on to advise
on health resources, as well as anyone
interested in ‘healthcare literacy’.
by the contributions of international
experts and their particular views on
eProcurement, which gives the book a
global perspective and hence allows its
readers to learn from a variety of different
approaches. Each chapter of the book
is structured in a way that satisfies the
needs of executives as well as academics.
A management summary, tables and
graphics together with key statements of
experts allow the quick reader to capture
the main message of each chapter,
whereas background information and
reference to the literature address readers
who wish to gain a deeper and more
comprehensive insight into the field. The
management summary and the expert
statements will appear in boxes separated
from the main text by visual cues, e.g.
background color, font size, font type.
www.asianhhm.com 87
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Advances in Telemedicine Systems
Frost & Sullivan
Synchronous telemedicine is an indus-
try, which though a part of the medical
and healthcare industry vertical, is more
affected by the developments and changes
in the communication industry. The tech-
nology belonging to telemedicine, which
is basically remote data communication
system cardinally belongs to the informa-
tion communication technology (ICT)
industry. The data that these commu-
Advances in Clinical Information Systems
An Impact Analysis Frost & Sullivan
Clinical Information Systems (CIS) is
an industry, which though a part of the
medical and healthcare industry vertical,
is more affected by the developments
and changes in the IT industry. The
technology belonging to CIS is basi-
cally information system, which is IT in
nature. The data that these information
systems acquire, process, and archive is
medical or rather clinical data. Hence,
the CIS industry is a fusion of the IT
and healthcare Industry.
This research explores the overall
technologies in the market and R&D.
88 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
nication systems dynamically acquire,
process, and communicate in either half
duplex or full duplex manner is medical
or rather clinical data acquired through
the biosensing modes. Hence, the tele-
medicine industry is a fusion of the ICT
and healthcare Industry.
This research explores the overall
technologies in the market and R&D.
It focuses on examining the telemedicine
It focuses on examining the clinical
information systems industry and appli-
cations that drive the larger markets.
Frost & Sullivan provides an integrated
focus by ferreting out the trends of the
vendor community, the opinions of the
IT community, and the needs of the
user community. The research service
not only reports the opinions and views
of the entire global community linked
with the CIS industry, but also further
analyzes the impact of these opinions and
trends. This sort of analysis has facilitated
the portrayal of a constructive future
ISS Ue - 18 20 09
systems industry and applications that
drive the larger markets. Frost & Sullivan
provides an integrated focus by ferret-
ing out the trends and opinions of the
vendor community and the opinions of
the ICT experts at Frost & Sullivan, the
opinions of the academic community,
and the needs of the user community.
The research service not only reports the
opinions and views of the entire global
community linked with the telemedicine
industry, but also further analyzes the
impact of these opinions and trends.
This sort of analysis has facilitated the
portrayal of a constructive future for this
industry. There are two types of tech-
nology forecasts done here. First, the
research service gives a roadmap of the
technological developments occurring
over time and forecasts the developments
in the industry. Second, this research also
talks at length at the developments in the
individual technologies (comprising the
telemedicine industry) and charts out
the mechanism in which developments
will occur.
for this industry. There are two types of
technology forecasts done here. First, the
research service gives a roadmap of the
technological developments occurring
over time and forecasts the developments
in the industry. Second, this research also
talks at length at the developments in
the individual technologies (comprising
the CIS industry) and charts out the
mechanism in which developments will
occur. Further to it, based on the future
forecast, this research service also identi-
fies a new type of service business model
that will easily branch out CIS.

Healthcare Technology – Opportunities
in the Electronic Health Record Market
Datamonitor
EHRs will help change the healthcare
industry from today’s reactive, frenetic
environment to one that is more proac-
tive, informed and leverages planned
workflows. The majority of players in
healthcare realize this, but reaching a
consensus on how to make this transition
has been difficult to say the least. This
report will explore the EHR market and
its technologies in four different ways.
The Market Focus section establishes
the context for the report, focusing on
key drivers and inhibitors in the EHR
market. The Strategy Focus section offers
insight into the evolving EHR market and
analyzes different approaches to increasing
EHR adoption. EHR technology trends
are discussed and parallels between EHRs
and technology solutions in other indus-
tries are drawn in the Technology Focus
section. Finally, the Databook sections
provide a five-year forecast on EHR spend-
ing segmented by geography, technology
and application.
Examining the Global Market for
Electronic Health Records (Market
Focus)
The Market Focus section discusses the
main factors affecting the EHR market,
specifically those driving and inhibiting
the adoption of technology.
EHRs are a major breakthrough in
healthcare. They will change the ways in
which healthcare is delivered and medicine
is practiced, improving care and creating
a more efficient system. However, the
obstacles organizations face implementing
these solutions will be anything but small.
Datamonitor will discuss the following
issues influencing the uptake of EHRs
in the global healthcare market:
• Electronic health records will become
a “must-have” for healthcare organiza-
tions;
• EHR adoption will be inevitable due
to internal as well as external factors;
and
• Cost is the most significant, but not
the only, barrier to adoption.
Using a Multi-faceted Approach to
Increasing EHR Adoption (Strategy
Focus)
The Strategy Focus section forecasts the
size of the global EHR market through
2012 in addition to providing an overview
of strategies to increase EHR adoption.
The potential for EHRs is not diffi-
cult to comprehend, but the adoption of
the technology has been painfully slow.
Though the barriers to EHRs are signifi-
cant, Datamonitor believes the market will
grow rapidly during the next five years
and the rate of adoption will increase
through multiple strategies. This brief will
explore the following statements about
EHRs in more depth:
• Worldwide interest in EHRs will
continue as the market evolves; and
• No one-size-fits-all, but EHR adoption
will increase if approached from many
angles.
Leveraging Existing Technologies
for Electronic Health Records
(Technology Focus)
The Technology Focus section provides
an analysis of technology-specific trends
in the EHR market and a framework for
prioritizing EHR investment.
EHR technologies have improved
immensely over the last few years but are
still far from perfect. Vendors, however,
do not need to design every new feature
of EHRs from scratch. Datamonitor
believes the following ideas will help
further advance EHR technologies and
aid end-user implementation:
• No need to reinvent the wheel: EHR
Industry
reports
technologies are already available in
other industries; and
• As EHRs become more advanced, they
will require solutions from multiple
vendors.
North American Spending on
Electronic Health Records Through
2012 (Databook)
This Databook section provides datas-
ets relating to EHR spending in North
America. Key information provided in
this Databook section includes:
• Spending by country as well as technol-
ogy segment; and
• Comparisons between hospital and
ambulatory care markets.
European Spending on Electronic
Health Records Through 2012
(Databook)
This Databook section provides datasets
relating to EHR spending in Europe. Key
information provided in this Databook
section includes:
• Spending by country as well as technol-
ogy segment; and
• Comparisons between hospital and
ambulatory care markets.
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European Healthcare IT Outsourcing Market

Frost & Sullivan
Objectives Scope Emerging Scenario for Vendors in
The objective of the research is to present The market for healthcare IT Outsourcing Europe
a comprehensive analysis of the Euro- systems is witnessing increasing activ- The Current Scenario Wherein Customers
pean healthcare IT outsourcing market. ity across Europe. The market can be are Adopting Technology to Boost
The analysis includes the factors driving broken down into three segments that Productivity and User Confidence
growth, challenges, revenue forecasts are examined in the report: Will Change in the Coming Years With
through 2010 and opportunities within • Applications Management More Stress on Competitive Pricing
the market. Outsourcing and Solutions Capabilities as a Whole.
Detailed financial analysis of • Infrastructure Management Services Will Have the Power to Tilt
European healthcare IT outsourcing Outsourcing the Scales.
market is presented. The analysis is based • Integration Services Outsourcing
on four key factors. The geographical regions analysed Competitive Structure in Europe –
• Forecasted market dynamics include: Germany, United Kingdom, Healthcare IT Outsourcing Vendors
• Market shares France, Italy, Spain, Benelux and Types of Competitors
• Segment revenues Scandinavia. • Pure IT Solution Vendors Offering
• Regional trends Outsourcing Services
• Healthcare IT Vendors Able to Offer
Regional Analysis
Outsourced Applications
Applications/ Germany, France, Emerging Markets Segment • IT Consulting and Services Firms
Infrastructure/ Uk, Italy Trends • Infrastructure/Technology Outsourcing
Segments

Integration Services
Vendors
Market Engineering $ 396.4 million Growth Rates $697.71 Distribution Structure
Measurements (2005) Million • Sales Subsidiaries and Independent
(2010)
Distributors, Partnerships
Market Metrics

2008
Highlights Featured Applying Path Innovation
Healthcare IT Seeking revolutionary HIT
articles Healthcare requires a revolution in the way
we deliver care by utilising IT in new and
innovative ways. Path innovation allows
experts to work together in the develop-
ment of workflows that best leverage HIT.

Semantic Web and Patient Records Online Barry P Chaiken, Fellow of HIMSS, USA

Translational Medicine Shared access for

Creating the next generation
healthcare enterprise
Translational Medicine, which aims to
improve communication between the basic
and clinical sciences, coupled with informat-
ics and semantic technologies will help in
creating the next generation healthcare
enterprise.
Vipul Kashyap, Clinical Informatics R&D
Partners Healthcare System, USA
quality care
Online Personal Health Records signal a
aradigm shift in the management of a atient
data. By allowing easy access to patient
nformation, online health records can
enhance patient care and create a healthy
doctor-patient relationship.
Prasanthi Potluri, Editor
Asian Hospital & Healthcare Management
Akhil Tandulwadikar, Editor
Asian Hospital & Healthcare Management
Healthcare IT
Innovations for better care
Innovations will move to areas of consumer
empowerment by providing greater ac-
cess to services and information including
personal health applications populated with
data.
Thomas M Eberle, Senior Clinical
Architect, Digital Health Group
Intel Corporation, USA

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 Industry
reports

European healthcare IT outsourcing and

Drivers European Healthcare IT
ASP market-key drivers and restraints, 2006-2010
Outsourcing and ASP Market:
Increasing focus on Core-Competancies Conclusions
And Advantages Associated with
Increasing Emphasis on The ASP Model IT Modernization
• The European healthcare IT market is
Post-Clinical Care Initiatives set to experience steady growth riding
Impact on the initiatives shown by regional
Low Medium High
and national health authorities
Issues Related Lock of Quality
• State of the art information technology
to Patient-Data in-house solutions adoption is inevitable. Some
Ownership Management inputs
regions will move swiftly to capital-
Fragmented Nature Improper Identification ise on the benefits to the healthcare
of the Industry of Strategic Sourcing
Needs industry. These markets represent the
Restraints biggest potential for Outsourcing.
• Three main segments identified in the
Competitive factors application software via the Internet healthcare IT outsourcing market.
• Ability to offer flexible scalable solu- • Widen business opportunities, save Several sub-systems likely to gain
tions time and money importance in the market. The speci-
• Integration of new systems with exist- • Access to high-end software applications fications of Integrated Care will drive
ing HIS platforms Who is Providing ASP in Europe the outsourcing markets.
• Services support during implementa- • Independent Software Vendors • European technology vendors in a strong
tion and beyond • System Integrators position to consolidate market share.
• Ability to maintain a diverse and satis- • Telecom Companies Global players will not give up the fight
fied client portfolio What Does the Future Look Like for ASP in to attain respectable market share. Fair
Healthcare amount of consolidation / joint ventures
From Outsourcing to ASP- The Next • Increase in delivery of new applications expected in the industry.
Step? by this model
Utilities of ASP in Healthcare • ASP enabling of old complex healthcare For more reports,
• Provide outsourced management of IT applications visit knowledge bank section of
www.asianhhm.com

Commoditising Healthcare IT
The next wave
With the costs of healthcare rapidly increasing, the monolithic model of
HIT is no longer sustainable. HIT commodity capability that provides a
new level of convenience and serviceability to the healthcare environ-
ment while being cost-effective.
Werner van Huffel, Health and Social Services, Industry Strategist
Regional Public Sector Group, Microsoft Asia Pacific, Singapore

Medical Banking Information Technology in Healthcare

A new stakeholder
As the management of healthcare data progressively moves to
an electronic platform, banks are realising that their technical
systems, privacy and security frameworks, identity management
engines and marketing channels can be leveraged to fast forward
e-Health.
John Casillas, Founder
The Medical Banking Project, USA
Creating a stronger healthcare system
While improving computer systems would not eliminate all medical
errors, researchers believe it will reduce the errors dramatically. Now
is the time to share progress, challenges and best practices to enable
interoperability and link the ecosystem
in the delivery of better quality care.
Madhav Ragam, Director
Healthcare & Life Sciences, IBM Asia Pacific, Singapore

w
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Microsoft and HIMSS launch
IT

Health Users Group

The Microsoft Corp. and the Healthcare Information and Management
Systems Society (HIMSS) launched the Microsoft Health Users Group
HL7 publishes (Microsoft HUG) across Europe, the Middle East and Africa (EMEA). The
launch was announced at the World of Health IT Conference and Exhibition
PHR standards in Copenhagen, Denmark.

draft
The Health Level Seven (HL7) Personal Health Record
System Functional Model (PHR-S FM) is available as a
draft standard. It has been made available for download
as a trial use. The PHR-S FM allows global users to
work with a stable standard for up to two years while
it is being refined into an American National Standards
Institute-accredited version.
The PHR-S FM defines the set of functions that
may be present in PHR systems to create and manage
an effective PHR. It also offers guidelines that facilitate
health information exchange among different PHR
systems and between PHR and EHR systems.
Microsoft HUG comprises more than 5,000 members and 31 corpo-
rate supporters across North America.
Intel introduces Health Guide
Intel introduced a new device, Intel Health Guide in a series of health
monitoring devices aimed at tracking chronic and age-related conditions.
The technology offers interactive tools for personalised care management
and includes vital sign collection, patient reminders, surveys, multimedia
educational content and feedback and communications tools such as
video conferencing and alerts.
The Intel Health Guide combines an in-home patient device with an on-
line interface—the Intel Health Care Management Suite—making it possible
for clinicians to monitor patients in their homes and manage care remotely.

Europe launches its health data

exchange pilot
With the support of European Commission, involving 12 European countries, a project
titled European Patient Smart Open Services (epSOS) ‘large scale pilot’ has been un-
dertaken for ensuring healthcare interoperability of national e-health systems in Europe.
The countries involved in the epSOS project are Austria, the Czech Republic, Denmark,
France, Germany, Greece, Italy, the Netherlands, Slovakia, Spain, Sweden and the UK.
The project plans to connect what already exists. Through this large pilot, the coun-
tries will look at all of their systems for electronic health records and see what can be
shared and every member country has its own system of storing healthcare information,
yet these systems often can’t ‘talk’ to each other.

SRISHTI SOFTWARE APPLICATIONS PVT LTD

PARAS, HMIS, PACS, INTEGRATED EHR SYSTEM AND
profiles of TELE-HEALTHCARE SYSTEM
it companies Srishti Software Applications Pvt. Ltd. is a specialized
software engineering and business solutions com-
pany. Established in 1997, Srishti now serves global
clients across various sectors. Among the notable
clients of the company are healthcare institutions, big
corporates, financial service companies, and media
companies. Srishti, with headquarters located in
Bangalore, has offices in Delhi, Mumbai and London.
Its wholly owned subsidiary IntelliApp is a UK based
services provider. Key markets served by Srishti are
UK, USA and India. Presently strong efforts are being
made by the company to enter new markets like
Middle East, Africa and East Asia.
The company broadly offers
• A one stop HMIS for a wide variety of healthcare
service providers
• Offers integrated electronic patient records across
entities in the healthcare universe
• Best in close image recording and communica-
tions platform to exchange critical components of
patient records (PACS)
• Offers powerful assisted diagnostics and prescrip-
tion to support healthcare delivery
• Guarantees clinical pathways following accepted
global standards
• Features powerful tele-healthcare functionalities
to adapt to a geographically dispersed healthcare
delivery organization. PARAS-The Healthcare Suite
from Srishti.

92 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09

 happenings
in 2008

Google Health introduces application

to help patients with prescriptions
Google Health added a new application to help users find assistance programs
for their prescription medications online using PatientAssistance.com. This new
application allows users to automatically search for patient assistance drug pro-
grammes they are eligible for on the basis of medications included in their Google
Health profile.
Rex Bowden, President, PatienceAssistance.com said, “our new integrated
service on the Google Health platform is designed to make that process much
easier by allowing users to search for programs on multiple medications at once,
while using existing information to save time in searching for eligible programs that
meet all, or most, of the patient’s needs.”

PHRs emerge as the Robotic technology boosts

biggest trend
2008 was the year for more opportunities and
challenges in Healthcare industry. Personal Health
Records (PHR) emerged as the biggest trend all
set to change healthcare. Entry of Google (Google
Health) and Microsoft (HealthVault) and many other
online PHR services marked this trend. PHRs will help
patients to get connected to numerous data sources
and manage their own health records.
With the increasing focus on the patients, PHRs
are likely to evolve in the future in a big way and
adopted by consumers. The prevalence of PHRs will
create many challenges for healthcare institutions,
payers and employers.
stroke recovery
Scientists have performed first study using a new, hand-operated robotic device
and functional MRI to map the brain in order to track stroke rehabilitation.
Functional MRI measures the tiny changes in blood oxygenation level that occur
when a part of the brain is active.
From this study, scientists have found that chronic stroke patients can be
rehabilitated. And the results showed that rehabilitation using hand training sig-
nificantly increased activation in the cortex, which is the area in the brain that cor-
responds to hand use. Furthermore, the increased cortical activation persisted in
the stroke patients who had exercised during the training period but then stopped
for several months.
For more happenings,
visit www.asianhhm.com

PHENIXVISION
PhenixVision is a company with a conscience and a soul. Our exist-
ence is governed by our belief in these core values. PhenixVision
provides the software solution like the lifeblood of digital radiography
system. Its products and services have always been designed to
meet the needs of enterprises and consumers alike. PhenixVision
has been focused like a laser on high quality, high speed, high cost-
efficiency of Digital Radiography system.
PhenixVision established FUMA as an image processing tool
and DXView as an operating workstation for various kinds of digital
radiography systems based upon amorphous-silicon, amorphous-
selenium, and CCD, and linear scan detector, etc. PhenixVision is
composed of experts with many experiences in medical imaging
field. Since its inception in 2001, as a global digital radiography solu-
tion provider, PhenixVision has provided the products and services of
unparalleled quality which can accommodate a wide variety of needs
in a dynamic environment.
FUMA is the PhenixVision’s unique software technique which in-
corporates the fuzzy concept into the image enhancement method:
• It creates homogeneous image (pre-processing)
• It provides an important step to aid a physician in visualizing detail
and structure of the lesions
• It improves diagnostic utility as well as the properties of soft and
hard tissues
• It provides the ability to reduce noise and unwanted background
that may affect the visualization quality of digital radiograph.
DXView, an optimized and easy-to-use operating workstation,
fully conforms to international standard protocols, and the acquired
digital images are immediately sent to PACS network, or laser cam-
era for film printing:
• Its workflow, in conjunction with digital x-ray control interface and
elegant graphical-user-interface, assures maximum diagnostic
flexibility and increased patient throughput
• It supports full integration of digital radiography system
• Synchronization of the timing between the detector and x-ray
equipment
• Digital control interface of various x-ray generator.
PhenixVision’s customers are now satisfying their customers
completely. It is very encouraging for all of us.
For more companies,
visit www.hospitals-management.com

www.asianhhm.com 93
 2008
Highlights featured
non-healthcare it
articles

Globalised Healthcare Echocardiography

What lies ahead New and evolving roles
Echocardiography plays a key role in the di-
With the increasing complexity of globalisation, escalat- agnosis of many cardiac conditions and in the
ing cost of healthcare and rapid advances in technol- assessment of response to therapies. Despite
ogy—both equipment and IT—the challenges and choices the emergence of new, advanced diagnostic
facing the practising physician, managers and leaders are tools such as cardiac computer tomography
daunting. The effects of these changes on patient care and cardiac magnetic resonance, echocardi-
may be even more difficult to discern. ography still plays an important role in patient
Basri JJ Abdullah, Professor care because of its unique capabilities.
Department of Biomedical Imaging, Faculty of Medicine Michael H Picard, Director
University of Malaya, Malaysia Echocardiography, Massachusetts General
Ranjit Kaur, Lecturer Hospital, USA
Department of Biomedical Imaging, Faculty of Medicine
University of Malaya, Malaysia
Patient-Centred
Care Pathway for Total Hip Replacement Healthcare
An innovative approach Moving beyond ailment
Using clinical pathways to standardise care across the continuum—from the physi- An involved patient is a blessing for health-
cians’ office to the O.R., recovery post operation—improves communication among care organisations, provided they are able
the care-giving team. The pathways are also a tool to educate and involve patients to facilitate comprehensive communication
in their care, as they identify variation from expected outcomes and goals. Pathways between the staff, physicians and the patient.
improve the delivery of care to patients through encouraging early ambulation for To enable this, providers would need to put in
those patients who undergo total hip replacement surgery while increasing clinical and place an appropriate channel of communica-
organisational efficiency and revenue. tion. Unless healthcare establishments take it
upon themselves to introduce a patient-cen-
Yosef D Dlugacz, Senior Vice President and Chief tred approach organisation-wide, a change
Clinical Quality Education and Research, Krasnoff Quality Management Institute, of this proportion can never be positive in the
USA long run.
Carolyn Sweetapple, Vice President Akhil Tandulwadikar, Editor
Finance and Business Operations, Krasnoff Quality Management Institute, USA Asian Hospital & Healthcare Management

Techno ACuRay™ chip, a new technology

trends
Posture device
featuring Nanosensor
Technology
Moacir Schnapp, a Memphis-
based neurologist has launched
a posture correction device. His
innovation, called ‘the iPosture’, is
intended to aid men and women
in improving their posture that
benefits their health in the long
run. The iPosture is to be worn for
approximately four hours each day
for the initial two to four weeks in
order to correct posture by estab-
lishing a habit in the user.
for cancer screening
Researchers from the Georgia Institute of Technology have launched ACuRayTM (which stands for
ACoustic micro-arRay) a acoustic sensor that can detect, treat and monitor cancer in patients. It
can report the presence of small amounts of mesothelin, a molecule associated with a number of
cancers including mesothelioma, as they attach to the sensor’s surface. The findings of the research
were reported at the American Association for Cancer Research’s second International Conference
on Molecular Diagnostics in Cancer Therapeutic Development.
Luminex launches xTAG™
Respiratory Viral Panel
Luminex Molecular Diagnostics, a division of Luminex
Corporation, has launched xTAG Respiratory Viral Panel (RVP),
an assay for the detection of multiple viral types and subtypes,
including influenza, metapneumovirus and adenovirus. xTAG has
been developed in association with a team of leading virologists
and infectious disease specialists. The test can assess 12 viral
targets at once and provide qualitative results in just few hours.
The test has received 510(k) clearance from the US Food and
Drug Administration (FDA) and CE mark for sale in Europe.

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 Global Health Landscape
Healthcare “beyond borders”
At a time when the global citizen is transforming how healthcare
is delivered worldwide, there’s a need for a vision for delivering
coordinated, high-quality and affordable care “beyond borders.”
Ori Karev, CEO, UnitedHealth International, USA
Telemonitoring in
Cardiac Device Therapy
Enabling optimal management of patients
The vastly increased complexity of cardiac rhythm therapy over the
past several years, demands commensurate improvements in overall
device monitoring and telecommunication technology.
Auricchio Angelo, Professor
Division of Cardiology, University Hospital, Germany
Devices Containing Membranes
Better membrane, improved outcomes
Devices containing artificial membranes for the treatment of kidney
disease lack the ability to replace or augment metabolic and endo-
crine functions, which are non-selective and biologically reactive.
Nicholas Hoenich, Clinical Scientist
Medical School, Newcastle University, UK
Queen’s University introduces
innovative antennas
Experts at Queen’s University, Belfast, UK have intro-
duced a new type of antenna that is up to 50 times
better and efficient than the existing designs. The new
design is capable of utilising ‘wireless body area net-
work’ (WBAN) technology to full potential. A WBAN is
a network of biosensors attached to different parts of
a patient’s body.
Digital Ward
Hospital of the future
Imagine a future where hospital wards have no paper case
notes or files. Information on a Patient’s medical condition is
automatically captured via intelligent context-aware devices and
sent directly to the central computer systems.
Noah Tay Chin Seng, Manager
Fong Choon Khin, Group Chief Technology Officer
Grace Ng Yi Lin, IT Specialist
Yvonne Eng, Systems Specialist
InfoTech department Singapore, Health Services Pte Ltd
(SingHealth), Singapore
Medical Devices Meet
Consumer Electronics
Revolution in healthcare delivery
Advanced semiconductor technology is transforming healthcare.
At the vanguard is an entirely new way of monitoring the human
body-wirelessly, intelligently and at low cost. Microchip-sized
wireless body monitoring systems are offering quality of life for
users and providing critical data for healthcare professionals.
Alison Burdett, Director
Technology, Toumaz Technology, UK
Stanford researchers develop
new Spectroscopy technique
A team of researchers from Stanford University School of Medicine
has developed a new type of imaging system that can depict tu-
mours in living subjects with a precision of around one-trillionth of a
meter. The technique is called Raman Spectroscopy. This is the first
time the technology is being used to see deep within the body.
World’s first Bluetooth(R)-Enabled,
Wireless Fingertip Pulse Oximeter
The US-based Nonin Medical, Inc. has introduced a wireless fingertip
oximeter with Bluetooth wireless technology for the first time. The
fingertip oximeter assists patients who suffer from diseases such
as chronic obstructive pulmonary disease (COPD) and congestive
heart failure (CHF) by allowing vital signs to be easily monitored and
sent wirelessly through communication devices (cell phones, PDAs,
PCs, etc.). Patients can also take readings outside of the home and
transmit the time-stamped data after their return using the device’s
Store and Forward facility.
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96 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISS Ue - 18 20 09
 HEALTHcare
projects

Apollo to set up a medicity Macquarie University to set up

focussing on Ayurveda
Apollo Hospitals has revealed its plans to set
up a medicity in the state of aharashtra in
India. The new construction will take place
in collaboration with Hindustan Construction
Co (HCC), a real estate firm. A total of US$
47 million will be invested for the project. It
will offer ‘first rate ayurveda treatment’. There
would be facilities for ayurvedic healing of
various diseases and complete rejuvenation.
The effort will boost the medical tourism
scenario in the country. Apart from all his,
Medicity will be involved in extensive research
on cancer and heart related issues. To begin
with the hospital will have 50 beds and will be
upgraded to a 150-bed hospital by 2012.
new Private Hospital in Australia
Macquarie University and Dalcross Private Hospital based in North Ryde New South Wales
in Australia have announced plans for a joint venture to build a private hospital with an
investment of US$ 80 million. The new Macquarie University Private Hospital will deliver
medicine involving training, medical research and high quality patient care.
KPC to build a Healthcare City in West Bengal, India
KPC Healthcare Services, a part of US-based KPC Group has revealed its plans to build
an integrated healthcare city in West Bengal, India. The company has acquired around 300
acres of land for the healthcare city. KPC Healthcare Services is investing around US$ 325
million in the project.
The Healthcare City will include a 750-bed medical college, a 260-bed multi-speciality hospital,
a 400-bed super speciality hospital, an infectious disease hospital, medical information
technology centre and a medical store that will sell medicines and healthcare consumables.

Balco to build US$ 75 Apollo to set up a Panacea Biotec

million cancer hospital in
Chhattisgarh, India
The Bharat Aluminium Company Ltd (Balco),
a part of the India-based Vedanta Group, has
announced its plans to build a new cancer
hospital and research centre in north Indian
state of Chhattisgarh with an investment of
US$ 75 million (Rs 300 crore). The project
is expected to be completed in the mid
of 2010. This new hospital will be the first
of its kind in the state. Apart from regular
health services, Balco plans to provide free
healthcare to the poor people of the region.
The Chhattisgarh state government has
allocatd a 41 acre plot of land free of cost to
Balco for the new hospital.
medicity India to build a
new Cancer Institute
The Government of India is going to
build a National Institute for Cancer in
the South Indian city of Chennai. The
institute will have research, service
and education activities and will
be the first-of-its-kind in India. The
institute will be built on 10 acres of
land in Vepery, Chennai. This will be
the second Cancer institute to open
in Chennai. The institute is expected
to be operational by mid 2011. The
government of India is ready to make
an investment of US$ 125.2 million.
plans to set up a
multispeciality hospital
Panacea Biotec, a health management firm
has revealed its plans to set up a multi-
speciality hospital with Gurgaon-based
Umkal Medicals. Panacea Biotec has 75 per
cent stake in Umkal’s project at Gurgaon.
A total of US$ 200 million will be invested
for the project. Upcoming hospital will have
overseas patients and affluent Indians as its
target making 25-30per cent of the market.
For more projects,
Visit Knowledge Bank section of
www.asianhhm.com

events
February
February 12- 13, 2009
Chronic Heart Failure and Hypertension
Venue: Institute of Physics, London
London, United Kingdom
Organiser: MA Healthcare Ltd
Email: lisa.f@markallengroup.com
www.mahealthcareevents.co.uk
February 21 - 23, 2009
Meditec-Clinika 2009
Venue: Hitex Convention Centre,
Hyderabad, Andhra Pradesh, India
Organisers: Orbitz Exhibitions Pvt. Ltd.
Email: sksingh@meditec-clinika.com
www.meditec-clinika.com
February 24, 2009
Reducing Medication Errors 2009
Venue: Manchester Conference
Centre, Manchester, UK
Organiser: Healthcare Events
Email: matt@healthcare-events.co.uk
www.healthcare-events.co.uk/conf/
booking.php?action=home&id=240
February 26 – 27, 2009
Hospital Management
Sydney Harbour Marriott
Sydney, NSW, Australia
Organiser: Informa
Email: info@iir.com.au
www.iir.com.au/bedmanagement
March
March 10 - 12, 2009
The 5th Annual World Health
Care Congress - Europe
Venue: Berlin, Germany
Organiser: World Congress April
Email: indsay.pater@worldcongress.com
www.worldcongress.com
April 1-3, 2009
13th Southeast Asian Healthcare
March 11-13, 2009 & Pharma Show 2009
5th Health Asia 2009 Venue: Kuala Lumpur, Malaysia
Venue: Karachi Expo Centre, Pakistan Organiser: ABC Exhibitions
Organiser: Ecommerce Gateway Email: sales@abcex.com
Pakistan (Pvt.) Ltd www.abcex.com
Email: info@health-asia.com
April 16 - 19
www.health-asia.com The 6th Annual World
Health Care Congress
Venue: Washington DC, USA
Organisers: World Health Congress
March 14-16, 2009 Email: amy.wilder@worldcongress.com
HOSPIMedica India 2009 www.worldcongress.com/events/
Venue: Bombay Exhibition Center HR09000/index.cfm?confCode=HR09000
Goregaon, New Delhi, India
Organiser: Messe Dusseldorf India For more events,
Email: UllalS@md-india.com visit www.hospitals-management.com
www.hospimedica-india.com and www.asianhhm.com
www.asianhhm.com 97

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Diagnostics
Inverness Medical Innovations, Inc.............................................5
Greiner Bio-One GmbH.............................................................41
Facilities & Operations Management
Ratcliff Architects . ..................................................................47
Robinsons Global Logistics......................................................49
Healthcare Management
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International Business Conferences .........................................15
Inverness Medical Innovations, Inc. ...........................................5
Information Technology
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Acuity Information Systems Private Limited........................... OBC
Binary Spectrum .....................................................................84
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Medical Sciences
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Shimadzu (Asia Pacific) Pte Ltd . .............................................45
Surgical Speciality
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Technology, Equipment & Devices
Electrolux Professional SpA ....................................................IFC
Hitachi Medical Systems (S) Pte Ltd....................................... IBC
Inverness Medical Innovations, Inc ............................................5
Shimadzu (Asia Pacific) Pte Ltd . .............................................45
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Aavanor Systems Pvt. Ltd. ......................................................67
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Acuity Information Systems Private Limited........................... OBC
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Binary Spectrum .....................................................................84
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Elekta Limited .........................................................................27
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Electrolux Professional SpA ....................................................IFC
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Greiner Bio-One GmbH.............................................................41
Hitachi Medical Systems (S) Pte Ltd . .................................... IBC
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International Business Conferences .........................................15
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Inverness Medical .....................................................................5
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Plus ninety one .......................................................................19
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Ratcliff Architects . ..................................................................47
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Robinsons Global Logistics .....................................................49
www.rglindia.com
Shimadzu Asia Pacific Pte Ltd ................................................ 45
www.shimadzu.com.sg
Wipro HealthCare IT Limited ....................................................57
www.healthcareit.wipro.com/aboutus.htm
To receive more information on products & services advertised in this issue,
please fill up the "Info Request Form" provided with the magazine and fax it, or
fill it online at www.asianhhm.com by clicking "Request Client Info" link.
1.IFC: Inside Front Cover 2.IBC: Inside Back Cover 3.OBC: Outside Back Cover