Issue 19 2009 £12 €18 $25 Rs.300 www.asianhhm.

com

Between
Public and
Private Care
in India

Cultural, Social & 21st Century Home Telehealth

Linguistic Barriers Healthcare Understanding
Can they be overcome? New paradigms the outcomes

Healthcare in India
A picture of contradictions
“...whatever you can rightly say about India, the opposite is also true”.
- Professor Joan Robinson as quoted by Dr Amartya Sen
T
his observation is perhaps best vindicated by
the state of healthcare in India. While the private
healthcare continues to grow buoyed by invest-
ments from domestic and international healthcare provid-
ers, the condition of state-owned healthcare institutions
remains as appalling as it used to be before the private
sector boom. According to the Government of India’s
10th Five-year plan, private sector accounts for “82
per cent of outpatient visits, 58 per cent of inpatient
expenditure, and 40 per cent of births in institutions.”
This number has steadily grown post-independence
when private sector used to account for 4 - 5 per cent
of the total healthcare provided.
It is not difficult to understand why. Over the decades,
the care provided by the state-owned institutions has
steadily deteriorated thus forcing people to look for
alternatives. The private sector, however, with its profit-
oriented approach and also , the encouragement from
the government due to booming medical tourism, has
grown from strength to strength.
The public spending on healthcare, at around 0.9
per cent, is among the lowest in the world. The prob-
lem with this situation, obviously, is that while people
living in cities have access to the best healthcare money
can buy; the majority of the country’s population that
lives in rural areas has access to mediocre quality of
care resulting in high-mortality rates even in cases that
could be easily managed if the standards procedures
are followed. This condition is further aggravated in
times of natural disasters and pandemics. Employing
the services of the private providers is often a big strain
on their finances for the rural folks. It is imperative for
the government to shift its focus to improve the present
deplorable state of rural healthcare.
Foreword
Fixing the healthcare system, however, will require
a multi-pronged effort that targets various aspects of
healthcare such as healthcare research, quality stan-
dards and infrastructure and so on. An approach that
focusses on improving access to healthcare that adheres
to minimal standards of safety and quality with continu-
ous improvements is the need of the hour.
Among some of the positive steps towards over-
coming these issues, the government has set up the
National Accreditation Board for Hospitals and Healthcare
providers. But this was long overdue when it was intro-
duced in the year 2006. Stricter implementation of the
Board’s standards and mandatory certification for private
and public providers could go a long way in boosting
the quality of care provided, especially in the state-
run institutions. Also healthcare insurance needs to be
encouraged all over the country so that financial strain
is reduced for rural and urban patients alike.
This issue of Asian Hospital & Healthcare Management
features expert views from Debasish Mishra, Executive
Director at PricewaterhouseCoopers, India and
Dr Pradeep Chowbey, one the leading surgeons in the
country on the situation of healthcare in India and what
factors will influence its future.
Akhil Tandulwadikar
Editor
 State of Indian Healthcare

18 Unfolding opportunities
Debasish Mishra, PricewaterhouseCoopers, India

State of Indian Healthcare

22 A need for uniformity

Pradeep Chowbey, Sir Ganga Ram Hospital, India

Healthcare Management 44 The ‘vital signs’ of Performance Improvement in

Cardiac Outcomes
05 21st Century Healthcare Lewis G Hutchison, Sheikh Khalifa Medical City, UAE
New paradigms

Medical Sciences
Sir J A Muir Gray, National Knowledge Service, UK

07 Effective Leadership for Patient Safety 47 Bariatric and Metabolic Surgery

Lessons from the ‘Safer Patient Initiative’ Anaesthesia concerns
Gren R D Kershaw, Conwy & Denbighshire NHS Trust, UK
Sunita Goel, Saifee Hospital, India
Annette Bartley, North Wales NHS Trust (Central Division), UK

50 Stroke Assessment
11 Decision-Based Evidence Making
A medical emergency
Developing tools and strategies for Anil Sharma, University Hospital Aintree, UK
comparative effectiveness Hannah Jane Cronin, University Hospital Aintree, UK
Sean Tunis, Justine Seidenfeld
Center for Medical Technology Policy, USA
53 Transcriptional Control of Heart Failure
24 Healthcare Disparities Recent developments
M Saleet Jafri, George Mason University, USA
Closing the gap
Mildred M G Olivier, Midwest Glaucoma Center, USA

27 Direct Practice Medicine

Surgical Speciality
Better outcomes, lower Costs 56 Assessing surgical outcomes
Jordan Shlain, San Francisco, USA New techniques
Graham P Copeland, North Cheshire Hospitals NHS Trust, UK
30 The Electronic Health Record
Delivering healthcare for the 21st century
Louise Liang, Kaiser Permanente, USA Diagnostics
62 Predictive, Preventive & Personalised Medicine
33 Ensuring Patient Safety
A novel strategy for healthcare
Role of regulation Olga Golubnitschaja, Preventive & Personalised Medicine, Belgium
Jill Crawford, Nursing and Midwifery Council, UK

36 Cultural, Social & Linguistic Barriers
Can they be overcome?
Marina Sleptsova, University Hospital Basel, Switzerland
66 Lab-on-chip
Innovative approach towards telemedicine in primary care
Kurt Schicho, Medical University of Vienna, Austria

68 PET-CT
40 Palliative Care
A step towards personalised radiation medicine
Reaching out to patients with heart failure Anna Simeonova, Frederic Wenz
Miriam J Johnson, Hull and York Medical School, UK University of Heidelberg, Germany
 Contents
71 PACS
Role of the end-users
Bram Pynoo, Pieter Devolder, Tony Voet, Luk Adang
Dries Ovaere, Jan Vercruysse, Philippe Duyck
Ghent University Hospital, Belgium

Technology, Equipment &

Devices
75 RFID for Medical Devices
An exciting future
Rajit Gadh, University of California Los Angeles, USA

79 Artificial Intelligence
Applications in healthcare
Prasanna Vadhana Kannan, Frost & Sullivan, Singapore

Facilities & Operations

Management
81 Reducing ICU Mortality
Strategies for the 21st century
Djillali Annane, University of Versailles, France

84 Surgical Workflow
Methods and applications
Oliver Burgert, Universität Leipzig, Germany
Thomas Neumuth, Universität Leipzig, Germany

Information Technology
88 Home Telehealth
Understanding the outcomes
Ronald Merrell, Virginia Commonwealth University, USA

94 Telehealth
Strategies for successful, cost-effective implementation
Kathryn H Bowles, University of Pennsylvania School of Nursing, USA

25 40 84

www.asianhhm.com 
Advisory Board John R Adler
Professor Editors
Neurosurgery and Director Radiosurgery and Akhil Tandulwadikar
Stereotactic Surgery Prasanthi Potluri
Stanford University School of Medicine, USA
Language Editor
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Sandy Lutz Copy editor

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Health Research Institute
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PricewaterhouseCoopers, USA
M A Hannan

Senior Designer
Pradeep Chowbey Ayodhya Pendem
Chairman
Sales Manager
Minimal Access, Metabolic and Bariatric Surgery
Rajkiran Boda
Centre, Sir Ganga Ram Hospital, India
Sales Associates
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Harald Becher Murali Manohar
Professor Sherley Jones
Cardiac Ultrasound Mark Twain
Oxford University, UK Assistant Manager – Compliance
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Peter Gross CRM

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Internal Medicine
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Hackensack University Medical Center, USA
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Information and Technology Services
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Abu Dhabi Health Service Company (SEHA), UAE
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21st Century
Healthcare
New
paradigms
The 21st century is the
century of the patient,
or the citizen who might
become a patient. Many
health services are now
based on a paradigm which
assumes that the patient
or citizen is competent and
should be fully involved.
Sir J A Muir Gray
Director
National Knowledge Service, UK
B
y the end of the 20th century very
significant improvements had
been made in the effectiveness
of healthcare; half of the added years of
life were due to the second healthcare
revolution.
The first healthcare revolution took
place in the 19th century when public
health measures such as the provision of
clean clear water led to the first great leap
in population health. In the second half
of the 20th century, the second health-
care revolution took place. Mirroring the
developments that created computers,
The eight major
problems of healthcare
1. Errors
2. Poor quality care delivery
3. Poor experience of patients
4. Waste
5. Unknowing variations in
policy and practice
6. Failure to introduce high
value interventions
7. Uncritical adoption of low
value interventions
8. Failure to recognise
uncertainty and ignorance
Table 1
Healthcare Management
aeroplanes, television and space flight,
healthcare saw the introduction of hip
replacement, transplantation and effec-
tive drug therapy for a wide range of
conditions. The second healthcare revolu-
tion had a major impact on the health
of populations, but at the end of the
20th century, the eight major problems
still remained and these problems, set
out in Table 1, show no signs of being
diminished by the application of labora-
tory science or genome technology.
The five dimensions
Twenty-first century healthcare will have
five dimensions which will be signifi-
cantly different from 20th century health-
care. These dimensions, which together
help in forming the 21st century para-
digm, are:
• Knowledge-based healthcare
• Citizen-centred healthcare
• Web-enabled care
• Better value healthcare
• Sustainable healthcare.
Knowledge-based healthcare
The 20th century healthcare was based
on bureaucracies—on hospitals, payers,
insurance companies, primary care organ-
isations and private providers. The 21st
century healthcare system, however, will
be based on knowledge-based systems
www.asianhhm.com 
Healthcare Management
Values of the
population
Evidence of the
Benefit of healthcare Choice
investment
Needs of the
population
of care. For example, it is possible to
think of a National Epilepsy Service
for India which would exist without
any bureaucracy except that which was
needed to run the web service, and this
could be done by different organisations
making a contribution. The National
Epilepsy Service for India, England or
Estonia would be an entity that would
have:
• A community of practice of patients
and professionals
• A dataset
• A clear depiction of patient path-
ways using the Map of Medicine
software
• An evidence base updated annually.
These and other knowledge features
will create 21 st century healthcare
systems. Obviously, bureaucracies are
needed to employ people and manage
money, but the priority is for systems
of care which create networks of indi-
viduals and organisations and path-
ways for those patients to follow. This
requires the knowledge of using the
web applications.
Citizen-centred healthcare
The 20th century was the century of the
clinician; the 21st century is the century
of the patient, or the citizen who might
become a patient. Many health services
are now based on a paradigm which
assumes that the patient or citizen is
competent and should be fully involved,
contrary to the 20th century assumption
that patients were less intelligent and
hence be given less information. The
 A s ia n H o s p i ta l & H ea lt hcare M a nage ment
Making decisions
Decision
Figure 1
truth of the matter is that many patients
are more intelligent than clinicians and
that it is easier to help the public learn
concepts, for example the appraisal of
risk, than to help highly trained profes-
sionals unlearn the wrong concepts with
which they were inculcated during their
professional training. The involvement
of citizens also emphasises the need to
focus on healthcare and its outcomes.
Web-enabled healthcare
IT is an old-fashioned term which is still
reasonably useful, but with the advent of
cloud computing, the concept of tech-
nology changes and the most important
step that an organisation can take is
to use the power of the Internet. The
power of the Internet allows:
• every patient to have their own
record
• images to be passed easily from one
organisation to another
• Provide access to the up-to-date qual-
ity information to both patients and
professionals Update the documents
such as laboratory reports with up-
to-date findings or evidence.
It is important not to go too far
down the road of ‘technological deter-
minism’, namely that change in tech-
Sir J A Muir Gray, CBE is the Director for National Knowledge
A u t h o r
Service in UK. He is also Chief Knowledge Officer to the NHS.
ISS Ue - 19 2009
nology inevitably drives social change,
but neither is it important to ignore the
contribution that technology can make
to social change. As Manuel Castells
emphasised, it is both knowledge and
IT that citizens are using to transform
society.
Better value healthcare
Every society on earth is faced with the
possibility of funding more ‘cost-effec-
tive’ services than it can afford, either in
terms of money or manpower. Where
there is a finite budget, decisions have
to be made on the basis of value, both
by individual patients and by those who
make decisions about groups of patients
or populations, as shown in Figure 1.
The key concept in the 21st century
is better value healthcare, identifying
ways in which the resources invested
can be used to maximise value.
This is particularly important when
taking into account the constraints
imposed by the 21st century’s greatest
challenge—climate change.
Sustainable healthcare
In many countries, healthcare takes about
10 per cent of the gross national product,
and in many countries a significant foot-
print is left by the health service with,
in the UK, the NHS being the major
public sector carbon footprint. There
is also good evidence that in almost
every healthcare system there is very
significant waste. Making better use of
the resources available, the same amount
of care could be provided from a smaller
carbon footprint or, if more money
were available to put into healthcare,
that money could be used to provide
services without increasing the carbon
footprint.

Effective Leadership
for Patient Safety
Lessons from the ‘Safer Patient Initiative’
Achieving success in
the area of patient safety
requires leaders to
adopt a new approach.
Gren R D Kershaw
Former Chief Executive
Conwy & Denbighshire NHS Trust, UK
Annette Bartley
Head of Modernisation
North Wales NHS Trust
(Central Division), UK
E
stimates suggest that one in ten
patients admitted to hospital,
experience an incident which puts
their safety at risk. These incidents may
result in harm and in some circumstances
death. A stark reality is the fact that
about half of these events could have
been avoided. In England alone there are
over 100,000 cases of hospital acquired
infections per year, which are estimated
to cause over 5000 deaths and cost
£ 1 billion. It is evident that patient
safety needs to be placed high on the
leadership agenda.
In 2005, in a response to this grow-
ing international problem, the Health
Foundation launched the ‘Safer Patient
Initiative’ (SPI), a UK-wide programme
designed to bring about radical improve-
ments in patient safety through the
implementation of a range of specific
interventions using improvement meth-
odology. The pilot involved four UK
National Health Service Hospital Trusts
and runs over a four-year period. This
paper will describe the progress made
through the pilot but principally the
work undertaken in the Welsh site,
Conwy & Denbighshire NHS Trust,
a large health organisation providing
acute community and mental health
services for a population of 250,000 in
Wales, UK.
Supported by the Institute of
Healthcare Improvement from Boston,
USA, the SPI pilot hospitals were given
some specific objectives to achieve:
• To reduce adverse events by
50 per cent
Healthcare Management
• To create a culture that puts patient
safety at the centre
• To demonstrate leadership that reflects
safety as a strategic priority
• To implement a range of evidence
based changes in wards, operating
theatres and intensive care units.
The programme also focussed on
some cross cutting themes such as
medicines management and infection
control.
Results from the initiative
A formal evaluation of SPI is due for
completion in late 2008. However, early
results released by the Health Foundation
in November 2006 showed impressive
safety improvements at the four pilot
hospitals. In the first two years of the
programme the four sites had on aver-
age halved the number of adverse safety
events. In addition some hospitals are
already seeing improvements in their
mortality.
At Conwy & Denbighshire NHS
Trust the implementation of a Ventilator
Associated ‘bundle’ saw the ventilator
associated pneumonia rate being virtually
eliminated. The Average Length of Stay
(ALoS) in the Intensive Care Unit (ICU)
was reduced significantly as patients were
weaned from ventilators at an earlier
stage (see Figure 1). Over £ 78,000 cost
savings were identified in the ICU in
the first 18 month of SPI.
Hand hygiene compliance in all sites
has increased by more than 95 per cent
and associated reductions in MRSA rates
have also been observed.
www.asianhhm.com 
Healthcare Management

who could be trained as ‘Improvement

ALoS ICU Leads’ by IHI. ‘Go with the willing’ was
Individual Value a mantra IHI encouraged organisations
12
to use. Rather than waste time trying to
10 convince the ‘laggards’ to get on board
Wearing &
8 Extubation with the initiative, change was driven
Guldeness through enthusiasts from across most
6 professional groups.
4 The Chief Executive gained the
2 Ventlator car personal commitment of his execu-
Central line bundle tive team which included the Director
bundle
0 of Finance (an important and often
July-02
Oct-02
Jan-03
Apl-03
July-03
Oct-03
Jan-04
Apl-04
July-04
Oct-04
Jan-05
Apl-05
July-05
Oct-05
Jan-06
Apl-06
July-06
Oct-06
Jan-07
Apl-07
overlooked resource / champion in
improvement projects). Each executive
Period Figure 1 director took on the role of executive
champion for different aspects of the
Down Lisburn Health and Social Establishing clear executive accountability for work streams.
Service Trust reduced the number of patient safety Measurement was a key element of
medication errors to below 10 per cent, Firstly, the Board of directors formally the programme. However, unlike other
following the development of system to recognised patient safety as their number national target-driven projects, the data
track and manage the drugs that patients one priority. The Board signed up to this collection in SPI was designed to get
take. This system is helping to reduce within its corporate objectives, and by the frontline teams to understand their
mistakes in the primary care setting. directing more of their time and attention own performance. They used the data
A reduction in cardiac arrest calls has to quality and safety matters. Non-execu- to improve their processes of care, as
been observed with the introduction of tive directors actively participated in some opposed to the familiar system of using
outreach teams (rapid response teams) aspects of the Safer Patient Initiative, e.g. data to judge performance or to bench-
and an early warning scoring system. The Patient Safety Walk-rounds. mark and compare teams. The concept
scoring system enables staff to effectively Whilst in principle SPI was a finite in SPI was to understand your own
monitor patient’s condition and to take ‘project’, leaders were expected to ensure performance and work to improve it,
rapid action if they go into a decline. that the work was fully integrated rather than shift your attention outside
into their organisation’s wider quality the organisation and lose focus on what
A new leadership approach performance management and govern- matters. Teams began to measure compli-
The breadth and depth of change involved ance arrangements. The concept was to ance with agreed processes of care. They
is significant, and the introduction of build a more sustainable infrastructure were able to monitor whether any of the
such an initiative requires a new approach to support the quality and safety agenda. changes they were implementing were
in leadership for patient safety. There is The Chief Executive took a leading role actually resulting in improvement.
emerging evidence that success in this in SPI by chairing the implementation Demonstrating visible leadership in
area, is dependent on hospital leaders team. Key responsibilities were to get the patient safety
enhancing the priority given to patient right team on board; a team containing The hospitals developed a communi-
safety and taking a real and continuing not only enthusiastic local champions for cation strategy to ensure that patient
interest in patient safety within their specific clinical areas but also individuals safety was promoted at every opportunity.
organisations. Often the pressures placed
on Chief Executives and their Boards Date Topic Aim
relate to financial stability, or satisfying
government and other regulatory targets. June 2008 Sample identification Reinforce correct process of identifying specimens,
It is generally accepted that it takes a following an increase in inadequately labelled
specimen samples.
significant change of emphasis by leaders
to affect organisational culture. July 2008 Passwords Following a password breach, which caused a patient
In this initiative, Chief Executives to be given the wrong treatment, staff are reminded
to ‘log in’ and ‘log out’
were expected to introduce a set of initia-
tives in leadership, which included three August 2008 Prescription and Following an audit of charts, staff are reminded of
key aspects: Infusion charts their obligations to record all prescribed medications.
Table 1

 A s ia n H o s p i ta l & H ea lt hcare M a nage ment ISS Ue - 19 2009

 Healthcare Management

This ranged from specific ‘News-sheets’

Hand hygiene improvement radar Feb 2006 - March 2008
to ‘Open days’ which involved employ-
ees, patients and the public. Promotion
through local media was an important
aspect.
On a practical level, ‘Patient Safety
Walk-rounds’ were introduced. These
consist of leaders drawing up a sched-
ule of dates where an executive visits a
ward/department to meet informally with
staff to discuss safety issues. A standard
set of questions was designed to ensure
consistency of approach, and the results
of discussions are recorded by a scribe.
Where safety concerns are highlighted, Figure 2
the corrective actions are suggested and
concerned individuals are assigned with These walk-rounds have been enor- prevent frontline staff doing their work
the responsibility. mously successful. They not only enabled effectively and safely.
A feedback / follow-up system is also staff to see patient safety as a priority Addressing the need for cultural change
put in place to ensure the actions happen. but also empowered and encouraged As the Board begins to shift its way of
Key themes from the Safety Walk-rounds them to solve operational issues that doing business by channelling more
are fed back to the Board. can cause harm. Additionally, executives attention to quality and safety, there is
Staff from all levels and professions, were requested to identify examples of a need to demonstrate this throughout
from senior doctors to volunteers, are good practice in patient safety. Instead the organisation. One simple and effec-
encouraged to attend the discussions. of the focussing on the negative aspects tive means of achieving this in Conwy &
Typical discussions to start proceedings of safety, good ideas were captured, Denbighshire was to make Patient Safety
include: celebrated and spread. the first item on the Board’s agenda.
When was the last patient harmed Whilst executives resisted the temp- All monthly Board meetings commence
in your unit / ward and how? tation to resolve operational problems, with a Patient Safety issue which in turn
What have you done to prevent this it was quickly recognised that the role becomes the first item on staff brief-
happening again? of leadership is to remove barriers that ings and routine management meetings
throughout the organisation. Nurses have
now adapted this idea and incorporated
Key Learning Points from SPI* safety items into their handover meeting
on shift changes. Summarised examples
of such items are given in Table 1:
• Support from the senior management team is vital. However, if the culture of an
organisation truly is to change, people at all levels of the organisational need to make
These practical steps encourage staff
patient safety a priority to pay more attention to patient safety
issues and as a result the culture is gradu-
• Efforts to improve patient safety need to be coordinated across the hospital. Senior
teams need to emphasise the significance of patient safety in all they do. Clinical ally changing. As part of SPI there was
teams need to feel confident that they can report their concerns about patients’ a requirement to measure any shift in
safety culture, all sites were expected to carry
• The senior executive team needs to pay attention to how the clinical teams’ work is out a baseline culture survey. Figure 2
contributing to improvements in patient safety and how they can be spread across is an illustration of change in culture
the hospital. It may be helpful to appoint a patient safety officer at Hand Hygiene.
• Focus attention on those most willing at the outset to create patient safety champi-
ons Summary
• For safety to improve, all members of the multidisciplinary team need to be actively The Health Foundation has demonstrated
involved. Each individual should be valued for the professional knowledge and through the Safer Patients Initiative that
expertise they contribute. significant improvements in patient safety
can be realised with focussed effort.
*Sites taken from www.health.org.uk
Leadership is an essential ingredient in

www.asianhhm.com 
Healthcare Management
the battle to reduce harm to patients.
There is still much to do in order to
achieve a global reduction in the current
levels of harm within healthcare and
to implement programmes such as the
Safer Patients Initiative. In the UK in
November 2006, following on from
the early successes of SPI, a second
programme was launched involving a
further 20 NHS organisations across the
UK. This second programme is building
on the learning from the original sites
but the core elements of the programme
remain the same.
The initiative has generated impor-
tant discussions and activity at UK level.
It has also promoted the introduction
of national patient safety campaigns in
England, Scotland, Wales and Northern
Ireland. The initiative has changed our
way of thinking about safety and qual-
ity and has reaped many rewards for
patients, staff and organisations as a
10 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
whole. The journey is not over by any received from a member of the public
means. The constant and relentless who participated in a competition to
drumbeat of improvement needs to be find a slogan that captured what we were
continued. trying to achieve across the organisa-
To conclude, we will leave you with tion: Patient safety is contagious—Pass
a simple yet profound quote. It was it on!
Annette Bartley is a registered nurse with over 27 years experi-
ence in healthcare. Whilst her professional background is nursing,
her passion for improving healthcare has taken her career into the
field of service modernisation and quality improvement. A founder
member of the Welsh Faculty for Healthcare Improvement, Annette
is currently seconded part-time to the Welsh Assembly government
A u t h o r s
as a faculty / content area lead in their 1000 Lives National Patient
Safety campaign.
Gren Kershaw is Former Chief Executive, Conwy & Denbighshire
NHS Trust, Wales, UK. He has worked in the UK National Health
Service for 35 years. He has held a number of senior managerial posi-
tions in different health organisations covering acute, community and
mental health services. He has advised the National Patient Safety
Agency on the successful introduction of the National Reporting and
Learning system. More recently he led the Safer Patients Initiative in
his own organisation and is advising on leadership in the 1000 Lives
campaign in Wales.
ISSUe - 19 2009

Decision-Based
Evidence Making
Developing tools and strategies
for comparative effectiveness
Despite the publication of
over 18,000 Randomised
Clinical Trials (RCTs) each
year, available clinical
evidence is often of
limited quality. Generating
the evidence needed to
support an evidence-
based healthcare system
will require collective
effort, and needs to
be driven by decision
makers in the healthcare
community such as
patients, physicians,
policymakers and payers.
Sean Tunis MD
Director
Center for Medical Technology Policy
USA
Justine Seidenfeld
Research Associate
Center for Medical Technology Policy
USA
D
espite the steady increase in
public and private funding
of clinical trials and health
services, the current research enterprise
in the US is not meeting the rising
demand from decision makers for stud-
ies demonstrating evidence of clinical
effectiveness. According to the National
Library of Medicine, results from over
18,000 randomised clinical trials were
published in 2007 along with numer-
ous other non-experimental studies, all
intended to provide information about
‘what works in healthcare.’ Despite this
healthy output of scientific literature,
the majority of systematic literature
reviews, technology assessments and clini-
cal practice guidelines that evaluate all
available published literature on virtually
any topic have concluded that the avail-
able evidence is ‘limited’ and that many
published studies are of ‘low quality.’
For these reasons, these reviews generally
conclude that the available evidence does
not support reliable conclusions about
the most important clinical and policy
questions related to the topic reviewed.
This paradox—the large volume of clinical
and health services research and the low
quality of evidence—requires some expla-
nation if one is hoping to move further
toward evidence-based clinical and health
policy decision making. It is, therefore,
Healthcare Management
important to understand the nature of
the gaps in evidence; how and why does
the current body of research predictably
fall short? This is particularly important as
the US Federal government has recently
decided to invest billions of additional
dollars in clinical and health services
research, including US$ 1.1 billion for
comparative effectiveness research.
There are some key observations
that provide insight into the apparent
discrepancy between the volume and
the quality of evidence. Systematic
reviews, clinical guidelines and health
technology assessments review evidence
with the goal of informing decision
makers—primarily patients, clinicians,
payers, and policymakers. The process
of conducting a review begins with a
deliberate effort to identify the critical
questions faced by these decision makers,
and the literature search and appraisal
process is conducted with reference to
these key questions. Viewed through
this prism, they commonly conclude
that the available evidence on these
key questions is limited. The process of
generating evidence through clinical and
health services research does not usually
begin with a careful assessment of what
information decision makers most need
to know. Most research is investiga-
tor initiated, with topics selected and
www.asianhhm.com 11
 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
in the healthcare industry.

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www.asianhhm.com 13
Healthcare Management
studies designed with reference to previ-
ously published studies and through
dialogue with other researchers working
on related issues. Decision makers are
rarely involved in the process of refining
study questions or the actual design of the
studies. In those infrequent cases where
they are included in some of these early
discussions, their unfamiliarity with the
technical content of research may limit
their ability to participate meaningfully
in the discussion. Given these very differ-
ent starting points and perspectives, it
is unsurprising that systematic literature
reviews, which are guided by the ques-
tions faced by decision makers, gener-
ally highlight that these questions are
not consistently addressed by research
because it was designed and implemented
without attention to or involvement of
these decision makers.
The molecular basis of uncertainty
An analogy from molecular biology may
be useful in communicating the discon-
nect that exists between those who gener-
ate scientific evidence and those who
utilise this evidence to make clinical and
health policy decisions. Figure 1 depicts
the cycle of information flow from the
‘extracellular environment’ of the clinical
research enterprise to the ‘intracellular
world’ that is inhabited by the decision
makers. On one side of the cell membrane
is the realm of those who generate new
scientific evidence through clinical and
health services research—guided for the
most part by their intellectual curios-
ity, and not particularly attentive to
the needs of those on the other side of
the cell wall. The evidence produced by
these researchers encounters a number
of barriers during the process of ‘diffu-
sion’ across the membrane and into
the cell. The first barrier in Knowledge
Transfer (KT1) involves the commonly
observed slow translation of knowledge
into practice and policy, resulting in a
lengthy time-lag between the publica-
tion of new evidence and the impact of
that evidence on what is actually done.
The speed of translation can sometimes
14 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
be increased when scientific evidence is
compiled and analysed through Health
Technology Assessment (HTA) organi-
sations (KT2), and this active transport
mechanism is an important pathway by
which the linkage between evidence and
decision making can be considerably
enhanced. Once decision makers have
applied the available evidence to their
decisions, they will frequently observe the
gaps in knowledge on critical questions.
Ideally, these unanswered questions, or
areas of ignorance, would be fed back to
the research community so that further
research could be focussed on these issues.
However, a defective transport mechanism
(KT3) severely impairs the communica-
tion of these research priorities to the
clinical research enterprise. This defec-
tive transport mechanism ensures that
Decision makers are
rarely involved in the
process of refining study
questions or the actual
design of the studies.
many of these important questions remain
unanswered, leading to an accumulation
of ignorance which surrounds the deci-
sion makers. Potential interventions to
improve the cycle of information flow
between the intra and extra-cellular space
will need to focus in part on improving
the consistency with which the unan-
swered questions of decision makers are
effectively communicated to the clinical
and health services research community,
and become a higher priority for atten-
tion.
Tools and strategies for decision-
based evidence making
The molecular model suggests that there
is a need for tools and strategies through
which the link between decision makers
and researchers can be strengthened.
ISSUe - 19 2009
While there have been numerous informal
and ad hoc efforts in this direction to
increase dialogue between decision makers
and researchers, such informal interac-
tions are inconsistent in their ability to
produce relevant and timely informa-
tion for decision making. One general
requirement is that communication
about important gaps in evidence and the
appropriate design of research to address
those gaps must take place long before
there is a decision to be made. When
payers and policy makers are faced with
a specific decision, it is generally much
too late to begin a conversation about
what sort of evidence would be useful. A
number of tools and strategies intended to
support ‘decision-based evidence making’
are currently being piloted the US-based
Center for Medical Technology Policy
(CMTP), a private, non-profit organi-
sation that provides a neutral forum
in which patients, clinicians, payers,
manufacturers and researchers can work
together to improve the quality and effi-
ciency of clinical research to benefit deci-
sion-making in clinical and health policy.
These initiatives are made possible by the
active collaboration of numerous public
and private sector experts, stakeholders
and policymakers.
Pragmatic clinical trials
One method of addressing evidence gaps
is through the expanded use of Pragmatic
Clinical Trials (PCTs)—prospective
controlled studies designed specifically
with the objective of assisting patients,
clinicians and payers in making informed
decisions about alternative medical thera-
pies. A number of important character-
istics generally distinguish pragmatic
trials and traditional clinical trials. First,
PCTs involve the deliberate selection of
clinically relevant alternative interven-
tions for comparison, chosen based on
the most common decision-making
scenarios. Many trials do not include
highly relevant comparison arms, leaving
decision makers to depend on less reli-
able, indirect comparisons with which to
make clinical and policy choices. Second,
PCTs are designed to make the results as

generalisable as possible, and therefore
are more likely to include a more diverse
population of study participants. While
many important studies have been done
with narrow inclusion and exclusion crite-
ria, one of the common ways in which
many RCTs fail to address important
questions is by unnecessarily excluding
patients with common co-morbidities
and demographic characteristics, making
the application of results to individual
real-world patients more challenging.
Third, PCTs select outcomes that are
intended to address the primary issues
and concerns of patients, clinicians and
payers. Many RCTs include outcomes
that are of primary interest to regula-
tors, and pay less attention to the post-
regulatory decision makers that will also
use those studies to guide their choices.
These outcomes may include more qual-
ity-of-life information, and may involve
longer follow-up periods than are typical
for traditional clinical trials. Selecting
the most useful and relevant outcomes
requires direct consultation with decision
makers during study protocol develop-
ment. In fact, one of the keys to the
successful design of clinical trials that are
more useful for decision making is the
greater engagement of decision makers
in trial design.
CMTP has been working on meth-
ods for developing pragmatic clinical
trials, and has recently begun a project
in collaboration with experts, stake-
holders and policy makers to create a
conceptual, methodological and policy
framework that will improve the design
and implementation of pragmatic clinical
trials for phase III pharmaceutical trials.
This initiative will clarify the nature of
evidence desired by decision makers,
explore methodological approaches to
the design of phase III trials, identify
regulatory, methodological, business, and
other challenges to PCTs, and discuss
potential strategies to overcome these
challenges.
Effectiveness guidance documents
Another approach to improving the link
between the evidence desired by decision
makers and the output of the clinical
research enterprise is to develop a shared
understanding of the nature of the desired
evidence. CMTP has begun to develop
a library of Effectiveness Guidance
Documents (EGDs), which are analo-
gous to the guidance documents issued by
the U.S. Food and Drug Administration,
intended to provide product developers
and clinical researchers with guidance on
the design of clinical studies intended to
support regulatory approval. In contrast,
EGDs provide recommendations for
study designs about specific categories of
technologies that are intended to provide
Molecular basis of uncertainty
healthcare decision makers with a reason-
able level of confidence that the technol-
ogy will improve healthcare outcomes.
Current topics under development include
gene expression profiling for cancer risk
prediction, cardiac imaging and treatment
of chronic wounds.
The target audience for EGDs is
similar to the audience for FDA guid-
ance documents—clinical researchers
and product developers. The process for
developing these documents involves inte-
grating the perspectives of the full range
of stakeholders, including consumer,
payers, clinicians, product developers,
Healthcare Management
regulators, researchers and others. By
setting clear prospective standards for
evidence, decision makers can increase
the chances that these recommendations
will be incorporated into clinical stud-
ies, and that those studies will be more
likely to produce the information that
all of these stakeholders consider most
relevant.
While EGDs have no legal or binding
effect on any decision maker or stake-
holder, their influence would derive from
the transparency, creditability, neutrality
and technical accuracy associated with the
iterative multi-stakeholder development
Figure 1
process. Product developers would not
be required to design studies in accord-
ance with the relevant EGD, and payers
would not be bound to those principles in
making coverage decisions. Nonetheless,
these documents should reduce some
of the uncertainty about what sort of
evidence decision makers are looking
for when considering the use of new
technologies.
Coverage with evidence
development
Decision makers in the public and private
health insurance industries have long
www.asianhhm.com 15
Healthcare Management

been faced with the problem of making
coverage decisions for ‘promising’
but unproven medical technologies.
Frequently, they are torn between the
demands of patients and their physicians
for innovative healthcare techniques, and
the desire to have definitive evidence
about the clinical and comparative
effectiveness of the new technology.
For most new technologies, substantial
questions exist about their optimal use
for many years after they are initially
introduced, and the incentive for these
questions to be addressed is substantially
reduced once payment has been secured.
In 2005, the Center for Medicare and
Medicaid Services (CMS), the federal
agency that provides health insurance
to special populations within the US,
began a programme called ‘coverage with
evidence development’ (CED.) CED
was a new approach to offer coverage
for promising technologies under the
condition that patients participate in
a registry or clinical trial, which would
generate clinical evidence that could be
used at a future date for more definitive
decision making and coverage decisions.
While CED has its share of challenges
to overcome as the programme is further
refined, it has the potential to be an
effective approach to allowing rapid
coverage decisions while still generat-
ing valuable evidence for future decision
making. CMTP is currently working
with private payers as well as a range of
other stakeholders in the US to develop
a policy framework for private sector
Sean Tunis is the Founder and Director of the Center for Medical
Technology Policy, where he works with healthcare decision makers,
experts, and stakeholders to improve the value of clinical research
on new and existing medical technologies. He consults with domes-
tic and international healthcare organisations on issues of compara-
A u t h o r s
CED. The goal is to establish a routine BOOK Shelf
process by which important emerging
technologies can be identified for CED,
and adequately designed studies can be
developed. Individual health plans can
then make a decision to participate in
a given CED initiative, and the actual
research will be sub-contacted to an
independent and credible research
organisation.
Conclusions
Important gaps in evidence for deci-
sion making have now become widely
recognised, and this was a major factor Understanding Health
behind the recent decision of the US Policy, Fifth Edition
Congress to provide US$ 1.1 billion
to support comparative effectiveness
(LANGE Clinical
research. In order for this money to Medicine)
be spent effectively, it will be impor-
tant to have a meaningful and sustained Author : Thomas S Bodenheimer
collaboration between researchers and Kevin Grumbach
decision makers in deciding on research
Year of Publication : 2008
priorities, establishing methodological
standards, developing methods that Pages : 232
accurately reflect important questions Published by : McGraw Hill
and developing a sustainable framework
to guide and support the work. CMTP
has been working for the past several Description
years to develop some specific tools Understanding Health Policy is the
and strategies to facilitate comparative best-written, most informative book
effectiveness research. It is our hope available on the subject--and it’s the
that these ‘targeted interventions’ will #1 choice for healthcare students
address the ‘defective transport mech- and professionals alike. The authors
anisms’ that prevent communication carefully weave key principles,
between ‘intracellular’ decision makers descriptions, and concrete
and the ‘extracellular’ clinical research examples into chapters that make
important health policy issues both
enterprise.
interesting and understandable.
Fully updated to reflect current
issues in the ever-changing world
of healthcare, the newest edition
addresses all the topics that affect
you most, from the structure and

tive effectiveness, evidence-based medicine, clinical research and organization of the industry to
technology policy. issues regarding government and
private insurance, to access to
Justine Seidenfeld is a Research Associate at the Center for healthcare.
Medical Technology Policy, where she works on projects involving
comparative effectiveness research, patient advocacy, and tech-
nology topic prioritisation. She graduated in 2008 from Stanford For more books, visit Knowledge Bank
University with a degree in Human Biology, and a concentration in section of www.asianhhm.com
bioethics and science policy.

16 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009

Debasish Mishra Pradeep Chowbey
Executive Director / Partner Chairman, Minimal Access, Metabolic
PricewaterhouseCoopers and Bariatric Surgery Centre
India Sir Ganga Ram Hospital, India

India’s healthcare sector is

booming. Indians today have
access to the best healthcare
through the private care
providers whose presence has
grown at a rapid pace over
the last decade. But the public
healthcare system, which caters
to most of the population of the
country that lives in the smaller
towns and villages of the country,
is in disarray. Providing access
to quality healthcare has been
on the agenda of successive
governments in the country,
but the condition has hardly
changed. There is, therefore, a
need to fix the system before the
situation goes out of hand. While
some initiatives have been taken
up by the government, there is a
need to involve the private sector
in the provision of healthcare
across the country.

www.asianhhm.com 17
 State of Indian Healthcare
Unfolding
opportunities Debasish Mishra
Executive Director / Partner
PricewaterhouseCoopers, India

Where does India stand with regards

to the research happening in health-
care? What can be done to improve
the scenario?
Indian Council for Medical Research (a
Government of India agency) conducts
research in areas related to healthcare.
The quality of research being done
represents a mixed picture—while
research in some institutes is on par
with those being conducted in other
parts of the world—the research on
use of stem cells for movement disor-
ders being a case in point, the research
output on respiratory infections, diar-
rhoeal diseases, cardio vascular diseases,
is insignificant compared to the burden
of disease due to these conditions in
India.
India is also a big destination for
clinical trials given our population size
and ethnic diversity.
Government of India has given
incentives for research and develop-
ment in health, pharma etc—expenses
incurred on pharma R&D are tax
deductible.
There is an immediate need for stra-
tegic planning to improve the level of
research and also to collate and dissemi-
nate findings from various small scale
community-based research projects that

18 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009


are being performed across the coun-
try. Creating a network of research
and innovation centres—‘knowledge
clusters’ will help improve the efficacy
of research.
Institutions such as Public Health
Foundation of India are a timely intro-
duction in the field of public health
and would go a long way in address-
ing the gap in Public Health Research
appropriately.
What are your views on the current qual-
ity and patient safety standards in India?
Are the standards good enough?
The National Rural Health Mission has
given a thrust on the rural healthcare
system in India. For the first time in the
country, infrastructure standards have
been introduced for all public health
facilities—primary, secondary and terti-
ary. The Indian Public Health Standards
specify the infrastructural requirements
for all facilities with the aim of stand-
ardising the quality of care imparted in
all facilities. However, implementation
is still an issue—while the new facilities
are being built as per IPHS, the exist-
ing facilities across the country need
upgradation.
There is no mandated quality and
patient safety standards which private
hospitals are required to adhere to—the
current standards are more voluntary in
nature. National Accreditation Board
for Hospitals and Healthcare providers
has set up some standards on quality
and patient safety but accreditation is
a voluntary process. Similar standards
exist for diagnostic laboratories, blood
banks and wellness centres etc.
All large hospitals, however, have
internal clinical audit processes through
which they review events within the
hospitals and institute appropriate
corrective measures.
Since the standards are voluntary in
nature and not mandatory, acceptabil-
ity by providers is slow. However, the
situation may improve if the purchas-
ers of healthcare (insurance companies,
corporate, government agencies) insist
on adherence to standards before empan-
elling providers.
What are the current trends that are
shaping the Indian healthcare sector?
Some of the current trends are:
• Higher economic growth and higher
disposable income leading to higher
per capita health spend
• Changing profile of disease from
more infectious diseases to more
lifestyle diseases which are chronic
in nature
• Health status of the urban poor is a
growing concern, owing to the increase
in migration to cities, and congested
and unhygienic living conditions.
• Increased role of private sector in a
completely unregulated manner is
creating several qualities of service
issues
• Emergence of public private partner-
ships
• Increased penetration of private
health insurance, but the share of
out-of-pocket purchases continues
to be an overwhelming proportion
of total healthcare spend
• Better government schemes for health-
care delivery and health insurance for
the poor
Healthcare Management
• Increased interest by private equity
players in investments in healthcare
delivery.
How has the growth of the private sector
changed India’s healthcare scenario?
Private Sector now provides more than
70 per cent of the healthcare in India.
The growth of private healthcare has had
many positive impacts on the healthcare
scenario in India:
• Availability of services has improved
tremendously with all services availa-
ble under one roof for example people
do not need to travel abroad for any
medical condition
• Cost of services is lower in relation
to rest of the world
• Quality of healthcare has improved:
Success rates of Indian healthcare
providers is equal to or better than
their counterparts in developed coun-
tries
• Employment opportunities have
increased. Healthcare sector now
employs more than 5 million people
and is now the second largest employer
in the services sector after educa-
tion
• Growth and establishment of medical
tourism to India. High quality medical
services at corporate hospitals have
positioned India on the global map
as a preferred destination for high
end medical / surgical care.
What are your views on the current
boom in the investments happening
in Indian healthcare?
The health industry is now receiving
its due attention from financial inves-
tors. Tie ups with foreign universities
and medical institutions are common
place now with most up coming
hospitals. This has led to a significant
improvement in quality of care being
imparted.
However, most of the current invest-
ments in private healthcare are taking
place in the large metropolitan cities
and in the tertiary care space. There
www.asianhhm.com 19
Healthcare Management
is a crying need for investments in
Tier II cities where there is demand
for healthcare services and incentives
from government for setting up health
infrastructure.
The government health services,
though, need much more focus than
is being currently meted out. Health
sector budget is less than 1 per cent of
GDP and with a billion plus popula-
tion, and significant proportion being
below poverty line, the requirement is
much more. The overall public health
spend must go up.
What challenges does Indian health-
care face today? How can they be
overcome?
The challenge in Indian Healthcare
is to make healthcare access available
and inclusive—improving budgetary
allocation to public healthcare, reducing
the urban / rural, male / female, rich /
poor and social inequities in healthcare
delivery. Another challenge is to ensure
healthcare quality is consistent across
the country. A third challenge is to
reduce costs of delivery without reduc-
ing quality. A proper regulatory mecha-
nism needs to be introduced (overcom-
ing the Centre and State Government
opposition to each others’ initiatives) to
improve the quality of service delivery
and keeping unscrupulous elements at
bay. The large scale public health chal-
lenges need to be met with technology
enabled solutions as well.
In the global arena, what do Indian
healthcare providers need to do in order
to become more competitive?
Indian providers have world class
quality. They are also cost efficient
as compared to developed countries.
However, Indian providers need to
improve their understanding of cultural
sensitivities of people of different coun-
tries to serve them better.
Patient participation (patient-centred
care) is a relatively new phenomenon in
20 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Indian healthcare. Can Indian hospitals
benefit from this?
Any healthcare system cannot be
sustainable without active partici-
pation from the patient. Hospitals
can use this trend of better informed
patients to encourage awareness on
the real risks that Indian popula-
tion faces and the need for preven-
tive care and healthy life style.
Providers can also use this knowledge
to become more responsive to patient
needs.
There is a crying
need for investments
in Tier II cities where
there is demand for
healthcare services
and incentives from
government for
setting up health
infrastructure.
All over the world, the patient is becom-
ing more and more knowledgeable about
the options available to them. Is the
same thing happening in India?
Awareness is largely in urban areas
thanks to the role of the media and
the Internet. Not so much in rural areas
where the patients are largely dependent
on the doctor for medical advice and
in their absence on quacks.
What can today’s healthcare providers
do to bring healthcare services to the
poor?
Healthcare providers can
a. Use technology extensively for
• Telemedicine, medical call centres,
ISSUe - 19 2009
mobile phones in healthcare
delivery
• E-learning solutions and medical
simulation to improve quality of
training
• Electronic Medical Records for coor-
dinated care, Computerised Physician
Order Entry and RFID to improve
safety of care.
b. Enter into Public Private Partnerships
with the government for various health
/ subsidiary services and improve
the overall quality of care—such as
ambulance services, facilities manage-
ment, diagnostics, urban health facili-
ties, mobile medical units for rural
areas.
As compared to developed economies,
Health insurance plays a relatively small
role in Indian healthcare, what is your
take on this issue?
Currently, health insurance has
only 3 per cent coverage in India—
that indicates a huge potential for
growth in this industry, but it will
need a quantum change in people’s
attitude towards insurance and health
in general.
There are many reasons for poor
health insurance penetration
• Poor awareness of need for insur-
ance
• Lack of innovative products in medi-
cal insurance
• Lack of distribution channels
• Inadequate provider network
• Poor perception of consumers with
regard to claims settlement and to a
large extent the insurance companies
are responsible for this perception.
• Regulatory requirements like very
high start-up capital.
The situation is however, chang-
ing slowly. People are realising the
benefit of health insurance; especially
with the increase in lifestyle diseases
such as diabetes, hypertension, asthma
etc. and the insurance industry is likely
see a 25 to 30 per cent growth over the
next five years.
www.asianhhm.com 21
 State of Indian Healthcare
A need for
uniformity
Pradeep Chowbey
Chairman, Minimal Access
Metabolic and Bariatric Surgery Centre
Sir Ganga Ram Hospital, India

Where does India stand with regards

to the research happening in health-
care? What can be done to improve
the scenario?
India has a very large pool of qualified
scientific man power which is essential
for research in healthcare. It therefore
follows that India now forms a hub for
basic and advanced research in health-
care. A lot of activity has taken place
in this connection in the last few years
and as the research protocols and infra-
structure fall in place, there is going
to be a quantum jump in these activi-
ties here.

What are your views on the current

quality and patient safety standards
in India? Are the standards good
enough?
India is a large and diverse country
where facilities and expertise in health-
care are varied in different regions of
the country. Since there is such a lot of
diversity in healthcare delivery systems
across the country, standards of health-
care vary within the country. Currently,
we are in the process of accrediting our
healthcare delivery systems from reputed
organisations within the country and
abroad to ensure an acceptable level
of quality and patient safety standards
in India.

22 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009


What are the current trends that are
shaping the Indian healthcare sector?
Health insurance is a major factor that is
shaping the development of the Indian
healthcare sector at present.
How has the growth of the private sector
changed India’s healthcare scenario?
The private sector has played a major
role in advancing the frontiers of
various specialities in medicine today.
Healthcare services available with in the
large private and corporate hospitals
compare with the best globally.
What are your views on the current
boom in the investments happening
in Indian healthcare?
With an expanding middle class in the
country and an opening of the economy,
the investment boom in Indian health-
care was waiting to happen. It would
appear that the current investments in
Indian healthcare are being made with
a medium to long-term perspective.
What challenges does Indian health-
care face today? How can they be
overcome?
The major challenge for Indian health-
care today is to provide a modicum
of uniformity in healthcare services
throughout the country. Healthcare
facilities at the peripheral areas in our
country is patchy in some places and
totally unavailable in others.
The Government needs to involve
private and corporate healthcare provid-
ers to participate in providing basic and
advanced healthcare facilities to the
teeming masses in the country.
In the global arena, what do Indian
healthcare providers need to do in order
to become more competitive
Strict and uniform accreditation
procedures need to be adhered to ensure
uniform and quality medical services.
There is no shortage of qualified and
trained medical specialists, doctors,
nurses and technicians. What is needed
are protocols and audit to ensure that
the quality of healthcare services remains
uniformly high.
Patient participation (patient-centred
care) is a relatively new phenomenon in
Indian healthcare. Can Indian hospitals
benefit from this?
Patient centred care appears to be
the bay that we are headed. Patient
follow-up, supervision and guidance
may be provided at home by qualified
healthcare professionals. This in turn
can save patients several trips to the
hospital and also reduce demand for
beds for admission to hospitals. Selected
The Government
needs to involve
private and corporate
healthcare providers
to participate in
providing basic and
advanced healthcare
facilities to the
teeming masses in
the country.
Healthcare Management
patients may be advised, supported
and treated at home by appropriately
trained healthcare delivery personnel.
This would ensure high patients satis-
faction, increased patient comfort and
acceptable results in the long term.
I can foresee that patient centred
care is likely to be a key driving element
in the expansion of healthcare facilities
in the country.
All over the world, the patient is becom-
ing more and more knowledgeable about
the options available to them. Is the
same thing happening in India?
With the expansion of the Internet to
all nooks and corners of the country,
patient awareness has increased tremen-
dously. This phenomenon seems to have
caught on more in the larger metros and
it is quite likely that a patient undergo-
ing treatment has done research on the
Internet (for good or bad).
What can today’s healthcare providers
do to bring healthcare services to the
poor?
A concerted private and governmental
effort has to be made to reach out to
the poor. Insurance companies shall,
no doubt, be the key element in such
a scenario.
As compared to developed economies,
health insurance plays a relatively small
role in Indian healthcare, what is your
take on this issue?
The quality of healthcare services
provided today in India varies quite a
bit from one region to another. This may
be due to a variety of factors ranging
from infrastructure and equipment to
expertise available in a region. In such
a scenario, health insurance companies
may be trying to assess and then work
on healthcare services that are provided
in the country. There is a rapid growth
of healthcare insurance within the coun-
try and it appears that a much larger
segment of the population would be
covered by health insurance in some
form in time to come.
www.asianhhm.com 23

Eliminating healthcare
disparities is the need
of hour. The author
discusses various
options—increasing
self-awareness among
physicians, increasing
minority representation
in the workforce
and collecting data
and evidence based
medicine to increase
the quality-of-care
for all individuals.
Mildred M G Olivier
President and Founder
Midwest Glaucoma Center, USA
Healthcare
Disparities
Closing the gap
Increasing awareness
Educational resource tools were developed in terms of training programmes,
videos, speakers’ kits, Internet-based materials, print materials and conferences.
A business case model, to educate medical professionals and their employers
on workplace changes that contribute to the elimination of disparities, was
part of the objective. All medical societies would be encouraged to incorporate
disparities elimination into their strategic planning processes. Identification
of practical, evidence-based solutions to eliminate disparities in specific
conditions, diseases and clinical practices were developed. The Professional
Awareness, Education and Training Advisory Committee developed a slide
kit and DVD that are used in 3-hour workshops that discuss disparities and
offers solutions focussed on improving patient-physician communication. The
workshop materials use vignettes of patients from a variety of racial and ethnic
backgrounds to break down stereotypes and demonstrate how language and
cultural beliefs can affect the delivery of healthcare. Articles and references
are provided for background information. The workshop can be tailored for
physicians in different specialties and different geographic areas.
Patient / Physician communication and trust
Central to improving communication is sensitising physicians to the fact
that nearly half of all adults and the non-English speaking patients in the US
may have low health literacy. Developing community networks could help
provide patients with understandable, respectful, culturally and linguistically
appropriate information.

T
he Institute of Medicine (IOM)
report documented that racial
and ethnic minorities experi-
enced higher mortality rates, worse health
outcomes and were less likely to receive
routine procedures. Such practices reduce
high quality health and effective, patient-
centered, timely and efficient manage-
ment. Recent national data suggest that
some disparities are declining or have
been eliminated, but many others have
remained the same or even increased in
the last few years [National Healthcare
Disparities Report, 2008].
Five years ago the Commission to End
the Health Disparities was created and
formed objectives regarding this subject.
The Commission is made up of medi-
cal and subspecialities. Their emphasis
was on healthcare disparities rather than
the more broad, complex landscape of
health disparities. Different racial and
ethnic groups have poorer health status
for many reasons that are not directly
linked with healthcare delivery. Even the
most active leadership group would not
be able to solve such widespread problems
Leadership for the elimination of
disparities
Increased political activity, obtain-
ing cooperation from the Centers for
Medicare & Medicaid Services in elimi-
nating disparities, and creating a unified
message that includes local-level solu-
tions to address disparities would be key
activities.
Cultural competence of physicians
Physicians would have to examine their
own attitudes in order to recognise preju-
dice and avoid or eliminate biased medical
decisions. Educational tools, mentoring
programmes, and healthcare disparities
content in Continuing Medical Education
(CME) offerings could help build cultural
competence.
A diverse professional workforce
A closer examination of how provider
diversity relates to improved patient
satisfaction and healthcare outcomes by
as patients who live in poverty, lack trans-
portation, or do not live within reasonable
proximity to a physician’s office, while also
trying to transform the current system
into one that is more culturally sensitive
and diverse.
The heart of their mission, the partici-
pants decided, was to attack disparities
from the perspective they knew best: clini-
cal medicine. Even though an array of
social problems contribute to healthcare
disparities, physicians can fulfill their roles
in society most effectively by providing
high-quality care regardless of patients’
racial or ethnic backgrounds. Unequal
Treatment also suggested that although
health professionals dedicate themselves
to providing the highest quality of care
possible to every patient, they also may
harbour unconscious biases and stere-
otypes that affect their decision-making
and attitudes towards minority patients.
For example, the report cited a 1999 study
by Schulman et al. that showed physicians
were significantly less likely to refer black
women for cardiac catheterisation than
black and white men and white women,
attracting and recruiting more under-
represented minorities into medical
school and other health professions are
being examined. Students are provided
with information and strategies to gain
competitive criteria for successful entry
into medical schools.
The creation and maintenance of a
diverse workforce changes the cultural
experience of non-minority students and
exposes those students to a culturally rich
learning environment. Incentives such as
loan repayment programmes could help
reduce physician shortages in underserved
communities. The Workforce Diversity
Advisory Committee had focussed its
efforts on increasing minorities in training
programmes by taking an in-depth look at
how medical schools’ admissions processes
affect minority student enrollment.
A first step is to examine the racial
and ethnic composition of admissions and
selection committees, and factors involved
in their first-tier selection process. Next,
Healthcare Management
even when they had the same symptoms.
Another study cited in the report (vanRyn
and Burke, 2000) examined actual clinical
encounters and revealed that physicians
viewed black patients, in comparison
with white patients, as less intelligent,
less educated, more likely to abuse drugs
or alcohol, and less likely to comply with
treatment advice, despite their knowledge
of patient income, education and personal
characteristics. Based on research on the
reverse situation—how patients’ biases
and attitudes influence clinical encoun-
ters—the IOM report indicated that
minority patients perceive higher levels
of discrimination in healthcare settings
than do non-minority patients.
The development of workshops to help
train physicians to understand the impact
of healthcare disparities and improve
communications with their diverse patient
populations was undertaken. More specific
recommendations that addressed how
to meet the ultimate goal of eliminating
racial and ethnic disparities in healthcare
were also put forward. Recommendations
prioritised the following activities:
a broader assessment would be made of
the differences between schools that enroll
higher proportions of minority students
compared to those with lower minority
enrollments.
The Committee also discussed plans
to convene key stakeholders—educators,
organisations representing minorities,
financial groups, government agen-
cies, and the media—in 2006 with the
goal of implementing some of the 37
recommendations of the highly regarded
report, Missing Persons: Minorities in the
Health Professions. This 2004 report was
released by the Sullivan Commission on
Diversity in the Healthcare Workforce,
which was named for its chair, former US
Secretary of Health and Human Services
Louis Sullivan. Recommendations in the
report addressed the underlying reasons
why minorities are under-represented in
the health professions, in spite of the
country’s increasingly diverse population.
Another way to increase representation
www.asianhhm.com 25
Healthcare Management

is through the Doctors Back to School
(DBTS) programme, was launched in
2002 by the AMA Minority Consortium.
Minority physicians and medical students
who volunteer in the DBTS programme
act as role models by visiting elementary
and high schools to talk with students,
particularly those in under-represented
racial and ethnic groups, about careers in
medicine. The programme demonstrates
to minority students that a medical career
is well within their reach.
Improving quality
Another goal is to help physicians recog-
nise that inconsistent healthcare across
different populations is a quality issue,
and that disparate care affects patient
safety. Physicians should be educated
to recognise that cultural competence
is related to technical competence.
Conditions such as cardiovascular disease,
which present greater opportunities for
improvement, should be prioritised.
Incentives such as discounts on medi-
cal liability premiums could enhance the
success of quality improvement initiatives
such as the use of practice-based assess-
ment tools. Increased minority repre-
sentation on accrediting bodies such as
the Joint Commission also could help
improve quality.
Addressing cultural diversity
A core curriculum on healthcare dispar-
ities could be developed and made a
requirement for medical students and
medical school accreditation. Medical
students would benefit from more inter-
actions with ethnically and racially diverse
faculty and patients. Medical student
selection committees should be made
aware of provider diversity as an issue
of meeting patient needs and increasing
patient safety.
Residency and fellowship selection
committees should consider the impor-
Health disparities / cultural compe-
tence education should be required in
states with CME requirements. Disparity
and diversity issues should be included
in certification examinations.
Focussed research
Race, ethnicity and language profi-
ciency should be incorporated into
clinical quality performance measures.
Healthcare disparities could be an
important area for the AMA-convened
Physician Consortium for Performance
Improvement to consider in its work to
develop and test evidence-based clini-
cal performance measures. Additional
research in healthcare disparities is
needed to refine teaching techniques
to improve cultural competence.
Collaborate with other
organisations to reduce disparities
in care
Collaboration could be established with
health plans, Centers of Excellence,
health and medical organisations includ-
ing the American Heart Association
and the American Cancer Society, the
US Department of Veteran’s Affairs,
the Association of American Medical
Colleges, the Accreditation Council
for Graduate Medical Education, the
American Board of Medical Specialties
(focussing on its role in recertifica-
tion), and community and religious
organisations that serve minority
communities.
Interventions and tracking
Creation and dissemination of toolkits.
Toolkits are an important intervention
that could energise physicians to imple-
ment initiatives to monitor and track
Mildred M G Olivier is an Associate Clinical Professor at Midwestern
A u t h o r
target diseases. In addition, they could
enable state medical societies to offer
frontline support. Programmes that
improve the image of physicians could
help build trust with minority patients.
A calendar of organized medicines events
that address healthcare disparities could
encourage physician participation and
act as a planning guide.
Data collection to improve the
factors effective to improve that qual-
ity improvement initiatives intended
to eliminate disparities is needed.
Collection of patient data, identify-
ing factors that help or hinder prac-
titioners and organisations in their
efforts to eliminate disparities and
gathering physician and patient data
on race, ethnicity and language groups
(Hasnain-Wynia & Baber, 2006, Siegel
2007, IOM) should be collected by
health plans, hospitals, large medi-
cal group practices and community
health centres (Audet et al., Health
Affairs 2005; Nerenz et al., HSR,
2006). Instead, many of this type of
data are collected in a non-systematic
and unreliable way (Hasnain-Wynia &
Baber 2006). Among smaller groups
of physicians—practices with 1-5
members—there is reason to believe
that collecting and using demographic
data to track and reduce disparities is
even less common.
Implementation of these various
objectives throughout the healthcare
community allows each of us to take
a part in trying to eliminate healthcare
disparities by increasing our self-aware-
ness, increasing minority representation
in the workforce and collecting data and
evidence based medicine to increase the
quality-of-care for all individuals.

University and Assistant Professor at John H. Stroger, Jr., Hospital

tance of recruiting under-represented at Cook County and at Olympia Fields Osteopathic Hospital. She is
currently the CEO of Midwest Glaucoma Center. Olivier received her
minorities. Programme chair meetings bachelor’s degree from Loyola University and her medical degree
should address identification of racial from Rosalind Franklin University of Medicine and Science, formerly
and ethnic disparities and strategies to The Chicago Medical School.
reduce or eliminate them.

26 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009


Direct Practice Medicine
Better outcomes, lower costs
Direct Practice Medicine
(DPM) is a new model
for healthcare that
emphasises a deepening
of the doctor-patient
relationship. It
eliminates the disruptive
impact of set pricing
of healthcare services,
and the control of
reimbursements by third-
party payers. DPM aligns
the medical and fiscal
interests of doctor and
patient, fostering a trusted
relationship that increases
the opportunities
for improving health
outcomes.
Jordan Shlain
Medical Director
Current Health, USA
W
hile times and technology
have changed dramatically
in the last 50 years, the basic
practice of medicine has remained the
same through generations. A doctor is
still a medical problem solver armed with
three primary tools: knowledge, experi-
ence and technology. More importantly,
even while the tools have evolved from
penicillin and X-rays, to multi-drug regi-
mens and PET scans, the pre-eminent
criterion for successful medicine has
nothing at all to do with technology, or
even physician-training. The most critical
criterion of good medicine is time. More
specifically, it is the units of time that a
patient spends with his or her physician.
In trying to improve my own clinical
practice, I have given a name to this crite-
rion. I call it the ‘healthcare minute.’ My
premise is that simply by attending to the
‘healthcare minute’ we can do more to
enhance outcomes than when we throw
more money, or even the most innovative
technologies, at the problem.
The value of the ‘healthcare minute’
has been squeezed to near irrelevance
over the last several decades, in three
ways: (1) The third-party payer system
has eliminated individual accountabil-
ity for healthcare costs; (2) set-pricing
mechanisms in the payment system have
removed free-market transparency; and
(3) medical advances have, paradoxically,
created a population that lives longer
through more illnesses, magnifying the
demand for healthcare minutes. Trouble
is, there are a finite number of minutes
in each day.
The perfect storm in healthcare
Of these three factors, the set pricing
of healthcare services may be the most
Healthcare Management
perverse. Begun in 1965 as part of the
National Social Security Act, the federal
pricing model was intended to streamline
billing systems fraught with variability
and herd the cottage industry of doctors
into a coherent framework. Logically,
premium prices went to the most urgent,
complicated and risky medical procedures
—services that almost always take place
in the late stages of care. In the pricing
standards, however, too little considera-
tion was given to the value of the services
provided by the doctor responsible for
the patient’s complete illness and wellness
profile: the primary care physician.
Using Medicare as their guide, private
payers similarly allocated their premium
reimbursement dollars to specialists and
sub-specialists who perform urgent or
late-stage procedures. The unforeseen
consequence of this was that it margin-
alized the very physicians who deliver the
early, comprehensive services that should
make costly, late-stage medical procedures
unnecessary in the first place. [This is why,
according to the annual Physician Fee
Schedule Survey performed by the trade
journal Physicians’ Practice the average
reimbursement for an office visit with
an existing patient was just US$ 71.67
in 2008—down from Tk in 1965. It is
barely enough to cover office overhead.
Compare this to the average pacemaker
procedure, which is reimbursed at
US$ 3,500.]
Unable to bill competitively due
to set-pricing, and watching as their
 http://209.85.173.132/search?q=cache:fUN-
bxGDvFr0J:www.physicianspractice.com/in-
dex/fuseaction/articles.details/articleID/1293.
htm+average+reimbursement+for+primary+c
are+office+visit+2008&cd=7&hl=en&ct=cln
k&gl=us&client=safari
www.asianhhm.com 27
Healthcare Management
reimbursement rates from private payers
continued to shrank, primary care physi-
cians are left with just one option to keep
their practices solvent: see more patients.
This is how the precious ‘healthcare
minute’ was unintentionally sacrificed to
the costly ‘healthcare procedure.’ Forced
to see as many patients in a single day
as possible, primary care physicians have
begun spending only enough time with
each, to determine just which higher-cost
specialist must see them next. Primary
care physicians today refer approximately
50 per cent of their patients to specialists
—up from just 20 per cent three decades
ago. Stuck on the “referral treadmill,”
doctors have reluctantly whittled down
their average medical office visit to a mere
seven minutes.
The real costs to the healthcare system
of displacing 30 per cent more patients
from early stage care, which costs less,
to late stage care, which costs more, is
enormous. What is worse, as late stage
care grows bloated with patients, more
and more resources are siphoned from
primary care. This is a positive feedback
loop with negative consequences that
is slowly starving the physicians best-
positioned to improve overall health
outcomes.
Can’t we do better than this? Isn’t
there a model that efficiently allocates
resources, while also prioritising the early
inputs that provide the most value in the
healthcare delivery chain? And what do
patients really want, anyway? How many
people would opt for bypass surgery, if the
alternative were simply more time spent
with their internist earlier in life?
I contend that most patients would
opt for a deeper relationship with their
doctor, given the choice.
Most patients want the comfort of
close counsel, and information-rich advice
on how to be healthy. When things go
wrong, they want compassion, responsive-
ness, and confident crisis management.
It is time for physicians—especially
young physicians, who lack the burden
of entrenched interests or history—to
turn the 20th Century model on its ear.
28 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Rather than minimising office visits with needs will be more committed to improv-
internists and family practitioners, we ing his or her health outcomes ultimately,
should be minimising visits to special- their asset. An individual willing to invest
ists. Instead of maximising late-stage discretionary income in their health and
procedures, we should be maximising the wellness, is also a person willing to invest
‘healthcare minute’ shared by doctor and more time in his care. Show me a person
patient at the entry point of the medical who invests in more healthcare minutes,
ecosystem. This is the model of Direct and I’ll show dramatically improved health
Practice Medicine. I believe it can achieve outcomes.
the changes that providers and patients
both want: increase access; decrease costs; The math in the healthcare minute
and improve overall outcomes. The power of Direct Medicine, of course,
is in the minutes—or rather, the math
The Economics of Direct Practice behind the minutes. I illustrate this by first
vs. Managed Care / 20th Century drilling down into the standard, and very
Care hurried visit, of a traditional clinician.
In business, the open market determines In the current US healthcare system,
the value of goods and services. In its the average doctor has at least 2,000 and
current state, the healthcare market is as many as 4,000 patients. This is why
anything but open. In fact, it is like a most doctors see 32 patients a day—and
black hole. As a consumer culture, it is why the average clinical exam has been
hard to appreciate the value of some- compressed to just seven minutes. What
thing without knowing its cost. Very few is often left out of this calculus, is that a
could report the actual cost, in inflation- doctor must review each patient’s chart
adjusted dollars, of our annual physical before the exam, plus conduct follow-up
exam, much less the cost of an inpatient paperwork—including calls to relevant
colonoscopy. Direct Practice brings some specialists, and order prescriptions or lab
fiscal rationale to healthcare in two ways. tests. Charting and follow up requires
One, it offers pricing transparency. Two it about 20 minutes per patient, so even a
empowers a patient to determine precisely seven minute exam can be as long as 35
what market value he wishes to place on minutes in total. Given that some patients
his healthcare. The benefit of this new require more comprehensive exams requir-
sense of ownership is a more committed ing even longer, to do a thorough job,
patient. An individual who is willing to a good doctor should see no more than
invest discretionary income on their health 12 patients in an eight hour day.
Introducing Direct Practice Medicine
Practice Medicine emphasises a deepening of the doctor-patient relationship. It is
based on a principle of mutually aligned incentives. The doctor commits to delivering
a higher level of service, chiefly demonstrated by the hours spent with the patient,
and other intellectual resources made available by the doctor. The patient promises
to adhere to preventative medical regimens, and agrees to pay—up front—fees
commensurate with the time and resources expended by the physician.
This implies that the patient values his or her health as an asset, takes
responsibility for the management and growth of this asset, and is willing to pay for the
professional advice and insights of a trusted adviser. Freed of the bureaucracy of third-
party payers, formerly risk-averse physicians will suddenly become more enterprising,
migrate to the latest technologies, adopt new clinical practices and deliver personalised
services in more creative ways.
In these ways, Direct Practice eliminates the disruptive impact of set pricing. It
dispenses with reimbursements of third-party middlemen. It aligns the medical and
fiscal interests of doctor and patient.
ISSUe - 19 2009
 Healthcare Management

Furthermore, at any given time, two
per cent of a physician’s patient panel
will be ill. Therefore, a practice with
3,000 patients, 60 will be sick at any
time. We would never expect a high
school teacher to effectively tutor 60
students at one time. Few consumers
would knowingly pay to be just one of
60 people competing for their doctor’s
time and expertise. In the Direct Practice
model there is no such competition.
Introducing CurrentHealth
In 2009 my partners and I initiated a
US$ 50-a-month membership program
called CurrentHealth . Practicing medi-
cine is historically a labour intensive
endeavour. It takes one doctor and about
2.5 office support staff to schedule,
conduct and manage a single office. To
leverage so much overhead, and mini-
mize the average cost per office visit, it
is easier to ramp up the “throughput”
of patients than it is to cut down staff
– just one more reason why doctors try
to see so many patients each day. In this
scenario, outcomes suffer.
As an innovator, CurrentHealth
offers patients open access through
a variety of communication channels
aimed at increasing value and reduc-
ing inefficiency. The Internet, e-mail,
and SMS are all available options for
contacting CurrentHealth doctors and
our office 24 hours a day, seven days
a week. Our patients can follow their
medical progress with the latest commu-
nications tools, including Twitter and
texting or emailing with their physi-
cian.
We believe the CurrentHealth model
is scalable and can be replicated in most
any market, including the Asian market
– so long as patients value their health
and doctors can practice in an economic
framework where the health minute is
in the US, the Society of the Innovative
Practice of Medical Design  is a rela-
tively new organization that aggregates
direct practice doctors. In five short
years, their membership is well into
hundreds and growing everyday.
The patient experience
If a Direct Practice doctor is not living
up to his promise of service and qual-
ity, the patient community will learn
about it. In the world of Twitter
(CurrentHealth), Facebook (Current
Health Medical Group), Myspace, Yelp,
and Healthgrades, a practice cannot
afford to say one thing and do another.
There are too many eyes and too much
connectivity that will expose and chip
away at inadequacies. Physicians have a
great opportunity to step up and deliver
a new brand of healthcare. To reiterate,
this is nothing new rather a return to
medicine’s roots. It’s all about patient
care, the patient experience and the
doctor-patient relationship. The direct
practice model elevates the patient expe-
rience and improves outcomes.
The new model for 21st century
medicine
To be fair [be fair or clear, not both],
Direct Practice Medicine is not for
everyone. It especially suits those who
desire medical care that is competent,
lean and engaging. Direct Practice
appeals to patients who wish to invest
in a system that rewards the doctor-
patient relationship and improved health
outcomes over transactions and marginal
cost-savings.
 www.SIMPD.org <http://www.SIMPD.org>
Jordan Shlain is a pioneer in the evolving field of ‘direct practice’
medicine. He is board certified in Internal Medicine, lectures at
A u t h o r
Of course there are those in any
society who will not wish to, or will
not be able to, opt into a private system
like Direct Practice Medicine. However,
contrary to popular belief, this new model
can scale to serve the needs of all kinds of
patients. QuickHealth in San Francisco
offers US$ 49-office visits and caters to
the un-employed.
I believe that any healthcare system
must have, at its core, a provision for
a safety net to protect those who are
stricken with unforeseen illnesses of
especially high costs. But if we are to
reform the healthcare system, at large, we
must encourage—and enable—innovative
thinking on the edges, too. By empha-
sizing the doctor-patient relationship,
and eliminating the disruptive impacts
of set pricing and third-party payers,
Direct Practice Medicine offers one such
opportunity for innovation. If we can
succeed at aligning our fiscal and medi-
cal interests, and once again foster the
trusted relationship between doctor and
patient, Direct Practice Medicine will
increase our opportunities for improving
health outcomes. I believe that doctors,
and patients, will follow.
Now let’s place this value proposi-
tion in a larger context: in the throws
of a global recession, where your stock
portfolio or your real estate holdings have
all lost value, your most precious asset
is surely your health. Most of us don’t
think about our health as a depreciating
asset, but it takes just one moment of
living in medical peril to come to the
realization that your health is an asset
worth protecting. In this context I believe
most patients would agree that investing
a little extra money in their ongoing
health makes sense.

prioritised. Starbucks and Apple have
succeeded at branding a consumer expe-
rience across geographies. Why not in
healthcare? Data is beginning to Also
University of California Berkeley on Healthcare Economics and is the
medical director for the leader in direct practice medicine (www.cur-
renthealth.md). He sits on the local San Francisco Medical Society
board of directors as well as the national concierge physicians’ as-
sociation. He is married to a Swiss and has three children. TWITTER:
Follow his updates at http://twitter.com/CurrentHealth

 www.currenthealth.md

www.asianhhm.com 29
Healthcare Management
The Electronic Health Record
Delivering healthcare for the 21st century
T
An enhanced he delivery of healthcare has been
appreciation of the largely unchanged in fundamen-
connection between tal aspects for decades. Despite
significant advances in science, medical
quality and coast has diagnostic tools, surgical interventions and
made the question pharmacology, the basic transaction has
of mass-market remained almost solely face-to-face inter-
penetration of the action between healthcare professionals
EHR an issue of and patients in institutional settings.
In almost all other spheres of busi-
broad importance. ness and industry, electronic information
systems coupled with the Internet have
Louise Liang driven fundamental shifts in how busi-
Senior Consultant
ness is conducted and healthcare will not
Kaiser Permanente, USA
be different.
In 1999, the Institute of Medicine
published To Err is Human followed by
Crossing the Quality Chasm in 2001.
These publications attracted broad atten-
tion to quality and safety problems in
American healthcare and identified four
key factors underlying these quality gaps:
(1) The increasing complexity of science
and technology, (2) The rise in the inci-
dence of chronic conditions, (3) A poorly
organised delivery system and (4) A lack of
critical information technology supports.
Concerns about the failure to deliver qual-
ity care have been linked with concerns
about escalating costs in the minds of
policy analysts, governmental agencies,
purchasers and patients. Most recently, the
US government forecast that healthcare
spending will increase to 17.6 per cent of
the economy in 2009. This combination
of escalating costs, poor outcomes and
15 per cent of the population without
health insurance is unsustainable and
has drawn understandable scrutiny and
criticism from many quarters.
Today, Electronic Health Records
(EHR) has capabilities that can be
brought to bear on the key factors that
30 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009
drive system quality. At the same time, an
enhanced appreciation of the connection
between quality and cost has made the
question of mass-market penetration of
the EHR an issue of broad importance.
President Obama has included signifi-
cant funding for the implementation of
EHR as part of his healthcare reform plan
designed to stabilise healthcare costs and
extend health insurance coverage.
In the US, services for patients with
chronic disease now account for 75 per
cent of total healthcare expenditures.
This is a consequence of the mastery of
many aspects of the treatment of acute
disease, and the increasing life expectancy
of the populations we serve. Treatment
of chronic disease requires longitudinal
tracking of treatment and outcomes both
for individual patients and identifiable
populations made feasible via an EHR.
The increasing complexity of medical
science creates a burden for individual
physicians to stay current. As knowledge
in diagnosis and treatment expands,
the time and processing speed required
to achieve an optimal level of quality
performance exceeds any individual’s
capability. The number of years it takes for
a medical advance to be broadly adopted
into regular practice has been estimated
at 17 years. In contrast, the EHR with
clinical decision support has the capacity
to summon current information, recom-
mendations and research instantly at the
point of care.
Patient Engagement
Once an EHR captures and organises
the clinical information, offering a secure
Internet-based view to the patient has
a multiplying effect on the value and
changes possible with a Personal Health
 Healthcare Management

Record (PHR). Through My Health expanded to include family and commu- Whether coordinating care between
Manager, Kaiser Permanente patients can nity locations and resources. New trans- physicians, nurses and other healthcare
view key information in their medical action options made possible with an professionals in the same organisation or
records including office visit and hospital EHR and secure Internet capabilities have among multiple, separate parties across
visit summaries, diagnoses and recom- resulted in over a 20 per cent decrease in many organisations, the EHR supports
mendations; send secure messages to office visits. In the KP Hawaii Region, the coordination of care. The 24-hour
physicians they have seen; view lab results; the first region to fully implement KP availability of patient information in a
make appointments; and renew prescrip- HealthConnect in the outpatient setting, legible, organised format decreases medi-
tions. In the fourth quarter of 2008, 2.7 between 2004 and 2007, the annual total cal errors, duplication of tests and other
million (31 per cent) of our patients had office visit rate decreased 26.2 per cent, services including emergency room visits
secured access to these capabilities and the primary care office visit rate decreased and hospitalisations.
generated 12.6 million among multiple, 25.3 per cent, and the specialty care At the same time that duplicative
separate parties website visits for a variety office visit rate decreased 21.5 per cent. tests and services are eliminated, infor-
of purposes including requesting 358,000 Scheduled telephone visits increased more mation technology can leverage scarce and
appointments, viewing 4.3 million test than eightfold, and secure e-mail messag- specialised clinical resources via virtual
results, and sending 1.6 million secure ing, which began in late 2005, increased consultations regardless of geography and
emails to their physicians and other nearly six-fold by 2007. Secure messaging time zone constraints. KP HealthConnect,
clinical team members. Almost a million and telephone visits have replaced office combined with an integrated disease
registry for chronic conditions has made
The experience at Kaiser Permanente it possible for a single nephrologist to
oversee and consult on the care of the
chronic renal failure patients for a popula-
The experience at Kaiser Permanente in implementing and using an EHR may be
instructive regarding the desired impact on advancing healthcare delivery. Kaiser
tion base of over 250,000, significantly
Permanente provides health insurance and healthcare to 8.7 million people primarily improving clinical outcomes by delaying
in a fully integrated healthcare delivery system for a fixed monthly fee. It began the renal dialysis.
full-scale implementation of an integrated Electronic Medical Record (EMR) in 2004,
covering over 420 medical offices and 36 owned hospitals and medical centres. We Reliability and customisation
anticipated many changes, but significantly underestimated both the breadth and the Effective treatment for hypertension is
challenge. To guide our work, we developed a set of principles to ensure that the imple- well understood but only 40 per cent
mentation and use of the EHR, Kaiser Permanente HealthConnect would achieve the of the diagnosed patients receive the
quality and strategic goals of the organisation. The past several years of implementa-
appropriate care in the US, resulting
tion and use of KP HealthConnect has validated these principles and demonstrated the
significant impact on the way healthcare is delivered.
in needless complications and deaths.
Diabetes affects a rapidly growing per
centage of the population, account-
patients visited the evidence-based health visits while increasing patient satisfac- ing for a substantial burden of illness
encyclopedia and 165,000 visited the tion, maintaining or improving quality and expense. Yet only half of patients
featured seasonal health topic on colds outcomes, and increasing total patient with diabetes receive care proven to
and flu. Even when these website visits contacts. Given our current experience reduce or prevent serious complica-
do not avoid a telephone call or office and trajectory, our patients will likely tions. Data from KP HealthConnect
visit, our patients appreciate and benefit choose alternatives to office visits to populates panel management tools to
from the additional information and inter- access care for well over a third of their help clinical teams to track and manage
change at their convenience. Engaging interactions in the very near future. The patients with chronic conditions such
patients in their care has long been an rapidity and degree of patient adoption as cardiac disease, diabetes and chronic
espoused value, but the PHR makes it has been very strong, cutting across age, renal disease. This allows each team
a reality and the changes this will drive gender and socio-economic differences. to efficiently and proactively identify
have only begun to become clear. Obtaining healthcare has become similar which of their patients are in need of
to the way many of us shop, bank and additional care and interventions. The
Beyond our walls work every day. tools support mail, phone and email
The home and other personal settings outreach; pre-visit preparation; and
such as work or community have become Integration and leveraging referrals to other specialists.
the location of choice for much of care Healthcare is mostly provided in very In 2005, the Institute for Healthcare
delivery. The care delivery system has loosely organised delivery systems. Improvement in Boston, Massachusetts

www.asianhhm.com 31
Healthcare Management

launched the ‘Saving 100K Lives
Campaign’ to improve hospital care
and prevent complications by ensuring
the reliable delivery of evidence-based
care. EHR-imbedded documentation
templates and evidence-based orders
make this task consistent and efficient.
A recent study of 41 hospitals in Texas
reported the correlation of the level of
sophistication of the EHR used with
lower mortality and complications, lower
costs and shorter hospital stays. While
many clinical processes will be vastly
improved by standardisation and the
EHR, patient involvement and customi-
sation are also readily supported. The
easy availability of information on
medical conditions and recommended
care helps patients and families make
knowledgeable choices based on personal
preferences, constraints and values.
Seamless transitions
Although the EHR can eliminate
unwanted and unnecessary face-to-face
encounters, healthcare is still fundamen-
tally based on relationships. Patients
and healthcare professionals alike need
and benefit from in-person interaction,
made richer by full availability of inte-
grated longitudinal patient information
coupled with the best knowledge and
recommendations science can offer. By
having complete information, every
clinician contributing to the care of
an individual patient has the advantage
of providing a seamless experience for
the patient. Valuable time during office
visits, emergency visits, and hospital
rounds can be devoted entirely to
understand patient concerns, prefer-
ences and issues.
Louise L Liang, a 25 year veteran in healthcare administration and
operations, speaks, writes, and consults on a broad set of health-
A u t h o r
Transitions in care are a time of partic- BOOK Shelf
ular risk in healthcare. Nurse shift changes,
general medicine referrals to medical or
surgical specialists, and hospital discharges
are all vulnerable times. Personal commu-
nication style, verbal versus written
communication and variation in what
information is conveyed and where it is
documented all contribute to the risk that
critical information may be omitted or
misinterpreted. The EHR provides the
vehicle and the opportunity to design a
consistent information flow to enhance
safety and efficiency. Dozens of staff nurses
learned techniques to design a process for
shift change that is now the standard proc-
Keys to EMR Success:
ess in Kaiser Permanente hospitals. After Selecting and
incorporating information from patient Implementing an
and family interviews, a template was Electronic Medical
developed that is now imbedded in the
hospital EHR. All clinical staff can access
Record
a single place for the same information on
Author : Ron Sterling
each patient. A similar process is underway
to redesign the hospital discharge process Year of Publication : 2008
informed by over 100 interviews includ- Pages : 253
ing patients and families at home after
discharge as well as doctors, nurses and Published by : Greenbranch Publishing
pharmacists both in the hospital and in
their medical offices. Description
Fundamentally, the EHR has the Electronic Medical Record (EMR)
capacity to integrate and organise all systems can dramatically improve
patient information, facilitate its instan- patient care, office workflow, regulatory
taneous distribution among all partici- compliance, and profitability. So what
pants in the healthcare system including keeps every medical practice from
patients, and inform and support the work having an EMR? For starters, there is
of practitioners with the most current the significant investment and learning
curve. Plus, implementing the wrong
evidence. In doing so, it will simultane-
system can handicap practice growth,
ously change industry work processes,
patient care and compliance with
improve quality, patient safety and satisfac- evolving standards and regulations for
tion, and alter our understanding of the years to come. But now, Keys to EMR
process and cost of delivering healthcare Success offers medical practices a clear
in the 21st century. and systematic way to evaluate what an
EMR would contribute, choose the best
system for today (and down the road),
and get it up and integrated with your
Practice Management System with a

care issues including electronic information systems, quality, safety, minimum of technical headaches and
service, and practice redesign. From 2002 to 2009, Louise served as
Senior Vice President, Quality and Clinical Systems Support, Kaiser staff resistance.
Foundation Health Plan and Kaiser Foundation Hospitals, where she
oversaw the national quality agenda and led development and im-
plementation of a US$ 4 billion+ organisation wide electronic health For more books, visit Knowledge Bank
record. section of www.asianhhm.com

32 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009

 Ensuring
Patient
Safety
Rules and regulations can only be
truly effective in contributing towards
patient safety if individual healthcare
practitioners take on accountability
for their own actions and omissions.
Role of regulation Jill Crawford
President, Nursing and Midwifery Council, UK

T
he regulation in ensuring safety
of the patient will play a very
important role. The Nursing and
Midwifery Council (NMC) was set up
by the UK Parliament for the expressed
purpose of safe-guarding the health and
well-being of patients and the public.
The Council does this by establishing
and maintaining standards of education,
training, conduct and performance for
nurses and midwives. Similar regulators
exist to help ensure the other healthcare
professionals, such as doctors, dentists and
pharmacists practise to safe standards.
However, professional healthcare
regulators like the NMC cannot work
in isolation. Patient safety is a shared
responsibility between regulators, employ-
ers, service users and most importantly,
practitioners. The NMC believes that
the starting point for public protection
rests with individual nurses and midwives,
and the professionals on their register are
personally accountable for their actions
and omissions in their practice.
This principle is enshrined in the
NMC Code through a set of standards
nurses and midwives can use to demon-
strate the safety of their working practice
and behaviour to patients, members of
the public, employers and colleagues. The
NMC Code, which was updated and
re-launched earlier in April 2008, empha-
sises that nurses and midwives must make
the “care of people their first concern,
treating them as individuals and respect-
ing their dignity.” It also states that they
must, at all times, protect and promote
the health and well-being of those in their
care. The Code also emphasises that failure
to comply with it could bring the fitness
to practise of a nurse or midwife into
question and endanger his or her registra-
tion. The Code is not just a tool for the
professionals. It is also a document aimed
at patients and the public to help them
understand what they can expect from
the nurse or midwife providing care.

www.asianhhm.com 33
Healthcare Management
However, NMC Code cannot provide
a blue print to nurses and midwives as to
how to behave in every circumstance—
professionals will always have to make
judgements in a wide variety of chang-
ing circumstances. Fundamentally, the
accountability of these professionals rests
on their responsibility to weigh up the
interests of patients using their profes-
sional knowledge, judgement and skills to
make a decision. As mentioned above, it
requires a partnership for the Code to be
effective, involving the NMC, employers,
nurses and midwives themselves.
A key element of the NMC’s role in
this partnership is support for profes-
sionals. The NMC believes that regula-
tion can only be effective when it ensures
that nurses and midwives are encour-
aged in their efforts to achieve the high-
est standards, and to provide the best
possible care at all times. This principle
of supporting best practice of offering
advice and guidance is becoming increas-
ingly important as nurses and midwives
take on new responsibilities, and are faced
with fresh challenges and situations. These
challenges include, for instance, working
in multi-disciplinary teams. This can mean
that nurses work under managers who
are not qualified nurses, or that they are
required to delegate tasks to a healthcare
assistant who may not be registered with
the NMC. Similarly, in the UK we are
seeing a greater emphasis on delivering
healthcare close to patient’s homes and
moving away form the hospital model of
care. This concept has come with many
challenges that are directly impacting
on nurses within both community and
acute care. The NMC is aware of these
challenges, and is doing what it can to
support nurses and midwives, wherever
they work, in giving the best care.
One way in which we do this at the
NMC is through the Professional Advisory
Service (PAS). This service facilitates
professionals to get speedy advice from
experts using a direct phone line and an
e-mail address. Our professional advisors
are often asked about how to maintain
registration, the role of healthcare assist-
34 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
ants and the rules around conscientious
objections to particular procedures or
types of care. To give an idea of the use of
the service, we receive on average, around
29,000 enquiries a year. Another service
the NMC provides is the Advice by Topic
section of the NMC website. This facility
allows nurses and midwives quick access
to information on topics ranging from
delegation to rules on receiving gifts from
those in a nurse’s or midwife’s care.
Another strength of the NMC’s
mandate is its capacity to undertake risk
assessment in relation to public protection
and the direction of practice, and act upon
identified risks. NMC reflects that respon-
sibility by providing guidance regarding
those issues that affect practice in the 21st
No matter how
effective a system of
regulation and revalidation
is, nurses and midwives
can face conflicts when
exercising professional
accountability.
century. One of the key challenges is to
develop a revalidation mechanism, which
demonstrates to patients and the wider
public that nurses and midwives remain
up-to-date in their education, training and
skills and are fit to practise. It is currently
working with Government and other
healthcare regulators to develop a system
of revalidation, which is proportionate
to the risks inherent in the work with
which nurses and midwives are involved.
The NMC is also working at improving
networks and partnerships with other
nursing and midwifery regulators, both
within the European Union and beyond.
A major focus of such partnerships is
developing systems for the exchange of
information about practitioners seek-
ing to practise across borders. Dialogue
with other regulators, within the UK and
more widely, also provides the NMC with
ISSUe - 19 2009
opportunities to learn about innovations
in regulatory systems, including advanced
ways of applying IT to the goal of public
protection.
But no matter how effective a system
of regulation and revalidation is, nurses
and midwives can face conflicts when
exercising professional accountability. This
is especially the case where resources are
limited or badly managed. Employers—
and ultimately Government—must ensure
that systems are designed and resources are
provided to support nurses and midwives
in their practice. Patient safety can be
compromised in circumstances in which
there are inadequate staffing levels. For
example, the potential risk to patient safety
is increased if a midwife is left unsup-
ported in charge of a busy maternity ward
over a weekend shift. The risk increases
further, if the midwife is exhausted by
the lack a much-needed rest break due to
lack of any cover. Individual nurses and
midwives placed in such situation are faced
with difficult decisions. It is their duty to
raise concerns, if they feel their ability to
provide safe care is being compromised.
Indeed the Code states specifically that,
“You must inform someone in authority
if you experience problems that prevent
you working within this Code or other
nationally agreed standards”. In practice,
it can be difficult for nurses and midwives
working in such high-pressured environ-
ments to make their voices heard.
The final element of responsibility
for patient and public safety lies with
service users themselves. Without a well-
informed public willing to get involved
in the process of setting standards for
healthcare professionals, regulation can
never truly reflect the needs of society.
The NMC works hard to involve the
public in its work—not just through
lay membership of Council, but through
wide consultations. These consultations
take a variety of forms. For instance, in
drafting the Code, the NMC consulted
not just nurses and midwives, but patient
groups, employers, trade unions, nurse and
midwife educators, and the four govern-
ment departments in England, Scotland,
 Healthcare Management

Wales and Northern Ireland. The focus
groups provided invaluable insight into
how NMC as an organisation is viewed
from the ‘outside’—and it certainly gave
it food for thought.
The NMC, alongside the other health-
care regulators in the UK, is currently
moving towards a governance structure
that will see the lay voice being strength-
ened. Currently, the Council consists of
33 Members, of which 24 are elected
nurses and midwives (although only 12
of those sit at Council meetings at any
one time). Following proposals in the
Government’s recent White Paper enti-
tled “Trust, Assurance and Safety – The
Regulation of Health Professionals in the
21st Century”, the NMC will be moving
to a smaller, fully appointed Council.
patients is heard and their input flows
directly into the business of regulation,
although that is of course, a key element.
Lay participation also means the NMC
benefits from the knowledge and skills
of experts in different fields, such as
law, accountancy and management. The
structure of the new Council sets a clear
message that modern regulation is aimed
squarely at representing the interests of
patients and the public, rather than repre-
senting interests of nurses and midwives,
which is the role of trade unions and
professional bodies.
In conclusion, healthcare regulators
can and do set out standards, rules and
Jill Crawford was elected President of the Nursing and Midwifery
A u t h o r
guidance to enable healthcare practition-
ers to practise safely and effectively. But
such activity can only be truly effective
in contributing towards patient safety if
individual healthcare practitioners take
on accountability for their own actions
and omissions. Where does the respon-
sibility ultimately rest for patient safety?
Although, as previously explained, there is
a shared responsibility for patient safety,
ultimately such responsibility must start
with the individual healthcare practitioner.
Rather than talking about ‘the buck stops
here’, perhaps we should be talking about
the buck starting somewhere—with
individual healthcare practitioners.

Council in August 2008, having been a lay member of the Council

This new 14-member board-like Council,
which will see parity between lay and
professional members, will take up office
on January 2009. Lay involvement is
not just about making use; the voice of
for six years. Jill has a background in campaigning for improve-
ments in maternity services in the UK. She is a member of the
National Childbirth Trust and has chaired Maternity Service Liaison
Committees.

www.asianhhm.com 35
Healthcare Management
Cultural,
Social &
Linguistic Barriers
Can they be overcome?
I
Cultural, social and ncreasing migration worldwide leads
linguistic barriers are to formation of multi-ethnic socie-
a great challenge for ties. In 2006, there were about 200
million immigrants worldwide. Ethnic
healthcare providers. In
and cultural diversity presents a great
order to overcome these challenge for all healthcare providers.
barriers, clinicians must Problems arising through this diversity
rethink their daily clinical are wide-ranging and require rethinking
work. The data compared of already existing healthcare approaches
and structures.
in this article show that
Talking about racial and ethnic differ-
immigrants in Europe ences highlights an important question:
differ from natives but also terminology of ethnic categories is often
from their countrymen at inconsistent and problematic. Use of
home. The investigation such basic terms like ‘race’, ‘ethnicity’
and ‘minority’ is almost always undif-
of this population should
ferentiated. The diversity of minority
help us to provide groups less homogenous is not usually
better healthcare. perceived by an observer who does not
belong to this group. Usual terminol-
Marina Sleptsova ogy also does not take into account the
Clinical Psychologist and Master in degree of acculturation to the country
Cognitive-behavioural Psychotherapy of immigration.
University Hospital Basel
Switzerland
Racial disparities in health and
health treatment
Racial disparities in health have been well-
described in current literature. Data shows
that members of minority groups suffer
disproportionately more cardiovascular
disease, diabetes, asthma, and cancer.
Musculoskeletal pain is more preva-
lent among immigrants in Europe than
among native Europeans. Mood disorders
36 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009
among immigrants to Europe have also
been reported to be more prevalent than
among native Europeans, but not all stud-
ies confirmed these findings.
Racial differences among migrants
result in migrants receiving unequal
treatment. Most studies find that vari-
ous ethnic groups are not given equal
healthcare. This inequality of healthcare
for various ethnic groups was observed
for instance in pain treatment for all
types of pain (i.e. acute, cancer, chronic
non-malignant) and in all settings (i.e.
postoperative, emergency room).
Communication between doctor and
patient is often negatively affected by these
cultural differences. In medical consul-
tation, both migrant patients and their
providers interact differently than natives
and their clinicians do. To reduce racial
and cultural disparity in care, the authors
recommend that healthcare providers and
organisations employ a culturally sensi-
tive approach.
Culturally competent approach
The quality of the relationship between
the clinician and the patient is crucial for
diagnosis, treatment and healing. Patient-
centred encounters increase patient satis-
faction and improve medical outcomes.
Similarly, cultural competency in treat-
ment of migrant patients is recognised
as an essential factor for the quality of
 Healthcare Management

What characterises migrants in Europe? Sleptsova et al., Huge et al., 2006

In their host country, migrants differ from natives. Migrants 2008 114 Turkish 83 German native
are disrooted in many ways from their country of origin. At Scales, SF 36 migrant chronic chronic pain
pain patients patients
the onset of their migration, there are two possibilities. Either
migrant who voluntarily leave their home country are more Mean, SD Mean; SD
courageous and healthier than the average population in their Physical Functioning 39.35; 21.6 50; 20.4
country, or migrants forced to leave their country represent a Role-Physical 6.36; 20.7 15.9; 32.3
sociologically handicapped section of the population. Healthy Bodily Pain 18.67; 16.5 27.2; 13.5
migrants to Europe consider their quality of life to be higher
General Health 21.85; 14.9 46.9; 18.3
than that of their healthy fellow countrymen who remain home .
However, if Turkish migrant patients in Switzerland get ill, they Social Functioning 37.06; 23.8 56.3; 28.3
assess their quality-of-life a great deal worse than their country- Role-Emotional 11.4; 27.9 66.7; 43.6
men in Turkey do (See Table 1). Mental Health 32.04; 18,5 59.1; 22.7
Vitality 22.76; 17,8 39.6; 22.4
Sleptsova et al., 2008 114 Tuzun et al., 2004
Table 2. Comparison of Scales SF36 of Turkish migrant patients in
Turkish migrant chronic 99 Turkish chronic
Switzerland and German patients in Germany.
Scales, SF 36 pain patients pain patients in Turkey
Migrant workers coming from outside the European Union to
Mean, SD Mean; SD Western Europe tend to be more socio-economically disadvantaged.
They are less educated than natives. Migrants work in low-paid
Physical Functioning 39.35; 21.6 67.27; 18.59 and more hazardous jobs. The following comparison illustrates
Role-Physical 6.36; 20.7 39.09; 37.26 that Turkish migrant chronic pain patients in Switzerland have less
formal education than native chronic pain patients in Germany.
Bodily Pain 18.67; 16.5 33.18; 17.73
General Health 21.85; 14.9 36.42; 22.26
Social Functioning 37.06; 23.8 59.09; 28.17 Characteristics Basler et al., Sleptsova et
Germany al., Switzerland
Role-Emotional 11.4; 27.9 44.43; 43.83
Number of participants 220 116
Mental Health 32.04; 18,5 54.91; 21.85
Education duration
Vitality 22.76; 17,8 39.32; 19.83
No school education, % 0 23.3
Table 1. Comparison of Scales SF36 of Turkish migrant patients in Switzerland and First 5 school years, % 0 54.3
Turkish patients in Turkey. Iranian and Turkish immigrants in Sweden report poorer
Further 3 school years, % 43.9 15.5
health and poorer health-related quality-of-life than native Swedes do, unless socio-
economic status, Swedish language proficiency, and racial discrimination are also University, % 56.1 6.9
considered.
Likewise, Turkish chronic pain patients in Switzerland report lower quality-of-life than Table 3. Comparison of formal education of Turkish migrant
German native chronic pain patients do (See Table 2). patients in Switzerland to that of native patients in Germany.

www.asianhhm.com 37
Healthcare Management

healthcare. Thus, patient-centred commu- of these roles is that of the so-called

nication should contain the specification
of cultural competency.
Many authors present ‘cultural
competency’ as an integrative model of
the healthcare system at both institutional
and professional levels. The institutional
level of such a culturally competent health-
care system requires primarily that both
interpreter services and culturally and
linguistically appropriate health educa-
tion materials are available. Training
programmes for healthcare providers
to develop their cultural competency
are necessary at the professional level of
such a healthcare system. Such training
programmes improve knowledge, atti-
tudes, and skills of health profession-
als, which influence patient satisfaction
positively.
The perspective of the patient to
culturally sensitive healthcare has also
been investigated. Along with universal
themes like individualised treatment,
effective communication and professional
competency, results revealed that patients
wish a culturally specific patient education
and culturally sensitive staff.
Culture, culturally sensitive and
culturally competent
An increasing quantity of current litera-
ture has begun to reflect on terminol-
ogy. Fundamental terms such as ‘culture’,
‘culturally sensitive’ and ‘culturally
competent’ in medical context begin to
be used by clinicians who are confronted
everyday by migrant patients. The need
to articulate clear definitions of these
terms and find consensus has been slowly
recognised. One thing is clear: Culture is a
dynamic concept. Moreover, culture varies
within an ethnic group and is in change.
Most authors emphasise that clinicians
must become aware of and also respect
differences in cultures. Clinicians should
recognise unique cultural and religious
beliefs, ethnic values, and traditional
Several studies
establish that professional
interpreters have a positive
impact on clinical care.
Lack of linguistic
comprehension decreases
patient satisfaction.
is necessary to develop awareness of one’s
own attitude toward persons of different
ethnic or cultural groups.
Linguistic barriers in healthcare
Although current studies show that
language is not the only influence on
the quality of clinical communication,
nevertheless language proficiency does
play a very important role in medical
encounter. Several studies establish that
professional interpreters have a positive
impact on clinical care. Lack of linguistic
comprehension decreases patient satisfac-
tion. Whereas concordance of language
between the clinician and his or her
patient does reduce emergency visits and
their costs, in general, such enhanced
interpreter service intervention does not
significantly change hospital costs.
Growing use of the interpreter
presents new problems to researchers and
clinicians. The role of the interpreter in
the clinician-patient consultation has not
been clearly ascertained. The so-called
transmission model of communication
introduced by Shannon and Weaver
requires precise and complete transla-
tion. In clinical reality, however, this
theoretical model does not suffice.
The role of the interpreter in health-
care settings has been discussed, but
consensus is yet to be achieved. One
Marina Sleptsova Schwander is a clinical psychologist and
A u t h o r
‘cultural broker’. Can culture really be
translated?
In any case, the quality of clini-
cal consultation depends on mutual
agreement by all participants about the
interpreter’s role. However, innovative
strategies of medical translation, for
instance Remote Simultaneous Medical
Interpreting (RSMI) have been intro-
duced and tested in the clinical practice.
This strategy of translation removes the
person interpreting from the presence of
the patient. Patients believe their privacy
is better protected and feel more satis-
fied than in consultations with usual
interpreting.
Conclusion
In healthcare systems today, the prob-
lems of cultural diversity seem to be
perceived and taken seriously than ever
before. Nevertheless, far too little research
has been made on this topic. A natural
tendency of most health researchers is
to take on the cultural perspective of
the majority ethnic group to which they
belong, at the expense of the perspective
of minority ethnic groups. Development
of culturally competent researchers
is in any case needed. Such culturally
competent researchers could initiate both
needed investigations as well as culturally
competent practice. Because there is so
little research about the effectiveness of
culturally competent healthcare systems,
it could not even be determined.
If ethnic and racial disparity and its
ensuing consequences are to be reduced
or even eliminated, healthcare systems
must overcome cultural, linguistic and
social barriers.
References are available at
http://www.asianhhm.com/magazine

psychotherapist, was born in the Russian Republic of Sakha. She

practices—all of which can be in trans- studied psychology in St. Petersburg. She earned her MA in cogni-
formation—within any ethnic group. tive behavioural therapy at the University Basel, Switzerland. Since
2000, she has been working at the Psychosomatic Department of
Cultural sensitiveness and competency the University Basel Hospital. She is married and is mother of two
requires that the clinician reflect on his children.
or her own cultural system. Self-reflection

38 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009

www.asianhhm.com 39
 Palliative Care
Reaching out to patients with heart failure

40 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009


Patients with end stage
heart failure and their
carers carry a prolonged
and heavy symptom
burden that affects all
domains of life. Moreover,
access to supportive and
palliative care is patchy,
and recognition of the
dying stage remains poor.
Extending palliative care
to this group of patients is
now an important priority.
Miriam J Johnson
Senior Lecturer
Palliative Medicine
Hull and York Medical School, UK
P
atients with heart failure, and
those who care for them, carry a
prolonged burden of symptoms
which affect all domains of life. The
burden is similar to those with cancer,
but with less access to supportive and
palliative care. Recent years have seen a
raised awareness of this issue and services
which integrate palliative care for patients
with heart failure are growing in the UK
and elsewhere in the world, although they
remain patchy.
Reasons for poor access to
supportive and palliative care
Historically, palliative care services have
grown around cancer services and, in the
UK at least, with a heavy dependence
on cancer charities. It is taking time
to extend organisational boundaries to
people with non-malignant disease and
address the potential lack of skill and
confidence of palliative physicians in this
area. Services which have been successful
have adopted an extended team model
of cardiology and palliative care services
Healthcare Management
working together, rather than a mutually
exclusive approach.
Given the pattern of slow decline
punctuated by episodes of severe decom-
pensation and risk of death, much is made
of the difficulties of estimating prognosis
in heart failure. This is used by some
to explain the late referral for palliative
care. Successful services give less weight
to prognostication, but rather, use a prob-
lem-orientated approach working along-
side cardiology colleagues. Palliative care
clinicians use their skills to address the
problems when their services are required
and discharge the patients once they are
resolved. This approach helps to reas-
sure the cardiology colleagues that the
palliative care team will not stop vital
optimal cardiac medication unless this
is no longer tolerated.
There can be a misperception that
palliative care is only for the imminently
dying. This leads to referrals that are too
late—if at all—and a potential reluctance
to discuss palliative care referral as it is
generally misconceived as telling a patient
that he is about to die.
Many clinicians also lack confidence
in their ability to communicate serious
issues regarding different management
options in the context of advanced disease
Barriers to palliative
care access
Palliative care services are traditionally
developed around oncology services
Uncertainties regarding prognosis
lead to late referral to palliative care,
or none at all
Misperception that palliative care is
only for the imminently dying
contributes to late referral
Poor confidence regarding palliative
care skills (cardiologists)
Poor confidence regarding cardiology
skills (palliative physicians)
Lack of communication skills
(cardiologists)
www.asianhhm.com 41

Learning point: Symptoms
in heart failure patients
Symptoms affect all areas of the
patient’s life: physical, psychological,
social, spiritual and financial
Symptoms may be experienced
over a prolonged time
Those looking after the patient such as
family and friends may also require support
A full assessment is needed of needs of
both patient and those who care for them
An extended team approach
between cardiology and palliative care
seems to be effective.
without taking away a patient’s hope, and
causing great distress. To address these
issues, communication skills training must
be recognised as important by clinicians
and managers. Advanced communication
skills training is now mandatory for UK
oncologists enabling this sort of discussion
and patient involvement in key decisions
to become routine.
Just as palliative physicians may feel
uncertain of their cardiology skills, so
cardiology clinicians may feel uncertain
of their palliative care skills. However,
the majority of palliative care skills are
those with which all clinicians should be
competent. There is a need for the usual
care team to be educated in assessment
and palliation skills so that they can deal
with most of the problems themselves, but
refer to specialist services if the problem
persists. Likewise, palliative care teams
need education regarding optimal cardiac
medication and diuretic management.
Symptoms in heart failure and their
management
Breathlessness
Breathlessness is a cardinal symp-
tom of heart failure and forms a key
part of the assessment of New York
Heart Association class. As with any
42 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
symptom control, a full initial assess-
ment is important looking for reversible /
treatable features such as decompensated
failure, infection, pulmonary embolus,
sub-optimal management of chronic
pulmonary disease. Other co-morbidities
such as lung cancer may also be found. It
is also important to distinguish a history
of paroxysmal nocturnal dyspnoea due to
decompensation from alarming noctur-
nal ‘breathlessness’ episodes due to sleep
apnoea. The heart failure patient may have
intractable breathlessness despite optimal
cardiac treatment and dry weight, with
no other explanatory causes. This is due
to several factors including enhanced
chemosensitivity resulting in abnormal
ventilatory patterns. Management includes
non-pharmacological approaches such as a
breathing training and exercise programme
along with anxiety management. Some
patients may benefit from a hospital type
bed where not only the head, but also
the feet, can be raised to prevent slip-
ping down in the night. A hand-held
fan may also be helpful. Pharmacological
approaches include low dose opioids (e.g.
morphine 2.5 – 5 mg qds or morphine-
equivalent dose of opioid), taking care
with opioids that are renally excreted if
there is renal dysfunction, and low dose
benzodiazepine (e.g. lorazepam 0.5-1 mg
sublingually) where panic is a prominent
feature. Currently there is little evidence
that oxygen administration helps the
sensation of breathlessness, and unless the
patient is hypoxic, should not be routinely
prescribed. If sleep apnoea is demonstrated
with episodes of nocturnal desaturation,
nocturnal oxygen, or continuous positive
airways pressure may be helpful to prevent
nocturnal distress.
Fatigue
Fatigue is the other common debilitating
symptom. Assessment should look for
reversible factors like over-diuresis with a
postural drop in blood pressure, hypoka-
laemia from loop and thiazide diuret-
ics, anaemia, insomnia or depression.
As with breathlessness, exercise training
programmes may play an important role
and should be encouraged.
ISSUe - 19 2009
Pain
Pain is a less recognised feature of end
stage disease and may be due to ischaemia,
gout or musculoskeletal co-morbidities.
Optimisation of cardiac medication is
important, and consideration of other
measures such as trans-cutaneous nerve
stimulation (in the absence of devices)
may help. The World Health Organization
(WHO) analgesic ladder is applicable.
The use of colchicine or low dose ster-
oid is preferable to Non-Steroidal Anti-
Inflammatory Drugs (NSAIDs) in the
management of gout. NSAIDS should
be avoided in heart failure because of
the risk of decompensation due to fluid
retention.
Other physical symptoms
Constipation may cause much misery. Bulk
laxatives such as ispaghula husk should
be avoided unless there is another indi-
cation such as irritable bowel disease, as
a high fluid intake is required for them
to work best.
Nausea may be caused due to medi-
cation (digoxin, spironolactone), renal
dysfunction, or liver engorgement and
gut oedema. Attention to oral hygiene is
important and they may require an anti-
emetic such as a prokinetic (metoclopra-
mide or domperidone 10-20 mg t-qds) or
a small dose of haloperidol (1.5 mg once
a day). Theoretically, cyclizine may impair
cardiac function but evidence that this is
a problem in practise is slight. It may be
wise to avoid cyclizine if possible, but if
a nauseated heart failure patient was end-
stage and cyclizine was the only available
anti-emetic then it seems inappropriate to
with-hold it. Poor appetite may herald the
cardiac cachexia of late stage disease or be
due to poor fitting dentures and lack of
energy to prepare food. A dietary assess-
ment is important with use of protein-
calorie supplementation if necessary. If,
however, it is judged that cachexia is the
underlying cause of anorexia and weight
loss, then the patient should be advised
to eat little, but regularly.
Dry skin is asignificant problem which
is often overlooked. Good skin care with
regular use of emollients is necessary to
 Healthcare Management

prevent breaks in the skin which allow
a portal of entry for bacteria, leading to
cellulitis.
Psychological symptoms
Depression and heart failure seem to be
integrally connected with an increased
prevalence compared with the general
population. In addition, patients who
are depressed are more likely to develop
heart failure. Heart failure patients who
are depressed are more likely to be admit-
ted to hospital and die sooner. Diagnosis
and treatment are, therefore, crucial. Non-
pharmacological management includes
exercise and cognitive behavioural therapy
programmes, if available. Pharmocological
therapy centres on the use of the serot-
onin-reuptake-inhibitors and tetracyclic
antidepressants which appear to be safe.
Tricyclics should be avoided because of
their pro-arrhythmic potential. Anxiety
is, likewise, a common problem and may
respond to a full assessment, addressing
specific symptoms and issues of concern.
Non-pharmacological approaches to anxi-
ety management should be used, and
intermittent use of benzodiazepines for
panic may be helpful. Maintenance of
anxiety states may benefit from serotonin-
reuptake-inhibitors rather than long-term
benzodiazepines which may increase the
risk of memory loss and falls.
Care of the dying
Recognition of the dying phase
Patients with heart failure may have several
episodes of decompensation, often trig-
gered by an intercurrent event such as
infection, where they are severely ill,
but then respond to hospital treatment.
However, as the disease progresses, decom-
pensation may occur spontaneously, ACE-
inhibition and beta-blockade are no longer
tolerated due to hypotension, and diuretic
requirements increase or frank diuretic
resistance may occur. Renal failure adds
to the difficulty of optimising medication.
Care of the dying
Recognition of the dying phase can be
difficult but not always impossible
Open and gentle discussion regarding
the stage of the illness is required
Pulmonary oedema can be a problem,
and loop diuretics administered by
intravenous or subcutaneous infusion
In general, the skills used to care for
other dying patients are transferable to
those dying with heart failure
‘Do not resuscitate orders and
re-programming’ of implantable
cardioverter devices (if present)
should be arranged
low serum sodium may also help, if avail-
able. In this context, the patient who fails
to respond to optimal treatment in the
first few days after decompensation, or
becomes bedbound, unable to manage oral
medication, is no longer able to eat but
only manages to sip water, and is progres-
sively more fatigued and less responsive,
is likely to be in the dying phase.
General palliative care measures for
the dying are transferable to the heart
failure patient and are not discussed here.
However, particular issues may need to
be addressed. Pulmonary oedema is not
necessarily a problem, especially when the
patient is unable to drink. But if it is,
parenteral administration of a loop diuretic
(either by stat injections or continuous
infusion intravenously or subcutaneously)
may be needed in addition to an anti-
secretory such as hyoscine. Discussions
regarding the futility of an attempt at
cardio-pulmonary arrest may be needed,
particularly if a patient or their family
have unrealistic expectations. If an inter-
Miriam Johnson is Senior Lecturer in Palliative Medicine at Hull-
A u t h o r
nal cardioverter device is present, similar
discussions related to its reprogramming to
pacemaker mode should take place, if not
done already to prevent distressing multiple
activations as the patient dies. Cheynes-
Stoke’s respirations may be marked to
the extent of causing distressing apnoeic
induced arousals in the patient. These can
usually be minimised by small doses of
opioid medication.
Conclusions
Optimised medical, device and surgical
therapy for the heart failure patient has
made a massive impact on quality and
quantity of life. This approach should be
coupled with access to supportive and
palliative care to address the remaining
symptom burden experienced by such
people and their families. A problem,
rather than prognosis approach will ensure
timely access to services. An extended team
approach between cardiology and palliative
care will ensure the best management for
both treatment of the heart failure itself
and its unwanted effects on the person
involved. Excellent communication skills
are needed to enable clinicians to have
the courage and sensitivity to inform the
patient of the stage of their illness and
discuss the aims for possible treatment
in the light of the issues that the patient
and their family consider important.
If this does not happen, then patients
with heart failure will continue to have
poor understanding of their disease, be
denied best symptom control, support
for their families, and the opportunity to
make plans for their own death. It is said,
“you have to have cancer to have good
palliative care”—this should no longer
be acceptable.
References are available at
http://www.asianhhm.com/magazine

Recurrent ‘revolving door’ admissions are York Medical School and Honorary Consultant to St. Catherine’s
Hospice. Her research interests include breathlessness and pallia-
often a feature of the patient nearing the tion for patients with heart failure. In conjunction with her local car-
end of life. Other prognostic markers such diology service, she has developed one of the UK’s first integrated
as a rising Brain Natriuretic Protein (BNP) cardiology -palliative care services for patients with heart failure.
or falling serum albumin and persistently

www.asianhhm.com 43
Healthcare Management
The ‘vital signs’ of
Performance Improvement
in Cardiac Outcomes
E
Every healthcare very healthcare executive, admin-
executive, administrator istrator and clinical staff member
has heard and understands the
and clinical staff
phrase ‘vital signs’. Temperature, blood
member has heard and pressure, heart rate, and respiration, and
understands the phrase come to mind. Vital signs are used to
‘vital signs’. The vital assess and measure the state of the patient
signs play an important and monitor their progress to a desired
‘cure’ or outcome. But what about your
role in monitoring the
organisation’s ‘vital signs’ and ‘outcomes’?
well-being of the patient. What organisational disease states will
Using the analogy of ‘vital you improve or ‘cure’?
signs’, author explains the Sheikh Khalifa Medical City (SKMC)
importance of identifying is located in Abu Dhabi City, the capital
of UAE. SKMC consists of a 550-bed
Key Performance
Acute Care Hospital and 14 Specialised
Indicators (KPI) to improve Outpatient Clinics accredited by the
the healthcare services Joint Commission International (JCI).
offered by the hospitals. SKMC also operates 120-bed Behavioral
Sciences Pavilion, an 88-bed Rehabilitation
Lewis G Hutchison Center, 9 Primary Healthcare Centers
Quality Management & Accreditation and 2 Dental Centers distributed over
Director the city of Abu Dhabi. SKMC employs
Sheikh Khalifa Medical City (managed
over 4,600 caregivers and administrators
by Cleveland Clinic), UAE
from different nationalities. SKMC is a
Governmental Healthcare Institution
managed by Clinic Cleveland in part-
nership with HAAD and SEHA, the
Abu Dhabi Health Services Company.
Cleveland Clinic is consistently named
one of the top hospitals in the USA by
U.S. News & World Report.
Diseases and disorders of the circu-
latory system rank as the number one
diagnostic category at SKMC. This terti-
ary care programme offers comprehensive
surgical, cardiac and interventional care for
adult patients with acquired heart disease.
44 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009
The programme offers the entire scope
of modern adult cardiac diagnostic and
cardiac surgery including mechanical
circulatory support but excluding heart
transplantation. Given the scope, volume
and complexity of such an important serv-
ice line, it is imperative that the perform-
ance of this department be monitored,
measured and managed with patient and
process outcomes at the ‘heart’ of ones
focus.
Process Improvement is defined by
Joint Commission as “The continuous
study and adaptation of an healthcare
organisation’s functions and processes
to increase the probability of achieving
desired outcomes and to better meet
the needs of patients and other users
of services” and outcomes as “the effect
an intervention has on a specific health
problem’. So instead of stethoscope and
blood pressure cuff one can select from
a variety of Performance Improvement
tools to take its operational ‘pulse’ and
improve outcomes. Current method-
ologies and literature identify many
Performance Improvement tools including
Plan Do Study Act (PDSA), Total Quality
Management (TQM), Six Sigma and Lean
Sigma processes are available for use in
assisting an organisation in its outcome
management process. The overlay below
compares the various systems.
In a multidisciplinary approach,
the PDSA process uses a centralised
Quality Department, an oversight body,
the Quality Improvement and Patient
Safety Committee, and through the
 Healthcare Management

ment of the process. Validation includes

TQM, PDSA, Six Sigma, & Lean Overlay measuring and analysing whether your
organisation has met its goal, improved
Customer Focus outcomes, reassigned thresholds and
benchmarks or implemented an improve-
ment process change.

Pr
s

Pla Documentation is important. The

Identify Waste

oc
es

me n Co
t outcome, its metric and definition are

es
as unt
oc

en ure er
m ity

sM
Pr

u
c l s recorded on a PI template tool (see Figure
Do Rea
ing

1) and a record of action documented

an
nn

ag
e Me through the use of a QRO template.

Re heck
th ity as

em
Pla

ali
e
n

n ure Dashboards are then used to compile

fin rtu
agai

ty

en
e
D p o the results into an easy-to-use, simple
Do it

t
op
Plan DO graphical representation. Hyperlinks are
provided to move between dashboard and

Changes
Make
PI Template views. This gives the user
Celebr

the ability to review the outcomes at the

Act Study
Con

macro and micro level. Each of these tools

ate

trol

e is available and recorded on the SKMC

alyz intranet to provide access (feedback) and
An
To

Impr nt enhance ease of use. SKMC & Cleveland

ta

Ma ove e
an ty
s

k
em
lP

Ch Veri
ge

sta e th Clinic use an intranet-based format to

nd is
ov
ar

ar the r share and disseminate results throughout

mp
tic

d
sI
ipa

the system.
Measure s
ce
tio

Results Registries are also widely used in

o
n

Pr the compilation, management, analy-

An example of performance indicator
placement of Quality Review Officers the desired outcome. Documenting the
(QROs) designated in each department flow of the process to be monitored is
or area, including Cardiac Sciences. The critical. This allows for a point-by-point
QRO’s role is to facilitate and direct or action-by-action review and visually
departmental process improvement illustrates the intended and actual proc-
activities. Each QRO is made aware of ess. Third, identify who performs the
performance improvement methodolo- pivotal actions and ensure communica-
gies, tools and team building techniques tion and documentation of expectations.
to enable and empower departmental Fourth, determine the wherewithal and
ownership. This process is coordinated resources needed to achieve the actions.
and monitored to ensure that six steps Fifth, establish the time lapse between
of alignment are maintained. when a pivotal action does not occur and
Alignment involves, first, review- notification of follow up (i.e. feedback
ing the process to identify the Key loop). This is most easily done by face-
Performance Indicator (KPI) or perform- to-face communication, simply paging or
ance outcome to be achieved. Outcomes telephoning a colleague for clarification
may include, but are not limited to or comment.
mortality, complications, readmissions, Other effective ways of closing the
distribution of appropriate discharge feedback loop include the use of Grand
instructions, Door to PCI time and ‘All Rounds, Peer-conducted Mortality and
or none compliance’ to evidence-based Morbidity Review (M&M), Failure Mode
quality measures. Second, determine the Effects Analysis (FMEA) and Root Cause
pivotal actions in the process to achieve Analysis (RCA). Lastly, validate the align-
sis and comparison of performance
Figure 1 outcomes and data. According to the
Agency for Healthcare Quality and
Research (AHRQ), a patient registry is
defined as “an organised system that uses
observational study methods to collect
uniform data (clinical and other) to evalu-
ate specified outcomes for a population
defined by a particular disease, condition,
or exposure, and that serves a prede-
termined scientific, clinical, or policy
purpose(s)”. Cardiac Science registries
currently used at SKMC include the
European Society of Cardiology Euro
Heart Survey PCI Registry, Euro Heart
Survey—ACS Registry, Global Registry
of Acute Coronary Events and The Get
with the Guidelines-Heart FailureSM
(GWTG-HF) programme.
With over 140,000 registered
patients and more than 450 hospitals
participating, it is the largest hospital-
based heart failure registry in the US.
Recently published studies of GWTG-
HF, and its predecessor, by Fonarow,
et al. OPTIMIZE-HF, “have clearly

www.asianhhm.com 45
Healthcare Management

Performance through
6 Step Alignment
STEP 1
Identify a KPI or performance
outcome to be achieved
STEP 2
Determine the pivotal actions
in the process to achieve the
desired outcome
STEP 3
Identify who performs the pivotal
actions and ensure communication
and documentation of expectations
STEP 4
Determine the wherewithal and
resources needed to achieve the
actions
STEP 5
Establish the time lapse between
when a pivotal action does not occur
and notification of follow up
(i.e. feedback loop)
STEP 6
Validate alignment
demonstrated the ability of this
programme and the GWTG-HF PMT®
to improve care.”
Sheikh Khalifa Medical City is the
first institution outside of the US to be
permitted to attempt the first use of the
American Heart Association’s Get with
the Guidelines programme to analyse
and describe HF epidemiology and
outcomes. The programme emphasises
protocols created to ensure that cardio-
vascular patients are cared for accord-
ing to accepted standards and current
evidence-based guidelines and recommen-
dations. Over 140 elements are recorded
for analysis and comparison. In addition,
this programme was modified to include
have shown that process affects outcomes.
These include studies regarding ACE
inhibitor, Angiotensin Receptor Blockers
(ARBs), and beta blockers and their
performance in reducing mortality,
readmission and reduce symptoms.
In the interest of transparency, SKMC
shares its operational ‘pulse’ with patients,
caregivers and community. A health-
related publication is in print and was
distributed to healthcare providers and
interested parties. Outcomes books for
each of our major clinical service lines are
in the process of being published. One
outcomes book will be ready for issue
each quarter of 2009 with the first of
these centering on Cardiac Sciences. Four
(4) SKMC Performance Improvement
Projects received awards at the 2008 Arab
Health Awards, recently held in Dubai,
UAE. Of the four, three received were
“Highly Commended.” The Cardiac
Science Performance Improvement
Project “Four years of Delivering Primary
Angioplasty in the U.A.E” was named the
winner of Arab Health 2008 Achievement
and Innovation Awards in Emergency
Medical Services. This process used most
of the techniques previously described,
including, PDSA, Lean, Morbidity and
Mortality Review, feedback through
weekly team meeting and registries to
document the reduction of Door to PCI
times from 101 minutes in the year 2006
to 85.5 minutes in the year 2007 to an
average of 82.6 minutes in 2008.
Anecdotally, teams using similar proc-
esses have won three out of four top
awards in the Cleveland Clinic Patient
Safety Best Practice Awards programme
in 2007 and 2008. This included a
programme Called ‘Code Crimson’, a
Door to Balloon (PCI) improvement
process, which is now the recommended
Lewis Hutchison joined Sheikh Khalifa Medical City (SKMC) in
A u t h o r
best practice for PCI and AMI care in the
Cleveland Clinic Healthcare system.
In addition, 86 ‘vital signs’ or KPIs
are monitored throughout the Sheikh
Khalifa Medical City. In 2008, 86 qual-
ity-related Key Performance Indicators
were monitored with 68 or 79 per cent
showing improvement or achieving their
target value. New outcomes and KPIs
are currently being reviewed and revised
for 2009.
Through a multidisciplinary proc-
ess SKMC created and implemented a
comprehensive Quality and Leadership
Education Programme. All presentations
are posted on the SKMC intranet and are
available for use by any interested party
at SKMC, its parent organisation and the
Government of Abu Dhabi. Courses are
open to not only SKMC employees but
also other SEHA hospitals, HAAD and
other medical facilities. A curriculum of
31 topics covering all aspects of continu-
ous process improvement and leadership
was initiated in 2008 and is continuing
in 2009. CME credits are approved and
awarded. As of 2008, 14 courses have
been conducted with over 770 persons
having attended with approximately 11
different content experts contributing to
them. Overall satisfaction scores and indi-
vidual speaker evaluations are quantified
and forwarded for speaker use. Courses
have been very well received with 90
per cent of the scores in the ‘Good’ to
‘Excellent’ categories.
Our organisational ‘vitals’ are strong,
but we’ll continue to ‘take our pulse’
(monitor) and administer ‘treatment’
(performance improvement practices)
in the interest of improving our organisa-
tional ‘well-being’ and enhance the health
status of the patients and communities
we serve.

36 additional elements unique for the January 2008 as the Director of Quality Management Department
and resides in Abu Dhabi, UAE. He is currently focussed on the ap-
Middle East and Asia. GWTG is effec- plication of Performance Improvement techniques and evidence-
tive as hospital and achieved quantifi- based practice in the provision of International Healthcare services,
able care improvement in a short time. outcomes improvement and patient safety.
Globally, More than 50 clinical trials

46 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009


Bariatric and Metabolic Surgery
Anaesthesia concerns
As it has been realised
that western diagnosis
criteria for obese and
metabolic syndrome do
not hold true for Asian
patients, anaesthesia
care providers should
be completely aware
of the pathphysiology,
risks and difficulties
encountered by obese
patients during the
bariatric surgeries.
Sunita Goel
Consultant Anaesthesiologist
Saifee Hospital, India
T
he word ‘bari’ is the plural of
‘baros’. In Greek, ‘baros’ means
weight / burden / load or heavi-
ness. From this stems ‘Baris’ referring
to the obese or fat / heavy / overweight
people.
Obesity has reached epidemic levels
within a short span of time with an alarm-
ing rise in the number of Type 2 diabetics
globally. Asia Pacific itself has seen an
upsurge of more than 50 million Type 2
diabetics with no signs of regression. It
has also been seen that specifically in Asia
the comorbidities, especially diabetes and
cardiovascular disease, develop at a lower
BMI and develop significant complica-
tions leading to fatality at a low age.
Health effects of obesity
As per the WHO criteria, the preva-
lence of obesity in Asia Pacific region is
lower than western regions. According to
research studies, health hazards occur at
a much lower BMI in the Asian region.
It has been predicted that by 2010 the
number of diabetics in Asia alone would
constitute to 130 million of the total 236
million worldwide, thus constituting more
than half of the world’s diabetics.
Treatment of obesity
Treatment of obesity includes various
options outlined below as well as a
team effort as obesity is multifactorial
and needs a combined effort by various
specialists like the physician, nutritionist,
psychologist, physiotherapist and last,
but not the least, surgical intervention
and the anaesthesia care giver.
• Assessment of Weight
• Dietary Therapy
Medical Sciences
• Physical Activity
• Behaviour Therapy
• Drug Therapy
• Combined Therapy
• Surgery
It has been observed that a weight loss
of even 10 per cent significantly lowers
the comorbidities, which is significantly
seen in case of obstructive sleep apnoea
wherein a weight loss of even 10 per
cent might decrease the sleep apnoea
by 50 per cent
Because bariatric surgery has become
common these days, it is imperative that
anaesthesia care providers be knowledge-
able about the pathophysiology, risks
and difficulties encountered during their
care. Problems include difficulties with
intravenous access, tracheal intubation
and extubation, appropriate use of
narcotics, muscle relaxants and other
drugs. Based on Body Mass Index (BMI),
humans may be classified as non-obese,
overweight, obese, morbidly obese and
super-morbidly obese.
Cardiovascular system
With the onset and progression of
obesity, patients develop hypertension,
increased blood volume and dyslipi-
demia. Even when they are normoten-
sive, there is echocardiographic evidence
of a significantly larger internal diam-
eter of ventricles, thicker end diastolic
septum and posterior wall of the left
ventricle. These changes are related to
the increased amount of intra-abdomi-
nal fat deposition. The hypertension is
mild to moderate in the majority but
severe in 5 to 10 per cent. For every
10-kg gain in body weight, systolic blood
www.asianhhm.com 47
Medical Sciences
pressure is reported to increase by 3 to
4 mm Hg and the diastolic increases
2 mm Hg. Obesity is also associated
with Ischemic Heart Disease (IHD). This
is because obese patients are prone to
hypercholesterolemia, a reduced density
of lipoprotein levels, hypertension and
diabetes mellitus. The Framingham study
noted a direct correlation between angina
pectoris, sudden death and obesity. Obese
patients are also prone to cardiac arrhyth-
mias because of increased fat infiltration
of the cardiac conduction system, the
presence of cardiomyopathy and coro-
nary artery disease. Extra-cardiac factors
such as obstructive sleep apnoea with
the associated hypoxia, hypercapnia
and electrolyte imbalance along with
an increase in circulating catecholamines
increase this predisposition. Many obese
patients are asymptomatic even though
they have varying degrees of cardiovas-
cular dysfunctions. The primary reason
is limitation of mobility. As a result of
48 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
this, they may not complain of symptoms
such as angina on exertion or exertional
dyspnea.
Respiratory system
Obesity exerts profound effects on the
respiratory system. The anatomic changes
result in Obstructive Sleep Apnoea
(OSA) and Obstructive Hypoventilation
Syndrome (OHS) because of a reduc-
tion in pharyngeal free space. This is
because of deposition of adipose tissue
into the pharyngeal walls including the
uvula, tonsils, tongue and aryepiglottic
folds. The compliance of the chest wall
and difference between extraluminal and
intraluminal pressures along with oropha-
ryngeal muscle tone determines airway
patency. In obese individuals, collapse of
the soft walled oropharynx and obstruc-
tion of the airway occurs easily because
the pharyngeal free space is markedly
diminished and extraluminal pressure
is increased.
ISSUe - 19 2009
As a single independent factor, obesity
is responsible for OSA in 60–90 per cent
of the population with this disorder. OHS
is different from OSA in that there is no
cessation of airflow. Both OSA and OHS
repeatedly disrupt sleep due to increased
ventilatory effort induced arousal and
causes daytime sleepiness and cardiop-
ulmonary dysfunction.
Pulmonary function tests may be
necessary to note effects on lung capaci-
ties and airflow mechanics. Arterial blood
gases will indicate if the patient is retain-
ing carbon dioxide or has hypoxemia.
The presence of polycythemia will suggest
long-standing hypoxemia. A chest x-ray
will evaluate the anatomical status of the
lung and cardiac structures
Effects of obesity on the liver
Obesity predisposes patients to Non-
Alcoholic Steatohepatitis (NASH)
and cholelithiasis. However, metabolic
function of the liver is not affected in

the majority of obese patients. Diabetes
mellitus predisposes obese patients to
NASH.
Patients with NASH may have
elevated liver enzymes, increase in trig-
lycerides, hepatomegaly and cirrhosis.
Deep Vein Thrombosis (DVT)
Both polycythemia and venous stasis
predispose obese individuals to DVT.
Venous stasis results from increase in
intra-abdominal pressure and accompa-
nying immobilisation noted in obesity.
Decreased fibrinolytic activity along with
increase in fibrinogen concentrations has
been observed in obese individuals.
The risk of DVT is doubled in obes-
ity (48 per cent vs. 23 per cent) when
compared to lean individuals during
abdominal surgery. This automatically
increases the likelihood of Pulmonary
Embolus (PE) and is reported as being
between 2.4-4.5 per cent following bari-
atric surgery. To reduce the risk of DVT
and PE in obese patients, most surgical
protocols favour the use of anticoagulant
prophylaxis and pneumatic compression
lower extremity stockings.
The morbidly and super-morbidly
obese are particularly challenging patients
because of their size. In addition to
routine evaluation, areas of concern in
this patient group are as follows:
Intravenous access – The presence of exces-
sive subcutaneous tissue decreases the
easy visibility of peripheral veins. Portable
ultrasound equipment may be required
for identification and cannulation of
peripheral veins
Preoperative airway assessment – Obese
patients are more difficult to mask
ventilate and intubate. This is because
of their size, presence of a neck that has
a widened circumference, is shorter and
the presence of excessive pharyngeal tissue
with a tongue that has a large base. It
is imperative that every obese patient
be carefully examined for the feasibil-
ity of mask ventilation and intubation
including aspiration risk. Neither obesity
nor body mass index has been associ-
ated with difficult intubation. Large neck
The various associated
health hazards
• Arthritis, Osteoarthritis (OA),
Rheumatoid Arthritis (RA)
• Cancers, Breast Cancer, Cancers
of the Esophagus and Gastric
Cardiac, Colorectal Cancer,
Endometrial Cancer (EC),
Renal Cell Cancer
• Birth Defects
• Cardiovascular Disease (CVD),
Stroke, Hypertension
• Carpal Tunnel Syndrome (CTS)
• Daytime Sleepiness, Sleep Apnoea
• Deep Vein Thrombosis (DVT),
Chronic Venous Insufficiency (CVI
• Diabetes (Type 2)
• End Stage Renal Disease (ESRD)
• Gallbladder Disease
• Gout
• Heat Disorders
• Impaired Immune Response
• Impaired Respiratory Function
• Liver Disease, Pancreatitis
• Low Back Pain
• Obstetric and Gynecologic
Complications, Infertility
• Surgical Complications, Infections
Following Wounds
• Urinary Stress Incontinence
and Mallampati score are the only two
predictors of potential intubation prob-
lems. Also, patients with a Mallampati
score greater than or equal to three
have increased difficulty with tracheal
intubation. Other routine assessments
namely, jaw and neck mobility, dental
status, patency of nostrils, and inspection
Sunitha Goel is a Consultant Anaesthesiologist in Saifee Hospital, Dr
A u t h o r
L.H. Hiranandani Hospital, Cumbala Hill Hospital and Breach Candy
Hospital. She was awarded Industry Leadership Award in 2004.
Medical Sciences
of oropharynx should be done prior to
implementation of an anaesthesia care
plan for obese patients.
Patients undergoing bariatric surgery
are prone to slipping off the table, so they
must be securely strapped to the table.
Anaesthetic pharmacology – The physi-
ological changes associated with obesity
lead to alterations in distribution, binding
and elimination of many drugs. Many
doses have to be calculated according to
the ideal body weight or more accurately
according to the lean body mass. In 20
to 40 per cent of obese individuals, ideal
body weight and lean body mass are not
identical. This is because increase in body
weight may be due to an increase in lean
body mass.
Extubation – Obese patients must be
extubated when they are fully awake and
after they have returned of motor power.
It is less threatening to extubate those
that were not difficult to mask ventilate
and or intubate. Factors that play a role
in determining successful extubation
include the severity of obstructive sleep
apnoea, duration and type of procedure.
Either facemask, nasal Continuous
Positive Airway Pressure (CPAP) or Bi-
level Positive Airway Pressure (BiPAP)
support with oxygen may be required
in some patients following extubation.
This is usually the case for those with a
history of sleep apnoea or those using
CPAP before surgery and supplemental
oxygen is usually required.
Conclusion
Caring for obese patients remains a
challenge for anaesthesia providers.
Some patients require special care in a
low-cost obesity care unit while others
may need prolonged care in the intensive
care unit.
www.asianhhm.com 49
 Stroke
Assessment
A medical emergency

T
he World Health Organization (WHO) estimates that world-
wide 15 million people suffer a stroke each year. Within
the UK, stroke is the third most common cause of death
and the single largest cause of adult disability. It is estimated that
110,000 new strokes occur within the UK annually and currently
there are 900,000 people living in England who have had a stroke.
It has long been recognised that rapid and accurate stroke assess-
ment and management improve patients’ outcome from stroke.
However, there have been many obstacles to this in the past, some
of which persist today.
Rapid recognition of stroke enables rapid treatment of stroke.
In ischaemic stroke, thrombolysis is proven to be the most effective
initial treatment reducing the number of patients with long-term
disability from stroke by 30 per cent. The faster this is delivered,
the greater the chance of reducing long-term disability and death
given that the potential benefit from thrombolysis decreases over
time. The need to treat stroke as a medical emergency is key, time
delay costs neurones!
Alteplase is currently the only licensed drug for thrombolysis in
the UK. It was first licensed in the US in 1996, a restricted license
was granted in Europe in 2003. Several landmark thrombolysis
trials, including the NINDS trial in 1995, have proved the efficacy
of the drug.
More recently, the ECASS III trial published in September 2008
established a favourable outcome with thrombolysis delivered within
4.5 hours of stroke onset.
The National Sentinel Audit for Stroke 2008 assessed stroke care
within the UK over the previous two years (2006-2008). Currently, 215
hospital sites offer thrombolysis within the UK. However, only 72 of
the 215 relevant sites gave Alteplase to one or more of their patients.

50 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009

 Medical Sciences

Early recognition of stroke signs and symptoms by the gency services and therefore arriving at
public and professionals, rapid transfer of the stroke Accident and Emergency within 1-3
hours.
patient to hospital, early stroke specialist assessment
The rapid and accurate assessment of
and treatment including thrombolysis and transfer stroke by emergency physicians within
to a specialist acute stroke unit are all evidence- the A&E department is vital in aiding
based interventions leading to improved outcome appropriate and emergency referral to the
with lower disability and mortality from stroke. stroke team. The ‘Recognition of Stroke
in the Emergency Room’ or ROSIER
tool is used by emergency physicians to
Anil Sharma
Consultant Physician, Divisional Medical Director for Medicine, RCP Regional aid stroke diagnosis (see Table 1). It is
Advisor for Stroke, University Hospital Aintree, UK proven to help differentiate stroke from
Hannah Jane Cronin common stroke mimics, such as seizure
Specialist Registrar, Stroke Unit, University Hospital Aintree,UK and syncope, with a score of greater than
one necessitating urgent stroke refer-
ral. Initially developed and validated by
Nor et al. the tool was found to have
a 92-93 per cent diagnostic sensitivity
and 83-86 per cent specificity for the
diagnosis of stroke. It has now been
widely adopted by A&E departments
throughout the UK.
During this period, 204 patients were per cent were able to name three stroke The development of an effective
thrombolysed, i.e. only 1.8 per cent of symptoms. The FAST test, a validated model for stroke care within indi-
patients with ischaemic strokes. Clearly stroke recognition tool, was developed vidual trusts is the key to providing a
we have a long way to go to improve in 1998 from the Cincinnati Prehospital comprehensive stroke service. Immediate
stroke care within the UK. Stroke Scale. It was initially designed blue-light transfer by ambulance to
The National Stroke Strategy was to assist ambulance technicians in the a hospital with hyper-acute stroke
published in December 2007. Its aim recognition of acute stroke and aid rapid services, with a stroke triage system,
was to improve stroke care across the UK transfer to hospital. Nor et al., Stroke
and outlined 10 key goals to help achieve 2004, assessed the agreement between when stroke strikes
this. The need to improve awareness ambulance technicians and paramedics act f.a.s.t.
of stroke symptoms by the public and and stroke specialists when using the
health professionals, the need to treat FAST tool to identify neurological signs
stroke as a medical emergency involv- in 278 patients with suspected stroke.
ing specialist teams, 24-hour access to They concluded that the use of FAST by
specialist care and early transfer to a ambulance technicians and paramedics
stroke unit were all key goals highlighted showed moderate to excellent agreement
in the document. The target for throm- with stroke physicians.
bolysis for acute ischaemic stroke within The FAST test comprises four
the UK is 10 per cent by 2011. However, elements (F) facial weakness, (A) arm
this is unlikely to be achieved. weakness, (S) speech problems and
Public recognition and perception (T) time to call 999. The Act FAST
of stroke remains a significant factor campaign was commenced across the
in the delay of initial stroke assessment UK in February this year. It compro-
and transfer to hospital as an emergency. mises adverts on TV, radio and in print
Although most patients are able to iden- and aims to raise public awareness of
Image 1

tify the symptoms of a myocardial infarc-
tion, a MORI poll performed by the
Stroke Association UK in 2005 revealed
only 50 per cent of patients were able
to identify what a stroke is and only 40
the symptoms of stroke and that emer-
gency stroke treatment can limit stroke
damage and save lives (see Image 1). It’s
hoped that this campaign will increase Images taken from The Department of Health’s
the number of patients contacting emer- Stroke: Act F.A.S.T campaign. www.dh.gov.uk

www.asianhhm.com 51
Medical Sciences
Recognition of Stroke – ROSIER SCORE
Assessment
1) Has there been loss of consciousness or syncope?
2) Has there been seizure activity
Is there a new acute onset (or on awakening from(sleep)
In the following:
Asymmetrical facial weakness
Asymmetrical arm weakness
Asymmetrical leg weakness
Speech disturbance
Visual field defect
NB: Stroke is unlikely but not excluded if total score is <zero
Provisional Diagnosis Stroke
IF STROKE IS LIKELY CONTACT STROKE TEAM
An example of the ROSIER tool used within the University Hospital Aintree Trust
24-hour access to specialist stroke team
assessment, 24-hour access to throm-
bolysis and early transfer to a designated
acute stroke unit are vital to delivering
effective stroke care. There is overwhelm-
ing evidence in support of acute stroke
unit care. In 2007, a systematic review
of stroke unit care was performed by the
Stroke Trialists Collaboration, Cochrane
database. It concluded that patients
treated within an organised stroke unit
are more likely to survive their stroke,
return home and become independent
in looking after themselves and that the
benefits are proven over five and ten
years. The National Sentinel Audit for
Stroke 2006 estimated that if 75 per
cent of stroke patients had timely access
to stroke unit care 500 deaths per year
would be prevented and 200 more indi-
viduals would live independently per
year. The key to stroke unit success is a
multidisciplinary approach, including
early rehab assessment, goal setting and
discharge planning, early swallow assess-
ment and dietician review, as well as
access to stroke specialist medical input
and specialist nursing care.
The Stroke Unit in University
Hospital Aintree was established in
52 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
based on the stroke unit. The stroke
nurse clinicians work closely with the
Score radiology services to ensure a rapid CT
Yes (-1 point) No (0 point) brain scan and with the unit as a whole
Yes (-1 point) No (0 point)
to ensure rapid transfer of patients to
the acute unit.
The Stroke Team for Audit and
Research (STAR) is an integral part of
Yes (+1 point) No (0 point) the system enabling data collection and
Yes (+1 point) No (0 point) analysis to inform service developments.
Yes (+1 point) No (0 point) We have thrombolysed 79 patients to
date—4 patients in 2004, 20 patients
Yes (+1 point) No (0 point)
in 2008 and 13 since Christmas 2008.
Yes (+1 point) No (0 point)
Our target for this year is 50 patients,
Patients total score = which is around 12 per cent of the total
TOTAL SCORE ………… (-2 to = +5) number of stroke patients admitted to
Aintree.
Non Stroke (specify).....
Conclusion
It is vital that we continually strive to
improve the care we deliver to stroke
Table 2 patients within this rapidly evolving
1993 and started offering thromboly- speciality. Basic principles, however,
sis in 2004, 24-hour thrombolysis has are the key. The rapid assessment,
been available since September 2008. recognition and triage of stroke are
The stroke service starts at the front all fundamental factors to enable
door of the hospital having established effective management of stroke and
links with our local ambulance trust to improve patients’ outcome. The need
ensure rapid transfer to hospital and a to raise public awareness of stroke as
pre-alert system to A&E Resus and the an emergency is also crucial in order to
stroke team for suspected thrombolysis increase the number of patients arriving
cases. The stroke team comprises four to hospital within 4 hours of stroke to
stroke nurse clinicians, who triage and enable thrombolysis for ischaemic stroke
coordinate all new suspected stroke cases, within 4-5 hours to be an option for
three consultant stroke physicians and these patients.
one consultant neurologist, two special-
ist registrars and a team of nurses and References are available at
therapists specialising in stroke who are http://www.asianhhm.com/magazine
Anil Sharma has been a Consultant Physician at University Hospital
Aintree since 1980 and is in charge of the Clinical and Research
Stroke Unit at Aintree. He has been the Divisional Medical Director of
Medicine since 2003 and the RCP Regional Advisor for Stroke and
A u t h o r s
has lectured widely at national and local meetings.
Hannah Cronin graduated from the University of Leicester in 2002.
She has been working as a Specialist Registrar within the Mersey
Deanery since 2006 and is currently working as a Specialist Registrar
within Stroke Medicine at University Hospital Aintree, Liverpool.
ISSUe - 19 2009

Transcriptional
Control of
Heart Failure
Recent developments
Heart failure is a major
health problem worldwide.
Current therapies manage
the symptoms of heart
failure. New experimental
findings suggest possible
future therapies that
arrest the development
of heart failure.
M Saleet Jafri
Professor and Chair
Department of Bioinformatics and
Computational Biology
George Mason University, USA
H
eart failure afflicts 1-2 per cent
of the general population and
6-10 per cent of the elderly
(<65 years) population in developed
nations. The five-year survival rate for
heart failure patients is 50 per cent. There
is a growing incidence of reported heart
failure in other parts of the world includ-
ing Asia, Africa and the Middle East.
Pathological cardiac hypertrophy exhibits
increased ventricular-wall tension and
cardiac contractile dysfunction, and is a
major predictor of heart failure.
The current treatments of heart failure
address normalisation of its symptoms by
using pharmacological agents to improve
contractile performance. For example,
drugs such as digitalis can improve beat-
to-beat force generation, drugs such as
Medical Sciences
Angiotensin Converting Enzyme (ACE)
inhibitors and β-blockers modulate
neurohumeral signalling to enhance
contractile performance, and drugs such
as calcium channel blockers normalise
cardiac calcium handling. Furthermore,
it has been shown that exercise helps to
normalise cardiac function by reversing
some of the systemic changes seen during
heart failure. In spite of these therapies,
there currently exist no approved drugs
that can reverse or prevent the develop-
ment of heart failure.
In order to understand the disease
progression of heart failure, it is neces-
sary to understand the changes to heart
contractile function at the cellular
level. Heart failure is characterised by
changes in the expression of the proteins
www.asianhhm.com 53
Medical Sciences
Schematic of selected signalling pathways involved in
pathological cardiac hypertrophy.
governing ionic currents and calcium
handling. This is most easily studied in
laboratory animals. Examples of patho-
logical cardiac hypertrophy in laboratory
animals include agonist-stimulated hyper-
trophy, hormone-induced hypertrophy
(e.g. Norepinephrine (NE), Phenylephrine
(PE), or Isoproterenol (ISO), and pres-
sure-overload hypertrophy induced by
banding of the thoracic aorta.
The physiological symptoms of
cardiac hypertrophy and heart failure are
accompanied in part by renewed expres-
sion of the fetal cardiac genes i.e. there
is dysnormalisation of gene expression
concomitant on the disturbed signalling
that cascades in diseased cardiomyocytes.
Translocation of the transcription factor
NFATc2 (nuclear factor of activated T-
lymphocytes) to the nucleus has been
shown to be required for the induction
of hypertrophy. Export of the signalling
protein class II HDAC (histone deacety-
lase) has been observed to accompany the
translocation of NFAT into the nucleus.
The elevation of intracellular calcium
is a common regulatory factor in both
NFAT import into the nucleus and class
II HDAC export from the nucleus. The
activation of NFAT requires the calcium
/ calmodulin dependent activation of
calcineurin, which dephosphorylates
NFAT allowing its import into the
nucleus (Figure 1). In fact, calcineurin
54 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Figure 1
has been implicated as a necessary signal-
ling molecule in the induction of cardiac
hypertrophy. In the heart, the cytosolic
calcium concentration is elevated peri-
odically as calcium is elevated to cause
contraction of the myocyte. A number
of investigators have suggested that the
periodic release of contractile calcium
can trigger activation of the transcrip-
tion factors that lead to hypertrophy and
heart failure. In fact, there are several
lines of evidence that suggest this. For
example, the rapid pacing (tachycardia)
of the canine ventricle by an implanted
electrode (about four beats a second or 4
Hz) for prolonged periods has been used
to induce hypertrophy and heart failure.
Furthermore, other work has shown that
in neonatal rat ventricular myocytes,
exposure to angiotensin II caused an
increase in the rate of contractile cytosolic
calcium transients and an increase in the
amount of NFAT translocated to the
nucleus. Additionally, these investiga-
tors also showed that increasing the
pacing of neonatal ventricular myocytes
by field stimulation also resulted in an
increase in NFAT translocation to the
nucleus. Activation of NFAT leads to the
expression of MCIP1 that acts to inhibit
calcineurin. Experiments have shown that
overexpression of MCIP1 inhibits cardiac
hypertrophy. Furthermore, NFAT tran-
sclocation to the nucleus can be blocked
ISSUe - 19 2009
by immunosuppresants such a cyclosporin
A and FK506. Unfortunately the use
of immunosuppresants would leave the
patient immunocompromised.
Another important class of tran-
scription factor involved in the advent
of heart failure are proteins that regulate
the histone proteins. The DNA in the
nucleus is tightly wrapped around histone
proteins. Histone Acetyltransferases
(HATs) acetylate the histones allow-
ing portions of the DNA to become
accessible for transcription. Histone
Deacetylases (HDACs) oppose the
action of HATs. Nuclear class I HDAC
inhibits anti-hypertrophic gene transcrip-
tion. Inhibitors of class I HDAC such
as tricostatin A, sodium butyrate, and
HC-toxin block cardiac hypertrophy and
improve contractility in failing hearts.
Nuclear class II HDAC inhibits pro-
hypertrophic gene transcription, in fact,
nuclear class II HDAC is thought to
block the activation of NFAT-activated
genes. Thus, it has been proposed that
normalising cardiac gene expression with
small molecules, such as class II HDAC
inhibitors, will halt cardiac remodelling
processes by controlling the disrupted
signalling cascades, and thus might be
a successful ‘transcriptional therapy’ for
the failing heart. In fact, knockout of
class II HDACS produced spontane-
ous hypertrophy in mice and antiviral
overexpression of active mutants of class
II HDAC prevented agonist-induced
hypertrophy in cultured myocytes.
The export of class II HDAC requires
activation of calmodulin kinase II and
local calcium release from perinuclear
IP3. Hypertrophic growth can be blocked
by expression of a calmodulin kinase
II resistant mutant HDAC in COS
cells. Nuclear export of HDAC-GFP
in isolated myocytes in response to
endothelin-1 activation can be blocked
by the IP3 receptor antagonist 2-APB.
In these studies, contractile calcium
transients were not sufficient to cause
HDAC export from the nucleus suggest-
ing another source of calcium, such as
release of calcium from the nuclear
 Medical Sciences

envelope triggered by inositol 1,4,5-
trisphosphate (IP3).
Protein kinase D also regulates
HDAC through a related pathway as
follows: Activation of phospholipase C,
typically in response to agonist cleaves
phosphatidyl inositol into Diacylglycerol
(DAG) and IP3. DAG activates protein
kinase C which activates protein kinase D
which in turn promotes class II HDAC
export from the nucleus. DAG kinase
phopshorylates DAG and hence decreases
its concentration. This reduction in DAG
concentration reduces class II HDAC
export from the nucleus through protein
kinase C and D. Additionally, DAG
kinase has been shown to suppress cardiac
hypertrophy and loss of left ventricular
function in mice. It blocks endothelin-1
DNA transcription of hypertrophic
proteins. Curcumin is a natural polyphe-
nolic compound found in turmeric that
does just that. Curcumin blocks phenyle-
phrine- and pressure overload-induced
cardiac hypertrophy in primary cultured
rat cardiac myocytes through inhibition
of P-300 HAT activity. Hence, this
provides another potential mechanism
to control hypertrophy.
There are also other pathways that
might be exploited. For example, resvera-
trol is a non-flavinoid polyphenol found
in the skin of red grapes. Resveratrol acti-
vates the AMP-Activated Protein Kinase
(AMPK) and inhibits Akt pathways.
M Saleet Jafri received his BS from Duke University, MS from New
A u t h o r
Resveratrol inhibits pressure overload-
or phenylephrine-induced heart failure
in rats. This drug also has other potential
applications. For example, resveratrol is
currently under phase II clinical trials
for prevention of colon cancer.
In summary, recent experiments
have given insight into the complex
signalling pathways associated with
cardiac hypertrophy and heart failure.
These suggest potential drug targets and
lead compounds that warrant further
study. Due to the complexities of the
signalling pathways, further studies are
likely to additional drug targets and lead
compounds.

induced growth and activation of fetal
gene programs caused through the PKC
pathway.
Inhibition of HAT, which opposes
the action of HDAC, leads to reduced
York University and PhD from CUNY/Mt. Sinai School of Medicine.
Previous positions include Assistant Professor at University of Texas
at Dallas, Research Associate at Johns Hopkins University, and
post-doctoral researcher at University of California, Davis.

www.asianhhm.com 55
Surgical Speciality

Methods that assess individual

patient variables would appear
to offer the best methodology
for assessing surgeon and
anaesthetist performance.

Graham P Copeland
Consultant General Surgeon
North Cheshire Hospitals NHS Trust, UK

Assessing
surgical
outcomes
New techniques

C
linicians have struggled with the capri-
cious nature of predicting surgical
outcomes for hundreds of years. If one
wanders of the beaten track to the basement
of the Louvre in Paris you will come across a
black diorite plinth inscribed with hieroglyphics
from the time of King Hammurabi of Babylon
(Figure 1). As early as 1750BC he was issuing
edicts aimed at practising clinicians. The best
known being:
‘If a surgeon operates on a free man and
the man dies or goes blind then the surgeon
should have his hand cut off’.
‘If a surgeon operates on a slave and the
slave dies then it is the responsibility of the
surgeon to replace the slave’.

56 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009


It would appear at first sight that
little has changed over the intervening
four thousand years, but over the past
thirty years there has been an increasing
clinical awareness of the importance
of clinical audit and clinical govern-
ance as tools to help with overall qual-
ity improvement. Although mortality
alone is often used as a quality measure
itself, clearly a number of factors can
influence the outcome from surgical
endeavour. The quality and experience
of the surgeon and the anaesthetist
preparing the patient for surgery and
its subsequent performance can have a
significant effect on outcome. However,
the patient themselves will often bring
with them the major prognostic factor
with regard to subsequent outcome, that
of their physiological fitness. This may be
reflected in their chronic disease status
or the acute physiological disturbance
caused by their acute illness. Finally,
the procedure itself will have a major
affect on surgical outcome.
All these variables are amenable to
change. We can expand our clinical
knowledge to encompass new proce-
dures. We can contract our practice
to those areas in which we can excel.
We may be able to improve a patient’s
Figure 1
King Hammurabi of Babylon: Diorite
plinth to be found in the Louvre
Paris 1750BC
Index and (Standard)
% Cancer patients seen within 2 weeks (100%)
% Cancers with preoperative diagnosis (>90%)
% Patients with adequate FNA or core biopsy
(>80%)
Benign to malignant surgery ratio (<1:1)
Radiotherapy and chemotherapy compliance
against guideline at that time (100%)
Local recurrence rate (<5%)
Standardised mortality ratio (SMR) (no
standard but norm 100)
Complaints (no standard)
Successful litigation (no standard)
The relationship between clinical audit standards and outcome in one unit in the North West of
England. Comparison between 2 ten year periods
chronic disease status or devise new
methods of anaesthesia to minimise risk
in particular patients or we may be able
to amend a patient’s acute physiologi-
cal disturbance. We can even alter the
magnitude of our surgical intervention
to a degree. It was with these thoughts
in mind, rather than fear of lawyers and
legislators, that probably led clinicians
to look at methods for measuring and
predicting the outcome from surgical
intervention.
Let us look at some of the meth-
odologies available for predicting and
measuring surgical performance and
examine the application of clinical audit
and outcome measures to this field.
Clinical audit tools
Clinical audit techniques use existing
research or effectiveness data to formulate
the design of quality standards against
which it is possible to assess perform-
ance. In the main, these standards are
process rather than outcome driven and
assume that improvements in process
will result in improvements in care and
thus, ultimately, outcome There is now
available a wealth of published guidelines
produced by national and international
bodies as well as local specialist networks.
In the UK The National Institute for
Surgical Speciality
Jan 1983-Dec 1992 Jan 1993-Dec 2002
87% 100%
68% 95%
57% 87%
3.1:1 0.4:1
86% 99%
6.7% 1.2%
121 76
12 1
4 0
Table 1
Health and Clinical Excellence (NICE)
publishes guidelines with regard to new
treatments, new interventions and
clinical treatment with an expectation
that the health service as a whole will
comply with this guidance within a
three month period. The currently avail-
able NICE treatment guidelines focus
mainly on high volume disease states
such as cancer, chronic disease states
(e.g. diabetes, ischaemic heart disease,
hypertension) and a smaller number
of acute conditions (e.g. depression,
anxiety). Nationally, there is now some
evidence to suggest that improvements
in process measures have resulted in
improvements in outcome with regard to
mortality at least in medical specialities
like myocardial infarction and stroke.
There is, however, little national data
for the surgical specialities that clinical
audit has as yet significantly improved
outcome. At a local level there is some
evidence that implementation of guide-
lines and audit quality improvement
programmes can improve survival and
reduce complaints and litigation (see
Table 1) but it is always difficult to
assess the contribution made to quality
improvements by audit, the introduc-
tion of new staff and the development
of multidisciplinary team working.
www.asianhhm.com 57
Surgical Speciality

death, complication or survival. Most

Patient risk Mortality 10% 30% 70%
experienced surgeons and anaesthetists
1st Year Trainee 9% (5-15) 28% (22-36) 65% (55- 80) are able—accepting wide confidence
limits—to guess the probable mortal-
5th Year Trainee 10% (5-15) 25% (20-35) 70% (60-80)
ity outcome from a particular interven-
Consultant 10% (5-15) 35% (25-40) 70% (60-80) tion. Interestingly, the ability to predict
morbidity often deteriorates with the
Variation in predictive ability of various grades of staff.
Study based on three standardised patient histories with defined predicted outcomes of 10 per cent,
seniority of the clinician (see Tables 2
30 per cent and 70 per cent with regard to mortality using the POSSUM system. 50 clinicians in each and 3). Some specialist societies are now
category were requested to assess the likely outcome as a percentage for each of the three patient attempting to define outcomes for indi-
histories. The median value and ranges are shown. vidual procedures (vascular, colorectal
Table 2 and orthopaedics in particular) to allow
comparisons to be made between units.
Patient risk Morbidity 10% 30% 70% The Vascular Society of Great Britain and
1st Year Trainee 8% (5-20) 25% (20-40) 75% (50- 80) Ireland has produced mortality ranges
for surgical intervention for abdomi-
5th Year Trainee 9% (5-15) 28% (22-40) 70% (60-80) nal aneurysm and peripheral vascular
Consultant 5% (2-12) 20% (10-35) 50% (40-70) disease (Table 4). And the Association
of Coloproctology for Great Britain and
Variation in predictive ability of various grades of staff.
Ireland also produces mortality rates for
Study based on three standardised patient histories with defined predicted outcomes of 10, 30 and
70 per cent with regard to morbidity using the POSSUM system. 50 clinicians in each category were emergency and elective colon resection
requested to assess the likely outcome as a percentage for each of the three patient histories. and anastomotic leaks rates for anterior
The median value and ranges are shown resection and other anastomoses (Table
Table 3 5). In England the Department of Health
now publishes Standardised Mortality
Index procedure: Crude mortality rate (95% confidence limits)
Ratios (SMR) for 4 procedures (hip and
Carotid Infrainguinal Unruptured Ruptured ALL knee replacement, elective and emergency
endarterectomy bypass AAA repair AAA repair aneurysm).
<61 yrs 0.3% 1.5% 3.8% 25% 2.3%
Although the latter has tried to
0.1-1.4% 0.7-3.2% 1.7-7.9% 14.8-38.6% 1.6-3.4% introduce some form a risk adjust-
ment for age, sex, social deprivation and
61-70 1.2% 2.5% 3.5% 27.9% 4.3%
co-morbidity. The methodology is far
0.7-2.0% 1.5-4.0% 2.4-5.1% 22.5-34.0% 3.6-5.1%
from accurate and confidence limits are
71-80 0.9% 5.7% 7.1% 43.2% 8.1% wide. It remains to be seen whether the
0.5-1.6% 4.3-7.4% 5.9-8.6% 38.4-48.0% 7.3-9.0% availability of such SMRs to the general
>80 2.7% 9.9% 14.9% 58.9% 15.3% public reassures them of the equality
1.4-5.0% 7.1-13.5% 11.5-19.0% 51.1-66.4% 13.4-17.4% of care or produces patient flows from
Unspecified 0% 7.1% 6.7% 66.7% 7.5%
units with SMRs above 100 to those
0-6. 9% 1.2-25% 1.2-23.5% 24.1-94% 3.6-14.8% below 100 despite all units performing
within 99 per cent confidence limits.
ALL 1.1% 4.6% 6.8% 41% 7.2%
As with many surgeons, the public at
0.8-1.5% 3.9-5.5% 5.9-7.8% 37.7-44.3% 6.7-7.7%
large do not always understand complex
Vascular society of Great Britain and Ireland mortality standards 2004 mathematical models but do understand
Table 4 the concept of good (SMR under 100)
and bad (SMR over 100).
Whatever the contribution, there Techniques for assessing true Perhaps differing models may provide
can be little doubt that regular clinical outcome the solution. Models which merely
audit monitoring of process guidelines Whereas clinical audit methods tend to produce an assessment of high or low risk
prevents performance slippage and will concentrate on process and structures, with various graduations between such
identify outliers at an early stage, provid- most patients and indeed surgeons are as ASA clearly do not offer the solution.
ing the guidelines up to date and widely more interested in true outcome. These Neither do those similar systems appor-
available. could fall into three main end points tioning risk but without a numerical

58 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009


Standard
Mortality Elective <7%
rate
Emergency <20%
Anastomotic Anterior <8%
leak rate resection
Other <4%
anastomosis
Colorectal quality standards: Association of
Coloproctology of Great Britain and Ireland
2007
Table 5
individual patient outcome prediction.
APACHE requires observation over a
twenty four hour period and the worst
variables are applied to a mathematical
formula which has extensive correction
weightings for individual disease condi-
tions. In comparison with those meth-
ods discussed previously it produces an
individual numerical patient prediction
for mortality but clearly more variables
are necessary and the mathematics can
be complex usually requiring significant
hardware and software support. These
APACHE problems have limited its
application in general surgery where
successful surgical intervention can
have a major and immediate effect on
physiological status.
In an attempt to overcome some
of these difficulties, general surgeons
during the late 1980s began to develop
a methodology which would produce an
individual patient prediction of both
mortality and morbidity utilising data
which was regularly collected and easy
to obtain. This lead to the development
of the POSSUM system (see Table 6
and 7), first published in 1991, which
has now become one of the best known
and widely applied methods for surgical
audit. It has been validated in a wide
range of surgical specialities including
vascular surgery, colorectal surgery,
thoracic surgery and general surgery. An
orthopaedic POSSUM has been recently
described and validated in which the
general equations are still utilised but
there are minor modifications to the
Table 6: The POSSUM surgical scoring system
operative severity score assessment. A
modification of the POSSUM system
has been devised which is of particular
use in individual patient prediction. The
p-POSSUM (Portsmouth POSSUM)
system has proved to be particularly
popular in vascular surgery. The same
variables are assessed but a linear rather
than logistic model (Table 8) is used
making it an easier mathematical model
to use and to self-design applicable
software.
More recently further refinements
of the original POSSUM system have
been described specifically for colorectal
and oesophageal surgeons. Tekkis et al.
have described both a CR-POSSUM for
colorectal surgeons and an O-POSSUM
(Table 9) for oesophagogastric surgeons.
These have the advantage of reducing
the variables required for prediction and
improving the accuracy for these partic-
ular fields of surgery. O-POSSUM, is
however, somewhat complex and requires
knowledge of individual variables, coef-
ficients similar to the APACHE systems.
As yet unlike the original POSSUM
equations they have not been validated
in units outside the UK but the original
estimation data set was obtained from
Surgical Speciality
Table 6
many differing sites across the UK,
and as the variables and weightings are
similar to the original POSSUM scoring
system, it is likely that their accuracy
will be confirmed by other observers.
However, all these adaptations, unlike
the original POSSUM system, have as
yet no morbidity predictive model and
cross speciality comparison is, of course,
not possible.
Using predictive models of surgical
outcome
If one has the ability to assess and predict
individual patient outcomes how can this
information be utilised? The easiest and
most widely utilised technique is as an
audit aid when discussing adverse events.
However, it soon became apparent that
techniques of this sort could be used to
assess individual surgeon / anaesthetist
and unit performance.
Systems such as POSSUM and
APACHE which produce such a predic-
tion have obvious advantages in this
regard. Some authors have suggested
that the p-POSSUM mathematical
model has advantages in individual case
review and this may well be the case in
low risk cases as both the POSSUM
www.asianhhm.com 59
Surgical Speciality

Examples of operative magnitude within the operative severity score

Operative C lasses

Minor Intermediate Major Major+

Hernia Cholecystectomy Cholecystectomy – Exploration of CBD Aortic aneurysm
Varicose Veins TURT Rt Hemicolectomy Aorto – bifem graft
Breast lumps TURP Lt Hemicolectomy APR resection
Simple lumps: Prosatatectomy Anterior resection Oesophago
Epidiyamal cysts Appendectomy Gastrectomy – gastrectomy
Hydrocele Mastectomy Bowel resection Pancreactectomy
Circumcision Thyroidectomy Any laparotomy Hepatectomy
Amputation
Vascular: Femoro – Popliteal bypass

Table 7

Score 1 2 3 4 8 Variable Coefficient β

Physiological score Age 0.055

Age (years) <60 61-70 71-80 >81 POSSUM Physiological score (see table 3) 0.080
Cardiac failure None or Moderate Severe POSSUM STAGING (x1)
mild
No malignancy 0
Systolic Blood 100-170 >170 or <90 Primary only 0.168
pressure (mmHg) 90-99
Nodal disease 0.365
Pulse (beast/min) 40-100 101-120 >120 or
Metastatic disease 1.042
<40
Urgency of Surgery (x2)
Urea (mg/L) <10 10.1-15.0 >15.1
Elective 0
Haemoglobin 13-16 10-12.9 <10 or
(g/dl) or 16.1- >18.1 Emergency 0.678
18
Type of Surgery (x3)
Operative severity
Oesophagectomy 0
score
Total gastrectomy 0.283
Operative severity Minor Intermediate Major Major complex
Partial gastrectomy -0.767
Peritoneal soiling None or Local pus Free pus or
minor faeces Palliative gastrojejunostomy -0.366
serous
The O-POSSUM scoring system. Tekkis et al
Operative urgency Elective Urgent Emergency Br J Surg 2004, 91, 288-295: The coefficients β are
inserted in the equation as indicated below. Logit R =
Cancer Staging None or Dukes C Dukes D
In (R/(1-R) = -7.566 + 0.055(age in years) + 0.080
Dukes A-B
(POSSUM Physiological score) + POSSUM staging (x1) +
COLORECTAL POSSUM urgency of surgery (x2) + type of surgery (x3).
Table 8 Table 9

and APACHE models are logistic equa-
tions based on populations of patients
rather than individuals. Certainly the
p-POSSUM and POSSUM systems are
the ones recommended by the Royal
College of Surgeons of both England
and Edinburgh and by NCEPOD and
are probably the methods of choice.
The POSSUM system is the only
system that produces a numerical
prediction of morbidity across the surgi-
cal spectrum.
Clinical audit of adverse outcomes
can be a particularly depressing affair.
While it can be of great value to discuss
cases where death occurs and predictive
models indicate a risk of death of less
than 20 per cent, the opposite end of
the spectrum (risk greater than 80 per
cent) often yields little audit gain except
to discuss whether the operation was
indeed indicated. Predictive models of
these types can produce a new audit
spectrum, that of the patients whose risk
exceeds a certain level (for example >50
per cent) but who survive. Often, audit
of these cases can identify best practice
and produces changes in resuscitative
protocols which produce a sustained
quality improvement. Such an approach

60 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009

 Surgical Speciality

CRAB system: available from CRAB

Surgeon and speciality Mortality % Morbidity % O/E mortality O/E morbidity
Clinical Informatics Ltd) which includes
A Vascular 4.8 13.0 1.02 1.03 all available POSSUM algorithms and
which allows for the first time analysis
B Hepatobiliary 2.6 10.0 0.96 0.96
of all POSSUM related quality indica-
C Colorectal 2.9 15.1 1.00 0.99 tors from audit aid to surgeon, unit and
specialty specific outcome measures.
D Vascular 3.5 13.6 0.98 0.98
These techniques have now been
E Gastrointestinal 3.1 11.7 1.04 1.03 widely validated and from personal
0.3 2.1 0.5 0.75
observations it would appear that
F Urology
when performance deteriorates, it is in
G Urology 1.0 4.9 1.00 1.02 the management of patients whose risk
Raw and risk adjusted outcome measures for a 12 month period in one unit. Results apply to all
lies between 10-80 per cent that major
non day case surgery in 7 individual surgical teams within one hospital. The O/E ratio indicates the differences in unit performance have
Observed number of adverse outcomes (O) / the Predicted number of adverse outcomes (E) been identified. Where O/E ratios are
Table 10 persistently above 1.00 examinations
of individual patient deaths and of the
Year Mortality % Morbidity % O/E ratio mortality O/E ratio Morbidity
morbidity spectrum, when compared to
2002 3.8 16.7 0.99 0.97 similar clinician or unit spectra, can often
3.7 15.5 1.01 1.00
identify the cause of poor performance.
2003
Local complications and wound related
2004 3.2 13.9 0.97 0.98 problems are often surgeon related.
2005 3.8 13.9 0.97 0.98 Respiratory and cardiac problems are
often anaesthetist related. Renal and
2006 3.1 12.9 1.02 1.01 to a lesser extent respiratory problems
2007 3.4 14.2 0.98 0.95 are often related to the availability of
appropriate high dependency facilities
All patients scored represent those undergoing non day case surgery and the overall quality of nursing services.
Use of the POSSUM system to assess hospital performance over time. The hospital shown is a While these may be oversimplifications,
United Kingdom district general hospital providing emergency general surgery, non cardiac vascular from a personal perspective I have found
surgery, and cancer surgery. them to be useful tools over the past ten
Table 11 years when assessing both my own and
has the added value of making clinical anaesthetist performance. Table 10 other units.
audit an uplifting rather than depressing illustrates the marked differences in
experience. outcome of surgeons with varying case Conclusion
mix. However, with the application of It would seem that when assessing surgi-
Assessing performance the POSSUM system it is possible to cal performance process and structures
Over the past fifteen years, there has predict the expected number of deaths are best measured using classical clinical
been increasing interest in the outcomes and comparing this with the actual audit techniques. When assessing true
from individual unit as well as individual number yields a ratio (the observed to outcome, be this mortality or morbidity,
surgeon endeavour. If one simply applied expected ratio; O/E ratio) which poten- then some form of refined risk adjust-
mortality rates—as any mathematician tially produces a true quality measure ment is necessary to avoid the risks of
will point out if you choose to take a radi- (see Table 10 and 11). There is now utilising simple mortality or morbidity
cal stance and close the worst performing commercially available software (the rates.
5 per cent, after 10 years you will have
closed 40 per cent of units and probably
still not improved overall care. Fortunately Graham Paul Copeland is a Consultant General Surgeon at North
A u t h o r

no country has chosen, to date, to take Cheshire Hospitals NHS Trust with a special interest in biliary and
breast disease. I am the inventor of the POSSUM surgical audit scor-
such a radical decision. ing system and the CRAB audit software system.
Methods that assess individual patient
variables would appear to offer the best
methodology for assessing surgeon and

www.asianhhm.com 61
Diagnostics

Predictive,
Preventive &
Personalised Medicine
A novel strategy for healthcare
Predictive medicine is a
new philosophy in the
healthcare and novel
strategic activity aimed at
a potential application of
innovative biotechnologies
in the prediction of human
pathologies, a development
of well-timed prevention and
individual therapy-planning.
Essential components
of this approach include
well-organised population
screening protocols using

C
novel diagnostic biomarkers urrent healthcare practices
of disease states, targeted essentially rely on emergence of
prevention of common signs and symptoms of human
human pathologies such pathologies prior to initiation of inter-
ventional modalities. A major limitation
as Diabetes mellitus Type 2 of this approach relates to the fact that
and breast cancer, optimal often the disease process has already
treatment planning and taken its toll through manifestation of
personalised medicine, its complications. As a result, despite
thereby resulting in high costs associated with care of these
individuals, long-term prognosis usually
substantial improvement remains poor due to inadequate control
of the quality-of-life. of disease manifestations, treatment fail-
ure, disease-recurrence and the appear-
Olga Golubnitschaja ance of severe secondary complications,
Secretary-General, The European among others, thereby contributing to
Association for Predictive, Preventive &
relatively low life-quality of the treated
Personalised Medicine, Belgium
persons, high morbidity and mortality.
Here we demonstrate some examples
on both Diabetes care and Diagnostics
and treatment of breast cancer.
Applications in diabetes care
The ever increasing number of diabetic
patients presents a serious healthcare
challenge to most industrialised coun-
tries and developing societies with a
large population: every 10 seconds, one
patient dies of diabetes-related conse-
quences. Diabetic care faces a whole
spectrum of problems including the
necessity for population screening,
targeted preventive measures, ethics,
economics and broad dissemination
of the issue-related information that
still wait for a dramatic improvement

62 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009


in each of them. Currently we already
recognise:
• The epidemic scale of the disease
• The contemporary onset of the domi-
nant diabetes Type 2 in early adulthood
or even in childhood and
• A permanently growing number of
well-acknowledged severe complica-
tions for which diabetes predisposes
and .which have only now been associ-
ated with diabetes.
Diabetes Mellitus (DM) Type 2,
historically characterised as an adult-onset
disorder, now comprises approximately
one-third of new DM-cases already in the
second decade of life. Imbalanced nutri-
tion and widespread ‘fast food’ consump-
tion as well as low body activity in child-
hood currently result in the increasing
prevalence of obesity in young people.
Consequently, the mean age at diagnosis
of DM Type 2 in young people is 12-
14 years. Despite the current progress
in individualised insulin therapy, the
common onset of DM Type 2 in early
adulthood breeds dramatic consequences
linked with the early onset of diverse
severe complications that are secondary
to DM such as retinopathy, nephropa-
thy, silent ischemia and dementia. The
recent years have brought new knowledge
concerning the predisposition to cancer
in diabetics. The large population stud-
ies performed indicate an increased risk
of liver, pancreas, bladder, digestive and
urinary tracts, and endometrium cancer
types in DM with some age-specific differ-
ences and gender-dependent preferences.
Consequently, the costs of diabetes care
are growing dramatically. In the USA, the
cost burden compared for the years 2002
and 2007 grew from US$ 132 to 174
billion. These statistics do not include
intangible costs (e.g. care provided by
unpaid caregivers, pain and suffering) or
individuals with undiagnosed diabetes
or impaired fasting glucose.
Importance in long-term outcomes
of breast cancer
Breast cancer is the most common cause
of cancer death in female population with
New philosophy of predective
medicine & targered prevention
of deseases
Current healthcare
Life quality
appearance of symptoms
therapy
Development of pathologies, years
Figure A. Strategies in the current
healthcare systems—a major limitation
of those approaches relate to the fact
that the disease process has already
taken its toll through manifestation of the
complications.
Desirable healthcare
predictive diagnosis
Life quality
targered prevention
appearance of symptoms
Development of pathologies, years
Figure B. Advanced strategies by
predictive diagnostics followed by the
personalised patient treatment in favour
of targeted prevention and optimised
therapy planning. (The figure originates
from the book .)
an average incidence rate of 10-12 per
100 women. Advanced stages of breast
cancer lead to development of metastasis
predominantly in lymph nodes, bone,
lung, skin, brain and liver. In 2005, breast
cancer led to 502,000 deaths (7 per cent
of cancer deaths; almost 1 per cent of
all deaths) worldwide. During the past
three decades, the incidence of breast
cancer continually increases worldwide.
Although induced population screening
by mammography and application of
adjuvant therapies keep breast cancer
mortality mostly unchanged or even
Diagnostics
persistently declined over last ten years,
currently applied diagnostic approaches,
however, are frequently unable to recog-
nise early stages in tumour development
that impair the outcome. The approach
of breast-MRI is currently the most sensi-
tive diagnostic tool for breast imaging.
However, its specificity is limited resulting
in a negative impact for surgical manage-
ment in approximately 9 per cent of cases.
Early diagnosis has been demonstrated
to be highly beneficial for significantly
enhanced therapy efficiency and possibly
full recovery in breast cancer.
Novel strategies
Predictive medicine is a new philoso-
phy in the healthcare and an attractive
subject for currently initiated research
activities aimed at a potential applica-
tion of innovative biotechnologies in
the prediction of human pathologies, a
development of well-timed prevention
and individual therapy-planning. Novel
strategies using predictive, preventive &
personalised medicine are illustrated
in Figure B compared to those of the
currently existing healthcare systems in
Figure A.
The major premise of the improved
strategies is that initially, chronic
pathologies are generally triggered at
the molecular level followed by pathol-
ogy-specific molecular events predispos-
ing the potentially affected organs to
certain pathologies long before organ
damage and symptomatic manifestation
of the disease. Therefore, detection of
pathology-specific molecular patterns
can create a well-founded basis for the
predictive approaches desirable in good
healthcare. It advocates the application
of innovative biotechnologies to predict
human pathologies, devise appropriate
and timely preventive strategies and
individualised treatment planning.
As a result, predictive medicine offers
great promise for the future practice of
medicine. Essential components of this
approach include well-organised popu-
lation screening protocols using novel
diagnostic biomarkers of disease states,
www.asianhhm.com 63
Diagnostics

The mission of the ‘European association for predictive, preventive & personalised medicine’

The decisive progress in the current healthcare can be achieved
only by well-coordinated fulfilment of the following components
that are crucial for the practical realisation of this new philosophy
in healthcare:
• Adequate investment creating novel technologies
• Development of non- or minimally-invasive diagnostic tools
• Well-organised process for exchange and transfer of knowledge
among biomedical research entities and biotechnological indus-
tries for production of the advanced diagnostic tools
• Quality assurance through the introduction of international stand-
ards for technological tools and devices, patenting and licenses
• Correct professional education in terms of the application of
biotechnological high-tech in medicine
• Intelligent political regulations in the healthcare sector—intro-
duction of the obligatory guidelines and clear regulations for the
health insurance industry to ensure patients’ needs are met
• Measures to ensure confidentiality of patient information and
personal databank
• Distribution of relevant information among healthcare profes-
sionals and users.
These coordinated measures should be focussed on solving the
accumulating problems in healthcare and the increasing, concomi-
tant economical burden that societies face across the globe. The
mission of the European Coordinator in this field is performed by the
‘European Association for Predictive, Preventive and Personalised
Medicine’ (EPMA).
Following objectives are registered in Brussels by the ‘Statutes’ of
the Association:
• Raising awareness and recognition of Predictive, Preventive and
Personalised Medicine (PPPM) throughout all member-countries
of the European Union and Associated countries
• Providing and disseminating accurate and up-to-date information
and educational materials on predictive & personalised medicine
and targeted preventive measures
• Encouraging the adequate allocation of resources for predictive,
preventive and personalised medicine;
• Encouraging and suggesting advanced programmes for person-
alised patient treatment
• Promoting high-quality research focussed on predictive diagnos-
tics and personalised patient treatment
• Promoting the standardisation of bio-analytical technologies for
predictive pre-clinical and clinical applications
• Consolidating professionals for effective European Network in
predictive, preventive and personalised medicine
• Coordinating multidisciplinary efforts in predictive, preventive,
and personalised medicine
• Having an advisory role in issue-related inter / national projects
as the official European Representative of predictive, preventive
and personalised medicine
• Contributing to creation of Guidelines in European healthcare
with the accentuated role of prediction, prevention and person-
alised patient treatment in favour of improved life-quality of the
European population.
All EPMA-activities are summarised at www.epmanet.eu. As one
can see at this website ‘Patient is in the Focus’ by EPMA, the real
application of the innovative technologies for the predictive diag-
nostics, targeted preventive measures and personalised patient
treatment in the European healthcare is the central idea of the
Association.

targeted prevention of common human
pathologies, optimal treatment planning
and personalised medicine, thereby result-
ing in substantial improvement of the
quality-of-life. This approach also offers
the advantage of delivering care at poten-
tially reduced costs to the population at
large, and, as a result, addressing social
and ethical issues related to access to and
affordability of healthcare.
More about the innovative
approaches
People from various walks of life and
socio-economic status are increasingly
demanding to be better informed of
anticipated changes in their health status
as they progress through life. Although
not simple, it is now feasible to predict
tissue / organ deregulation associated with
predisposition to particular pathologies
such as premature ageing, neurodegenera-
tive processes, cardiovascular disorders
and various cancers. Thus, high-accuracy
protein-expression maps of human body
fluids open new perspectives for early and
even predictive molecular diagnostics of
chronic disorders before the usual symp-
toms appear, and, therefore, allow well-
timed prevention. Further, the minimally-
invasive approach of expression profiling
in blood holds the promise of a revolu-
tion in population screening, predictive
disease diagnostics and prognostic indica-
tors. An individual’s susceptibility and
predisposition to premature ageing and
common pathologies such as develop-
ment of chronic complications in Type
2 diabetes mellitus, breast and prostate
cancer can be discerned non-invasively. A
broad distribution and a routine clinical
utilisation of these advanced technologi-
cal approaches could enable a significant
portion of the population to reach the
100-year age limit yet remaining vibrant
in excellent physical and mental health
and as actively contributing members
of society.
A large group of 60 leading experts
from 16 countries has recently prepared
the pioneering book on the predictive,
preventive & personalised medicine to
summarise the most advanced approaches
in the branch ‘Predictive Diagnostics

64 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009

 Diagnostics

Bookshelf

Predictive Diagnostics and Personalized Treatment: Dream or Reality?

This book is for everyone! On reading
this book, you can learn a new philos-
ophy in medicine, novel trends in
healthcare and biomedical education.
These may help you and your family
to define your own way of creating
a well chosen life-style. The book
provides important information for
individuals of various professional and
scientific backgrounds. Professionals
can consider the general concept of
multidisciplinary approaches and learn
the mindset of border areas and other
scientific branches. A partial list of
those who will especially benefit from
the information provided in this book is
as follows:
• Professionals in conventional and
molecular diagnostics, biomedicine,
biotechnologies, ethics, and econom-
ics
• Universities, research units, private
Author: Olga Golubnitschaja
and public hospitals
• Patients and their family members
• Scientific journals as well as public
journals with medical sections
• International associations with health-
care-oriented scientific, research and
public health-related activities/respon-
sibilities
• Political organisations and authorities
active in the healthcare sector
• Healthcare industry.

and Personalized Treatment: Dream or

Reality?’ . Olga Golubnitschaja was born in 1962 in Ukraine. She is edu-
A u t h o r

cated in medicine, biotechnology, journalism, music: each Diploma

In closing, we hope that the informa- with distinction. Since 2008 she is Secretary-General of “European
tion provided here will stimulate further Association for Predictive, Preventive & Personalised Medicine”.
discussions to address many issues in Scientific focus: non-invasive predictive molecular diagnostics, per-
sonalised patient treatment.
relation to the future practice of predic-
tive and personalised medicine.

www.asianhhm.com 65
Diagnostics

Lab-on-chip
Innovative approach towards
telemedicine in primary care

T
The project POCEMON elemedicine can be defined as the European Commission, known by
uses telemedicine “any transmission of medical the acronym ‘POCEMON’ (Point of
to enable point-of- information by means of tele- Care Monitoring).
care monitoring of communication technology”. Numerous The main objective of this project
well-known teleconsultation applications is the development of a LOC (lab-
diseases such as in medicine are based on the trans- on-chip) platform for the entering
multiple sclerosis and mission of imaging data, for example, of the Human Leukocyte Antigen (
rheumatoid arthritis. from computed tomography (‘store and HLA) complex where information on
forward’) or also on live video streams autoimmune diseases like multiple
Kurt Schicho such as from endoscopic interventions. sclerosis and rheumatoid arthritis is
Medical University of Vienna, Austria A solution for point-of-care-monitor- coded. However, the range of potential
Heimo Grüssinger ing and diagnostics of autoimmune applications of this project’s technol-
PCS Professional Clinical Software diseases is the usage of a lab-on-chip ogy is not at all limited to multiple
GmbH, Austria
device that communicates with a labora- sclerosis and rheumatoid arthritis. At
Leandro Lorenzelli tory infor-mation server. This concept present, diagnostic tests concerning
Fondazione Bruno Kessler, Materials
and Microsystems Area - BioMEMS is subject of a recently started large- the majority of autoimmune disorders
Research Unit, Italy scale integrating project founded by are mainly carried out in large-scale
Massimiliano Decarli
Fondazione Bruno Kessler, Materials
and Microsystems Area - BioMEMS The point-of-care monitoring concept based on LOC
Research Unit, Italy diagnostics for DNA-SNP detection
Andrea Adami
Fondazione Bruno Kessler, Materials
and Microsystems Area - BioMEMS Point-of-Care Communication Medical Centre
Research Unit, Italy
Lara Odorizzi
Fondazione Bruno Kessler, Materials
and Microsystems Area - BioMEMS
Research Unit, Italy PDA
Fabio Macciardi
University of Milan, Italy
Fanis Kalatzis
University of Ioannina, Unit of
Medical Technology and Intelligent Data
Information Systems, Department of Management
Computer Science, Greece Multipurpose Server (DMS)
Lab-On-Chip

Primary Care Intelligent Data

Practitioner (PCP) 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 ISSUe - 19 2009

 Diagnostics

laboratories and the patient only gets
the results a few days later. The develop-
ment of computer-based miniaturised
laboratories would permit any level of
healthcare—and especially primary—to
diagnose genetic abnormalities, diseases
or the patient’s general state of health
within a matter of minutes.
Overview of the technical concept
LOC systems based on Polymerase
Chain Reaction (PCR) modules and
cantilever ar-ray detectors will be inte-
grated with Personal Digital Assistants
(PDA) and diagnostic software for the
realisation of an automated and portable
diagnostic system. The investi-gation
of correlations between HLA Single
Nucleotide Polymorphisms (SNPs)
and autoimmune diseases based on
HLA-typing is the prerequisite for the
realisation of this idea in a distributed
architecture for point-of-care applica-
tions.
The concept comprises the combina-
tion and integration of high-end infor-
mation and communication technologies
based on microfluidics, microelectronics
and microarrays as well as intelligent
diagnostic algorithms.
From the technical point-of-view
the development of a LOC that is capa-
ble of reli-ably detecting a sufficient
number of SNPs is the fundamental
prerequisite for the whole concept:
SNPs can be observed in the human
genome frequently (in about one of
1000 nucleotides) and, consequently,
biosensors for SNP detection have
been gaining in signifi-cance over the
last years. As an example, for Multiple
Sclerosis (MS) a number of 49 SNPs
has been found to show an association
with the disease in a study published
by Hafler D et al. 2007.
The Lab-on-chip
by the microfluidic channels for sample
injection, reaction chamber for PCR
amplification and the detector cham-
ber, as well as the integrated microheat-
ers and thermometers for the control
of temperature in different parts of
the chip. An external LOC reader is
required in order to feed the micro-
fluidic module with sample, reagents,
power supply and control signals for the
manage-ment of the fluidic components
The development
of computer-based
miniaturised laboratories
would permit any level
of healthcare—and
especially primary—to
diagnose genetic
abnormalities, diseases
or the patient’s general
state of health within a
matter of minutes.
and microheaters. The second part of
the LOC chip is the detector module,
based on an array of microcantilevers
functionalised with the DNA probes
relevant for the detection of MS and
RA. A number of cantilevers suitable
for the detection of the relevant SNPs
can be integrated on a single chip, also
allowing replica-tions of each probe on
multiple cantilevers, in order to provide
the statistical significance of results. This
work is mainly focussed on the descrip-
Kurt Alexander Schicho is Professor of Biomedical Engineering
A u t h o r
tion of the detector module, which is the
core of the system. When high sensitiv-
ity is required, a proper technology is
required in order to reduce the beam
thickness to sub-micron scale. As fabri-
cation and release of such thin structures
is critical, we tested the technological
feasibility of this approach along with a
procedure suitable for the functionalisa-
tion of high-density cantilever arrays
with DNA probes.
Conclusion
The key benefits of LOCs as compared
with conventional PCR analysis are their
port-ability, automation, the reduction
of required sample and reagent volume,
leading to a reduction of costs and time.
In combination with the described
telemedicine set-up and the labora-
tory information server infrastructure,
this technology provides the perspective
to advance primary healthcare across
Europe by supporting point-of-care
diagnostics and monitoring of immune
system status for the management of
chronic autoimmune dis-eases such
as MS and RA. The combination of
Lab-on-Chip technologies with genomic
microarrays of HLA-typing and the inte-
gration with intelligent software systems
may pro-vide a state-of-the-art diagnosis
at primary care level for a large number
of autoimmune disorders, so the field of
possible future applications is not at all
limited to MS and RA. The principle
that is being investigated and prepared
for clinical routine can be adapted to
other pathologies and bring progress
for their early detection.
References are available at
http://www.asianhhm.com/magazine

at the Medical University of Vienna. His areas of research include

(Micro-electromechatronic system) Telemedicine, Computer Assisted Surgery. He is a regular speaker
The chip, a Micro-Electromechatronic at international conferences. He is the scientific consultant at the
European Community Research Projekt “POCEMON” (Point-of-
System (MEMS), incorporates two Care-Monitoring”). A Lecturer at several private universi-ties of ap-
main functionalities: the first part is a plied sciences, his hobbies include music, sailing.
microfluidic module. It is constituted

www.asianhhm.com 67
Diagnostics
PET-CT
A step towards
personalised radiation medicine
I
The introduction of n radiation oncology, progress has
been made not only because of a
functional data into the combination with systemically active
radiotherapy treatment antineoplastic agents, but also because of
planning is currently the technical improvements and the integra-
focus of commercial, tion of modern imaging. The objective
technical, scientific and of the radiotherapy is to improve the
dose distribution tailored to the borders
clinical development. of the target volume, and to reduce the
The integrated Positron dose to normal tissues because the efforts
Emission Tomography / to improve the dose escalation are valu-
Computer Tomography able and may improve the treatment
(PET / CT) offers a lot outcomes. This means that the precise
definition of the tumour volume and
of advantages in terms the involved lymph node (i.e. in lung
of tumour delineation cancer) is essential. Conventional imag-
and the description of ing modality for treatment planning is
biological processes. To Computer Tomography (CT), but it is
define the real impact not always possible to define the exact
limits between the tumour and the
of the PET / CT on the normal tissue (i.e. oesophageal tumour
radiotherapy planning, and oesophageal tissue). Accumulating
experimental and clinical evidence showed advantages of the
analyses are required. Positron Emission Tomography (PET)
over CT for detection of the primary
Anna Simeonova
tumour, involved lymph nodes and
Physician distant metastasis. This is of enormous
Frederic Wenz importance because if no distant metas-
Professor and Chairman tases are found, local tumour control
University Medical Center Mannheim remains crucial for successful therapy
Department of Radiation Oncology achieved either by radiation therapy or
University of Heidelberg, Germany
by surgery. Disadvantages of PET include
the poor correlation to precise anatomic
structures and the physiologic accumu-
lation in normal tissues. The answer to
these problems was the PET / CT scan-
ner. There are a number of ways in which
PET / CT images can be used for the
treatment planning: PET and CT from
separate scanners registered in software,
PET / CT images registered to a planning
68 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009
CT scan or an integrated planning PET
/ CT scan. The use of a PET / CT plan-
ning scan has the advantage of reducing
uncertainties in the patient’s positioning,
but the value of this scanner still has to
be evaluated. Though, a small number of
centres may have this integrated machine,
in practice, the separate PET / CT and
treatment planning CT will remain more
common for the majority of patients for
whom this imaging is an option.
PET / CT imaging in the treatment
planning
A lot of studies have shown that PET /
CT imaging in the treatment planning
results in significant changes by the defi-
nition of the gross tumour volume (GTV)
and the Planning Target Volume (PTV).
For example, Wong et al. showed 97 per
cent accuracy in the tumour definition
for PET / CT versus 69 per cent for
CT and 40 per cent for MRI. Most of
the changes occur frequently in patients
with head and neck cancer and Non-
Small-Lung Cancer (NSCLC). There are
studies for the NSCLC, which show that
a PET in a combination with chest CT
increases the accuracy of mediastinal
lymph node staging to around 92-95
per cent compared to 68-85 per cent for
CT alone. Another important aspect is
that GTV delineation in the NSCLC,
and also in other malignancies is subject
to major inter-observer variations and
this adds considerable uncertainty to the
target volume definition. The problem
is that there is no Standardised Uptake
Value (SUV) for quantitative determi-
nation of the tumour for all patients.
Upstaging (occurs in 10-25 per cent

PET / CT). Another
Gross tumour volume definition using PET /
CT in the lung problem of the treat-
ment planning of the
NSCLC with the inte-
grated scanner is the
tumour motion. By the
use of non-integrated
PET / CT scanner, the
patient’s position and
the breathing proto-
col used for diagnos-
tic scans often differ
form those used in CT
simulation and radio-
therapy treatment. A
new study from Grgic
Figure 1 et al. shows that, if
there is no planning
of the patients), for example, means a for PET / CT, significantly better fusion
larger GTV with potentially undeliv- of CT and PET images can be reached
erable radical radiotherapy because of if the patient is in the same position
excessive radiation dose to normal lung (the planning position) for both exam-
(pneumonitis, atelectasis). Downstaging inations. Additionally, quality can be
(in 15-35 per cent of the patients) means improved by using a special breathing
a smaller GTV, excluding suspicious but protocol—images should be taken in a
PET negative lymph nodes, allows a dose mid-breath hold.
escalation with an improvement of the The PET / CT also has advantages in
tumour control and survival. Ashamalla et the treatment planning of head and neck
al. demonstrated that in the lung there is cancer. Because of the close proximity to
a GTV variability decrease from a mean several critical structures in this region,
volume difference of 28.3 cm³ in the accurate details of tumour and normal
CT-based planning to 9.12 cm³ in PET tissue is important. As in the case of
/ CT-based planning. PTV also decreases NSCLC, in the case of head and neck
from 69.8 cm³ (in CT) to 23.9 cm³ (in cancer there are a lot of studies, which
Gross tumour volume definition using
CT (A) vs. PET / CT (B) in left nasopahrynx
A B
Figure 2
Diagnostics
investigate the difference between the
GTV in the CT and the same volume
in the PET / CT. A study from Paulino
et al. could show a decrease of the GTV
from 37.2 cm³ (in CT) to 20.3 cm³ (in
PET / CT). Another important question
is, whether there is a correlation between
higher SUV on the PET with the clini-
cal outcome. This is still controversial.
Braun et al. reported a study consisting
47 patients with head and neck cancer,
who undertook a PET / CT planning
scan. Above-median metabolic rate was
associated with remission in 62 per cent
of the cases versus 96 per cent in the cases
with below-median metabolic rate. Two
other studies could not show the same
outcomes. Schwartz et al. and Vernon
et al. showed that maximum SUV on
staging PET / CT is not predictive of a
treatment failure, comparing maximum
SUV or primary tumour, nodes or the
higher of the two. If there is a corre-
lation between higher SUV and poor
outcome, the dose for these areas can
be escalated and to improve the local
control. However, study is required to
confirm these findings.
For patients with anorectal carci-
noma, PET / CT is frequently used to
diagnose the stage, evaluate the treatment
response and assess for a tumour recur-
rence. For example, the exact staging
is of huge importance to the treatment
planning of anal carcinoma. If there are
nodal metastases, there will be another
treatment technique compared to the
situation without nodal metastases.
Cohade et al. determined in a study of
45 patients that PET / CT improved
the staging and restaging accuracy from
78 to 89 per cent compared with PET
alone. Trautmann et al. detected in the
PET nodal metastases in 24 per cent of
patients who were considered node nega-
tive in CT. Although several studies have
demonstrated the utility of PET scans
for the detection of colorectal primary
tumours, data on its impact on radia-
tion treatment fields for rectal and anal
tumours continues to emerge. Ciernik
et al. estimated the value of PET / CT
www.asianhhm.com 69
Diagnostics

CT- GTV and PET- GTV highlighted with red and yellow
contours, respectively.
on radiation planning for patients with
rectum and anal carcinoma. In more
than half of all patients (56 per cent),
the GTV delineation was significantly
altered. GTV increases were seen in
50 per cent of the patients with rectal
primaries and the PTV increase in 20
per cent. In patients with anal canal
primaries, the mean change of GTV
was 34 per cent.
CT showed a more caudal exten-
sion of GTV; PET showed uptake in a
presacral lymph node.
PET / CT in post-treatment or
evaluation during the course of
radiation
PET / CT could also be used as post-
treatment or evaluation during the course
of radiation or combined chemo radiation
treatments. In post-treatment situation, it
can be used to predict durable treatment
response, but during the treatment it may
be much more limited. Many investi-
gators are hesitant to use this imaging
during or immediately after the radio-
therapy because of concerns of increased
36 patients during and post-treatment
and showed a complete response during
the treatment of 6 patients and partial
metabolic response for 26 patients. And,
as we know, tumour volume regression
during the course of radiation therapy is
predictive for both local recurrence and
survival after treatment of carcinoma
of the cervix. Additional studies with
larger group of patients are necessary to
determine whether metabolic response
during the radiation therapy is indeed
predictive of post-treatment response
and survival outcome after the radia-
tion therapy for cervical cancer.
New investigations show advantages
in the PET / CT in the differentiation
between tumour progression and a post-
treatment effect particularly in patient
with glioblastoma. This could be useful
in predicting the patient’s outcome if
Anna Simeonova is a Physician in the Radiation Oncology,
Department of University Medical Center Mannheim, University
Heidelberg. She is working in the department since September
2007. Her research focuses on radiotherapy treatment of lung car-
A u t h o r s
treated with a combined therapy (chemo
and radio therapy). This imaging may
allow selecting patients who may benefit
from additional radiation boost.
In summary, we suggest that the
use of a PET / CT scanner in the daily
routine treatment planning is beneficial
for many anatomic regions. Data gathered
from this imaging modality can lead to
invaluable knowledge on the true extent
of the primary lesion and metastatic
spread and can lead to changes in radia-
tion treatment planning that may alter
clinical outcomes either by improving
local tumour control or reducing toxicity.
To date, PET / CT images have been
applied in the routine radiotherapy plan-
ning in many radiotherapy departments
for non-small-cell lung cancer, oesopha-
gus, anorectal carcinoma and head and
neck cancer. This fact shows that the
use of PET in treatment planning has
recently gained huge acceptance in the
radiation oncology community. However,
there is still not enough published data
about the use of PET / CT for the rest
of the malignancies. Therefore, future
clinical studies based on the integrated
PET / CT or on PET / CT / MRI image
fusion, which compare the outcome of
biologically directed treatment regimes,
need to be conducted for each individual
tumour entity before biological treat-
ment volume definition can generally
be recommended.
References are available at
http://www.asianhhm.com/magazine

cinoma.
uptake secondary to inflammation in
necrotic tumour and nearly normal tissues
incorrect by interpreted as metabolically Frederic Wenz is a Professor and Chairman of Radiation Oncology,
active tumour. A study from Schwartz et Department at the University medical center of Mannheim, at the
University of Heidelberg.
al. could show that performing PET /
CT during radiation therapy for patients
with cervical carcinoma is feasible. They
investigated the metabolic response from

70 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009

 CaseStudy
PACS
Role of the end-users

W
To fully achieve the hen a hospital decides more benefits like a reduced need for
benefits of PACS, to make the switch to a storage space, reduction of costs and
Picture Archiving and less waiting time for patients. So, the
the end-users (both
Communication System (PACS), it is benefits of PACS are tangible on all levels
radiologists and not only a huge financial decision; it is throughout the hospital. Table 1 displays
referring physicians) also the start of a journey with an unsure an overview of the benefits of PACS.
need to make some outcome. With PACS, a whole new To fully achieve these benefits, the
necessary efforts. world of possibilities opens up—both end users (both radiologists and referring
for radiologists and referring physicians. physicians) need to make some neces-
Next to the advanced image processing sary efforts. A major step for the end
Bram Pynoo
Researcher capabilities, we believe that some of the users is adapting their workflow and
Pieter Devolder most important features of PACS relate moving from an analogue to a digital
Project Engineer to the increased accessibility and avail- way of working. With this change in
Tony Voet ability of images. With PACS, images are workflow, there is also a shift in the way
Senior Information Technology available to all entitled users as soon as tasks are done. Tasks that were previously
Project Manager the images are in the PACS, from wher- executed by a nurse or a clerk now have
Luk Adang ever they are: in the hospital, at home to be done by the physician himself,
Database Nurse
or in the surroundings of a WiFi-spot e.g. retrieving radiological images. This
Dries Ovaere
Project Engineer
at Waikiki beach. When we compare shift could lead to physicians feeling
the digital way of working (PACS) to threatened regarding their autonomy and
Jan Vercruysse
Care Manager its analogue counterpart (radiological power vis-à-vis their subordinates. Next
Clinical Support Sector images printed on film), PACS provides to changing the workflow, the end-users
Philippe Duyck
Medical-logistic Head
Radiology Department
The Unified Theory of Acceptance and Use of Technology
Department of Radiology and
Medical Imaging
Ghent University Hospital, Belgium Performance
Expectancy

Behavioral
Effort Use
Intention
Expecrancy

Social
Influence

Facilitating
Conditions

Voluntariness
Gender Age Experience
of use

Figure 1

www.asianhhm.com 71
Diagnostics

have to become proficient in working

Benefits of PACS
with PACS. So training must be provided
to the end-users. This is not straight-
forward considering the busy schedule Level Benefit
of most physicians. Moreover, as their
education did not focus on working with Management Cost reduction
computers, some physicians will need
some extra training. Both the training Radiology Reduction of report turnaround time
and the change of workflow have to department
Increased productivity
be done in the period in which both
Higher job satisfaction
systems coexist, leading to a trade-off:
this period should be sufficiently long Lowered need for physical storage space
to give the end-users the time to learn
to work with PACS and change their Physicians Increased reliability of image delivery; significant reduction of
workflow, and as quickly as possible as it the number of lost images and a faster availability of the images
is very costly to maintain both systems. Decreased time for image searching
But, after the end-users made the transi- Availability of images 24/7
tion to PACS, its return-on-investment
is huge. So it is no surprise that from
Patients Faster availability of the images
then on (almost) nobody desires to go
back to the pre-PACS era. However, as Improved patient care
long as the end-users haven’t made the Reduction in average hospital-stay
switch, a lot of barriers could hinder or
Table 1
even stop the adoption process. Four
types of barriers could arise on any time
during the implementation process; Overview of the PACS project and timing of the questionnaires
here, the focus is on the behavioural
barriers—the acceptance of PACS by Date Action
the end-users.
02/06/2003 Request for proposal
To assess the acceptance of PACS
by the end-users, questionnaires were 15/01/2004 Decision: GE Centricity PACS
issued to the end-users at different times
during the implementation process: pre- 01/09/2004 Start implementation
implementation (T1), shortly after the
introduction of PACS (T2), and one year 01/01/2005 Introduction speech recognition
after the radiology department stopped
printing film (T3). The questionnaires 16/02/2005 Upgrade RIS
were grounded on the Unified Theory
of Acceptance and Use of Technology 03/2005 Questionnaire 1: radiologists
(UTAUT) presented in Figure 1, a deri-
vation of the Technology Acceptance 14/03/2005 Go live PACS in radiology (radiologists & nurses/technicians)
Model (TAM). According to this theory,
four factors predict the acceptance of 08/2005 Questionnaire 1: physicians
PACS:
25/08/2005 Go live PACS web in the hospital (physicians)
• PE – Performance Expectancy: useful-
ness of PACS
10/2005 Questionnaire 2: physicians
• EE – Effort Expectancy: ease of use
of PACS 14/02/2006 Radiology department stops printing film
• SI – Social Influence: pressure from
peers and superiors to use PACS 01-02/2007 Questionnaire 3: radiologists & physicians
• FC – Facilitating Conditions: provi-
sion of support of all kinds. Table 2

72 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009


Evolution of physicians’ (left side)
and radiologists’ (right side) scale ratings.
The acceptance of PACS is
measured as BI (Behavioural Intention
to use PACS) and / or Use. Next to the
UTAUT-constructs, the users’ attitudes
toward PACS (ATT) were also ques-
tioned. Scale items had to be rated on
a 7-point Likert scale from 1 (completely
disagree) to 7 (completely agree) with 4
as a neutral point.
Setting
The Ghent University Hospital has a
capacity of 1,062 beds and employs about
660 physicians and 1,500 nurses. Table
2 presents a schematic overview of the
PACS project.
In the hospital, two main groups of
PACS-users exist: radiologists and refer-
ring physicians. Radiologists work on a
PACS workstation, where PACS is inte-
grated with the Radiology Information
System (RIS) and speech recognition.
They use PACS almost continually to view
images and compare with old images, to
report on radiological images, to tutor
radiologists in training. Referring physi-
cians use the PACS web on their personal
computer, whenever they need to consult
radiological images and reports.
A project team was responsible for
the PACS project from start, when the
purchase of the PACS was planned, up
to now. The PACS project team consisted
initially of the head and head nurse of the
radiology department, two engineers and
two nurses / technicians. A psychologist
CaseStudy
end-users gained access to PACS. During
the transition phase both systems—PACS
and analogue film printing—coexisted,
while in the post-implementation phase
the users had no choice but using PACS
as the radiology department stopped
printing film.
Preparation phase
PACS was a point of attention on the
radiology staff meetings for two years,
so no further introduction of PACS for
the radiologists was needed. A letter was
Figure 2 sent to all hospital physicians—including
radiologists—to announce the advent
of PACS. Letters to referring physicians
and one more engineer were later added were accompanied by the first question-
to the team.. The tasks of the team are naire (T1). The project team opted for
comprehensive, including writing the a slow and gradual diffusion of PACS.
tender, preparing the end-users, provision Therefore, no further introduction on
of support, scientific research etc. The PACS was given at this moment. In this
scientific research concerns the accept- phase, the project team developed train-
ance of PACS by the end-users. ing material for the end-users to learn to
The next section of the article covers work with PACS. A distinction was made
three different phases of the PACS between the radiologists and the referring
project. The preparation phase starts at physicians. For the referring physicians, a
the time when the implementation of digital learning environment, a blotting
PACS was planned and ends when the pad and a mouse pad were developed.
The radiologists had the choice between
T1 T2 T3 following a training course and receiv-
ing hands-on training by an application
Adj. R² (BI) .37 .18 .30 specialist of the project team. Prior to
the introduction of PACS, the IT-depart-
PE .43*** .26* .26**
ment upgraded all computers to meet the
EE .14 .12 .02 minimum requirements for PACS.
The results of the first question-
SI .08 -.11 .14
naire showed that both the radiologists
FC .15* .18 .32*** and physicians were ready for PACS. A
graphical overview of their responses is
Adj. R² .50 .03 presented in Figure 2. For radiologists
(USE)
PACS was much more concrete, so it is
BI .73*** .10 no wonder that they held higher expecta-
tions concerning PACS and experienced
FC -.06 .14 more pressure to use it. As Table 3 shows,
Results of regression analysis with the it is critical for physicians that PACS is
physicians’ data. The values reported are useful and that there is support in case
standardised Beta regression coefficients. The of problems, to start using PACS.
values in bold denote how well (on a scale of
0 to 1) the independent variables explain the
dependent variable. Transition phase
Notes: Significance level *p<.05, **p<.01, When PACS was introduced, physi-
***p<.001 cians knew that they eventually had to
Table 3 work with PACS but that they could
www.asianhhm.com 73
Diagnostics
take time to make the transition. In this
phase, the project team invested more
time and effort on training the physi-
cians: several members of the project
team visited on three separate occasions
the staff meeting of every service. These
visits had multiple goals: introducing
the digital learning environment, solv-
ing user problems, showing advanced
possibilities of PACS etc.
The radiologists had to make the
transition to PACS immediately. This
was not a big step as they had already
taken several steps towards a digital
way of working with the introduction
of speech recognition and the upgrade
of the RIS.
The second survey (T2) was sent to
the physicians only. It was taken about
two months after the introduction of
PACS into the hospital. First, the impact
of the digital learning environment was
assessed. It was found that users who had
used the e-learning were more positive
towards PACS than others. In general,
mean scale ratings were slightly higher
than at T1, as is shown in Figure 2. At
this time, the most important reason for
accepting PACS and continue using it,
is its usefulness.
Post-implementation phase
The project team is responsible for the
daily support and solving user problems.
Recurrent problems were incorporated
into the digital learning environment,
leading to a gradual decrease of support
calls.
The questionnaire at T3 revealed
that the implementation has succeeded.
Physicians’ mean scale ratings were
higher than at T2, except for EE,
while the physicians didn’t feel that
they were put under pressure to use
PACS. The most important reason for
physicians to continue using PACS is
the usefulness of PACS and the avail-
ability of support. The scale ratings of
the radiologists were still higher than
at T1, approximating the maximum.
Radiologists’ ratings were also higher
than those of the physicians.
74 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Conclusion plays an important role in high-
The transition to PACS went smoothly. lighting the benefits of PACS and
This is due to two main causes: the providing support and training to the
features of PACS, and the work of end-users. The training through e-learn-
the project team. The advantages ing proved to be a good way to train
of PACS for the end-users, when fully a large group of professionals with a
deployed, are immense. However, the busy schedule.
end-users need to do some efforts
and it takes time to become a profi- References are available at
cient PACS-user. The project team http://www.asianhhm.com/magazine
Bram Pynoo obtained a master in experimental and theoretical
Psychology at the University of Ghent. His research interests con-
cern the psychological processes in changing environments. He is
also interested in the design of digital learning environments and
computational modelling.
Pieter Devolder being trained as an industrial civil engineer, his in-
terests lie in optimising workflow at all levels. His research interests
include acceptance of information systems, Human Interface design,
fuzzy analysis, software ergonomics and workflow optimisation.
Tony Voet obtained a master of science in electrotechnical engi-
neering. His coordinating efforts in the automation projects of the
department both revolutionised work methods and optimised work
flow for all members of the personnel.
A u t h o r s
Luk Adang is the designer of the e-learning environment used to
train hospital physicians and other medical staff in using PACS.
Dries Ovaere recently joined the PACS project team of the radiol-
ogy department. Being trained as a master of science in electronics
engineering, his interests lie in the technical background of informa-
tion systems.
Jan Vercruysse was the head nurse of the radiology department,
at the time of the transition to PACS; and thus responsible - together
with the department’s Medical Logistic Head - for guiding his depart-
ment into the digital era. His research interests are mainly change
management processes in medical and nursing settings.
Philippe Duyck is a published author in thoracic radiology and in
the acceptance of clinical information systems. As medical-logistic
head of the Radiology department he was responsible for guiding
this department into the digital era. His current research focuses on
PACS-acceptance.
ISSUe - 19 2009

RFID for Medical Devices
An exciting future
Imagine an RFID tag
travelling through the
human body such as in
Sci-Fi movie Fantastic
Voyage. In biotechnology,
bioengineering and
healthcare, RFID has
a lot of interesting
research opportunities.
Rajit Gadh
Professor
University of California Los Angeles
USA
In various industries like Retail, RFID
has not taken off the way it was expected
to. What are your views on the usage of
RFID in healthcare?
Let us first talk about RFID in retail. In
retail, RFID can be applied to the pallet
or the carton or the items in it. RFID has
already taken off in a big way in its appli-
cation on the pallet—where the pallets are
tracked from the manufacturing floor to
the distribution centre to the warehouse.
Companies like Wal-Mart and some big
European companies such as Tesco are
already using RFID. So in retail, I would
say the tracking at the pallet level has
already been a success. And companies
and suppliers are able to automatically
track the inventory without any human
intervention. Now, if you look at the
other levels i.e. case level and the item
level the technology is now coming out
to enable that. The case level is progress-
ing along nicely and in certain industries
such as apparel, individual shirts and
jeans are now being tracked at the item
level. So, I would say in retail, we have
already had some successes. We have got
to the pallet level and now there is intense
research being done on case and item
level in labs like ours.
I would say overall that retail is
coming along nicely. Now let us look
at healthcare. Here, the problem is a bit
more challenging because every hospital
has a very unique IT infrastructure. That
means all the hospitals do not share the
same standardised databases or security
systems or networking architecture or
computing platform. And that makes
RFID in healthcare more challenging
and that is why it has taken a little bit
longer to get RFID into healthcare. But,
it is already starting to happen. Our lab
Technology, Equipment & Devices
is involved in development of variety of
research projects which are resulting in
the development of different systems.
One of the systems we have developed
for healthcare is called SpecimentrakTM.
SpecimentrakTM system is the system that
is being used to track medical specimens.
And of course, what happens is that even
though we may have implemented it for
one hospital, going from one to the next
to the third to the fourth takes some
customisation. It cannot just plug ‘n
play because of the same reason I have
mentioned that the IT infrastructure
of different hospitals is different. And
that’s what slows down the scaling up
for RFID across different hospitals for
a given application.
Another application we have been
developing is called ‘Pediatrak TM’ that
tracks babies in the hospitals so as to
prevent theft of babies as well as to moni-
tor various activities about the babies. This
is a bit more challenging in the context of
the healthcare system in the US because
here we are regulated by certain laws
such as privacy laws of HIPAA. Some of
those US-based requirements make any
technology implementation whether it is
RFID or another IT-based technology a
bit challenging. Of course these technolo-
gies are to protect to the privacy of the
patient which is very important.
Nevertheless, progress is being made
in healthcare. There’s another system we
are developing is called ‘RadiologyTrak
TM
’ that is meant for tracking X-ray plates.
Here the problem (and the opportunity)
opportunity is that sometimes the identity
of two different people gets exchanged
or their X-ray plates get exchanged. In
this context, one can put RFID tags on
the wrist band of the patient and RFID
www.asianhhm.com 75
Technology, Equipment & Devices
tag on the X-rays so that you can keep
tracking things at every step so that
errors don’t happen. And yet another
area we are working on is called Patient
ID and Patient Information. For exam-
ple, in an RFID tag of the patient you
can store an ID and the ID can be
connected to the entire patient record.
So if you want to pull out a patient
record you know all the information is
connected to the RFID tag. Or, you can
think about eventually putting certain
types of information about the patient
such as the medication, blood pressure,
weight and height and so forth can be
put directly on the RFID tag. What that
does is that if a patient walks with that
information into the hospital then the
RFID infrastructure automatically reads
the data from the tag and the patient
does not have to keep sending out all
this information again and again which
in the US is a very big problem. So there
are a lot of interesting opportunities and
I think the healthcare system is looking
aggressively at this. There is one more
system that we are developing which is
PharmaceuticalTrakTM that tracks phar-
maceutical medicines in supply chain
with the objective of preventing coun-
terfeit.
Is current technology available meeting
the requirements?
In certain cases ‘Yes’ and in certain cases
‘No’. For instance, in Specimentrak, the
current RFID technology is meeting the
requirements very nicely. We have used
very low frequency RFID tags with mobile
hand-held readers. But for certain other,
more complicated applications, current
technology I would say still needs more
work. If you wish to track the location
of the baby but in combination suppose
you wish to track with the same RFID
tag the oxygen, blood pressure, body
temperature and all the variables of the
baby at the same time with the single tag,
then that technology either may not be
available or may be too expensive. So,
there are certain things where we need
to do lot of preparation.
76 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
All the hospitals
do not share the same
standardised databases
or security systems or
networking architecture
or computing platform.
And that makes RFID
in healthcare more
challenging
What challenges does a tracking medical
device bring to RFID?
Let us look at tracking of medical devices,
where the work is going on and what are
the types of medical devices that need
to be tracked. Tracking medical devices
needs to have a reason. There has to be
some benefit since there will be some cost.
The cost of tracking should be justified
by an appropriate benefit. For example,
there are some types of medical devices
that government needs to know actually
where they are. So, for devices that you
are required to track, you either track
them with a human being every day or
you track them automatically with RFID.
In this scenario, the cost justification is
easier because to have somebody track the
cabinet manually daily is a very expensive
proposition. So that is one class of track-
ing requirements for medical devices.
There is another class of medical
devices which are implantable devices
inside the human being where you want
to query the device, you want to ask the
device a simple question like what is the
status of the battery—this is because for
some of the devices you have to change
the battery every so often. So, if you
could query the device for status or
problems via RFID, or if the device had
some problem and it could communicate
that wirelessly to a remote monitoring
location a wireless sensor networks, then
the device becomes an intelligent device
and may not need to be removed from
the body.
ISSUe - 19 2009
Another type of RFID requirement
in hospitals is used for locating a device.
For example, consider a hospital that has
four or five ECG units in a 200-bed.
These devices being expensive, hospitals
do not purchase them in large numbers.
And when a nurse or a doctor uses this
device in a patient room, sometimes due
to the rush to see the next patient, they’ll
leave it there and the next nurse comes
in when the shift changes and wants
to use the device but can’t find it and
they send someone to find it. Hospitals
typically use a few extra units of these
devices for such a situation. If you could
track exactly which room the device is in
at every instant in time through say AA
cell phone, then the hospital may not
need as many ECG units and by finding
the unit when it’s needed, may actually
save more money and lives.
So finding asset locations is another
justification for investment in an RFID
system.
What are the research opportunities in
RFID for medical devices, equipment
and medicines?
There are a lot of research opportuni-
ties. If you look at all possible devices,
medicines and patients and every possi-
ble mobile asset in the hospital, you’ll
notice that a very small number of them
actually have an RFID tag. The oppor-
tunity exists in terms of identifying
what all can be tagged. And this can

be linked to the business benefits, but
before you do that, you have to make
sure that the technology works. If not
100 per cent, then at least up to a reason-
able level. The research opportunities
are pretty significant. For example, we
talked about the implantable devices.
The first generation of RFID tags gave
you the ID, the second generation has
been giving information about the status
via sensors—for example, the RFID tag
can give you vital statistics like blood
pressure from within the body? So, the
opportunity here is in making RFID tags
have many different sensing capabili-
ties, the third could be what is called
controlling RFID. For example, could
an RFID tag send a signal to an insulin
injecting pump attached outside to the
human body? Finally, if these smart tags
could be made really small and injected
into the human body, you could use
a cell phone to send instructions and
receive data remotely. Imagine an RFID
tag travelling through the human body
such as in Sci-Fi movie Fantastic Voyage.
In biotechnology, bioengineering and
healthcare, RFID has a lot of interesting
research opportunities.
There have been reports about RFID
interfering with a device’s functioning.
What are the quality and safety precau-
tions to be taken when it comes to RFID
in medical devices?
The analogy I would draw here would be
about a cell phone interfering with the
functioning of another cell phone. The
fact is they do not necessarily need to
interfere with each other – for example
how many times have you made a cell
phone call from a room with another
person on their cell phone and had
interference? Probably none. . This
happens because there is something
called frequency bands. Each frequency
band is very intelligently allocated and
managed. And so, you could have a large
Technology, Equipment & Devices
number of phone conversations going
on at the same time between the cell
tower and many cell phones because
the communications systems manage
the bands very efficiently. It’s the same
thing with RFID. If the RFID reader is
designed in the correct fashion, it can
read hundreds if not thousands of tags
at the same time. If there is a device
in the room that is getting interference
from an RFID reader, it could be that
either the device or the reader has not
been designed correctly. If the design is
correct, it would not interfere.
What are the risks / issues involved in
RFID tags for critical care equipment?
I would say the same thing again. Suppose
you want to use some critical care equip-
ment and RFID in the same vicinity,
you should run tests with the RFID
www.asianhhm.com 77
Technology, Equipment & Devices
readers to make sure that there is no
interference. What we would do in our
lab (UCLA RFID Lab) is we would meas-
ure the different frequencies and signal
strengths and we would see whether there
is interference or not. If indeed there is
interference, then one needs to figure out
who is it that has developed the flawed
design. I would like to give an example of
analogue cell phone networks and today’s
digital networks. If you took old analogue
network phone and put in the same room
with a digital network cell phone, they
may interfere because they are completely
different technologies. It is pretty straight
forward in today’s day and age the way
frequencies are shared in say the cellular
networks or the Wi-Fi space to redesign
old technology. Generally, it should be
noted that if the medical equipment is
old then the electronics of the medical
device may need a redesign to make sure
that it operates on the same principles as
the RFID reader and then you’d see that
the interference can be avoided.
If you look back a few years, RFID has
evolved pretty quickly. Where according
to you is RFID headed in the future?
There are several areas where innova-
tions are happening and will continue
to happen. Five years ago, the hand-held
readers had a read range of only 5-6 feet.
Today, these readers have a read range of
20-25 feet. The read range has gone up
five times. In the next five years I expect
the size of the tags to go down; the ability
to read large number of tags to increase,
the speed of reading to increase and the
memory in tags to increase. Also, we
would be able to put more sensors on a
single device to perform specific functions
like monitoring a patient’s vital statistics.
The idea is that as RFID technology gets
smaller and as you can integrate more
and more sensors into a single tag, more
stuff would be possible. I also think that
technologies like nanotechnology will be
contributing heavily into the reduction
of the RFID tag size even smaller. The
idea is to look at what happened in the
semiconductor industry with Moore’s law.
78 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
I look at a similar type of a trend here in
the RFID space. I think we will follow a
very similar trend. The virtuous cycle of
price decline resulting in increase in busi-
ness applications and tag volumes, result-
ing in turn in further decrease in prices,
will continue for a long time, putting
downward pressure on tag prices. I won’t
be surprised if RFID tag manufacturing
price on the low starts to see the 1 penny
level in the next five years.
Because of this convergence RFID
could be placed in pretty much any
device. I foresee a lot of changes coming
to both the embeddable and the non-
embeddable side of the medical equip-
ment marketplace. It’s the R&D that is
going to drive the costs down, improve
Tracking medical
devices needs to have
a reason. There has
to be some benefit
since there will be
some cost. The cost
of tracking should
be justified by an
appropriate benefit.
the quality and reduce the size. This is
what will allow people to do more with
RFID. Hitachi has already developed tags
that are thinner than a human hair. It is
costly right now since it is relatively low
volume, but who knows what we would
be able to do in the future?
Is the latest technology in RFID able
to overcome the information security
challenges?
Information security is an important
challenge. In the US, HIPAA regulates
who can look at a healthcare record. It
is very restrictive as to who can and who
cannot look at a record. When you start
putting patient information into a tag,
then there is going to be concern in any
ISSUe - 19 2009
hospital as to who can read the tag. A lot
of hospitals have overcome this problem
by assigning a random I.D. number to
the tag and reader looks it up in the
enterprise database behind a firewall and
until the system (governed by HIPAA)
does not know who it is that’s querying it
will not divulge the information. Hence
the data related to specific patients is
protected.
Any other comments?
RFID has progressed a lot in many differ-
ent disciplines. For example, in the aero-
space industry RFID is being used to
track aircraft parts. It is being used by
the automotive industry to track cars in
storage facilities after they are assembled
and ready to be shipped . It is being
used by the shipping industry to track
containers as they move across the planet.
So, RFID is already being used in a lot
of different industries and the healthcare
industry will have to learn from the other
industries. The important thing is that
to have a successful system, you have to
put technologies together and make them
work. A lot of technologies are already in
place and the healthcare profession can
benefit in a big way. The opportunities
in healthcare are really large.
I was in Washington a couple of
weeks ago, and the city is abuzz with
talk about President Obama’s stimulus
package, which includes US$ 20 billion
for healthcare IT. I look at this as an
opportunity to modernise the paper-based
infrastructure in the United States and
move it towards the path of modernisation
that has encompassed every other indus-
try in the world. A paperless healthcare
system will make it much easier for us to
provide RFID technology and integrate
it into the infrastructure of the healthcare
system. The benefits will be ten-fold and
cost of tags could see a non-linear decline
in price beyond even what we have been
predicting. So, I am very excited about
the future of RFID in healthcare and
am seeing a significantly rapid increase
in interest in our RFID Program from
healthcare organisations.

Artificial Intelligence
Applications in healthcare
For improving the
efficiency of treatments
and avoiding costs by
minimising the risks
of false diagnosis, it is
important to integrate
Artificial Intelligence
tools in everyday
medical applications.
This facilitates more
targeted pre-operative
planning and reduces
the risk of intra-operative
complications.
Prasanna Vadhana Kannan
Research Analyst
Frost & Sullivan, Singapore
I
nitially, Artificial Intelligence (AI)
buzzword was introduced as a
concept to mimic human brain and
investigate the real-world concerns with a
holistic human approach. Scientists and
researchers all over the world are very
excited about advancements in innovation
that have arisen from an innate desire
to create newer and better technologies
that facilitate mankind to extend beyond
their own physical calibre. The promise
of AI concept has always been on the
horizon from realistic science to the
imagination in movies and literature.
AI largely enables the capacity to store
and process huge amounts of data in an
intelligent manner, and more specifically
translate that information into functional
tools. Since its inception, AI has been
deployed for highly selective defence or
space exploration applications wherein its
success in solving problems for specific
areas just like risk prediction is involved.
Now, gradual transition of its utility in
healthcare is being widely experienced
through AI-based systems that allow for
better diagnosis, cure and treatment of
debilitating conditions.
Scope of AI in medicine
AI is a study realised to emulate human
intelligence into computer technology
that could assist both doctors and patients
in the following manner:
• By providing a laboratory for the
examination, representation, and
cataloguing of medical information
• By devising novel tools to support
decision-making and research
• By integrating activities in medical,
software and cognitive sciences and
finally
• By offering a content-rich discipline
Technology, Equipment & Devices
for future scientific medical commu-
nity.
Thus, increased integration of intel-
ligent AI tools in everyday medical appli-
cations could improve the efficiency of
treatments and avoid costs by minimis-
ing the risks of false diagnosis, facilitate
more targeted pre-operative planning,
and reduce the risk of intra-operative
complications.
The recent usage of AI in performing
sophisticated tasks and computations has
gradually led it to be introduced as a
key component of MRI and computed
tomography systems. The added advan-
tage of these systems is in the ability to
effectively acquire information, and sync
with established decision support data-
bases. Further, AI has begun transforming
the field of surgical robotics wherein it
has enabled the advent of robots that
perform semi-automated surgical tasks
with increasing efficiency. One of the ulti-
mate challenges faced in robotics could
be mimicking of human intelligence and
body motion. In spite of such a critical
challenge, robotics has attained consider-
able progress and is now applied across a
wide array of applications ranging from
the defence industry to the diagnostics.
Basically, robots are not built smartly,
but are integrated with certain software
components to make them intelligent.
Recent advances in the field of AI such
as neural networking, natural language
processing, image recognition, and speech
recognition / synthesis research, have
spurred our creativity and the future of
robotics looks very bright indeed.
It is worth mentioning here that the
biggest hurdle towards adoption of medi-
cal robotic surgical systems is the high
initial capital equipment costs involved.
www.asianhhm.com 79
Technology, Equipment & Devices
Many of these systems often require new
infrastructure to be constructed and the
staffing of high bill rate specialists who are
well-trained in these techniques emerges
to be a key hindrance in its widespread
adoption. A basic AI computer used today
in clinical practice could be visualised to
be applied for automation of routine tasks
and for other functions listed below:
• Alerts and reminders In most general
forms of AI integration, the machine
scans a patient’s lab results, drug orders,
and updates the patient with an appro-
priate reminder. In this manner for
generating alerts and reminders, more
advanced AI programs can be directly
interfaced with a patient monitor and
used for detecting changes in a patient’s
condition
• Diagnostic Help
• Therapy fore-planning Specific condi-
tions that require elaborate treatment
plans could benefit from AI tools during
therapy planning. By incorporating an AI
system that can automatically formulate
plans based on specific conditions would
add certain value to the physicians as
well as patients
• Information Retrieval Similarly, soft-
ware search agents can be created for
complex medical applications that are
much more efficient than current genera-
tion web-crawling agent’s performance.
This aids in information retrieval and
upgradation of data automatically
• Image Interpretation Multiple medical
images can be instantaneously identi-
fied, from plane X-rays through to highly
complex images like angiograms, CT, and
MRI scans. Such systems for image recog-
nition and interpretation have increas-
ingly been adopted for clinical use
Another key application of AI systems
is in the process of scientific research
through applying expert systems and
decision support systems. Such systems
are programmed to learn, i.e. to aggregate
& retain vast amounts of patterned data
for specific purposes. Today, DSS tech-
nology has been successfully employed
in the medical device industry that
encompasses cardiac monitoring and
80 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
automated ECG, medical imaging,
clinical laboratory analysis, respiratory
monitoring, electroencephalography,
and anaesthesia.
Insights on current systems using
AI
Agilent Technologies (Andover,
Massachusetts) has developed a smart
ECG device that estimates the probability
of acute cardiac ischemia/ACI. This ACI
time-insensitive predictive instrument
holds good promise in increasing the
accuracy of diagnosing ACI
Intelligent Medical Imaging, Inc.
(Florida) has designed the Micro21
microscopy workstation that success-
fully integrates neural network tech-
nology into blood analysis to identify
and display white blood cells as well as
red blood cells
ATL Ultrasound, Inc. (Seattle-based
firm) has developed a range of diagnos-
tic ultrasound systems for imaging and
monitoring cardiac tissue structures and
activity. This system utilises an adaptive
intelligence algorithm to scrutinise tissues
by optimising millions of parameters
during a patient examination, thereby
eliminating irrelevant frequencies in
returned signals
Neuromedical Systems, Inc. (New
Jersey) uses an application of neural
networks to scan Pap smears& identify
cells for review during cancer screen-
ing.
Development plans and key
understanding
With the effective implementation of
neural network technology in analysis
of blood, medical image interpretation,
and other complex tasks, a need to evalu-
ate these technologies in order to deter-
Prasanna Vadhana Kannan is a Research Analyst with the Frost
A u t h o r
& Sullivan. She focuses on tracking and analysing global emerging
trends and technologies pertaining to the healthcare industry
ISSUe - 19 2009
mine their real potential to develop into
future standards has emerged. The medi-
cal expertise that these AI systems use
must be subjected to thorough research
and all issues must be clearly identified
and well documented at the beginning
itself. This generates the demand for
detailed interviews with experts in this
field apart from considering secondary
sources of information. Collating in this
manner the information gathered from
domain experts will certainly help to
better understand the digital machine
and key logical patterns that emerge from
its data interpretation. The operational
understanding of the field under study, as
required by the AI computer will arrive
from iterative know-how & transfer from
human to machine protocols.
Some of the key influencing factors
like maturity attained by the AI systems,
user acceptance, and glitches in commu-
nications along with technical infra-
structure stand as huge barriers to the
commercialisation opportunities that
currently exist for AI. However, given
the thought that ongoing innovations
in this domain are poised to move from
academia and theory into reality, all of
which prove or exist as a definite sign of
growing momentum in this field. Most
advanced decision support systems are
guiding medical faculty to interpret
complex results and devise future plans
accordingly. The promising growth rates
demonstrated by companies in this field
are sure to drag attention to their devel-
oped technologies and increase invest-
ments in these companies, which will
in turn drive the future of healthcare.
Rising adoption of AI in medical devices
indicates that its way forward is certain
and AI could definitely be a major feature
of the future landscape of healthcare.

Reducing
ICU Mortality
Strategies for the 21st century
Over the years, Intensive
Care Units have become
the hot corner of hospitals.
In the near future, new
automated systems will
ease ICU patient monitoring
and secure delivery of
sophisticated treatments.
Djillali Annane
Director, General ICU, Raymond Poincaré
Hospital, University of Versailles, France
C
laude Bernard has introduced the
concept of intensive care when
arguing in favour of restoring
homeostasis as a key point of diseases
management. Intensive care became more
concrete to people in the middle of the
20th century when the introduction of
lung iron to support respiratory function
prevented death in most of victims of the
poliomyelitis pandemic. Politics rapidly
got the importance of creating specific
places to deliver life-supporting treat-
ments for acutely ill patients. Thereafter,
Intensive Care Units (ICUs) were built all
around the world including industrialised
and emerging countries and became the
hot corner of hospitals. Amazingly, there
is no consensus on what should be an
optimal ICU. They are markedly different
across countries in design and resources
and in management and care delivery.
Thus, unsurprisingly, death rates in the
ICUs vary on an average from 8 to 20
per cent around the world. Analysing the
causes of death in ICUs is risky. Basically,
people may die as a direct consequence
of the critical illness, as a consequence
of underlying co-morbidities, second-
ary to iatrogenic events, or as a conse-
quence of withholding, withdrawing
life-supportive treatments. Intuitively,
there is little to do on co-morbid condi-
tions or decision to terminate care. Thus,
reducing ICU mortality should focus on
advances in the management of critical
Facilities & Operations Management
illness and the prevention of iatrogenic
complications.
Sepsis accounts for a greater number
of diseases related deaths in the ICU.
Severe sepsis and septic shock are even
today associated with 20-25 per cent and
40-45 per cent of mortality rates, respec-
tively. Halting sepsis related deaths should
be a priority for physicians, researchers,
health policy makers and pharmaceuti-
cal industries. This is a reasonable goal
to achieve. Undoubtedly, some progress
has already been done and implementing
the Surviving Sepsis Campaign bundles
results in substantial survival benefit.
Most of the recommendations
are simple measures (the first 6-hour
bundles), e.g. early antibiotic treat-
ment and source control and restoring
cardiovascular homeostasis, that can be
applied right away almost everywhere
and may have a substantial impact on
survival. Similarly, when sepsis is asso-
ciated with acute lung injury or acute
respiratory distress syndrome, keeping
plateau pressures in the airway low, e.g.
25 cmH20 or less may prevent death in
many patients. More complex strategies
need to be used as second line measures
in patients who failed to respond to the
first 6-hour bundles. They may include
maintaining blood glucose levels below
150 mg / dl, infusing activated protein C
for four days, and low dose of corticos-
teroids, i.e. 200 mg of hydrocortisone or
www.asianhhm.com 81
Facilities & Operations Management

equivalent, for a week. These second line
strategies are aimed at restoring metabolic,
haemostatic and immune homeostasis. So,
applying the original concept developed
by Claude Bernard of maintaining home-
ostasis seems a very successful approach
to deadly critical illness like sepsis.
In the very near future, one expects
that most, if not all, patients with severe
sepsis or septic shock will be treated
according to the Surviving Sepsis
Campaign. In addition, prioritising
a better understanding of the mecha-
nisms behind the chaotic nature of critical
illness and designing diagnostic tools to
recognise subtle loss in biological systems,
homeostasis are key determinants for the
development of successful treatments for
sepsis and non-septic systemic inflam-
matory response syndromes.
Right now, the prevention of iatro-
genic complications in the ICU is a top
priority to reduce deaths. The critically ill
patient is exposed to a number of drugs.
Yet, for most of the medications, the
pharmacokinetics during critical illness
remain unclear, and little is known about
Intensive care became
more concrete to people in
the middle of the 20th century
when the introduction
of lung iron to support
respiratory function prevented
death in most of victims of
the poliomyelitis pandemic.
should be included in the development of
novel drugs particularities related to criti-
cal illness. The incidence of ICU acquired
superinfections is still unacceptably high,
albeit the efficacy of several preventive
measures is already recognised. The attrib-
utable mortality of blood stream infection
or ventilator associated pneumonia may
reach 20 per cent.
Djillali Annane is a Professor in Medicine at university of Versailles
A u t h o r
There is an urgent need for tools
allowing a more efficient translation of
evidence based information to the bedside.
It is also paramount to develop new strat-
egies for the prevention of multi-resistant
microorganisms. Life-support therapies
that are so paramount to surviving criti-
cal illness, e.g. mechanical ventilation,
renal replacement therapy or vasopres-
sor therapy, are also associated with life-
threatening complications. These treat-
ments need to be adjusted a la carte in
individual patients on a continuous basis,
which is almost unfeasible by humans.
Thus, researchers are developing close-
loop systems providing computer guided
adjustments of life-supportive therapies.
In the near future, new automated systems
will ease ICU patient monitoring and
secure delivery of sophisticated treat-
ments. So, it is expected that the cost
related to ICU will continue to increase
and this may be accepted by people only
if ICU risk of death is minimised.

and the Director of the general ICU at Raymond Poincaré Hospital

interactions between drugs. For example,
(Assistance Publique Hopitaux de Paris). His main research area is
activated protein C and corticosteroids pathomechanisms and treatment of sepsis. He has written more
may be widely used in combination to than hundred and fifty papers in medical journals and textbook,
including NEJM, JAMA, Lancet.
treat septic shock, though safety data are
lacking. The pharmaceutical companies
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82 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009

www.asianhhm.com 83
Facilities & Operations Management

Surgical Workflow
Methods and applications
Given a great demand for a rigorous analysis of surgical interven-
tions, Surgical Workflow Analysis proves to be a powerful
methodology to understand and describe surgical procedures.

84 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009


T
he performance of today’s business
processes is strongly supported by
information systems. Constant
adaptation of the business processes to
market requirements is achieved by busi-
ness process analysis and optimisation.
Until now, it was not possible to
analyse surgical and intraoperative inter-
ventions for optimisation potentials and
to support their execution by information
systems. Reasons for this were the high
variability of surgical processes caused
by patient-specific properties, lack of
methods for structured description of
surgical processes as well as missing data
acquisition methods.
The investigation of surgical work-
flows is an innovative approach for
describing surgical interventions. Based
on a rigorous Surgical Process Analysis,
the acquired data can be used to optimise
surgical procedures, to guide the develop-
ment of new surgical assist systems or to
compare different surgical approaches.
The term ‘Surgical workflow’ relates
to the description of surgical interven-
tion courses. Surgical workflow is an
abstraction of the surgical procedure.
Its descriptions are useful for several
user groups including surgeons, health
administrators, or medical engineers. To
use surgical workflows, e.g. for analy-
sis, it is necessary to describe them in a
formal language.
Characteristic for Surgical Workflows
is the high amount of potentially useful
information. However, the choice of
the suitable sampling of information
restricts, which surgical questions might
be answered by the help of surgical
workflows. A simple surgical question
such as “Who is doing what and when?”
results in highly complex descriptions
and large amount of information to be
processed.
One objective of the work of the
Innovation Center Computer Assisted
Surgery (ICCAS) at the Universität
Leipzig, Germany, is to use Surgical
Workflow Analysis to find answers to
typical questions arising during optimi-
sation of surgical interventions: “Does
using an intraoperative navigation system
is more time-saving then the conventional
approach without the system?”, “Surgeon
A has less complications than surgeon B
for similar cases. What’s the difference
between both approaches?” or “Will the
investment in the development of a new
surgical tool pay off for my company?
Will it bring significant benefit?”
Oliver Burgert
Head, The Research Group, Scientific Methods
Thomas Neumuth
Head, The Research Group, Workflow and Knowledge Management
Innovation Center Computer Assisted Surgery (ICCAS), Universität Leipzig, Germany
Facilities & Operations Management
When applying surgical workflow
methods, three subsequent steps are to
be performed:
1. Surgical Process Analysis: Surgical
Process Analysis records the existing
processes and stores the intervention
courses in a formal Surgical Process
Model (SPM). This model can be
visualised end explored by the end
user and it can be used for statistical
analysis.
2. Surgical Workflow Modelling: Based
on the recorded SPMs, a Surgical
Workflow is defined. It shall be capa-
ble of considering all variants of the
surgical intervention which appear
during normal and extraordinary
intraoperative situations.
3. Workflow Management System
(WFMS): A WFMS can be used to
guide the real world processes based
on the Surgical Workflow Model. This
step is rather visionary since there is
no methodology available to auto-
matically determine the current state
of an intervention.
Structured recording of surgical
process models
The most important step in each and
every study is to acquire a solid data
base. There are established methods in
nearly every scientific field for measur-
ing each and every aspect, but in surgery
one has to rely on the verbal descrip-
tion of intervention courses given by
experienced surgeons. Even though
structure interviews are a valuable tool
during a Surgical Workflow Analysis,
we strongly recommend to record real
surgical interventions. The data recorded
is more accurate and steps which might
be forgotten by the expert since they
are ‘unimportant’ or ‘well known by
everyone’ will be captured.
www.asianhhm.com 85
Facilities & Operations Management
Examples of granularity levels for surgical work steps
Activity
(i) Cutting (contains cutting and suctioning)
Cutting
(ii)
Suctioning
Cutting non-cutting
(iii)
suctioning non-suctioning suctioning non-suctioning
Time
Since the amount of information
which could be recorded during a surgical
intervention is enormous, we developed
dedicated software for structured record-
ing of surgical interventions: The surgical
workflow editor. The manifold of possible
questions for surgical workflow analyses
needs data acquisition methods with high
flexibility, therefore, the software can be
customised by anontology to support
every possible surgical intervention.
The surgical workflow editor is a soft-
ware application running on a tablet PC
which is operated by trained medical
staff for data acquisition. Using human
observers adds additional flexibility to the
recording process since the observer can
move around or ask questions. Observer-
based recording reaches its limitations
if a high amount of detailed informa-
tion needs to be recorded or surgical
work steps are performed with high
frequency.
For structuring surgical interven-
tions, basic considerations need to be
made regarding the desired granularity of
the observations. In the next section, an
approach for segmenting surgical inter-
ventions in surgical worksteps with differ-
ent granularity levels is presented and an
information model for acquiring surgical
work step information is shown.
How can a surgical work step be
modelled? If, for instance hemorrhages
are caused by the surgeons while cutting
tissue, the blood needs to be suctioned
in parallel to the cutting of the tissue.
This simple step might be considered and
86 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Exucuted by
Surgeon
Surgeon (right hand)
Surgeon (left hand)
Cutting Surgeon (right hand)
suctioning Surgeon (left hand)
Figure 2
described under various viewpoints and
granularity levels (cp. Figure 2):
(i) A work step “Cutting” is defined,
that consists of the sub work steps cutting
and suctioning, performed as smallest
atomic unit by the surgeon.
(ii) A second choice would be the
definition of cutting and suctioning
as two independent working units,
performed by the “Left hand of the
surgeon” and the “right hand of the
surgeon” as atomic organisational
units.
(iii) A third option would be the
consideration of the work steps of one
hand with the temporal segmentation
“suctioning-non-suctioning-suctioning”.
This granularity level shows a further
segmentation of (ii) and considers short
breaks by pausing suctioning by the
surgeon.
The choice of the granularity level
reveals a further challenge: the relation
of temporal and causal coherency. If
the choice (i) is made, the work step
‘cutting’ contains implicitly the work
step ‘suctioning’ for supporting the
cutting work step. A granularity level
according to (ii) requires in contrast an
explicit representation of the suction-
ing, which is performed in parallel to
the cutting. If the surgeon suctions at
another location at the same time, when
he cuts, both work steps have a tempo-
ral, but no causal relation, because then
the suctioning was not necessary caused
by the cutting. Considering granular-
ity level (iii), between the work steps
ISSUe - 19 2009
ICCAS surgical workflow-editor
Figure 3
‘suctioning’ and ‘non-suctioning’ exists
a causal, but no temporal and parallel
relation, because both work steps cannot
be performed by the surgeons hands at
the same time.
If the objective of the observation
is a more detailed recording, a consid-
eration of the performed work steps at
least at granularity level (ii) is necessary.
Recording surgical procedures on such
level of detail is a demanding task. For
example, if work steps of the assistant
or the scrub nurse should be acquired in
addition to the work steps performed by
the surgeon, the number and frequency
of activities can not be handled without
software support. For this objective, the
Surgical Workflow Editor was developed.
With the help of the software, detailed
information of procedure courses can
be acquired and analysed for clinical
questions. Figure 3 shows a screenshot
of the Surgical Workflow Editor. The
frame in the foreground is used to enter
a new surgical activity or an event. The
intervention course containing all work
steps is visualised in the background.
After recording, the SPM can
be analysed. Statistical methods can
be applied to count occurrence of
certain activities or instrument usage,
or to analyse the duration of certain
phases of the intervention. For explo-
ration of several recorded processes or
interdisciplinary discussion about an
intervention, a graphical representa-
tion of the SPM is helpful. Figure 4
shows a visualisation of an interven-
 Facilities & Operations Management

good support for non-technical people

Visualisation of a microlaryngoscopy intervention from
working with the surgical workflow.
otorhinolaryngology
To evaluate the surgical workflow
editor, it was applied to several inter-
Surgeon Nurse
vention types from multiple disciplines.
Position teeth
These included intervention types form
protection upper jaw otorhinolaryngology, neurosurgery, cardi-
ovascular surgery, interventional radiol-
Position ogy, and eye surgery. Intervention courses
laryngoscope larunx have been recorded at international sites
in Germany, France and the US. The
suction aspirator methodology has been used in many
glottis
ways, for example to optimise patient
Position
pathways, to compare different surgical
laryngoscope larunx approaches, to compare different surgical
devices, for the development of use cases
Fasten laryngoscope for an international standardisation body,
or for generating educational material.
Position microscope Surgical workflow analysis is a power-
ful tool to understand and describe surgi-
cal procedures at a formerly unknown
take photo AIDA edema level of detail. The methods for record-
on plicae vocales
cut sickle knife edema ing surgical processes are effective and
on plicae vocales applicable to surgical routine with-
Hold forceps edema 1x
on plicae vocales
out major restrictions. Statistical and
suction aspirator visual exploration of recorded SPMs are
plicae vocales a powerful method to select from the
Take photo AIDA
large amount of available information,
plicae vocales the most relevant ones for answering a
specific surgical question. In the future,
remove microscope workflow management systems will be
used to support the surgeon during the
fasten fiber cable intervention, for example by providing
the information needed during a specific
remove laryngoscope step. Basic research providing the neces-
sary situation awareness and automated
remove teeth protection process recording is currently being
Figure 4
performed in several research institu-
tions all over the world.
tion protocol for a surgical interven-
tion of the type Microlaryngoscopy from
Oliver Burgert is Head of the Research Group ‘Scientific Methods’
Otorhinolaryngology. This visualisation at the Innovation Center Computer Assisted Surgery (ICCAS),
is automatically generated from a SPM Universität Leipzig, Germany. He studied Informatics at the Research
and can even be displayed in parallel University Karlsruhe, Germany and did his PhD on Surgical Planning
A u t h o r s

Systems. His research at ICCAS includes modular surgical assist

to the intervention course e.g. for live systems, Surgical Workflows, Ontologies and Surgical DICOM.
transmissions of surgical interventions
during conferences. The visualisation Thomas Neumuth is Head of the Research Group ‘Workflow
of a surgical workflow, which contains and Knowledge Management’ at ICCAS. He studied Electrical
Engineering Management at the University of Applied Sciences in
all possible variations of a certain inter-
Leipzig. Subsequently, he graduated with a Master of Engineering in
vention type, is more challenging. We Automation at the UAS Leipzig. His research focus is on procedural
developed different methods for visual ontologies, data acquisition, data analyses and workflow schemes.
exploration of process graphs to provide

www.asianhhm.com 87
Information Technology

Home
Telehealth
Understanding
the outcomes
The use of telemedicine to embrace the
home as a health venue recognises the
possibility to maintain patient independence
for rehabilitation and disease management.

Ronald Merrell
Professor, Surgery
Virginia Commonwealth University, USA

H
ome telehealth is the use of telecom-
munications tools to amplify, initi-
ate or replace home health visits in
person. Care of patients in the home has a
greater application now than at any time since
healthcare arrived on horseback. The merits of
home healthcare have been extensively studied
and validated in terms of cost-efficiency and
improved clinical outcomes. The incentive for
care at home has several dimensions. Home
healthcare can: permit earlier discharge from
the very expensive inpatient environment;
reduce the need for rehabilitation stays in
nursing facilities; and extend the period of
independent living outside nursing homes by
providing services and by supporting family
members engaged in providing care. In disease
management, home care can reduce the need
for emergency department visits and inpatient
stays by early recognition of disease trends,

88 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009


improved compliance with a treatment
regimen and better education of patients
and families. Standard home health visits
can be organised into a system with facil-
itated access to caregivers through call
centres or direct calls to the health agency
which has the records of the patient and
an awareness of the medical situation.
Home health has been greatly
successful mainly due to reduced costs,
patient satisfaction and improved clinical
outcomes. Can this success be secure if
telecommunications and other technol-
ogy replace the physical visit by a home
health worker? How is success measured?
What are the guidelines to assure success
in the design and implementation of a
home telehealth programmes?
The success of home telehealth is of
fairly recent vintage and there are many
reports of less than successful outcomes.
As recently as early 2006, the Agency for
Healthcare Research and Quality (AHRQ)
reported that despite many studies on
the values of home telehealth, there was
great need for properly designed studies to
test the hypothesis that home telehealth
was valid in general and with specific
diagnoses. In 2004, Winters and Winters
reported that home telehealth could be a
promising model for rehabilitation. Jannett
in her review of telehealth outcomes and
home telehealth in 2004, reported clear
improvement in terms of both outcomes
and patient education. The overall results
for outcomes were mixed but there was
a consistent case to be made for cost-
effectiveness. In order to evaluate a study
to guide decisions relative to an invest-
ment in home telehealth, it is prudent
to understand this history, proper study
criteria and the abundance of articles by
true believers as opposed to critics. In fact
good decisions by healthcare managers
and health systems must come only from
the best data.
For Congestive Heart Failure (CHF),
Whitten published an early study in 2007
and a more comprehensive assessment
in 2009. In order to know the merits of
an intervention, there surely must be a
study that measures health, economic and
social outcomes and carefully explains the
technology used in the intervention. In
Whitten’s later work, 50 patients were
engaged in a programme of telehealth
with a strong message of education. All
the patients suffered from CHF and
were evaluated before the intervention
and two months after using well vali-
dated survey instruments. The patients
had an average of 39 telehealth visits
and 14 home visits in the study period.
Complaints of shortness of breath fell
from 24 to 12 per cent while medication
compliance rose to 84 per cent from 49
percent. Improvement in activity, edema,
fatigue and hospitalisation were at the
p<0.05 significance. The patients found
Information Technology
the set-up easy to use and equivalent to
face-to-face visits. These outcomes are
entirely appropriate measures for CHF
management. For diabetes mellitus, the
parameter of choice would be Hemoglobin
(Hgb) A1c for glycemic control and for
hypertension measure of diastolic blood
pressure. For asthma, the parameter or
interest is avoidance of emergency visits
and for chronic obstructive lung disease
(COPD), spirometry and hospitalisation
would be the data of note. For a home
telehealth programme to be worthwhile,
the health outcomes should at least be
equivalent to home health visits. If the
outcomes are not better and not equiva-
lent, there should be some considerable
advantage in reducing the overall cost
for service. For health systems, avoid-
ance of more advanced service levels is
the cost benefit.
Finkelstein in 2006 concluded home
telehealth improved clinical outcomes at
a lower cost in a study in Minnesota.
He compared controls that had a home
nurse visit with home nurse plus video
sessions and nurse, video and home
health monitoring in 53 patients with
CHF or COPD. Transfer to a higher level
of care, either hospital or skilled nurs-
ing facility, was record in 42, 21 and 15
per cent respectively. The advantage of
telehealth intervention is striking and the
value added by home monitoring is very
impressive. Here, the costs are reduced
primarily due to the avoidance of a higher
level of care.
The best database for the measured
effect of home telehealth is through the
Veterans’ Administration (VA) in the US.
It is generally considered that the huge
VA databases almost never support the
excited results of early reports on clinical
interventions. The story for telemedicine
is quite different. In 2004 a VA study
from Connecticut reported 104 patients
with CHF, pulmonary disease or diabe-
tes mellitus in a randomised controlled
trial of home telehealth. The reduction
in bed use was significant at p<0.0001
and use of the emergency department
p=0.023. Hgb A1c decrease was significant
www.asianhhm.com 89
Information Technology
at p<0.0001 and patient satisfaction at
p<0.001. Therefore, the intervention was
a success with clinical outcomes, patient
perception and cost. Continuing the VA
experience, which has been very carefully
collated and studied, Barnett in 2007
reported that for diabetes mellitus Care
Coordination/Home Telehealth, the
growing VA system was cost-effective
in one-third of 370 respondents. In this
instance, the technology of the VA system
was evolving. DelliFraine in 2008 did
a metanalysis of 29 articles out of 154
potentially acceptable reports and found
better outcomes for CHF or psychiatric
diagnoses but discerned that there was
a tremendous impact of the technology
on outcome. Telehealth is not the same
all over. The instrumentation is crucial
to success. The educational materials are,
of course, important. The quality of the
medical care product is highly relevant.
Telehealth in its interpretation and imple-
mentation calls for a careful assessment
of the equipment, hardware, middleware
and software plus a clear set of instructions
for patient and training of the personnel.
These elements are perhaps best applied
in the VA again as described by Darkins
in 2009. Between 2003 and 2007 the
VA Coordinated Care / Home Telehealth
(CCHT) programme has treated 31,750
patients. In a recent cohort of 17,025
there was a 25 per cent reduction in bed
days and a 19 per cent drop in admissions
with an 86 per cent satisfactory rating
by the patients. The telehealth cost was
90 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Standard home health
visits can be organised into a
system with facilitated access
to caregivers through call
centres or direct calls to the
health agency which has the
records of the patient
and an awareness of the
medical situation.
US$ 1600 per patient per annum. The
plan is for CCHT to provide 50 per cent
of all non-institutional care for the VA
by 2011.
The older papers do not provide
enough evidence on the efficacy of home
telehealth. However, the newer ones that
report large numbers of patients are clearly
better. At this juncture, there are no analy-
ses or reviews of strong evidence in the
Cochrane Library. However, there surely
will be soon for home telehealth and when
available decision makers can consider
their choices with Level I evidence. In
the meantime, careful reading of what is
published will allow sound decisions in
evidence based medicine as to technology,
programme design and the setting of both
clinical and financial expectations.
ISSUe - 19 2009
An interesting paper by Gagnon
followed the course of a programme in
Canada and concluded that decision
makers needed to be involved in the
scientific outcomes of a programme as
it evolved to make the best decisions for
ultimate success. Home telehealth like
any other endeavour can fail to meet the
expectations of patients, medical person-
nel, clinical outcome predictions, cost
containment or profit. Success requires
a clear understanding of the product,
service and market. Patients will readily
accept a well-designed service as equiva-
lent to a face-to-face intervention if they
feel empowered, have improved access
and confidence. The technology of the
imaging devices, sensors, video and trans-
mission must of course be thoughtful for
patient and family concerns and abilities.
Health workers will accept a telehealth
programme if it makes their work easier,
better and more rewarding. They are likely
to make a system work that is techni-
cally reliable and intuitive. Long technical
delays or lost connections will doom a
programme while professional connectiv-
ity will make success much more likely.
For the health worker, if telehealth is just
extra work acceptance will be less. The
expectations of home health physiologi-
cal sensors or monitoring for improved
clinical outcomes will not be met if the
education, implementation and operation
of the programme fail. Next, we must
also consider money.
It is logical that improved diabetic
management, wound management,
airway management, heart failure regi-
mens etc. lead to lower costs. However,
administrators may only see the cost
of the telehealth equipment and tech-
nical personnel. In order to avoid the
temptation to economise on equipment
and technical support, it is quite impor-
tant to write into a plan a way to track
savings to offset the cost. The overall
business plan should include Return on
Investment (ROI), amortisation, deprecia-
tion of equipment and staff training. It
is, of course, unrealistic to assume that
telehealth system will work, as it seemed
 Information Technology

in the advertisement, without providing
proper task-specific modification, training
and technical support. Furthermore, there
must be careful consideration as to the
scale of the service in the business and
operational planning. Installing a very
expensive telehealth system for a handful
of patients will never look good in a cost
analysis. This is where the ROI estimate
becomes crucial. The successful plan must
recruit enough patients to be cost-effec-
tive. Pilot efforts may be expensive in
terms of initial costs but their value comes
later as the full plan incorporates lessons
learnt from the pilot study in terms of
the application intended.
In the current economic climate in
general and for medicine in particular,
service. Home telehealth need not add
any expense to aggregate patient care if
the system is well-researched, designed,
implemented and monitored for an
appropriate patient population. Success
of home telehealth can be defined and
assured by the stakeholders (parties,
patients, caregivers, public and fiduciaries)
by careful reading, planning and admin-
istration. The extension of telemedicine
to the home is least expensive when it
is appended to an existing telemedicine
programme and an existing information
system to share some resources Therefore,
health systems with those programmes in
Ronald Merrell is Professor of Surgery at Virginia Commonwealth
A u t h o r
place are most likely to succeed. Home
telehealth appended to an existing home
health programme is also favoured for
success as in the case of the VA system.
Home telehealth is like all permutations of
telemedicine programmes in that they are
most expensive as a stand-alone. As part of
a mature electronic medical record effort
in a health system with a salutary experi-
ence in home health, a home telehealth
programme should flourish and show early
sustained profit. It is the right thing to
do for patients and, in this case the right
thing to do for patients is the best thing
to do for health system finances.

University in Richmond, Virginia. He has been a long time researcher

there is no likelihood that an enhance-
ment in care that is prohibitively expen-
sive can come to reality. Any innovation
really should reduce costs through better
health outcomes or some economy of
in telemedicine supported by NASA with an emphasis on technology,
the surgical suite and remote environments. He is an editor-in-chief
of Telemedicine and e-Health, the official journal of the American
Telemedicine Association

www.asianhhm.com 91
92 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009
eClinician: Clinical Decision Support System
A unique differential diagnosis tool
C oresys’ differential diagnosis module, eClinician,
is a valuable tool for practicing doctors. Clinical
decision making is a required skill for every physician
based on his subject knowledge and clinical acumen,
which is a combination of science and art. A physician
should have enough knowledge and a logical mind,
which support his intuitive mind to derive a conclusion.
Good conclusions (diagnosis) are based on facts in
the basis of accurate clinical judgment.
eClinician is a unique system, supporting the
physician in the whole process of decision making.
The database of 4568 diseases is more valuable
than keeping all specialty text books on consultation
table. But the real value of eClinician is not just the
amount of information provided. It is the method of
reaching differential diagnosis from signs & symptoms
that is the real value of eClinican to the physician.
There are two categories of signs & symptoms
listed in eClinician. Major Presentations and Other
Presentations. The Physician may choose one or
two major presentations and other presentations
of the patient as given in Image 1, and the system
will generate differential diagnosis with five possible
diseases (Image 2).Particular disease information—
clinical examinations, etiology, lab, treatment,
medications etc.—are also displayed for immediate
access.
The system has been developed in a user
friendly interface, enabling physicians with no prior
software experience to use eClinician with a simple
demonstration.
Product Review Message from a leading
Physician: “eClinician is practical & quite simple. I
believe every GP would be immensely benefitted by
it and I would very strongly recommend it to them. If
the benefit are not immediately apparent to an average
GP who is mostly hard pressed for time, those who
are forward looking and willing to invest the required
time to learn it and actively use it, will soon enough
make it as much a part of their equipment as an ECG
machine or even a BP apparatus”.
eClinician has been adopted by over 3000 users
in India in a short time of 24 months in market.
About the Developer: Coresys is an ISO 9001:2000
certified software company offering products and
services in healthcare industry. Coresys has a team
of in-house software developers and doctors who
work together to adapt latest technologies.

Other Products
A. Cortex, Hospital Management System. This is a completely integrated web application, capable of
meeting demands of hospitals of any size. The system has been evolved with over 12 years of expertise
in the domain. Cortex is available in a customized version for managing Clinics without In patients.
The system also comes integrated with complete Electronic Medical Records which has been developed
on international standards with easy to use and access user interface.
B. Campas: Campus management system is offered to schools and colleges on a SaaS model. The
system is hosted on our servers and institutions can subscribe to the service on a pay per student model.
This solution minimizes start up cost of implementing the management system at educational institutions.

For more information, contact: info@coresysit.com

www.asianhhm.com 93
Advertorial
Information Technology
Telehealth
Strategies for
successful, cost-effective
implementation
T
Telehealth is best used elehealth provides remote physio-
logic monitoring of patients with
in patients with illnesses
chronic illness such as diabetes
that respond to monitoring mellitus or heart failure. Most commonly,
and rapid intervention. It it is provided at homes in conjunction
is ideal for patients with with nurse home visits. Chronically ill
heart failure because patients use devices that measure blood
pressure, weight, blood oxygen or glucose
the weight monitoring
levels on a daily basis. Healthcare provid-
provides information ers, patients and family caregivers closely
that is responsive to monitor the readings and rapidly respond
health interventions. to deviations from normal. Several studies
have shown the benefits of telehealth in
Kathryn H Bowles providing rapid response and, therefore,
Associate Professor, New Courtland reducing hospitalisation and emergency
Center for Transitions and Health, department use. The benefits are many,
University of Pennsylvania School of but the technology does present some
Nursing, USA
challenges for the agency providing the
services. Here is a look at suggested
strategies to overcome the challenges
and provide successful, cost-effective
telehomecare.
The outcome of telehomecare inter-
vention is heavily, if not completely,
dependent on the people providing the
intervention. Their attitude towards the
value of the technology is important to
a successful programme. Often, the atti-
tude starts from the top management.
Management must communicate the
value of the programme to their staff
and implement support structures
that enable operations to proceed. For
example, managers must recognise that
telehealth adds time to the nurse’s day
because of equipment set-up and patient
teaching. Expectations about productivity
94 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 19 2009
may need to be adjusted. Also, the staff
must be properly trained for installing
and using the equipment. One strategy
when developing the procedures for the
programme is to get staff at all levels
of operation involved in conversation,
education and feedback. Any barri-
ers should be identified and solutions
devised.
• Choose staff that are interested in tech-
nology and have the ability to work
with new ideas
• Explore interests, understanding, and
comfort level with the use of technol-
ogy at all staff levels
• Specifically ask staff if they are inter-
ested in having telehealth in their
organisation and if they are opposed
discuss the reasons
• Share these concerns back to manage-
ment for resolution.
Successful telehealth requires team-
work and coordination. There are two
models of care delivery. In one, the
home care nurse is responsible for home
visits, monitoring the telehealth data,
and responding to deviations in the
telehealth data. In another model, the
home care nurse does in-person visits
only and another telehealth nurse moni-
tors the data and coordinates a response
with the home care nurse. Either model
requires teamwork and coordination to
install the equipment in a timely manner
and to assure a rapid response to patient
needs. Often, the type of equipment used
dictates which model is most practical.
 Information Technology

If the equipment is web–based, then the
first model works well; if video is used
then the latter model is required because
the nurse must be at the office to use
the video equipment and interact live
with the patient.
Telehealth is best used in patients
with illnesses that respond to monitor-
ing and rapid intervention. It is ideal
for patients with heart failure because
the weight monitoring provides informa-
tion that is responsive to health inter-
ventions. Telehealth is best used with
patients who are cognitively intact, able
to pull a blood pressure cuff on their arm
and stand on a scale. Also, motivated
patients are necessary to gain coopera-
tion in using the devices regularly. Those
recently hospitalised are often ideal since
the fresh memory of hospitalisation can
be motivating and a recent hospitalisation
puts them at risk for future events.
Equipment selection and installa-
tion is another important challenge.
Determine the devices needed by match-
ing them to the population being served.
For example, with diabetics, a glucom-
eter is needed, but perhaps not a scale.
Also, decide whether to use video or just
monitoring and ask if wireless devices are
available because they are easiest to install
and place into the patients’ home envi-
ronments. Choose a reliable vendor with
a good reputation and strong business
history. Seek equipment that is simple
to set up and use. Consider initial and
ongoing cost of the equipment and ask
about data storage or monitoring fees.
Consider direct delivery right to the home
from the manufacturer and determine
how the equipment will be installed,
collected, cleaned and redeployed. Home
care nurses prefer that these tasks are not
their responsibility. Some manufacturers
provide these services for a fee.
Early on, map out the work flow
Possible visit pattern
• Week 1: 2 Home Visits (HV),
install and begin daily monitoring
• Week 2: 1 or 2 HV and 1 Telehealth
video visit (TH)
• Week 3: 1 HV and TH daily moni-
toring and one video
• Week 4: TH
• Week 5: 1 HV and TH
• Week 6: TH
• Week 7: 1 HV and discharge
Table 1
The period of highest risk for the
newly admitted home care patients is
the first 24-48 hours. Therefore, the goal
should be to deliver and begin using
the equipment within the first week of
home care. Agencies must also determine
how long to leave equipment in the
home and how to use the technology in
conjunction with in-person visits to be
most efficient and effective. A suggested
pattern is found in Table 1.
Once the equipment is installed,
several process strategies can be employed
to promote successful telehealth. Provide
guidelines for nurses on the content of
the conversation via video or telephone.
This assures consistency in the monitor-
ing procedures and teaching content for
patients. To assist with rapid response,
secure collaboration with physicians for
medical orders based on monitoring
results. Seek standing orders for faster
response. For example, often physicians
may have a standing order for heart
failure that whenever the patient’s weight
increases by >2 pounds in 24 hours, the
Kathryn H Bowles is an Associate Professor in the New Courtland
Center for Transitions and Health at the University of Pennsylvania
A u t h o r
nurse should instruct the patient to take
an additional diuretic. Nurses should
also use the data as a ‘teaching moment’.
Nurses can show the patient changes in
their readings and how they correlate to
their behaviours. This helps to reinforce
healthy behaviours and adherence to
diet to medication.
Track outcomes continuously to
measure and communicate the value
of the programme to payers. Most
commonly, hospitalisation and emer-
gency department use are measured.
Others monitor patient knowledge
about healthy behaviours, adherence
to therapies, symptom improvements
and use of the equipment for self-care.
Costs in time, personnel and equip-
ment should be compared to gains in
efficiency and savings due to preventable
readmissions.
Finally, it is important to publish and
present results and lessons learned so that
others learn the value of this technology
for chronic illness and how to administer
the programme most effectively. Further,
payers may decide to adopt the model
for their patients and reimburse it as a
valued service.
Adequate training, staff attitude,
management support, careful selection
of equipment and the right patients all
contribute to a successful telehealth
programme. Developing a satisfactory
and efficient workflow is crucial to match
nurse, agency and patient needs; install
the equipment in a timely manner; and
provide coordinated care efficiently. The
main goal is to use the technology to
improve patient outcomes and prevent
costly readmissions and emergency
department use.

School of Nursing, leads an interdisciplinary programme of research

and define roles and responsibilities. that blends transitional care and the use of health information tech-
Some roles and responsibilities include nology to improve the care of the elderly. Bowles has led as Principal
Investigator or been a Co-Investigator on 5 telehomecare studies in
delivering the equipment and supplies,
a variety of home care agencies in Pennsylvania. Her NIH funded
installing , monitoring and acting on work includes an ongoing clinical trial testing the effects of telehealth
the data, and training the patient and with heart failure patients.
caregiver on its usage.

www.asianhhm.com 95

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Coresys Infotech Pvt. Ltd. .......................................................92
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