Ahhm 14

Healthcare Management Medical Sciences Diagnostics Information Technology Surgical Speciality
Issue 14 2007 £12 €18 $25 www.asianhhm.com
Published by
Where knowledge talks business
In association with
Transparency Small is
in Healthcare Beautiful
Seeing is believing Nanotechnology for
medical devices
Treatment of Healthcare
Lung Cancer Design
Immunotherapeutic
Need for consumer-driven
strategies
research
Patient Safety and Quality
Role of Governance w w w. a s i a n h h m . c o m
w w w. a s i a n h h m . c o m
Contents
HEALTHCARE MANAGEMENT MEDICAL SCIENCES
Treating Lung Cancer 23
CoverStory 9 Immunotherapeutic strategies
Dominik Ruttinger, Head, Laboratory of Clinical and Experimental Tumor
Immunology, Department of Surgery, Grosshadern Medical Center
Ludwig-Maximilians-University Munich, Germany
Truth in Ethics, Truth 29

in Science - Different?
Torbjorn Tannsjo, Professor and Chair
Practical Philosophy
Stockholm University, Sweden
SURGICAL SPECIALITY
Surgical Response to 35
Mass Casualty Incidents
The Israeli experience
Transparency in today’s globalised healthcare
Sharon Einav-Bromiker, Lecturer,
world has impressed governance with the
Anesthesiology and Critical Care Medicine
necessity of becoming increasingly accountable
Hebrew University, Israel
for patient safety by introducing quality
standards and methods in order to retain a William P Schecter, Professor, Clinical
competitive edge and attract market share. Surgery, University of
California San Francisco, USA
Yosef D Dlugacz, Senior Vice President, Chief of Clinical Quality
Education and Research, Krasnoff Quality Management Institute, USA
Surgical Skills Simulation 37
Effect on quality and safety
Patrick Cregan, Surgeon, Co-Chair,
McHealthcare 6 Sydney West Area Health Service Surgical Network and
Delivering consumer-driven healthcare Chair, NSW Department of Health, Surgical Services Taskforce, Australia
John Leifer, President
David Grazman, Vice President Surgical PACS 39
Design and implementation
CBIZ The Leifer Group, USA
Heinz U Lemke, Research Professor, Radiology, University of Leipzig
Germany
Transparency in Healthcare 13
Seeing is believing
DIAGNOSTICS
R Carter Pate, Global and US Managing Partner
Health Industries and Government Services
Sandy Lutz, Director
Digital Radiography 43
PricewaterhouseCoopers Health Research Institute, USA Efficiency with automated system movements
Michel Claudon, Professor and Chief, Department of Radiology
What can the Operating Room Learn 17 Children’s Hospital, University of Nancy, France
from the Cockpit?
Richard C Karl, Surgical Oncologist and Chairman, Department of Surgery Advances in Breast Imaging 45
College of Medicine, University of South Florida, USA Impact in Asia Pacific
Frost & Sullivan, Singapore
Communication 19
Challenges and
Opportunities TECHNOLOGY, EQUIPMENT & DEVICES
During Handoffs
Richard M Frankel, Professor, Medicine and Geriatrics, Senior Research
Scientist Regenstrief Institute, Indiana University School of Medicine, USA
47 Small is Beautiful
Nanotechnology for
NICE 21 medical devices
Making the best use of healthcare resources
Jorg Vienken, Professor, BioSciences
Andrew Dillon, Chief Executive, National Institute for Health Fresenius Medical Care, Germany
and Clinical Excellence (NICE), UK
Asian Hospital & Healthcare Management ISSUE-14 2007

CONTENTS
FACILITIES & operations

management
Issue 14 2007
50 Healthcare Design

Editor : Akhil Tandulwadikar
Editorial Team : Prasanthi Potluri
The need for Aala Santhosh Reddy
consumer-driven Sridevi Prekke
research Art Director : M A Hannan
Nicholas J Watkins, Director, Research
Visualiser : N Raju
Cannon Design, USA
Copy Editor : Jagadeesh Napa
Head - Sales : V R Rajeev Kumar
Desperately 54 Sales Manager : Naveed Iqbal
Seeking Safety Project Coordination Team : Sam Smith
Creating integrated surgical/imaging Bhavani Prasad Pasupuleti
Rajkiran Boda
environments that do less harm
Bill Rostenberg, Principal and Director, Research Project Associates : Shadaan Osmani
Anshen+Allen Architects Ifthakhar Mohammed
USA Madhubabu Pasulla
Sankar Kodali
INFORMATION TECHNOLOGY Asian Hospital & Healthcare Management is published by

Ochre Media Pvt. Ltd. in association with Frost & Sullivan
RFID in Healthcare 56
Enabling patient safety
Remko Van der Togt, Consultant, Geodan Mobile Solutions
The Netherlands
EMR in a Large Healthcare Organisation 58

Development and implementation
Where knowledge talks business
Yong Oock Kim, Professor, Department of Plastic &

Chief Executive Officer : Vijay Chintamaneni
Reconstructive Surgery and Director, EMR committee
Yonsei University Healthcare System, Korea Managing Director : Ashok Nair
Applying Path Innovation 62

Ochre Media Private Limited
Seeking revolutionary HIT #608, 6th Floor
Barry P Chaiken, Associate Chief Medical Officer, Bearing Point Saptagiri Towers, Begumpet
and Fellow, HIMSS, USA Hyderabad - 500016
Andhra Pradesh, India
Broadband Medical Network in Asia Pacific 65
Naoki Nakashima, Assistant Professor, Department of Medical Informatics Tel : +91 (0) 40 66655000
Fax : +91 (0) 40 66177633/55
Shuji Shimizu, Chairman, Medical Working Group of Asia-Pacific Advanced
Network (APAN), and Associate Professor, Department of Endoscopic Email: ahhm@ochre-media.com
Diagnostics and Therapeutics
www.asianhhm.com | www.frost.com | www.ochre-media.com
Koji Okamura, Associate Professor, Computing and Communications Center
Kyushu University Hospital, Japan
Subscription Details
Commoditising 67 Print* : 1 year (4 issues) for Rs. 1000 (India) and US$ 75 (Rest of world)
Healthcare IT 2 years (8 issues) for Rs. 1600 (India) and US$ 120 (Rest of world)
The next wave e-Book : 1 year (4 issues) for Rs. 400 (India) and US$ 30 (Rest of world)
2 years (8 issues) for Rs. 650 (India) and US$ 45 (Rest of world)
Werner van Huffel, Health and Social
* Print subscribers are entitled to receive e-Book free of charge for the
Services Industry Strategist, Regional subscription period.
Public Sector Group
To subscribe log on to www.asianhhm.com or use the form on the reverse
Microsoft Asia Pacific, Singapore side of the carrier sheet.
Interview © Ochre Media Private Limited. All rights reserved. No part of this publication
69
may be reproduced, stored in a retrieval system or transmitted in any form or by
any means, electronic, photocopying or otherwise, without prior permission of
RFID in Healthcare the publisher and copyright owner. Whilst every effort has been made to ensure
the accuracy of the information in this publication, the publisher accepts no
Prashant Agrawal, Chief Executive Officer responsibility for errors or omissions.
Orizin Technologies Pvt. Ltd., India The products and services advertised are not endorsed by or connected with the
publisher or its associates. The editorial opinions expressed in this publication
are those of individual authors and not necessarily those of the publisher or of its
associates.
Copies of Asian Hospital & Healthcare Management can be purchased at
the indicated cover prices. For bulk order reprints minimum order required is
500 copies, POA.
Foreword
Healthcare Governance
Time for a revamp
For hospitals across Asia, a transparent and accountable
governance structure is the need of the hour.
C
orporate governance structures across business- At a time when competition in the healthcare sector
es are witnessing a sea change with hierarchies is picking up and the consumer is asking for better care,
and egos being sacrificed for efficiencies. This hospitals cannot afford to continue functioning this
change has been abetted by factors such as globalisation
way. Therefore, the importance of the top management
and growing consumer awareness. Organisations have
in hospitals is going beyond mere administrative
realised the need to change and their leaders are work-
ing towards creating governing structures that recognise activities. The effort to make data available asks for the
the importance of feedback from their frontline staff. The active involvement and participation of each and every
healthcare sector, on the other hand, has been a laggard in employee of the organization. It’s for the governing board
adopting this change. Hospitals continue to follow age- to recognise the importance of having the data and
old practices as governing structures remain top-down create an environment where employees participate
in nature restricting the creation of a transparent and ac- actively in the syndication of data. For this to happen,
countable organisation.
the traditional top-down approach to governance needs to
Hospitals and doctors do a remarkable service to the
be done away with and replaced by a structure that gives
society, they save lives. What this also means is that all the
importance to the patient and not the hierarchy. This, of
possible man-made errors have to be avoided as they can
course, involves a considerable investment of time, effort
prove to be fatal. Medical science has made rapid progress
and money. The final outcome of this effort would, to a
in the last decade. Further, the advent of Information
great extent, depend on how well the management is able
Technology has changed the face of healthcare delivery.
to ‘sell’ the concept to the employees of the organisation.
Unfortunately, this progress has not been accompanied
It makes considerable business sense to the hospitals.
by similar improvements in patient safety. Reporting of
As the medical errors are brought under control, the
important data (such as wrong medication, injury and
quality of care improves. This in turn helps in attracting
infection rates) does not seem to be making it to the ‘top
more number of patients.
priorities’ list of the board. As a result, medical errors go
Of late, some positive signs have emerged. The
largely unnoticed and unaccounted for. This scenario can
number of hospitals in Asia opting for international
be changed only if the governing board takes the initiative.
quality accreditations has increased with most of them
Provided with the right data, the board can take decisions
being private sector hospitals.
that make a huge difference to the healthcare quality and
For hospitals across Asia, a transparent and
patient safety.
accountable governance structure is the need of the hour.
Our cover story this time deals with this very issue.
The importance of this need not be emphasised more in
In the article, Yosef Dlugacz, Chief of Clinical Quality,
an industry where patients trust doctors with their lives.
Education and Research at the Krasnoff Quality Management
Institute, USA, provides valuable insights on the role of
the governing body in creating a feedback mechanism
that results in the right data getting transmitted to the
decision makers. The article brings to fore the importance
of the human factor in the functioning of a hospital and Akhil Tandulwadikar
improving quality outcomes. Editor
H E A L T H C A R E M ana g ement
McHealthcare
Delivering
consumer-driven
healthcare
McDonald’s consumer focus offers some
important lessons for the healthcare providers
to ponder as they are forced to transform into
more consumer-driven organisations.
John Leifer, President

David Grazman, Vice President
CBIZ The Leifer Group, USA
A
s industrialised societies pursue the globe. While each national system can McAloo Tikki Vegetarian burger in India,
solutions for providing cost-ef- be characterised by its own unique context McDonald’s has mastered the art of
fective healthcare services to their and trends, there are several key principles satisfying its local customers. Health
larger and older populations, consumerism that, we believe, define consumer-driven effects of fast food aside, McDonald’s can
is emerging as a new force with the potential healthcare environments. We highlight offer some interesting lessons to health
to reshape the industry and its economics. these basic principles in table 1. providers worldwide.
Whether in the context of a fully public, While consumerism has been a trans- As an economic, social and cultural
fully private or a hybrid healthcare system, formational force in other industries, it has phenomenon, McDonald’s had adapted its
consumerism is now a global phenomenon yet to have the same impact in healthcare, operational and strategic model to every
that, many believe, may be the “holy grail” making the right side of the compari- national culture. To achieve the success it
for achieving greater efficiency and value sion above more of a projection than a has, McDonald’s has managed to stay true
in healthcare, while keeping costs under description. Even though healthcare serv- to some key principles as to how it can best
control. ice provision is so different than other suit the wants and desires of even the most
Media reports and marketing cam- consumer-driven services—not to men- demanding international customers.
paigns touting the potential of healthcare tion exponentially more complex—we be-
consumerism proliferate, but what that lieve that there are key lessons to be learned Predictability and consistency
means for providers—hospitals, in par- from other industries that have weathered McDonald’s success is deeply rooted in
ticular—remains cloudy. With so much at- the challenges of providing consumers ex- its ability to deliver a product with great
tention focussed on mechanisms that em- actly what they want. predictability and consistency, giving
power patients to shoulder greater financial In our search for example, one consumers great confidence in the
responsibility for their care, providers still consumer-driven company boldly McDonald’s brand. Whether a Big Mac
need guidance as to what they can do to shines as an international success story. is purchased in the US or Japan (depending
best cater to changing consumer needs. At McDonald’s, the fast-food behemoth, is the on regional variations), customers have
a minimum, we can realistically expect that envy of companies everywhere. With over come to expect a similar experience. Even
regardless of national boundaries, the con- US$ 21 billion in sales in 2006 and a behind the product, the tight engineer-
sumer-driven hospital of tomorrow is go- US$ 3.5 billion profit, they have much ing process used minimises variations
ing to need to look substantially different to covet. Last year, it served more than and results in tremendous efficiencies. To
from the system-driven hospital of today. 52 million people every day in one of hardwire that predictability, over 275,000
We first want to articulate clearly what its 30,000 restaurants in any of the 119 graduates of McDonalds’ Hamburger
we believe to be the newly emerging para- countries where it operates. Whether University have worked in franchises
digm in healthcare consumerism around serving a McOz burger in Australia, or a worldwide.

Traditional Healthcare Consumer-Driven Healthcare infinitely more complex and difficult to

measure. Healthcare could benefit from more
Patients paid a relatively small share of their Consumer-Driven plans, shifting responsibility
cost of care, if any; government or insurance for paying for care partially onto patients will lead science and far less marketing hype related
covered the rest. to a greater awareness of choices and value. to conveying quality. In a consumer-driven
Patients had little way of accessing data related Technology and increasingly accessible data environment, value cannot be assessed in
to quality of care and thus, assumed that will allow patients to better assess the quality the absence of reliable quality metrics.
hospitals were fairly equal in terms of their care. of care provided by hospitals and physicians.
Patients deferred to their physician regarding Technology, such as the Internet, will Price and value
treatment, partly due to cultural norms, partly allow more informed patients to work in McDonalds’ customers can easily determine,
due to a lack of any means for meaningful collaboration with their doctors in choosing
by looking at value and price, whether they
comparison. appropriate courses of treatment.
want to eat at another restaurant or not.
Patients acquiesced to poor levels of service Patients will demand convenience, service
Pre-packaged meal options, as well as
because there were simply no other choices excellence and high quality care. If they don’t
available. get it, they can choose to go elsewhere. portions of various sizes and prices, allow
Table 1
customers to select exactly what they wish
with a clear sense of the value it offers
What Consumer-Driven Lessons can McDonald’s Teach Healthcare? them.
When arriving at a hospital, few pa-
Key principles Potential lessons for healthcare
tients have any idea about the value of the
Quality Consumers desire predictability and consistency – in all aspects of their
care they receive. True compensation or re-
experience. Consistency is a hallmark of meeting consumer expectations. Though
intuition and innovation are important characteristics to preserve in medicine, imbursement in many systems varies based
there is a pressing need to move towards broader adoption of pathways and upon contractual allowances invisible to
protocols that are predicated upon efficacious and safe standards of care. By patients. Though some insurers and hospi-
adopting “best practices,” providers ,make a major leap forward in assuring
tals have developed small, limited menus
predictability.
with prices, that practice is still rare.
Price and Value Quality must be conveyed at all times to the consumer. Providers are responsible
for not only providing high quality services, but for helping consumers
understand what quality means and how it is measured. Providers must agree Accessibility
upon meaningful metrics for clinical, operational, and service quality, and then In some markets, it seems as if there is a
willingly disclose their performance on such standards. McDonald’s on every street corner. With
Price and Value Understanding price allows consumers to determine value. Providers should 30,000 distribution points around the
strive to make prices as transparent and understandable as possible – not only world (and growing), McDonald’s can of-
to their patients, but also to themselves as well. It will be difficult for providers to
move towards value-based pricing without more sophisticated cost accounting
fer its products to everyone, anytime and
systems that provide insight into the true cost of care at a patient or procedural almost anywhere.
level. The complexity of traditional health-
Accessibility Consumers want more convenient access. Providers should strive to offer care in care precludes the easy distribution of
more accessible (by time of day, place, amenities, etc.) and innovative settings. many services. While some services can
Service In an increasingly commoditised consumer-driven industry, service differentiates be offered in stand-alone ambulatory fa-
one provider from another. Providers need to change consumer’s low expectations cilities, few innovative models exist that
of healthcare by providing excellent and consistent service in a well-executed succeed on the same level. For privately
manner. Such a commitment must be both top-down and bottom-up driven, with
service excellence becoming a core tenet of the organisation’s culture. insured systems, lack of health insurance
also restricts accessibility.
Safety Safety concerns – whether for food or healthcare – are paramount. Safety issues
must be addressed at every point in the value chain. A culture of openness and
blame-free reporting are absolutely required. As with prices, transparency is Service
crucial. McDonald’s customers worldwide expect to
Table 2 be greeted rapidly and politely upon their
arrival. They can quickly place their order
Healthcare is the antithesis of Quality and know it will be delivered promptly. If
McDonalds: its ability to produce stand- McDonald’s has been methodical in devel- there are problems, the manager and staff
ard, replicable outcomes and processes is oping its supply chain to ensure timely and can remedy them immediately.
very limited. In the US, dramatic local access to the right ingredients for its For many patients, service in health-
geographic variations in delivery and products. It has set exceedingly high train- care is an oxymoron. Patients and providers
outcomes have been well documented. ing expectations to ensure that its brand have come to expect hassles, multiple forms,
Physicians, the key health decision mak- standards are understood, honoured and unreasonable wait times, mistakes and
ers in all cultures, have tended to adopt delivered every day. miserable conditions when they seek
pathways and protocols slowly, if at all, The healthcare industry is just be- healthcare services. Many hospitals speak
contributing to vast differences in how care ginning to make some inroads with the language of service; yet fall short when
is delivered. quality indicators, though quality is it comes to delivering it.
Safety the healthcare industry around the world? radiation oncology services in state-of-
McDonald’s has successfully infused its We summarise some of the key lessons in the art facilities designed to meet the
restaurants and suppliers with a culture of the table 2. needs of consumers. US oncology repre-
safety that includes 72 daily safety checks The need for transformational change sents an example of disruptive innovation
per restaurant per day, 2,000 safety and is being heeded by healthcare organisations whereby the market is fundamentally
quality checks in each chicken and beef across the globe, though the pace of change challenged by the emergence of a
supplier’s facilities, and 95 daily checks for seems glacial at times. Among the leading new model of care that resonates
potato providers. In the US, McDonald’s organisations in the United States commit- strongly with the needs and desires of
has a collaborative relationship with USDA ted to such change are: consumers
inspectors—who have unfettered access to • Intermountain HealthCare, Salt Lake
all points of production at all times. City, Utah, which has been a pioneer Summary
Issues of safety violations in health- in the adoption of clinical best prac- As consumerism evolves in each national
care abound around the world. With all its tices, and devotes significant resources market, healthcare providers are going
complexities, the healthcare industry is still to ensuring the quality and safety of its to be required to adapt to the unique
rife with structural barriers to safety and a services. demands and expectations of their pa-
culture of “shame & blame” when it comes • The Mayo Clinic, which has maintained tients and governments. To succeed,
to reporting errors. Too often, episodic a tradition of process standardisation and hospitals must quickly learn from oth-
care models simply do not allow for suf- quality since its very inception. Today, er industries and take action to make
ficient safety monitoring of patients, re- it is a pioneer in the adoption of health themselves as responsive to consumers
sulting in unnecessary infections, costs and information technology—which is as possible. While there is much con-
even deaths. transforming its organisation into a pa- ceptual distance between fast food and
Given McDonald’s unquestionable perless provider of care. healthcare, McDonald’s offers some
success as a global leader in providing • US Oncology, a premier provider of important lessons for providers to ponder
consumers with exactly what they desire, ambulatory oncology services, that as they are forced to transform into more
what lessons might we extrapolate out to integrates diagnostic, medical and consumer-driven organisations.

CoverStory
Transparency in today’s globalised healthcare world has impressed

governance with the necessity of becoming increasingly accountable for
patient safety by introducing quality standards and methods in order to
retain a competitive edge and attract market share.
Patient Safety and Quality
Role of Governance
I
n any complex organisation, it is the compete on an international level
role—and the responsibility—of the and assure the public that their or-
leadership to set standards for per- ganisations provide excellent care.
formance. This responsibility is especially Several of the organisations where
important if healthcare organisations are I consult, are looking to become accred-
to succeed, both clinically and financially. ited as a way to promote standardisation
The governing body, as representatives of of care. Many of the leaders I meet ask for
the community, must support processes education and guidance about how to in-
for patient safety to be monitored and troduce these cultural changes into their
improved, and it must hold the admin- hospitals and implement improvements.
istrative and clinical leadership account- As part of the curriculum in educating
able for good outcomes and quality care. CEOs in China and elsewhere, I instruct
Moreover, globalisation of healthcare them on the role of the governing body,
services and competition for market share and of accountability as a tool to improve
are encouraging standardisation, transpar- organisational performance and change
ency and the use of measures to objectify clinical outcomes. In a recent visit to
the delivery of care. Governing bodies Singapore, I gave a workshop to
can no longer rely on CEOs or medical physicians and nurses on the value of
leadership to provide the impetus for using statistics to improve the quality of
improvement efforts. care and promote a safer environment at
A central myth of healthcare—that the bedside.
doctors should not be questioned—must be Once the governing body commits
reevaluated and exposed as antiquated. To- to its oversight responsibilities, both fi-
day, doctors have to respond to the patients duciary and clinical, I encourage them to
who insist on the best care and to leader- adopt quality management principles and
ship who insists on returning value for ex- methodologies to implement patient safety
penditure. In the US, government agencies improvements. Through measurements of
and private groups are forcing physicians to the specifics of care and through aggregated
document that they are delivering specifi- data reports, governing bodies can learn
cally defined indicators of care for specific to effectively manage the complexities of
patient populations. Further, the myth of clinical care and organisational processes.
the all-knowing doctor is diminishing as Improvements are implemented when
the media highlights the vulnerability of members of the governing Board learn how
patients in the nation’s hospitals. to ask questions of the medical staff, gain
In my experience educating health- experience understanding quality reports,
care leaders in various Asian coun- evaluate how resources should be most
tries, I have been struck not only by the productively spent, and make informed
variation in governance structures but also decisions about improving care. When the
by the lack of clear lines of accountability clinical staff receives strong and effective
for delivering safe, effective and efficient guidance from the governing body, indi-
care. Many of the best healthcare organi- Yosef D Dlugacz vidual agendas collapse and organisational
sations are looking to introduce quality Senior Vice President goals become the yardstick for success.
management infrastructures into their Chief of Clinical Quality Education A strong and unified Board should
institutions and to incorporate evidence- and Research empower the quality management
Krasnoff Quality Management Institute
based medical standards of care in order to department in their organisation to
USA
10 Asian Hospital & Healthcare Management ISSUE-14 2007

CoverStory
Acute Care Quality Indicators develop measures to monitor care, train

staff on how to collect data regarding those
Prior Prior
Current measures, aggregate and analyse the data
INPATIENT Quality Indicators 12-Month 3-Month
Month for trends that reflect opportunities for
Average Average
Volume (Discharges) improvements and best practices, and
develop high level reports to inform the
Discharge ALOS
Board on an ongoing basis about how
Unplanned Readmissions Within 30 Days care is delivered and processes managed.
When leadership actively supports quality
Admissions With Pre-Existing Pressure Injuries (%)
and the use of data to standardise, monitor
Nosocomial Pressure Injury Rate (%) and improve care, staff are compelled to view
Nosocomial Infection Rate (%) care as a complex process managed by a team
that must effectively communicate with
Suspected Drug Reactions
each other rather than use an individualised
Medication Incidents Relative To Discharges (%) and idiosyncratic approach. As quality
data gets collected regularly and reported,
PCD Fall Index (1,000 patient care days less newborns)
ple
am the Board becomes increasingly familiar
Number of CareMaps® Implemented with understanding the processes of care.
Ex
Patients Discharged on CareMaps® They can begin to hold clinicians accoun-

table for errors, gaps in care and adverse
CareMap® Patients Discharged With Variances (%)
events, and begin to develop a proactive
Restraint Rate (%) approach to medical error prevention, thus
Table 1
changing the culture.
Prioritization Matrix (Importance of Governance)

Issue 1
Issue 2
Issue 3
Issue 4
Issue 5
Issue 6
Issue 7
Issue 8
Issue 9
Governance/Board of Trustees (Is it aligned with the Vision)
Governance/Board of Trustees (is it Aligned with the Vision)
Finance (i.e., Cost) / Budget

Inputs
Benchmarking (Is it Used / Recognized by CMS, IHI, JCAHO, DOH)
Inputs Total
Operation (How We Treat Patients/Delivery of Card)
Evidence-Based Medicine (Benchmark for Excellence of Care / Opportunity for Improvement

Process
Is it Measurable
Process Total
Trending in Negative Pattern
Compliance (Is it a Deviation from Practice)

Outcomes
Patient Satisfaction Surveys/Patient Complaints
Malpractice Rates/Insurance Premiums
HMOs/Denials
Outcomes Total
Issue Total
Table 2
w w w . a s i a n h h m . c o m 11
is to ask the people closest to the problem

Communication of Quality Information
for their input about the present process,
potential problems and suggested
solutions. Multidisciplinary task forces
Board of Trustees should be established with a physician
champion as the leader to determine
Executive Committee what processes need to be improved and
establish accountability for those improve-
Committee on Quality ments. Measures then need to be carefully
Nurse Executive System Performance Medical Executive established with appropriate numerators
Committee Improvement Coordinating Group Committee and denominators. If central line infec-
tions are being monitored, the measure
might be defined as the number of patients
who contracted central line infections over
the number of all patients who had cen-
tral lines inserted during a specified period
of time. Once the measure is defined, data
has to be collected, either retrospectively
or concurrently, and reported to various
members of the organisation. The task
force can suggest improvement efforts;
Table 3
perhaps introducing an improved sterilisa-
For example, when cardiac mortal- Not only could the Board monitor tion procedure and then monitor if that
ity was reported as high in one of the census data such as volume, but also pa- improvement has been effective. These
hospitals I work with, the Board charged tient safety indicators such as falls and cultural changes do not happen overnight.
me to discover where the process of care nosocomial pressure injury rates as well as They take time.
was flawed and to develop improvements, proactive safety methods such as the num- Finally, without an established effec-
monitor those improvements for effec- ber of patients on clinical guidelines or tive communication structure, informa-
tiveness and report back to them. It was CareMaps, and the number of near misses tion cannot be used for improvements.
the Board who insisted that processes reported about medication errors. Tables Organisations should establish lines of
be changed, and the Board that of Measures were developed for various communication that go from the front
supported new processes. Working levels of care, such as behavioral health, line staff to the people responsible for
with a multidisciplinary team, consisting ambulatory care, long-term care and the oversight (Table 3).
of clinicians, administrators and quality environment. Through the means of data, Quality management should work
professionals, we were able to decrease the governing board was able to over- with clinicians and administrators to
cardiac surgery mortality and become see care, and ask questions when varia- form performance improvement com-
one of the best cardiac surgery depart- tions were evident. Without quality data, mittees that coordinate information with
ments in the state. The CEO alone could they would have had no means to carry clinical leadership to report to the govern-
not have effected the change, nor could out their responsibility for oversight of ing body. The communication must be
an individual physician. Change required patient care. bidirectional, with members of the Board
aggressive action on the part of the Board, Because the Board had the responsi- interacting with clinicians and front
who took their oversight responsibility bility to evaluate competing areas for im- line staff, asking questions and hearing
seriously. provements, we developed a prioritisation firsthand about problems in the delivery
Once leadership commits to the over- matrix (Table 2) to help them weigh which of care.
sight of patient care, a method has to be improvements were most pressing. Through these processes and with im-
adopted to best communicate information This tool enables members of the proved education to the governing body,
from the bedside to the Board about the Board to make responsible decisions care can be standardised and patient safety
provision of patient care services. Data about how to allocate resources. Once an issues promptly recognised and addressed.
provide an effective communicative tool improvement has been identified as a top By creating an effective governance struc-
to encourage trust between governance priority, steps can be taken to implement ture, the relationship between governance
and clinical leadership. With expert input new processes. and clinicians can be redefined to create
from clinical staff, quality management For example, if the leadership of the improved processes that will enhance
developed a Table Of Measures of quality organisation determines that it is their patient care delivery. Open communica-
indicators about clinical and organisation- priority to reduce the rate of hospital-action will foster cultural change within the
al processes (Table 1) that were regularly quired infections, how can they go about organisation and promote a proactive
reported to the Board. making this happen? One useful method approach to patient safety.

Transparency in Healthcare
Seeing is believing
The growing demand for transparency in healthcare is lifting the veil on this notoriously
murky industry, but achieving transparency is a problematic journey that requires
unprecedented collaboration across sectors within the health industries and adherence to
world-class standards.
the sustainability of national health systems. activities. What’s clear is that transparency
The notion that “seeing is believing” is the is viewed as both a negative and a positive.
R Carter Pate
new mantra of consumer-driven healthcare. Skeptics contend that the health market is
Global and US Managing Partner
Health Industries and Government Without transparency in a consumer-driven unique, and cannot be treated like other
Services healthcare market, confidence in the medi- markets. The time and energy required to
Sandy Lutz cal profession will erode, and market par- publish the usable and credible cost and
Director ticipants will remain vulnerable to competi- quality of every medical procedure is simply
PricewaterhouseCoopers Health tion, corruption and potential collapse. too difficult and not practical.
Research Institute It is no secret that healthcare has lagged In theory, proponents of transparency
USA
other industries in becoming transparent outweigh the skeptics. But, in practice,
or that much of Asia is playing to catch up transparency creates enormous challenges.
on this front. Yet throughout Asia, there are So, we asked a group of health leadership
G
overnment and healthcare leaders mounting public aspirations that the time across health industries how they thought
around the world recognise that has arrived for people to have full access to a transparency health community would
transparency is critical to the sus- the benefits of the modern world, particu- affect their sectors and what they thought
tainability of health systems in the future. larly when it comes to healthcare and medi- they would need to achieve transparency.
The presumption is that when consumers cine. Consumerism now dominates the To create transparency, we believe that
are armed with accurate information and minds of the new Asian middle class, even as the framework must have the following
informed choices, providers will improve it meets resistance from old world traditions features:
the quality of care they deliver, government that have slowed the progress of healthcare • Information about cost and quality that
and other reimbursers can reward quality reform in many parts of the region. is trusted by stakeholders
and efficiency and consumers will assume Achieving transparency is a problem- • Incentives for patients, providers and
a greater role in the management of their atic journey, one that requires cross-sector government or other reimbursers that
own health. collaboration that is unprecedented in even improve the efficiency and effectiveness
The combination of these forces would the most advanced health systems. But best of care
produce higher quality care at less cost—an practices are beginning to emerge. As trans- • Connectivity to disseminate information
imperative for the future as health systems parency starts to define business relation- through interoperable health informa-
falter under of weight of an ageing, obese ships in health, it is important to understand tion systems
and more prosperous population with more the expectations of all stakeholders and to
chronic diseases. anticipate unintended consequences. Information about cost and quality
As part of global research into the Stakeholders often disagree on the de- that is trusted by stakeholders
sustainability of health systems, Pricewa- tails of how data is collected and dissemi- Health systems that have made progress
terhouseCoopers talked to more than 700 nated. Infusing a flood of information on in making health quality data transparent,
health leaders in 27 countries around the the public can cause disruption and mis- have been first to learn that publishing this
world, including government leaders and understanding. Lack of agreement about data poses additional challenges around
policy makers, executives from hospitals the definition of quality or cooperation on embedding quality standards into health
and health networks, private insurers and standards can result in a ballooning num- services, treatments and processes. Each
other business leaders outside the health ber of diverse and potentially unfair quality country’s unique combination of cultural,
industries. More than half told us that they measures. Then there is concern about the political, economic and historic factors
consider transparency of quality and pric- privacy and accuracy of information about shapes its definition of quality. In fact,
ing information to be “very important” to patients or participants in clinical trial the Commonwealth Fund International
Exhibit : The needs and challenges of stakeholders in a transparent community. defined in a pair wise fashion. The prob-
lem with this approach is that what any two
Stakeholder What they need Challenges
sectors might agree on regarding transpar-
Providers • Standard metrics for assessing quality • Unfair quality measures ency either aggravates or threatens another
• Performance-based payments • Loss of patient-physician confidentiality
• Reduced administrative paperwork • Reductions in payments
sector. For example, reimbursers and con-
• More information about the risks and • Increased uncompensated care sumers may agree on certain quality metrics
benefits of drugs • Additional regulations and paperwork
from physicians and hospitals. Yet, the hos-
requirements
pitals may disagree about how “quality” is
Consumers • Cost of an episode of care • Inappropriate disclosure of personal defined.
• Access to provider quality of care information information
• Quality data summarized in layman’s terms • Unaffordable medical care Or, perhaps providers and employ-
• Secure medical records • Complicated medical information ers agree that medical information should
• Cost of medications • Complicated EOBs (explanation of
• Personalised medicine benefits)
be openly shared with each other to aid in
• Risk and benefits of treatments patient compliance initiatives, but patients
may feel this violates their privacy. To move
Govt/ • Standard metrics for assessing provider quality • Disclosure of proprietary discounts
Reimbursers • Patient compliance data • Lack of trust from providers and beyond these collisions of interests, incen-
• Increased consumer involvement in care consumers tives need to be aligned and definitions
decisions
• Reduction in inappropriate medical services standardised across stakeholder groups. To
• Information on overall cost of treatment begin to make progress, the following ques-
• Provider capacity info
tion needs to be answered: “What is the
Pharmaceutical • Patient compliance data • Increased regulations minimum bundle of transparency initiatives
Companies • Adverse event reporting • Increased costs to bring a drug to
• Clinical trends that may impact product use market
that can come together and make the pain
equal so that the various sectors don’t feel
Employers • Metrics for assessing provider quality • Continuing cost increases in providing like they are the target?”
• Range of medical services available healthcare benefits
• Patient compliance data
• Health needs and goals of employees Connectivity to disseminate
• Risks and benefits of specific drugs
• Employee participation in wellness programs
information through interoperable
health information systems
Quality improvements will ultimately rely
Working Group on Quality Indicators example, consumer-directed health plans in on more widespread investments in elec-
found more than 1,000 potential indica- some markets are designed to increase cost- tronic medical records, more effective poli-
tors that could be measured across different sharing that will make consumers more sen- cies governing national standards for health
health systems. sitive to the consumption of medical prod- quality, and greater cross-border standards
Transparency of quality and pricing ucts and services. However, early evidence and information sharing such as develop-
hinges on the availability of accurate, reli- has shown that some patients have delayed ment of a global “network of health net-
able and valid performance measures. Data or avoided getting care due to high price, works”.
is not always what it seems. It needs to be which may result in even higher costs. Asia’s healthcare organisations, particu-
validated if it is to be useful, and much work In designing the incentives that are larly those dealing with both first and third
still needs to be done in this area. The ab- crucial to a transparent community, stake- World issues, are urgently seeking solutions
sence of global health standards is driving holders should consider developing a to temper costs while balancing the need to
many health systems to adopt best prac- therapeutic index for cost-sharing around provide access to safe, quality care. Across
tices in quality improvement used by other certain diseases or treatments. The clinical boundaries, languages and cultures, success-
industries and other countries. term, therapeutic index (also known as the ful initiatives – often involving technologi-
margin of safety), is a comparison of the cal innovation – are occurring, but the best
Incentives for providers amount of a drug that causes the therapeu- practices are only beginning to be shared
Real improvements in the quality of health- tic effect (good) to the amount that causes across geographic and industry boundaries.
care will occur only after incentives are a toxic effect (bad). Consumer healthcare The vision of electronically connect-
properly aligned around creating value and incentives have typically shown a very nar- ed health promises to revolutionise the
performance can be rewarded appropri- row therapeutic index, in other words, the way healthcare is delivered. Better use of
ately. Because patients have been insulated “good” incentive (or therapeutic effect) does technology and interoperable electronic
from the cost of healthcare for generations, not outweigh the “bad” incentive (or toxic networks will:
a key challenge goes beyond transparency effect) to effectively incentivise the consum- • Improve access, equity, quality and
of price and quality information. Patients er to perform a desired behaviour. accountability of care
not only need to understand how the cost A portion of the complexity and disa- • Empower patients through enhanced in-
of healthcare is directly connected to their greement stems from how transparency is teraction with providers
own behaviour, but also how changing their discussed and defined. Many of the govern- • Erase geographical and physical barriers
behaviour helps drive down that cost. For ment-sponsored transparency initiatives are to care
• Accelerate integration, standardisation problems, including data security, miscod- is sought and delivered across national bor-
and knowledge transfer of administrative ing issues attributed to language variations ders. Questions remain unanswered about
and clinical information and lack of broadband capabilities. who is responsible for mandating, monitor-
• Radically transform the way health pro- Creating a digital backbone requires ing and measuring quality standards, what
fessionals learn, train, teach and practice capital, interoperability, standard-setting information technology is needed to sup-
The use of personal health records is and cross-sector collaboration. Thus, imple- port transparency of quality and pricing,
being implemented throughout Asia and menting an e-Health strategy requires ac- and how published quality data affects re-
efforts are being made to consolidate patient tive involvement from government entities ferral and payment for medical services.
information on a common IT platform. and private organisations working in a col- Moving towards a transparent health
Right now, multiple medical records are laborative fashion with one another. Active community requires maintaining focus on
stored in different clinics and hospitals in partnerships are needed among hospitals, the ultimate goal: Packing information
different formats. They are not connected physicians, IT developers and suppliers, for patients around treatments for a given
or consolidated. As a result, when patients and colleges and universities so that they condition and creating information and in-
visit different doctors, they have to have can work together to build the infrastruc- centives that direct providers and patients
tests repeated and scans redone. This adds ture, set industry standards and provide the towards those treatments.
to unnecessary cost. training and research required for success. Following are the recommendations:
Other regions of the world are seeking • Cooperate on efforts to create interop-
interoperability as well. Electronic health Conclusion and recommendations erarable networks for electronic medical
records have been accepted by the European Improving transparency of healthcare is records and clinical systems
Union as a standard to be achieved in all Eu- a priority for health systems around the • Reduce administrative functions that
ropean countries regardless of their funding world, but a complex issue with no easy don’t add value to the transparency con-
model or infrastructure. Most countries are solutions, creating additional challenges for tinuum
seeking to achieve this goal in their own way. healthcare organisations and government. • Focus on information that can be shared
However, advanced information technology These challenges are exacerbated as pay is without compromising competitive
is not the panacea and can create additional tied increasingly to performance and care advantage of stakeholders
OchreDesignLab

What can the Operating Room

Learn from the Cockpit?
Though there are fundamental differences between flying an airliner and operating on the
esophagus, simple airline lessons have a lot to offer.
practising medicine. Some are regulatory. and likely underestimated. Another dif-
Richard C Karl
In most countries, pilots and airline op- ference is the primal motive for the avia-
Surgical Oncologist erations are carefully regulated, inspectedtor: the pilot is the first to the scene of the
and and evaluated by federal agencies. In the accident. In healthcare, only reputations
Chairman United States, most regulation of doctors are damaged if a mistake leads to a death
Department of Surgery
College of Medicine
is done by state medical boards, which or to harm.
University of South Florida are quite variable in their approach to Despite these immutable differences,
USA regulation. Likewise, pilots work for air- there are several aspects of commercial
lines and if a pilot decides not to follow aviation that lend themselves to medical
federal or company policies, he or she is application; some with effort, some readi-
fired. Doctors, on the other hand, are ly. The hard things would involve changes
T
he cascade of interest in patient independent contractors in the United in credentialing and assessment of com-
safety has prompted several ex- States. They are courted by hospitals to petency. Simulators, very advanced in
perienced healthcare providers bring their patients to those hospitals. Inaviation and still quite rudimentary in
to look to other professions for clues as most instances, they have no direct em- medicine, could be used to assess most
to how to be safe in dangerous situations. ployment relationship with a hospital. clinical competencies. There is a lot of
The nuclear power industry, the subma- Disciplining doctors is often a lengthy work to be done in this area, but experts
rine service and commercial aviation all (and litigious) process. reassure me that it can be done.
represent “high reliability” systems that Some differences might be called There are other airline-like things
have posted enviable safety records. Not emotional. When a big jet goes down, the that can be done right now that could
surprisingly, hospitals, insurers, patients headlines reach around the world. Medi- have a profound effect on patient safety.
and doctors have wondered what We could commit right now to
contributions might be made mentoring of new physicians
by these disciplines to patient and surgeons, realistic work
safety. Though there are fundamental hours to avoid fatigue related er-
Because my own interests in differences between flying an airliner ror and emphasis on teamwork
aviation and medicine developed and communication.
alongside each other, I’ve been
and operating on the esophagus, simple Teamwork and communica-
especially fascinated by the simi- airline lessons have a lot to offer. tion are especially fertile areas
larities of and differences between for safety advancement. Human
the two professions. Since com- factors experts long ago recog-
mercial aviation is demonstrably nised what the ancients knew: to
very safe and healthcare is not, what can cal error, in contrast, accounts for one err is human. Teamwork and patterned
we learn from the former to make the lat- death in hospital A, another in hospital B, communication strategies help avoid er-
ter better? Can aviation safety techniques so that no one doctor or administrator is ror, recognise error when it occurs and
be lifted from the airlines and deposited aware, in such a visceral way, of the enor- trap errors before adverse events ensue.
in hospitals with minor tweaking and be mity of the calamity. Yet, it is estimated JACHO (Joint Commission) analyses of
useful? Or is such a notion overly simplis- that 100,000 patients a year die because wrong site operations, adverse post oper-
tic? What is realistic? of medical errors in the United States ative events and other horrors have con-
There are some fundamental dif- alone, the equivalent of several jumbo jet sistently found communication to be the
ferences between flying airliners and crashes a week. Hard to believe, but true, most common cause of mistakes. When
you consider that mistakes not only take tolerated again, until a breaking point Do these things work? In a word, yes.
lives, but cause other types of survivable is reached, when some draconian ac- Studies are beginning to appear in peer
harm (as many as 15 million “incidents tion is triggered. There must be a code reviewed literature that show a decrease in
of harm,” according to the Institute for of conduct that applies to everyone on wrong site operations, fewer equipment
Health Care Improvement), training in the team. Make teamwork a cultural issues, improved efficiencies, decreased
teamwork and communication seems a value held in high regard. This increas- nursing turnover and improved nursing
reasonably inexpensive and efficacious es efficiencies. and physician satisfaction. Though there
way to begin to tackle the patient safety 3. Seize any opportunity to begin train- are fundamental differences between
problem. ing. In some institutions a pilot sur- flying an airliner and operating on the
Here are four common, preventable geon brings the idea forward. In others esophagus, simple airline lessons have a
harms occurring in operating rooms that a dedicated cath lab supervisor sees the lot to offer. That said, and without any
are inflicted on our patients every day: need and urges administration to make disrespect to aviation, it is useful to re-
1. Hypothermia in operative patients: A plans for training. The call for im- member that medicine is more complex,
2 degree Centigrade difference can ac- provement can come from any point in less organised and in many ways, harder.
count for a three-fold increase in surgi- the organisation. Leaders, both clinical These simple tools can decrease chaos and
cal site infection. and administrative, succeed when they make it easier.
2. Glucose control: Moderate hypergly- listen to those “in the trenches.”
cemia (200mg/dl) at any time during 4. Emphasise physicians as leaders. Their
the first post operative day increases role in moving training from the hy-
the risk of a surgical site infection four pothetical to reality is essential. “Push- BOOK Shelf
fold. back” from practitioners is reminiscent
3. Blood transfusion. A gratuitous unit of of airline captain behaviour thirty years
blood increases the risk of nosocomial ago. Yet even the crustiest pilot learned
Competency
infections by a factor of three and in- the value of teamwork when a first offi-
Management
creases the chance of cancer recurrence cer or flight engineer spotted a problem for the
in almost all cancers studied. the captain had overlooked. Data driv- Operating
4. Fluid administration: Restricted fluid en, physicians are especially moved by Room
administration during an operation compelling data that support increased
can significantly decrease complication safety and efficiencies with teamwork/
rates. communication training. Author : Adrianne E Avillion
Each of these harms is easily avoid- 5. Make the training brief, fun, rivet-
Year of Publication: 2006
able if there is good communication ing and logical. Teams are expensive.
Pages: 158
among anesthesia, nursing and surgical Training needn’t take all day. Sobering
staff. It is a simple matter. data detailing the consequences of er-
In the four years of its existence, the ror help motivate altruistic care givers; Description:
Surgical Safety Institute has learned a they come away committed to being Competency Management for the
good deal about teamwork and commu- safer and more efficient. Many teams Operating Room is a complete competency
nication training in a variety of different report improved emotional environ- program created specifically for assessing,
clinical settings. What are the key ingre- ments after team training. Equipment, validating, and documenting the skills
dients for successful application of sim- turnover and handoff frustrations of your OR nurses. This resource has
ple, but very effective, methods in clinical largely disappear. One surgeon said, everything you need to meet and exceed
areas where harm and death are common “This has made operating fun again. the competency requirements of the Joint
threats to patients and staff? I’ve got better relationships now with Commission and other regulatory bodies.
1. Create clear, cohesive, reliable policies nursing and anaesthesia than ever.” Within its pages, you’ll also find many helpful
that track the intent of the safety train- 6. Use tools. White boards, briefing pack- tips and strategies for effectively assessing
ing. If retained, surgical instrument ets, checklists and team observations all and evaluating the training needs of your
policies hold only nursing responsible, make the process intuitive, organised staff. Competency Management for the
then team training that emphasises and even fun. Once teams recognise Operating Room is jam-packed with expert
the involvement of surgeons, nurses the value of these simple techniques advice to help you schedule and organize
and technicians will not be as power- they become enthusiastic; in some cas- competency assessment, understand Joint
ful. Policies and job descriptions need es almost evangelical. Commission expectations, and develop
to have teamwork and communication 7. Support, support, support. Make sure your competency assessment program.
imbedded in their essence. administrative personnel join the phy-
2. Hire for teamwork skills: Deal with sician leadership in making these sim-
For more books, visit Knowledge Bank
disruptive team members. Too often ple, easy techniques important institu- section of www.asianhhm.com
disruptive behaviour is tolerated and tional values.

Communication
Challenges and Opportunities
During Handoffs
Richard M Frankel Orit Karnieli-Miller Amber Welsh
Professor, Medicine and Geriatrics Postdoctoral fellow, Indiana School of Patient Safety fellow
Senior Research Scientist Regenstrief Institute Medicine and Regenstrief Institute Roudebush VAMC
Indiana University School of Medicine USA USA
USA
I
n medical care, a handoff (also known Interest in handoffs has grown steadily
as sign-out or end-of-shift report) re- over the past decade as researchers, hospital
fers to information about a patient administrators, educators and policy mak-
Variations in communication
that is transferred by one professional or a ers have learned that variations in com- during patient handoffs
team to another. “The primary objective of munication during patient handoffs cause cause a significant number
a ‘handoff’ is to provide accurate informa- significant number of errors and “near
tion about a patient’s care, treatment and misses” to occur, leading to adverse out-
of errors and “near misses”
services, current condition and any recent comes and suboptimal care. According to to occur, leading to adverse
or anticipated changes.” The number and the Institute of Medicine (IOM), up to outcomes and sub-optimal
types of handoffs for any given hospitalised 98,000 patients die and another 15 million
patient can vary and may involve physi- are harmed in US hospitals annually due to
care. The research interest in
cians, nurses, pharmacists, transport, and medical errors. Root cause analysis of re- this area has been growing
even food service. ported sentinel events from 1994 to 2004 steadily.
Handoffs are not simply a mechanical reveals that two-thirds of these errors were
means for transmitting and receiving infor- due to communication failures.
mation. In medical care, a handoff requires Another reason for increased interest concerns that the increased number of
that the sender consider a patient’s present in handoffs is related to the adoption of handoffs results in loss of critical informa-
condition and his / her likely future over duty restriction hours by the Accreditation tion and continuity of care.
the next 8-12 hours; likewise, the receiver Council for Graduate Medical Education It is no secret that medical care in the
must comprehend what is being transmit- (ACGME) that has dramatically increased US is fragmented. Often this is reflected
ted and feel confident about the clarity and the number of care transfers that take place in the patient’s experience of care as a se-
reliability of the message. Thus, in addition among resident physicians during a typi- ries of confusing and sometimes conflicting
to sheer information exchange, handoffs cal hospital stay. The increased number of communication exchanges with different
also involve the transfer of rights, duties and handoffs results in a parallel increase in the types of healthcare providers, a situation in
obligations as they relate to the meaning potential for near misses and errors and which “the left hand does not seem to know
and interpretation of communication from worsened quality of care. Residents and what the right hand is doing.” The lack of
one professional to another. attending physicians have expressed integration is also reflected in the fact that
handoffs vary in approach and content as well as through empirical analyses. In a due to a number of factors, including the
across medical specialties, professional roles matched case-control study of inpatient number of patients involved in the handoff,
and sometimes even between shifts on a adverse events, the likelihood of prevent- the complexity and criticality of patients’
single service. Added to the fact that medi- able adverse events was significantly higher conditions, competing demands, time pres-
cine and nursing handoffs typically occur in under the care of a cross-covering physician sures and contextual cues (sights, smells,
parallel; without any cross communication, than under the admitting care team. Simi- sounds) nearby the exchange.
it is little wonder that patients experience larly, patients admitted to the hospital by Recent scholarship based on handoffs
care as discontinuous and fragmented. a cross-covering physician (rather than the across a variety of high reliability organi-
Recognising the importance of improv- primary physician) had longer inpatient sations has produced a set of generalised
ing inpatient handoff processes, the Joint stays and more laboratory tests. In a study handoff strategies that are associated with
Commission on Accreditation of Health- using critical incident and interview tech- improved reliability and outcomes. These
care Organizations (JCAHO) in 2006 niques, Arora et al. linked communication include being face to face, choosing a lo-
implemented a new requirement as part failures in handoffs in a sample of residents cation that is quiet with no interruptions,
of National Patient Safety Goal No. 2, to to adverse events, highlighting problem the use of checklist procedures and “teach
“Improve the effectiveness of communica- areas of missing content or errors in process backs” or “talk backs” (i.e. the receiver of the
tion among caregivers.” Requirement 2E (e.g. no face-to-face communication, illeg- information repeats it), to ensure that the
requires facilities to “implement a stan- ible handwriting). Another study’s findings intention and effect of a message have been
dardised approach to ‘handoff’ communica- indicate that handoffs may lack information heard and understood across an authority
tions, including an opportunity to ask and that could potentially affect patient care, or power gradient. It is only when the con-
respond to questions.” Notably, JCAHO such as anticipated patient events. tent of the message has been repeated that
requirements did not specify how a stan- A recent pilot study conducted by our the action contained in a request typically
dardised approach was to be achieved. In- research team suggests that there are vari- takes place. In medicine, checking for un-
stead each individual healthcare facility or ous social, linguistic and technological fac- derstanding of content, is rare. For example,
health system was left to its own to address tors that might contribute to a near miss or a 1999 study by Braddock and colleagues
the requirements. While this is a good first adverse event during a handoff. These fac- looking at several dimensions of informed
step, it leaves open the question of develop- tors may include: interruptions (e.g. people decision making showed that primary care
ing generalised standards and evaluation talking during a handoff, coming in and physicians and surgeons assessed patient
metrics for handoffs. out of the room); unclear audio-taping or understanding an average of 1.5% of the
In many high reliability industries out- unreadable handwriting; lack of time to lis- time. Recent attempts to improve commu-
side of medicine, such as aerospace, nuclear ten to all the reports (“running off” to the nication using standardised protocols such
power and recombinant DNA research, shift); inaccurate descriptions of (e.g. “the as Situation, Background, Assessment, and
handoffs are critical and mistakes can be patient is listed as DNR and he’s not,”); Recommendation (SBAR) and systematic
fatal. In these industries, handoff skills are lack of information provided, omitted in- training have shown promising results in
formally taught and practised repetitively, formation; gaps between rules and regula- physician and nurse handoffs.
often using simulation and other educa- tions and the actual handling of the handoff Handoff research in medicine is in its
tional techniques to optimise precision and (e.g. listening to the handoff and only then infancy. There is a need to better understand
anticipate errors. Research in these indus- reading the forms without the opportunity the range of ways that handoffs occur within
tries has shown that there are structured to ask clarification questions); second order and across professional roles. As well, there
communication techniques that increase re- handoffs (e.g. charge nurse summarises the is a need to incorporate what we know from
liability and reduce the likelihood of misun- patient’s report); and various behaviours other high reliability organisations and apply
derstanding and error. Unfortunately, these that might negatively affect the ability to them to medical care. Given the complexity
principles have not been transferred into listen and absorb the information (e.g. not of healthcare, some may translate more eas-
medicine to any great degree. A recent study writing down information, eating, having ily than others. Research suggests that there
of handoffs that included a national survey parallel conversations). is a pressing need for better education in
of medical schools found that a mere 8% A further complexity in handoffs is the medicine, nursing and pharmacy about how
teach the handoff as formal part of the cur- rapid spread of electronic medical records to conduct high reliability handoffs. Con-
riculum. This leaves students to observe and and the use of computer based tools. While tinued fragmentation of care can only lead
learn from those above them in the medical these tools provide greater flexibility and to increased risk of adverse events and “near
hierarchy. If residents and attending physi- access to data necessary for effective care, misses”. Finally, the impact of the electronic
cians perform handoffs poorly, risky and they also potentially reduce the amount of medical record and information technology
unreliable habits of practice may be trans- face-to-face contact time used to conduct on handoffs deserves greater study. There will
mitted through the “informal” or “hidden” handoffs, a feature recognised as critical undoubtedly be increased costs associated
curriculum of medicine from one cohort of for effective handoffs in virtually all high- with improving the reliability of transfers of
students to the next. reliability industries. Moreover, the face-to- medical care. Ultimately, the question is not
The haphazard nature of inpatient face conversation during handoffs is highly whether we can afford to underwrite these
handoffs has been reported in case studies complex and nuanced. This complexity is costs but whether we can afford not to.

NICE
Making the best use of
healthcare resources
Several challenges ahead

for the National Institute
for Health and Clinical
Excellence (NICE) in
providing national guidance
on the promotion of good
health and the prevention
and treatment of ill health.
Andrew Dillon
Chief Executive
National Institute for Health and Clinical
Excellence (NICE)
UK
A
long with the expected complexi- cutting costs and nothing more. But this well-resourced guidance that informs
ties of working in and on behalf of is not a marriage of political convenience, healthcare professionals and the public
a rapidly changing health system, and anyone who was familiar with the of the best way in which to improve and
it has been an interesting year in the evolu- work of NICE and the HDA will see huge protect health.
tion of National Institute for Health and potential benefits from the merger.
Clinical Excellence’s (NICE) work pro- How does NICE approach
gramme. The NHS is constantly striving Transition economic evaluation?
to make tactical and strategic alterations The role of the new organisation is to pro- Decisions about the total resources avail-
to its structure in order to adapt and to duce guidance for health professionals, pa- able for healthcare are the responsibility of
operate as effectively and efficiently as pos- tients and the wider public in three areas parliament and inevitably compete with
sible, and the organisations that exist to of health: other demands such as education, defence
support and advise it need to do the same. Public health – guidance on the promo- and transport. Within the allocations
An important change took place in 2005 tion of good health and the prevention made by parliament, the resources for the
that saw the core functions of the Health of ill health for those working in the NHS are finite, and the use of cost-inef-
Development Agency (HDA) transferred NHS, local authorities and the wider fective, or less cost-effective, interventions
to the National Institute for Clinical public and voluntary sector. in one area of practice will deny the avail-
Excellence, to form a new organisation: Health technologies – guidance on the ability of more cost-effective interventions
the National Institute for Health and use of new and existing medicines, treat- in another.
Clinical Excellence (which will retain the ments and procedures within the NHS. The Institute’s preferred approach to
abbreviation NICE). Clinical practice – guidance on the ap- the economic evaluation of clinical inter-
The decision to merge NICE and the propriate treatment and care of people ventions is cost–utility analysis. The prin-
HDA, taken as part of the government’s with specific diseases and conditions cipal measure of health outcome adopted
arms-length bodies review, has been seen within the NHS. by the Institute is the Quality-Adjusted Life
by some as controversial, principally due to Across all three programmes for work, Year (QALY). This embodies the important
the predictable accusation that it is about NICE’s task is to produce intelligent and social value judgement that to count only
gains in life expectancy, without consider- How will NICE fit into the public implementation of technology appraisals
ing the quality of the additional life years, health sector? guidance and interventional procedures
omits important dimensions of human The audiences for the new public health guidance is a core standard, whereas the
welfare. Value judgements embodied in guidance products extend beyond the NHS implementation of other types of NICE
health-related quality-of-life measures can to local government and education, the guidance is a developmental standard.
be reasonably captured in terms of physical public utilities, the private and voluntary The recent introduction of the Health-
mobility, ability to self-care, ability to carry sectors. Audiences also include a range of care Commission’s Annual Health Check
out activities of daily living, absence of pain central government departments and their should help ensure NICE guidance is
and discomfort, and absence of anxiety delivery arms with responsibility for taxa- implemented more quickly throughout
and depression. QALYs are underpinned tion, benefits, roads, transport, housing, the NHS. The Annual Health Check will
by an extensive body of empirical evidence criminal justice and other aspects of servic- require NHS bodies to declare whether
and have been shown to be appropriate for es that contribute to the health of the pub- they comply with the Department’s stan-
a range of conditions, including mental lic. NICE guidance will support evidence- dards, which includes compliance with
health. based decision-making by public health NICE guidance. The audits carried out in
The use of cost–utility analysis in re- physicians, medical and dental general line with The Annual Health Check will
source allocation has aroused a substantial practitioners, nurses, community practi- explore how new guidance from NICE
debate. Charges of discrimination against tioners, other NHS staff, local authority is being managed and introduced within
children, elderly and disabled people, and employees, employees of public utilities, trusts. Assessing the implementation
people who are terminally ill, have led teachers and others working in relevant of NICE guidance is a high priority for
some to conclude that the use of QALYs fields. the Healthcare Commission in its role of
leads to impermissible trade-offs in set- Examples of recent public health guid- encouraging improvement in the provi-
ting priorities. Nevertheless, most bio- ance include interventions on smoking sion, safety and quality of patient care.
ethicists and political philosophers are cessation and physical activity, as well as a
generally prepared to accept cost–utility clinical guideline on the prevention, iden- Challenges for the future
analyses provided they are used to inform, tification, assessment and management of Due to the sensitive nature of our work,
rather than direct, decisions about set- overweight and obesity in adults and chil- NICE is rarely out of the headlines. The
ting priorities, and that other consider- dren1. Public health programme guidance quid pro quo of inclusiveness and consul-
ations are available to constrain morally is also being developed for primary care tation means that NICE guidance often
offensive trade-offs. The Institute’s own and employers on the management of takes longer to produce than stakeholders
position is that while it endorses the use long-term sickness and incapacity2 and on would like. We are however acutely aware
of cost–utility analysis in the economic personal, social and health education focus- of this, and have responded accordingly
evaluation of particular interventions, sing on sexual health and alcohol3. with the aforementioned STA process.
such information is a necessary, but not We have also been flexible in terms of up-
sufficient, basis for decision-making. Its Implementing NICE guidance dating recently published guidance where
advisory bodies have discretion, informed throughout the NHS new evidence has emerged. This was seen
by advice from the Institute, on how to The Department of Health document in our clinical guideline on Hypertension,
take the outcome of economic assess- Standards for Better Health published where the subsequent emergence of the
ments into account in formulating their in 2004 set core and developmental highly significant ASCOT trial findings
recommendations. standards for NHS organisations. The resulted in an amended version of our
guideline being issued before the official
review date.
We are also continuing to provide
support to the NHS as it applies our
guidance. Our implementation support
programme now offers a range of tools and
resources for most of the guidance at the
time of, or soon after, its publication. Our
aim is to do everything we can to make
sure that those whom our guidance is
intended to benefit are able to do so.
1. More details of which can be found on the NICE

website at http://www.nice.org.uk/guidance/CG43
2. http://guidance.nice.org.uk/page
aspx?o=350209&c=296726
3. http://guidance.nice.org.uk/page
aspx?o=350208&c=296726

M edical sciences
Treating Lung Cancer

Immunotherapeutic
strategies
New treatment modalities such as immunotherapeutic

strategies may help improve the currently poor prognosis
and outcome of patients suffering from lung cancer.
However, thus far, lung cancer has not been considered an
immune-sensitive malignancy. Now, there is an increasing
evidence that specific humeral and cellular anti-tumour
immune responses can be evoked.
been shown to be overexpressed in many

Dominik Rüttinger solid malignancies where the overexpression
Head has been associated with a more aggressive
Laboratory of Clinical and Experimental course of disease and poor survival. C-erb
Tumor Immunology
B-1 and c-erb B-2 are the two growth recep-
Department of Surgery
Grosshadern Medical Center tor families that have been studied most ex-
Ludwig-Maximilians-University Munich tensively. C-erb B-1 is better known under
Germany the name HER1 or Epithelial Growth Fac-
tor Receptor (EGFR). HER2 is the more
common name for c-erb B-2.
L
ung cancer is the deadliest cancer in Cell Lung Cancer (NSCLC) accounts for Anti-EGFR (anti-c-erb B-1) monoclonal
the world. In 2005, in the US alone, approximately 80% of all lung cancers, the antibodies
there were an estimated 163,510 focus is mainly set on immunotherapy of Cetuximab (Erbitux®), a chimeric human:
deaths in patients suffering from lung can- NSCLC. murine form of the original mAB 225, has
cer, including 15,000 to 20,000 “never demonstrated safety and was well tolerated
smokers”. These numbers clearly demon- Antibody-based immunotherapy in early phase clinical trials, but low patient
strate that despite progress in the treatment Today, at least 12 monoclonal antibodies numbers currently do not allow for final as-
of this disease over the past two decades, (mAB) have received FDA approval and sessment of its therapeutic efficacy in lung
there are still few long-term survivors: only over 400 others are being tested in clini- cancer. A 28% partial response rate and 17%
about 10% of all patients will ever be cured cal trials. In lung cancer, a primary focus of patients with stable disease were observed
of this devastating disease. was put on mABs targeting the Epider- in a Phase II trial with combination of cetux-
Given the modest effect and consider- mal Growth Factor Receptor (EGFR) and imab and docetaxel which exceeds response
able toxicity of current standard treatment the Vascular Endothelial Growth Factor rates usually seen with docetaxel alone. In
(surgery, chemotherapy, radiation thera- (VEGF). The most advanced in devel- another phase II trial patients with recurrent
py), there is clearly a need for novel treat- opment are the anti-EGFR mAB cetux- or progressive NSCLC were treated with
ment options. Currently, a wide variety of imab (Erbitux®) and the anti-VEGF mAB cetuximab after receiving at least one prior
immunotherapeutic agents are being tested bevacizumab (Avastin®). chemotherapy regimen. The response rate for
in lung cancer. Antibodies targeting growth factors all patients (n = 66) was 4.5% and the stable
Here, we review strategies based on the To block growth factors and their receptors disease rate was 30.3%.
humeral and cellular immune system that seems an obvious strategy in fighting cancer The median time to progression for
are already in clinical use or well progressed because they are known to augment tumour all patients was 2.3 months and median
in early clinical trials. Because Non-Small cell proliferation and invasion and have survival time was 8.9 months. The authors
M edical sciences
of this study concluded that, although the Anti-HER2 (anti-c-erb B-2) monoclonal bevacizumab alone or in combination
response rate with single-agent cetuximab antibodies with chemotherapy in patients with meta-
in this heavily pretreated patient population Trastuzumab (Herceptin®), a humanised static NSCLC revealed promising results.
with advanced NSCLC was only 4.5%, the monoclonal antibody that targets the Other studies investigated the use of beva-
disease control rates and overall survival HER2 receptor, has been approved for cizumab, for e.g., in combination with the
seemed comparable to that of pemetrexed, metastatic breast cancer. However, to date, EGFR-tyrosine kinase inhibitor erlotinib
docetaxel and erlotinib in similar groups of it failed to demonstrate clinical efficacy in (Tarceva®) or as combination therapy with
patients. More Phase I/II clinical trials have patients suffering from lung cancer. Only paclitaxel and carboplatin in the neoadju-
been conducted on the use of cetuximab in few authors suggest further investigation of vant setting. In the largest trial evaluating
combination with systemic chemotherapy trastuzumab in HER2-positive lung cancer. bevacizumab, 878 patients with recurrent
and / or radiation therapy confirming not In contrast, pertuzumab (2C4), a mAB de- or advanced NSCLC (stages IIIB and IV)
only the low toxicity but also the clinical signed to inhibit the dimerisation of HER2 were included. The median survival was
response rates. with EGFR and other HER tyrosine kinases 12.3 months in the group assigned to che-
Grade 3 toxicities associated with the and, therefore, being independent of HER2 motherapy plus bevacizumab, as compared
use of cetuximab were fatigue, infections overexpression is currently under evaluation with 10.3 months in the chemotherapy-
and papulopustular rash. Development of in NSCLC in early phase clinical trials. alone group. The median progression-free
the rash, usually located on the face and Monoclonal antibodies against other growth survival in the two groups was 6.2 and 4.5
upper torso, has been related to a clinical factors months, respectively, with corresponding
response and has been suggested to po- Other factors relevant for tumour cell response rates of 35% and 15%. Rates of
tentially serve as a surrogate marker for proliferation, such as the intercellular clinically significant bleeding were 4.4%
cetuximab activity. Other anti-EGFR adhesion molecule-1 (ICAM-1), have and 0.7%, respectively.
mABs currently in development include been identified as targets for mABs. Of Other antibody-based immunotherapeutic
panitumumab (ABX-EGF), matuzumab these, bevacizumab (Avastin®), which tar- approaches
(EMD 72000), pertuzumab (2C4) and gets the Vascular Endothelial Growth In Small-Cell Lung Cancer (SCLC),
MDX214. Early phase clinical trials with Factor (VEGF) recently gained approval an anti-idiotype vaccine targeting the
these agents in patients with lung cancer are for the treatment of colorectal ganglioside GD3 (BEC2) has been evalu-
currently ongoing with results pending. cancer. A phase II clinical trial using ated. The European Organization for
Figure 1. Therapeutic vaccination in lung cancer. Patients are vaccinated with formulations of tumour antigens (whole tumour cells, proteins,
peptides, etc.), mostly subcutaneously or intradermally (1). Antigens are then taken up by antigen-presenting cells (e.g. dendritic cells),
transported to the draining lymph nodes and presented to the immune system (2). Antigen (tumour)-specific T lymphocytes traffic to the
tumour site (3) and elicit their anti-tumour activity (4).

M edical sciences
Monoclonal antibodies and tyrosine kinase inhibitors in clinical development for lung cancer GVAX®
The genetic modification of autologous tu-
Agent Target Stage of development
mour cells to secrete immunomodulatory
Monoclonal antibodies
cytokines has been shown to induce antitu-
Cetuximab (Erbitux®) EGFR III
mour immunity in a number of preclinical
Panitumumab (ABX-EGF) EGFR II models. Of these cytokines, GM-CSF has
Matuzumab (EMD 72000) EGFR II demonstrated the greatest induction of an-
Pertuzumab (2C4) EGFR-ErbB2 heterodimerization II titumour immunity. Two early-phase clini-
MDX214 EGFR II
cal trials using GM-CSF-secreting, autolo-
gous tumour cells (GVAX®) in patients with
Trastuzumab HER2 (ErbB2) I/II
NSCLC have revealed encouraging prelimi-
Bevacizumab (Avastin®) VEGF III nary results. Salgia and coworkers reported
Epithelial-cell derived on safety and feasibility of this approach
KS1/4-methotrexate I
carcinoma antigen in 33 advanced NSCLC patients with the
N901-blocked ricin NCAM (CD56) I most common toxicities being local injec-
SGN-15 (-doxorubicin) Lewis Y antigen II tion site reactions and flu-like symptoms. A
Tyrosine kinase inhibitors (TKI) mixed response in one patient and long re-
Erlotinib (Tarceva®) EGFR-TK III
currence-free intervals in two other patients
following isolated metasectomy were ob-
Gefitinib (Iressa®) EGFR-TK III
served. In another phase I/II trial using the
Lapatinib (GW572016) EGFR/ErbB2-TK II GVAX® platform, autologous tumour cells
Canertinib (CI-1033) EGFR/ErbB2/ErbB3-TK II were transduced with GM-CSF through an
HKI272 EGFR/ErbB2-TK I adenoviral vector (Ad-GM) and adminis-
ZD6474 EGFR/VEGFR-2-TK II tered as a vaccine. 78% of patients devel-
oped antibody reactivity against allogeneic
AEE788 EGFR/VEGFR-2-TK II
NSCLC cell lines. Three durable complete
Table 1
responses were observed.
Research and Treatment of Cancer Table 1 lists antibodies and tyrosine MUC1 vaccines
(EORTC) recently published data from kinase inhibitors currently under clinical Mucin-1 (MUC1) is expressed on the cell
a phase III trial using BEC2 in combina- investigation for lung cancer. surface of many common adenocarcino-
tion with induction chemoradiotherapy in mas, including lung cancer. Because of its
limited stage SCLC. A total of 515 patients Therapeutic lung cancer vaccines involvement in cell-cell interaction between
were randomly assigned to receive five In contrast to the prophylactic vaccination malignant and endothelial cells, anti-MUC1
vaccinations of BEC2 (2.5 mg)/BCG vac- against infectious disease or cancers associ- strategies may be useful in preventing meta-
cine or follow-up. There was no improve- ated with viral infection (cervical cancer, he- static spread of tumour cells in addition to
ment in survival, progression-free sur- patocellular carcinoma), for cancer patients their direct anti-tumour effect. A phase I
vival, or quality of life in the vaccination the only relevant vaccination strategy must study using a modified vaccinia virus (An-
arm. Among vaccinated patients, a trend be therapeutic. Generally speaking, cancer kara) expressing human MUC1, which also
toward prolonged survival was observed vaccines incorporate a source of tumour an- contains a coding sequence for human IL-
in those who developed a humeral tigens combined with some type of “adju- 2 (TG4010), revealed a safe toxicity profile
response. vant” to make these tumour antigens visible and some clinical activity. The phase II trial is
To increase their cytocidal potency, to the immune system. Sources of tumour- currently underway as a multicentre study.
mABs are being linked to cytocidal agents, associated antigens include whole autolo- MUC1 has also been targeted in another
such as toxins, chemotherapeutic drugs or gous or allogeneic tumour cells, defined trial of patients with NSCLC using the vac-
radionuclides. Approved for clinical use proteins, or specific peptide epitopes (see cine L-BLP25 (Stimuvax®). A multicentre
are, for e.g., gemtuzumab ozogamicin (My- Figure 1). Most likely due to the heteroge- phase IIB study investigating the vaccine in
lotarg®), which links the toxin calicheami- neous histology of lung cancers, the relevant NSCLC patients' stages IIIB and IV has re-
cin to a CD33-specific antibody for use immunologically dominant antigens remain cently been updated with promising results
in the treatment of myelogenous leuke- unknown. Therefore, the use of autologous for safety and clinical effectiveness in the first
mia and ibritumomab tiuxetan (Zevalin®), tumour cells might be especially suitable for publication. All patients had shown stable dis-
which links 90Y to a CD20-specific mAB. vaccination strategies in lung cancer, because ease or a clinical response following standard
To date, the available data on compa- no prior knowledge of specific tumour anti- first-line chemotherapy and were then vac-
rable antibodies for the treatment of lung gens is necessary and the induced immunity cinated with Stimuvax or received best sup-
cancer is, however, very limited and very may not be confined to a single, specific portive care alone. Although the overall sur-
few reports on clinical applications are antigen that could be downregulated by vival did not reach statistical significance, the
available. the tumour. survival in patients with stage IIIB
M edical sciences
Therapeutic lung cancer vaccines in clinical development

Phase Vaccine No. of patients1 Best response2 Reference
Autologous/Allogeneic tumor cells

I GVAX® 34 SD in 5 patients Salgia et al. [26]
I GVAX® 43 CR in 3 patients Nemunaitis et al. [27]
I B7.1 (CD80) 19 PR in 1, SD in 5 patients Raez et al. [36]
I (1,3)-galactosyl-transferase 7 SD in 4 patients Morris et al. [41]
I CTX+GM-CSF 4 Under evaluation Rüttinger et al. [46]
II Belagenpumatucel-L 75 PR in 15% of patients with stage IIIB/IV disease Nemunaitis et al. [39]
Autologous/Allogeneic tumor cells
I MUC1 77 SD in 4 patients Palmer et al. [29]
IIB MUC1 88 sign. advantage for stage IIIB (locoregional) Butts et al. [30]
(Phase III ongoing) ALVAC-CEA/B7.1 3 No clinical response in phase I Horig et al. [42]
I/II WT1 10 Decreased tumor markers in 3 patients Oka et al. [43]
I HER-2/neu 1 No response reported Salazar et al. [44]
I Telomerase (GV1001/HR2822) 26 CR in 1 patient, Immunol. response in 13 patients Brunsvig et al. [55]
I/II MAGE-3 17 No response reported Atanackovic et al. [32]
II MAGE-A3 122 Advantage for stage II (adjuvant) Halmos et al. [33]
II (Phase III ongoing) EGF 40 Seroconversion in 90% of pat., SD in 12 patients Gonzalez et al. [40]
Dendritic cells
I DC rF-CEA(6D)-TRICOM 3 Increase in CEA-specific T cells Morse et al. [35]
II I 16 Antigen-spec. response in 6 patients Hirschowitz et al. [34]
1 Number of lung cancer patients on trial. 2 Clinical or immunological responses. Table 2
(locoregional disease) improved at three years first cohort (no adjuvant), only one pa- Summary and conclusion
compared to stage IIIB patients with malig- tient showed a CD4+ T cell response. In For long, lung cancer was not considered
nant pleural effusion and stage IV patients contrast, 4 patients out of the second co- an immune-sensitive malignancy. With
with 48.6% and 26.7%, respectively. An in- hort (MAGE-3 plus adjuvant) developed a insufficient knowledge of relevant tumour
ternational, randomised, multicentre phase CD4+ T cell responses against the MAGE- antigens, lung cancer immunotherapy lags
III trial for unresectable stage III NSCLC 3.DP4-peptide. Based on these results, a behind similar efforts in melanoma, renal
patients with stable disease or better follow- multinational phase II trial investigating cell and prostate cancer. However, there
ing first-line chemoradiation has been initi- the therapeutic efficacy of the MAGE-3 is increasing evidence that NSCLC and
ated and the first patient has entered the trial vaccine in patients with resected MAGE-3- SCLC can evoke specific humeral and
in the US. positive stage IB/II NSCLC was initiated cellular anti-tumour immune responses.
Recombinant MAGE-A3 protein vaccine and recently completed. In this placebo- With increasing knowledge about the
Another protein vaccination strategy aims controlled study, 122 early-stage patients link between the induced immune response
at the melanoma-associated antigen E-3 (MAGE-3-positive NSCLC) where vac- and a resulting objective clinical response,
(MAGE-3), which is expressed in about cinated five times at three-week intervals. targeted agents may hold great promise in
30% - 50% of lung cancers depending on Preliminary analyses presented at the 2006 sequence with other (adjuvant) anti-tu-
stage and histological subtype and may be ASCO meeting revealed a 33% disease-free mour therapeutics. Obviously, not all of
associated with poor prognosis. First re- survival improvement for the resected and the immunotherapeutic approaches in the
sults reporting the successful induction of vaccinated patients. No significant tox- treatment of lung cancer can be mentioned
humeral and cellular immune responses in icities were observed. A large multicentre in this review, e.g. adoptive cell transfer,
patients with NSCLC following vaccina- phase III study is currently being initiated immuno-gene therapy, inducers of
tion with MAGE-3 with and without adju- based on these results. apoptosis, certain signal transduction
vant chemotherapy have been published in Other vaccination strategies inhibitors and others have not found
2004. Seventeen patients were enrolled fol- More lung cancer vaccines are currently their way into later clinical development
lowing surgical resection with no evidence being tested, but review of all strategies and, therefore, weren’t the focus of this
of disease. Nine patients received 300µg in clinical development would go be- review.
of the MAGE-3 protein alone, whereas 8 yond the scope. Table 2 lists therapeutic
Acknowledgement
patients were treated with MAGE-3 com- lung cancer vaccines currently in clinical This work was supported by the Chiles Foundation,
bined with the adjuvant AS02B. In the development. Portland, Oregon, USA, and the Walter-Schulz-
Foundation, Munich, Germany.
M edical sciences
e
ie ics
nc
Sc th
in E
action in question, we
express no proposition
h in capable of being either

true or false. To be sure, even
expressivists can make sense of
ut th
D
the word ‘true’, when used in ethical

contexts. When, according to the expres-
iff
Tr u
sivist, I say that it is true that it is wrong to

Tr
er
torture innocent children just for the fun of

it, this is merely a way of saying that it is
en
wrong to torture innocent children just for

the fun of it; and to say this, according to
the expressivist, is not to express any propo-
I
t?
s truth in sition, but merely to express an attitude.

ethics dif- But this means that, even if the expressivist
ferent from has access to the word ‘true’ in ethical con-
Torbjörn Tännsjö
truth in science? A way of texts, the expressivist, denying that there are
Professor and Chair
understanding the question is moral propositions, must deny that there
Practical Philosophy this: Is the notion of truth in eth- are truths (true propositions) in ethics. I
Stockholm University ics different from the notion of truth disagree. I believe that, when we say that it
Sweden in science? The answer to the question is is wrong to torture innocent children just
then straightforward: no. In my opinion, for the fun of it, we do express a proposition
shared by many but not all thinkers, there capable of being true or false. As a matter of
The notion of truth is same in is just one notion of truth, and it is the fact, I believe that this proposition is true.
ethics and science. However, same in all fields. In saying that it is true And I take it to be true (or false, if it hap-
that there is a table in front of me, that it pens to be false), independently of my con-
the data in science and ethics is true that 7+5=12, or that it is true that ceptualisation or thinking. But this is not
are different. In science one should not torture innocent children the place to argue the case. I will just take
we rely on observation, in just for fun, we are using the same notion this ‘realistic’ understanding of ethics for
of truth. However, this notion is a ‘thin’ or granted. This means that I will both make
ethics we rely on considered ‘deflationary’ one; it doesn’t mean much. the semantic assumption that when using
moral intuitions. There is For example, if I say that there is a table in moral language we express genuine propo-
little agreement about when front of me, and then goes on to say that it sitions capable of being true and false, and
is true that there is a table in front of me, the ontological assumption that some ethi-
we should trust our ethical the further implicature may be that I am cal propositions are true, i.e. I will assume
intuitions. It is remarkable, certain. However, I add no information. that there are ethical facts. This allows me
however, that neuroscience But are there any truths in ethics? The to ponder a further, epistemic, question: can
answer to this question is not straightfor- we know the truth in ethics? If so, how do
and psychology has recently ward. Many people (expressivists) believe we gain ethical knowledge? Are the methods
shed new light on how our that when we say that an action is wrong, we use similar to, or different from, the ones
moral intuitions arise. we merely express a con attitude towards the we use in science?
M edical sciences
Knowledge opt for one common answer, without argu- that our adherence to scientific methods
Just as we asked whether truth is different ing that it is the right, or best one: A person, leads us closer to the truth.
in ethics from science, we can ask the same S, is justified in the belief that p if, and only Once again, I see little difference here
thing about knowledge. Is knowledge in if, p coheres with the rest of his beliefs. This between ethics and science.
ethics different from knowledge in science? goes for ethics just as well as for science.
Once again I am prepared to claim that the What I just said is not only a bit dog- Evidence
notion of knowledge is the same. What matic, but it is also simplistic. However, I Some of our justified beliefs are such that we
does it mean, then, for a person, S, to know will not go into detail here. I will only note have no evidence for them. Observational
that p? According to received wisdom, dat- that the notion of coherence employed in beliefs are typically of this kind. I am justi-
ing back to Plato’s dialogue Theaetetus, it the present context is a bit special. Coher- fied in my belief that there is a table in front
means roughly that three conditions are sat- ence is not merely a matter of logical consis- of me. If asked for evidence to the effect that
isfied: (i) S believes that p, (ii) it is true that tency, but also a matter of explanatory rela- there is a table in front of me I am at a loss.
p, and (iii) S is justified in the belief that tions between propositions. All this means I see that there is a table in front of me, pe-
p. Some complications with this definition that justification is a matter of degree, the riod. It is not that my seeing the table gives
have been noted by Russell and Gettier, but more closely connected your beliefs are, the me evidence for the proposition that the
we need not bother about them in the pres- stronger is your justification. We can put table is there. In a sense one could say that it
ent context. this in terms of what must be given up, if does; I could say that I seem to see a table in
Is there knowledge in ethics? I believe you jettison a particular belief. The more front of me, a table being in front of me is
there is. This means that I believe we have other beliefs you have to give up, when you the best explanation why I do seem to see it,
moral beliefs, that some of them are true, give up on p, the better is your justification and hence the fact that I seem to see it is evi-
and that we are justified in having them. for p, according to this notion of justifica- dence for its presence. However, I need no
What does it mean, then to be ‘justified’ tion. evidence for this proposition so I don’t take
in a belief? Plato found no satisfactory an- It should be noted that justification is my seeing the table as evidence for its pres-
swer to this question. Philosophers disagree. different from truth. You may be justified in ence. How could I? How do I know that I
Once again I will be a bit dogmatic and just holding false beliefs. Our hope is, however, see a table in front of me? Am I more certain
OchreDesignLab

M edical sciences
about my seemingly seeing a table than of a ing in the universe is maximised. The fact The trolley cases
table being there? I think not. that an act is an act of intentional and active If we want to put utilitarianism and the
This does not mean that my observa- killing of an innocent human being (mur- sanctity of life doctrine to a crucial test, then
tion of the table is incorrigible, however. I der), if it is, makes it wrong, irrespective of we have to turn to thought experiments.
may learn that a psychologist is now and its consequences. The reason that we must resort to thought
then making fun of my philosophy lectures How should we go about if we want experiments and not real life cases, is that it
and me by cleverly projecting a hologram to test these and other ethical theories? is impossible to form any definite and re-
in front of me, just to get a chance to mock Some philosophers, of a rationalist bent, liable moral intuitions with respect to real
me, when I say that I am certain that there is have thought that morality can be derived cases. An action can be wrong, according to
a table in front of me. If I do learn this, then from reason itself, i.e. they have believed both theories, because it does not maximise
my justification in the belief that there is a that, once we understand each moral theory the sum-total of well-being in the universe.
table in front of me is lost (undermined). thoroughly and clearly, we can simply grasp But we cannot know for sure about any ac-
Furthermore, if I try to touch the table and which one is true. Few stick to this belief tion whether it maximises the sum-total of
find that my fingers run smoothly through now-a-days, however, and, I think, wisely well-being in the universe. We can certainly
it, then I have to give up my belief that there so. When we assess putative moral theories, not observe this. Furthermore, according
is a table in front of me. I now have evi- we must proceed in a manner, which is sim- to the sanctity of life doctrine, an action is
dence against the proposition that there is a ilar to how we assess scientific theories. We wrong if it is an act of murder. But we can-
table in front of me. I will return below to have to put our moral hypotheses to test. not know for sure whether an act is an act
the possibility that further knowledge un- We test our scientific theories against of murder or not (we cannot know for sure
dermines our firm beliefs. our observations. In a similar vein, we have whether it is intentional killing or not). In
Now, even if we hold some justified be- to test our moral hypotheses against not abstract though experiments we need not
liefs for which we lack evidence, this is not observations, but our considered moral in- bother with such details. We can simply as-
true about scientific theories. Typically, we tuitions. A moral intuition is an immediate sume that an action has better consequences
are only justified in our belief in a scien- reaction to an action with which one is pre- than another, alternative, one and we can
tific theory if we have evidence for it. And, sented, to the effect that the action is right stipulate that a certain action was an act of
typically, the evidence for a scientific theory or wrong. It is ‘immediate’ in the sense that murder and so forth. Then we can tease out
lies in observation. We say that something it is not the result of any conscious process our intuitions in relation to the examples.
we observe, say that p, is evidence for the of reasoning. I will return to the require- Now, if we want to choose between
theory T, if T gives the best explanation of p ment that our moral intuitions should be utilitarianism and the sanctity of life doc-
(we make an ‘inference to the best explana- considered. trine it might be a good idea to turn to the
tion’, as Gilbert Harman has famously put A scientific theory that is at variance so-called trolley-cases, developed and elabo-
the point (Harman, 1965)). with (the content of ) our observations rated upon, by the philosophers Philippa
Can we say something similar of ethics? is rejected. A scientific theory must be Foot (Foot, 1967) and Judith Jarvis Thom-
empirically adequate. In a similar vein, son (Thomson, 1967). As we will see, these
Testing ethical theories - an ethical theory must give the right an- examples seem to allow for crucial tests be-
Similarities with science swer to moral questions; it must con- tween these two theories.
Typical ethical theories state which actions form to our considered moral intuitions. Here is the first, simple switch, case. A
are right and which actions are wrong and However, empirical adequacy or conformi- trolley is running down a track. In its path
also why they are right and wrong respec- ty with our considered moral intuitions re- are 5 people who have been tied to the
tively. Two examples of such theories are ex- spectively, is just a necessary requirement, track. It is possible for you to flip a switch,
plained in this article, utilitarianism and the it is not a sufficient one. The theory must which will lead the trolley down a different
sanctity of life doctrine. According to utili- also, in order to gain support from the ob- track. There is a single person tied to that
tarianism, an action is right if and only if it servation (intuition), give the best explana- track. Many believe that they should flip the
maximises the sum-total of well-being in the tion of (the content of ) our observations switch. This is in agreement with utilitari-
universe; if it is not right, then it is wrong. and considered intuitions. This means that anism, of course. More lives are saved. But
And the fact that an action maximises the it must be general, simple, theoretically it is also consistent with the sanctity of life
sum-total of well-being in the universe, if it fruitful and so forth. doctrine, since the killing of the single per-
does, is what makes it right. Once again, I see no difference here son is not intended; it is a merely foreseen
The sanctity-of-life doctrine (as I here between ethics and science. On a structural consequence of your saving the five. If there
conceive of it) concurs in the idea that one level, what goes on in the testing of both had been a third track, with no one on, you
should maximise the sum-total of well-be- moral and scientific theories is the same. would have opted for this one, I assume.
ing in the universe, but claims that the end And yet, if we look closer to the ethical Here is the second, the so-called foot-
doesn’t justify the means. It is wrong actively case, an important difference surfaces: in bridge case. You are on a bridge under which
and intentionally to kill an innocent human science we normally rely on real experi- the trolley will pass. There is a big man next
being, even if killing this innocent human ments. In ethics we must rest satisfied with to you and your only way to stop the trolley
being means that the sum-total of well-be- thought experiments. is to push him onto the track, killing him
OchreDesignLab

M edical sciences
to save five. Few think this would be right, tex, a brain region associated with cognitive credibility and hence opt for the utilitarian
even among those who are prepared to flip control (Greene et al. 2004). By cheering solution.
the switch in the original example. Accord- people up, before we confront them with There is something to each line of ar-
ing to utilitarianism, this is what you ought the examples, it is possible, to move them gument. However, the proper way of ap-
to do however. But according to the sanctity closer to the utilitarian camp (Greene at al. proaching our intuitions, it seems to me, is
of life doctrine, you should not push the 2004). By keeping people busy with intel- to see what our reactions to the examples
man since, if you do, you kill him deliber- lectual tasks, while giving their verdicts on are, once we know about the origin of re-
ately, and you use him merely as a means to the trolley-cases, it is also possible to move spective kind of emotion. We should not
the rescue of the five. people closer to the non-utilitarian camp. rely on our intuitions before we know all
It may seem that people at large have Moreover, those who reach the utilitarian that can be known about their origin. We
intuitions that square better with the sanc- verdict have to overcome their own emo- should expose them to a kind of cognitive
tity of life doctrine than with utilitarianism, tional resistance to the conclusion, which psychotherapy, then.
then. But here comes a third version of the takes some time, and so forth (Greene at al, This is not enough, however. We need
example. 2004). And people suffering from focal bi- philosophical therapy as well. We must as-
The third case, often referred to as the lateral damage to the VentroMedial Prefron- certain that we have correctly understood
loop, as in the simple switch case, you can tal Cortex (VMPC), a brain region neces- the examples. We are easily misguided when
divert the trolley onto a separate track. On sary for the normal generation of emotions we ponder thought examples. We read
this track is a single big man. However, and, in particular, social emotions, easily things into them that should not be there.
beyond the big man, this track loops back reach the utilitarian solution when asked The scientists who have studied our reac-
onto the main line towards the five, and if about the cases (Koenig et al., 2007). tions have tried to compensate for this, but
it weren’t for the presence of the big man, When we know more about the origin they may not have been entirely successful.
flipping the switch would not save the five. of our moral intuition, can this help us to It is also important to make some dis-
Now many people, even among those who select the right moral hypothesis, utilitari- tinctions, which are simply absent in the
hesitate to push the big man, accept to flip anism, the sanctity of life doctrine, or some abstract description of the examples. We
the switch. But this is at variance with the other doctrine? The results from neuroimag- are here invited to assess what course of ac-
sanctity of life doctrine and in accordance ing of our brains and experimental psycho- tion is ‘morally permissible’. It is not quite
with utilitarianism. logical studies do not contradict our intu- clear what this means. One question is what
It seems, then, that neither utilitari- itions, Neither do they provide any evidence kind of response is right and what kind of
anism nor the sanctity of life doctrine can against them. It is not like the case in the response is wrong, when we abstract from
gain support from the intuitions of people opening of this paper where I can feel that long-term consequences (by assuming that
at large. I claimed above, however, that we there is no table in front of me. But perhaps there are no such consequences of impor-
should seek evidence in our considered in- they can help us to undermine the justifica- tance). Another question is: what sort of
tuitions. Is there a way of critically assessing tion for some of the intuitions, in the same people should we be, people who push or
our spontaneous reactions to the examples? way that my knowledge that psychologists people who don’t push the big man onto the
Well, one question we should ponder is how sometimes project holograms in front of me tracks? A utilitarian may well admit that in
we have arrived at our intuitions. And this is undermines my justification for my belief the long run it is better that people at large
where neuroscience comes in. that there is a table in front of me. Which are such that they don’t push. And yet, in
ones have their justification undermined, in the situation, we ought to push. Some may
Neuroscience enters the picture that case? be less willing to make this kind of distinc-
Joshua D. Greene at Harvard University This is a tricky question. It is obvious tion and claim that the crucial question is
and his collaborators have studied exten- that some immediate intuitions among peo- what sort of people we should be. But then
sively how we reach our verdicts in the ple at large just have to yield-you have to they cannot respond to the trolley cases in a
trolley cases. Here are, in a very simplified admit that even if you are among the major- reasonable manner! Philosophical subtleties
form, some of their results about what hap- ity. You have to admit that since there is no like these are lost in the experiments. When
pens when people react to the trolley-cases. plausible theory consistent with all the in- they are added, together with information
It seems as though a dual model makes best tuitions. But if you want to get rid of some, about how our intuitions are formed, and
sense of how we function. On the one hand, but not all intuitions, which ones should comprehended, then, I submit, we are al-
controlled cognitive processes drive our util- yield and which ones should be retained? lowed to rely on the kind of (firm) intuitions
itarian judgements, while non-utilitarian One could argue that we should try to we still hold. They are what I have called
judgements (don’t push the man) are driven muster the same emotional response to the ‘considered’ intuitions. Our justification of
by automatic, intuitive emotional responses. loop as the one we exhibit in relation to the them is not undermined by any knowledge
Different parts of our brains are responsible footbridge and opt for the sanctity of life we have been able to gain. Hence, quite
for these different responses, as can be seen doctrine. Or one could argue that our gut reasonably, we take them to be indicative of
from neuroimaging of our brains. ‘Utilitar- feelings, just because they are immediate the truth.
ian’ responses are associated with increased and probably the result of a selective pres- Can we expect inter-subjectivity in our
activity in the dorsolateral prefrontal cor- sure way back in our human history, lack thus considered moral intuitions? Perhaps,
M edical sciences
in the very long run, but I doubt it. In this, justified in my belief in utilitarianism, while ethics and science. We gain moral knowl-
ethics may well be different from science. the Pope is justified in his belief in the sanc- edge in a way similar to how we gain
Observations in science may be highly the- tity of life doctrine, provided we have each scientific knowledge: we have evidence
ory-laden and thus controversial, but there scrutinised our intuitions properly — and for ethical theories when these theories
is always a possibility of moving to neutral provided we have not just deduced them can best explain our data. However, the data
ground when we account for them. The from our respective favoured theory. This in science and ethics are different. In science
physicist may claim that he has observed a may well be so, but since utilitarianism and we rely on observation, in ethics we rely on
path of a positron in a cloud chamber. An- the sanctity of life doctrines contradict one considered moral intuitions.
other scientist claims that there is no such another, they cannot both be true. There is little agreement about when
thing as a positron. He sees no trace of any The possibility of such epistemic rela- we should trust our ethical intuitions.
positron. Now, there is a way of switching tivism may prompt us to believe that, after It is remarkable, however, that neuroscience
to a less theory-laden level of description all, there is no truth in ethics. The idea that and psychology have recently shed new
of the content of their respective observa- we should give up on some of our intu- light on how our moral intuitions arise.
tions. Perhaps they can agree, at least, that itions, because they have been undermined We should ponder these data and submit
there are certain traces of a certain shapes, by knowledge about their origin, may come our intuitions to cognitive psychotherapy.
which they are watching. The person who to be generalised to all our moral intuitions. When they resist this kind of therapy,
believes he sees traces of a positron can We may be tempted to accept moral nihil- when they do not go away, once we know
urge the other scientist to explain what, if ism and moral scepticism. I think we ought how we have come to hold them, we are
not traces of a positron passing, the traces to resist this temptation, but I must admit justified in relying on them. They have then
both see are traces of. However, in eth- that, in the present context I have not given become considered moral intuitions. We are
ics there is no similar neutral ground, no any good argument to this effect. then justified in our moral beliefs. If they
clearly observable traces to which we can happen to be true, furthermore, then we
move. This means, then, that different peo- Conclusion know them.
ple may very well be justified in their beliefs The notion of truth (just as the notion of All this means that theoretical moral
in competing moral hypothesis. I may be knowledge and justification) is the same in knowledge is possible, at least in principle.
OchreDesignLab

S u r g ical specialit y
Surgical Response
community hospitals must respond to waves
of civilian and military casualties while main-
to Mass Casualty
taining routine medical and surgical service
to the community depending upon the na-
Incidents
ture of the incident. Treatment of late medi-
cal complications such as sepsis, multiple or-
gan failure and the psychological sequelae of
The Israeli experience the incident are also major issues which occur
in the Third Phase.
Pre-event management
A thoughtful disaster plan outlining the mo-
When a Mass Casuality bilisation and optimal utilisation of available
Incident occurs, the medical resources is critical. Fewer additional
establishment of a defined resources are required if systems are in place
to optimise the use of existing resources. In-
system with central control dividual patient survival is highly dependent
is critical for the orderly on early transfer to a medical facility capable
evacuation and transfer of providing life and limb salvage surgery.
The utility of front-line military evacuation
of patients through a hospitals was demonstrated both during the
cascade of treatment from 1973 Yom Kippur War in the Sinai Penin-
resuscitation and damage sula and during the 1982 Lebanon War. A
similar concept has been employed in other
control to definitive care and military deployments and by civilian res-
eventually to rehabilitation. cue organisations responding to disasters.
Following resuscitation and initial damage
control surgery, patients are transferred in an
T
he frequency of recorded Mass orderly fashion to hospitals remote from the
Casualty Incidents (MCIs) has in- incident for definitive care freeing up beds in
creased over the past 50 years with the evacuation hospital for the next wave of
Sharon Einav-Bromiker
almost 2 billion people being affected by casualties.
Lecturer, Anesthesiology and Critical
disasters during the past 10 years alone. Ap- Care Medicine, Hebrew University
During the Second Lebanon War in
proximately half of all natural disasters occur Israel 2006, most casualties were evacuated to
in Asia even though it comprises only 31% of William P Schecter nearby civilian medical centers because of the
the total world area. In the second half of the Professor, Clinical Surgery proximity of the conflict to civilian popula-
last century approximately 70% of all disas- University of California, San Francisco tion centers. Four hospitals in the north of
ter-related deaths occurred in this region that USA Israel were designated as receiving hospitals.
contains 58% of the total world population. Only one of these hospitals functions as a
The medical sequelae of an MCI gener- The major issue in the Third Phase, Level 1 Trauma Centre during peacetime.
ally occur in three phases. The largest num- which occurs days to weeks following the Prior preparation for a disaster response is
ber of deaths occurs in the Initial Phase due disaster, is preventive medicine. Provision of imperative to ensure a smooth transition to
to injuries incompatible with survival. The adequate food, potable water, clothing, ener- the changed circumstances. Optimal prior
largest number of preventable deaths occurs gy sources and shelter is essential. Organisa- preparation includes not only a disaster plan
in the Second Phase, occurring minutes to tion of human waste and garbage disposal is but organisation of a system that has a cen-
hours following the MCI. The key medical also important. Provision of primary health- tral control responsible for conducting regu-
issues during the Second Phase are rescue of care for the local population should opti- larly scheduled MCI drills as well as ensuring
the victims, provision of timely first aid and mally begin as soon as 24-48 hours after the provision of adequate supplies.
early evacuation of patients with life and MCI. Circumstances will differ depending The establishment of a defined system
limb threatening injuries to medical facilities. upon the location of the incident, the previ- with central control is critical for the or-
The initial responders to MCIs resulting in ous level of medical care received by the lo- derly evacuation and transfer of patients
complete destruction of social infrastructure cal population and the degree of destruction through a cascade of treatment from resus-
are often uninjured local citizens. The large of local infrastructure. Access to emergency citation and damage control to definitive
number of casualties presenting for care medical care, delivery room services and care and eventually to rehabilitation. In-
usually overwhelms surviving local medical maintenance medication are all important ter-hospital competition can be minimised
personnel and facilities. issues requiring consideration. Surviving when a disinterested third party governs
the system. The Israel Emergency Medical in almost all Israeli hospitals following a mass condition, the anticipated length of the pro-
System (Magen David Adom) determines casualty event. cedure and the scale of the event, a decision
the evacuation destination after MCIs may be made to either abort the procedure
during peacetime. The Israel Defense Forces Event management or proceed with surgery. Surgical procedures
Medical Corps determines the evacuation All hospitals in the vicinity of a mass casu- underway at the time of notification of the
destination for casualties during war. The alty event will likely participate in the care of incident should proceed to completion.
goal is conversion of an MCI in the field to casualties. The key concepts for orderly pa-
a multiple casualty event for each receiving tient management are unidirectional patient Post-event management
hospital. flow throughout the hospital and thorough Early debriefing, usually on the day of the
A recent review of the Military Trauma documentation. Anaesthesiologists, general event, is important to record the events, create
System in Iraq identified a number of key and orthopaedic surgeons are in immediate order out of the initial confusion and identify
clinical issues which are important for disas- demand. opportunities for performance improvement.
ter planners. These issues include transfer of Initial triage of patients should occur An orderly and timely flow of casualties
casualties from point of injury to the most outside of the department of emergency through the diagnostic and therapeutic triage
appropriate level of care, the development of medicine (ED). Physicians and nurses who cascade will clear the ED which may easily
trauma clinical practice guidelines, the use do not have special training in the surgi- be inundated otherwise and hastens return of
of standard forms at all care stations, the in- cal disciplines should segregate ambulatory the hospital to routine operation. Return to
stitution of standard prophylactic antibiotic patients in an area outside of the ED itself normal hospital routine may, however, take
regimens, on-line regulation of medical evac- where they can be evaluated. Ambulatory pa- hours to days, dependant on the number of
uation, implementation of a performance tients injured in a blast should be screened for casualties received and the nature of the inci-
improvement programme including a careful asymptomatic pneumothorax and / or tym- dent. The medical consequences of the event
report of morbidity and mortality statistics panic membrane rupture at diagnostic ENT in terms of prolonged ICU and hospital care,
and trauma registry data. and radiology stations prior to discharge from the need for multiple reconstructive opera-
Estimation of receiving hospital surge hospital. Stretcher cases should be admitted tions, rehabilitation care as well as psychiatric
capacity including alternate site capacity is a directly to the ED for secondary triage to and social services are immense.
key element in disaster planning. Unfortu- Immediate or Delayed Care. Following ini- The psychological impact of MCIs (and
nately, the optimal method of surge capacity tial resuscitation, Immediate Care patients in particular those that have been caused
evaluation remains unknown. Both comput- are transferred to the operating theater (OR), by human acts of aggression) on health-
er simulation models and annual bed statis- intensive care unit, the Post-Anaesthesia Care care workers should not be underestimated.
tics have been used to estimate surge capacity. Unit (PACU) or the Radiology department Post-Traumatic Stress Disorder (PTSD)
Annual bed statistics do not account for daily depending on the diagnostic and therapeutic is common among healthcare workers
variation in patient volume and within-year requirements of the individual patient. The deployed to combat settings. Work in a
variation in bed supply and may, therefore, PACU is an ideal venue for establishing an directly threatened civilian environment
be misleading. Some types of MCIs result in extended ICU to accommodate the surge of (e.g. a general hospital targeted by missiles,
increased use of specific resources (e.g. inten- critically ill patients. a community comonly affected by acts of
sive care, surgery) and prolonged hospital stay Most patients will require diagnostic X- terror) predisposes hospital staff to PTSD.
thereby affecting surge capacity. Although rays and many require CT imaging. Insidi-
many patients can be discharged from the ous and missed injuries are a major concern. Conclusion
hospital within 24-72 hours following injury The Radiology department is the main bot- A coordinated response to a disaster or MCI
to increase bed availability, overzealous early tleneck impeding the orderly flow of patients requires a system-wide plan with central con-
ICU discharge may adversely affect outcome. through the diagnostic and therapeutic intra- trol. The initial medical issues include rescue
Staff training is an obvious crucial element of hospital triage cascade. This can be prevented of victims, provision of first aid and evacua-
disaster planning. Training should include: with staff training and prior preparation of tion of patients with life and limb threaten-
1. The principles of Advanced Trauma Life radiology protocols unique to MCIs. ing injuries to more sophisticated medical fa-
Support®, 2. Acquaintance with the unique Critically ill patients who have suffered cilities. Early attention to provision of food,
patterns of injury caused by manmade and penetrating injuries or traumatic amputa- potable water and sources of energy, clothing
natural disasters, 3. Participation in mass tions may require immediate access to the and shelter and waste disposal are critical to
casualty drills and 4. Mental preparation for OR. Upon notification of a disaster, elective prevent epidemic disease following a disaster.
acceptance of adequate rather than optimal surgery should be immediately suspended All hospitals in the vicinity of the incident
care of the injured under dire circumstances until the scale of the event is clarified. Pa- will likely be called upon for help. A hospi-
requiring triage. tients who have not yet been anaesthetised tal disaster plan is essential to define lines of
Finally, the disaster plan should clearly should be returned to the pre-operative hold- authority, identify diagnostic and therapeu-
delineate the in-hospital chain of command ing area or their wards. Patients who have tic triage stations and facilitate the orderly
to limit the inevitable competition and ego- been anaesthetised but have not yet received treatment of a large number of patients. The
clashes that occur within hospitals. Senior surgery can be considered on an individual goal is conversion of an MCI in the field to a
surgeons assume the clinical leadership role basis. Depending upon the severity of their multiple casualty event for each hospital.

Surgical Skills Simulation

Effect on quality and safety
There is an increasing evidence emerging that

Patrick Cregan
simulation in surgical training is effective. However, Surgeon, Co-Chair, Sydney West Area
the problem remains that if all patients had completely Health Service Surgical Network
and
error-free technical aspects to their admission Chair, NSW Department of Health
Surgical Services Taskforce
approximately 97% of medical errors and bad Australia
outcomes would still occur.
T
o give patients the best possible The question then is, what contribu- the General Medical Council in the United
care, healthcare providers need to tion can surgical skills simulation realisti- Kingdom to the Bristol Inquiry. In these
combine the three S’s. These are the cally make to safety and quality? In the documents, not more than a paragraph on
best Systems, the best Science and the best published Abstracts from Medicine Meets simulation is present. If one looks at a va-
Skills. The outline of this is seen in figure 1. Virtual Reality the word ‘safety’ is used 61 riety of publications on quality and safety,
Best Science incorporates concepts such as times in 21 published Abstracts, and ‘qual- one can see what might be termed “failure
evidence-based care, the use of randomised ity’ 75 times in 39 published Abstracts. of surgical skills” contributes a relatively
control trial data, meta-analyses, cochrane Thus, quality and safety seen to be drivers small amount to poor patient outcomes.
collaborations, the development thereafter of the simulation movement in surgery as Zhan & Miller found in a major paper re-
of guidelines, well-kept clinical data bases, well as anaesthesia, emergency care and viewing 20% of admissions to US hospitals
protocols and, of course, textbook learning. nursing. that only 2.2% of patient safety-indicator
These things are assessed usually by a form Unfortunately, quality and safety can events were due to “technical difficulty /
of cognitive assessment. Best Skills include be over-promoted and used out of context problem”. This compares to approximate-
technical communication, ethical and other to justify the need for simulation. ly 20% of postoperative physiologic and
skills and confident assessment is more dif- The ‘To Err is Human - Crossing metabolic derangement, 6.5% of venous
ficult. These are taught in an apprenticeship the Quality Chasm’ publications by the thromboembolic disease and 7.2% of decu-
model although simulation offers a great National Institute of Medicine in the United bitus ulcers, amongst other patient safety
opportunity for better assessment of skills States are two of the triggers for the quality indicators. The overall rate per thousand
in trainees and the workforce. Finally, there and safety movement are frequently cited in discharges at risk was in fact only 3.2%.
are Best Systems. These include things such the simulation literature as drivers for the Gawande et al. found that adverse events,
as physical facilities, clinical governance, adoption of simulation, as is the response of in fact occurred in approximately 3% of
appropriate culture in the workforce, hu-
man factors, good teamwork, best proto-
cols etc. Many aspects of this domain are
never assessed.
The range of skills amongst prac-
ticing surgeons is quite varied and
Gallagher et al., in an article in the Journal
of the American College of Surgeons in 2003,
demonstrated a wide range of variation in
surgical skill based on the number of errors
in a MIST-VR simulated environment.
Outcomes for a long time have been known
to indicate differences in individual surgeons
practice and volume has certainly been
well demonstrated as a predictor of good
surgical outcomes. Image courtesy: Davide Lomanto, Director, MISC, NUH, Singapore
attentional resource that is required can be
Three Ss of Best Care

reduced.
This model has subsequently been
explored by Fried and his colleagues at
McGill University (personal com-
munication). They have confirmed
Best Systems
this using a laparoscopic simula-
Protocols
Team Work tor trainer and having the candidates
Human Factors solve mathematical problems as well as
Appropriate Culture perform tasks within the trainer.
Clinical Governance
Indeed, it has even been suggested
Physical Facilities
?Assessment? within Gallagher’s model that the attention-
al resources of the below average surgeon
may be so challenged by the laparoscopic
Best environment as to reduce their overall
Best Science
Evidence Based Care
Care Best Skills
effectiveness.
There is increasing evidence emerging,
Randomised Controlled Trials Technical
Communication however, that simulation in surgical train-
Meta-analyses/Cochrane
Guidelines Ethics ing is effective. Further reviews that we have
Clinical Databases ?Assessment? conducted with ASERNIP-S have tended
Protocols Simulation to indicate that skills acquired by simula-
Cognitive Assessment
tion-based training are transferable to the
operative setting. This has been demon-
strated in ten randomised control trials
and one non-randomised study to date.
surgical and obstetric patients but training has yet been shown to be better Unfortunately, these studies have been of
adverse events overall were no more likely than other forms of surgical training”. variable quality and did not use comparable
in surgical than non-surgical care. This is hardly surprising given the simulation-based training methodologies.
If one looks at the safety literature, relative novelty of surgical simulator train- There is, therefore, a need for larger
very little mention is made at present of ing and the fact that even in aviation it has numbers of trainee assessments in different
simulation as a methodology to improve been identified that at least 70% of aircraft techniques but using equivalent methodol-
safety. By way of example, Leape in his evi- accidents and incidents are caused not by ogies. However, the problem remains that if
dence report # 43 2001 from the Evidence- a pilot’s technical skill but lack of human all patients had completely error-free techni-
Based Practice Centre at Stanford, (an factor skills. The aviation comparison is fre- cal aspects to their admission, approximate-
article which has been criticised for its quently thought to be analogous to the situ- ly 97% of medical errors and bad outcomes
focus on error rather than systemic prob- ation in the operating room. would still occur. Simulator training may
lems) identified 73 practices, 11 of which enable us, to reduce the attentional resource
had the greatest strength of evidence. When Why simulators? needed by novice and master surgeons in
these are reviewed, four of the seventy three Why then should we teach surgical skills on any particular setting so as to improve their
may possibly have been helped by the simulators? This has been addressed in par- situational awareness, teamwork and hu-
use of simulation, and simulation itself is ticular in an article by Gallagher in which man factors and thereby prevent these other
mentioned only once in the paper and this a model of attentional resources for the larger (by number) causes of harm.
is in the second lowest group (“lower impact master versus the novice surgeon was de-
or strength of evidence”). scribed. This model proposes that because Conclusion
the novice surgeon, much like the learner Technical skills contribute about 2-3%
Does simulation work? driver early in his experience, devotes nearly of quality & safety problems. Surgi-
The Australian Safety and Efficacy Register all his attentional resource to psychomotor cal simulation cannot be restricted to
for New Interventional Procedures—Sur- performance, depth and spatial perception procedural simulation alone if it is to
gery (ASERNIP-S) reviewed surgical simu- and operation judgement and decision have a real impact. We in the simula-
lation by way of a systemic review. This work making. This significantly reduces their tion community should not make exag-
was subsequently published in scientific attentional resources which can otherwise gerated promises (that we cannot keep).
format in Annals of Surgery. The conclusion be devoted to comprehending instructions Simulation should be assessed with the
of the assessment was that “while there may and gaining knowledge. By pre-training on same rigour as any other intervention in
be compelling reasons to reduce reliance on the simulator, the amount of psychomotor healthcare and we should not lose sight
patients, cadavers and animals for surgical performance, depth and spatial judgement, of the fact that outcomes are the ultimate
training, none of the methods of simulator operative judgement and decision making, measure of any intervention in healthcare.

Surgical PACS
Design and implementation
The OR and image-based interventional suites are the most cost-intensive sectors in
the hospital, therefore, the optimisation of workflow processes has become of particular
concern to healthcare providers. The understanding and management of workflows
should become an integral part in the planning and implementation of complex digital
infrastructure supporting diagnostic and interventional procedures.
i.e. the PSM, commences in the diagnostic • Multi-scale modelling

Heinz U Lemke workflow, making use for example of com- • Fusion/integration of data/images
Research Professor puter aided diagnosis and associated tech- • Coordinate systems between different
Radiology
nologies. Subsequently, it proceeds in all models including patient, equipment
University of Leipzig
Germany phases of the therapeutic workflow includ- and the OR
ing after care. • Modelling of workflows
By default, the broader the spectrum MGT is based on the gathering of all
M
odel Guided Therapy (MGT) of different types of interventional/surgical available medical information concerning a
is a methodology complement- workflows which have to be considered, the patient and, with the use of modern engi-
ing Image Guided Therapy more effort has to go in designing appro- neering principles and information technol-
(IGT) with additional vital patient-specific priate PSMs and associated services. The ogy, the construction of a patient-specific
data. It brings patient treatment closer to following list contains some examples of medical model. When implemented, a PSM
achieving more precise diagnosis, more ac- modelling tools and aspects, derived from is a multi-level data structure (e.g. matrices,
curate assessment of prognosis, and a more different types of surgical workflows, which tensors, graphs, lists, tables, fractales and
individualised planning, execution and may have to be considered: other mathematical artifacts) combining
validation of a specific therapy. • Geometric modelling including volume n-D n-dimensional and multi resolutional
MGT in its simplest instantiation is an and surface representations data of a patient in a coherent, reproduc-
intervention with a subset, a single or a set • Properties of cells and tissue ible and adaptable manner. Based on this
of voxels representing locations within the • Segmentation and reconstruction patient-specific medical model, diagnostic
patient’s body. With this view, it is an ex- • Biomechanics and damage and prognostic determinations and thera-
tension from Image (pixel) Guided Therapy • Tissue growth peutic decisions can be made, and responses
(IGT) to Model (voxel) Guided Therapy. • Tissue shift to therapeutic treatments can be monitored
Examples of Model Guided Therapy are: • Prosthesis modelling and recorded. MGT requires the transition
a) interventions within a subset of a voxel, • Fabrication model for custom prosthesis from an image-centric world-view driven
e.g. cells, organelles, molecules etc. • Properties of biomaterials by imaging technology to the model-cen-
b) interventions with a voxel, e.g. small • Pharmakokinetics and Pharmakodynam- tric world-view driven by the needs of the
tissue parts of an organ or lesion etc. ics of normal and pathologic tissue patient and the medical profession.
c) interventions with a set of voxels, e.g. part • Atlas-based anatomic modelling
of functional structures of organs, organ • Template modelling Therapy Imaging and Model
components, soft tissue, lesions etc. • FEM of medical devices and anatomic Management System (TIMMS)
Considering the needs of therapy spe- tissue Appropriate use of Information and Com-
cifically, the workflows for diagnosis and • Collision response strategies for con- munication Technology (ICT) and Mecha-
therapy need to be linked via the Patient straint deformable objects tronic (MT) systems is considered by many
Specific Model (PSM). In addition to de- • Variety of virtual human models experts as a significant contribution to im-
mographic data, the PSM comprises the • Lifelike physiology and anatomy prove workflow and quality of care in the
core information data set of the electronic • Modelling of the biologic continuum Operating Room (OR). Different imaging
medial record. The building of this data set, • Animated models modalities and a wide spectrum of other
Modules of a Surgical Assist System

Therapy Imaging and Model Management System (TIMMS)
Data Exch.
Repository Engine
Control
Images WF and Devices/

Modelling Computing Presentation Validation
and K+D Mechatr.
tools tools tools tools
signals tools tools
IO Imaging Kernel for

and Visualisation
Modelling Simulation WF and K+D Intervention Validation
Biosensors Manager
Management

ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy
Data and Models and

information intervention
Models WF’s, EBM, records
(Simulated “cases”,
Objects) MBME
Figure 1
information sources need to be digitally in- long-term, TIMMS can be expected to serve preoperative planning and intraoperative ex-
tegrated to build a suitable patient model. as a facilitator for a Model-based Medical ecution. Often this module (or parts thereof)
This will require an IT architecture support- Evidence (MBME) methodology providing is integrated into some of the other engines,
ing Surgical Assist System (SAS) which can a complement to Evidence-Based Medicine as the need may have demanded. In any case,
be adapted to specific surgical interventions (EBM). adaption of the therapeutic workflow to an
and patient care situations. Considering the software engineering actual patient care situation will be based on
A proper design of a TIMMS, taking principles such a system needs to be de- the PSM and realised by the Kernel.
into account modern software engineering signed to provide a highly modular struc-
principles such as service oriented architecture. Modules may be defined at different Realisation of a TIMMS
ture, will clarify the architectural and func- granulation levels. A first list of components All of the engines, tools, repositories, ICT
tional features of a SAS in general and its (e.g. high and low level modules) compris- infrastructure, data sources - including the
components in particular. Such a system ing engines and repositories of an SAS, operative team - are linked through a dis-
must provide a highly modular structure in which should be integrated with a TIMMS, tributed network, providing for the full
order to be able to adapt to different clini- is currently being compiled in a number of functionality of TIMMS, including plan-
cal workflows and specific variances in their R&D institutions. ning, guidance, learning and data mining
execution. Modules may be defined on Figure 1 shows a concept of a logi- and processing.
different granulation levels. Adaptability is cal structural model (meta architecture) of The ICT infrastructure used by TIMMS
achieved through a design concept-based on a high level generic modular architecture includes structures, objects, processes and
cognitive/intelligent agents. of an SAS. The high level modules are ab- interfaces from well established sources, to
The construction of the patient-specific stracted from many specific CAS/IGT sys- ensure compatibility and interoperability.
medical model will be used as the central tems which have been developed in recent This includes, but is not limited to:
construct within a TIMMS, which may years. In general, a combination of these • IHE
be described as an adaptive SAS. Ideally, can be found in most R&D as well as com- • HIS
the PSM engines and repositories will be mercial SAS. A central position in figure • RIS
integrated by a suitable TIMMS infrastruc- 1 is occupied by the “Kernel for workflow • PACS
ture to support the planning, execution and knowledge and decision management”. • DICOM
and validation of an intervention. In the It provides the strategic intelligence for • HL7

Interventional Cockpit/SAS modules

IT Model-Centric World View Therapy Imaging and Model Management System (TIMMS)
Data Exch.
Repository Engine
Control
Prototypical
implementation
Images WF and Devices/

Modelling Computing Presentation Validation
and K+D Mechatr
tools tools tools tools
signals tools tools
IO Imaging Kernel for

and Visualisation
Modelling Simulation WF and K+D Intervention Validation
Biosensors Manager
Management

ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy
Data and Models and

information intervention
Models WF’s, EBM, records
(Simulated “cases”,
Objects) MBME
Figure 2
Interfaces are provided for the input Significant hardware and software objects and services related to Image
of data and information from the outside infrastructure is required to support Guided Surgery (IGS). To determine these
world which are then processed and utilised research, particularly in IGT areas, that standards, it is important to define day-to-
by the functional components of TIMMS involve medical imaging and navigation. day, step-by-step surgical workflow practic-
and stored within the repositories. Hardware support can include a number of es and create surgery workflow models per
A possible physical realisation of different imaging systems (CT, MRI, X-ray, procedures or per variable cases.
interfaces required between major func- ultrasound, etc.) and several 3D tracking sys- As the boundaries between radia-
tional groups within and outside TIMMS tems based on a variety of technologies (opti- tion therapy, surgery and interventional
is shown in Figure 2. Appropriate use of cal, electromagnetic, etc.). Software support radiology become bleak, precise patient
standards (for example S-DICOM) allows includes standards such as DICOM, as models will become the greatest common
for the implementation of flexible pilot sys- well as open such as VTK, ITK, DCMTK, denominator for all therapeutic disci-
tems and in turn contributes to their further 3D Slicer, OpenTracker, and IGSTK. In plines. In addition to imaging, the focus of
developments. contrast, there is no off-the-shelf-robot WG24 should, therefore, also be to serve
Interfaces are also provided for the system—with an open interface—that is the therapeutic disciplines by enabling
output of various models, intervention suitable for medical use and no mature modelling technology to be based on
records, report data and information that open source packages for robot control. standards. A more detailed discussion which
have been synthesised within the TIMMS emphasises a model-centric world-view of
structure. Each possible realisation im- DICOM working group 24 “DICOM therapeutic disciplines as a complement
plies to give special attention to security, in Surgery” to the traditional image-centric world-
safety, systems recovery issues and the in- Standards for creating and integrating in- view of diagnostic radiology is presented
frastructure for rapid prototyping. Only formation about patients, equipment and in figure 3.
a subset of the indicated engines and procedures are vitally needed when plan- Following the inauguration of WG24
repositories of TIMMS are typically ning for an efficient OR and TIMMS. on June 25, 2005 during CARS 2005 in
implemented in a real clinical setting The DICOM Working Group 24 (WG24) Berlin, the following roadmap has been
(see Figure 3 as an example). has been established to develop DICOM agreed on by the members of WG24:
Monitors and Visualization Control and Input Devices

Devices
Enterprise-Wide Electronic
Medical Record Including
PACS, HIS, RIS, Data
Warehouse
TIMMS Medical TIMMS Surgical
Workstation Workstation
Engines and Repositories Interfaces for Operative Tools
Robotic Monitoring
Positioning
and other And Sensor
Devices(S)
Surgical Devices(S)
Devices(S)
Server(S) Server(S) Imaging

Containing Containing Model Devices(S) Navigation
TIMMS TIMMS Building e.g. X-ray Devices(S)
Engines Repositories Devices(S) CT, MR, US
Figure 3
1. Identify and build up a user community 4. Derive potential DICOM services from Association for Endoscopic Surgery,
of IGS disciplines in WG24. Initially these surgical workflows. American College of Surgery, Interna-
five surgical disciplines (Neuro, ENT, 5. Design an information/knowledge tional Society for Surgery, etc.
cardiac, orthopaedics, thoracoabdomi- model based on Electronic Medical Re- 9. Disseminate knowledge gained follow-
nal and interventional radiology) are se- cord (EMR) related work and identify ing the roadmap through workshops,
lected. Anaesthesia is included as long as IOD extensions to DICOM. Because of conferences and special seminars. Special
surgery is affected. similarities to the IHE activities, a close presentations should be planned each
2. Encourage experts from vendor and relationship to IHE should be estab- year for CARS, SPIE, RSNA, DICOM-
academic institutions to join WG24. lished. Meeting, and at a minimum for one
Vendors of endoscopic and microscopic 6. Take account of the special image surgical conference.
devices as well as implants (templates) communication (1D - 5D) requirements 10. Connect to integration profiles speci-
should be included in addition to the for surgery and mechatronic devices. A fied for surgery by IHE activities.
classic vendors of medical imaging and close cooperation with WG 2 and 17 The first two work items WG24 is
PACS. should be established. involved with are “Polygonal Segmenta-
3. Compile a representative set of surgical 7. Work in close cooperation with DICOM tion” (cooperatively with Working Group
workflows (with a suitable high level experts from radiology, cardiology, ra- 17 (3D)) and “Implants”. DICOM always
of granularity and appropriate workflow diotherapy and related fields which are combines Objects with the Services they
modeling standards and surgical ontolo- represented in WG1 - WG23. are using in Service Object Pair Classes
gies) as a work reference for the scope 8. Encourage close cooperation with work- (SOP-Classes). WG24 is therefore working
of WG24. Initially, 3-5 workflows, ing groups in the International Society on the Services which are needed for Po-
characteristic for each discipline, for Computer Aided Surgery (ISCAS), lygonal segmentation Storage/Retrieval and
should be recorded with sufficient Japan Institute of CARS (JICARS), implant usage (repositories and implant
level of detail. Workflow tools can be German Society for Computer- and planning). Both SOP-Classes are making
provided by the Innovation Center Robot-Assisted Surgery (CURAC), use of a common Surface Mesh Module.
Computer Assisted Surgery, Leipzig, European Federation for Medical They are considered as supplements for
Germany. Informatics (EFMI), European DICOM in Surgery.

D ia g nostics
Digital Radiography
Efficiency with automated system
movements
The introduction of a flat panel system in a filmless computerised radiology unit allows the
productivity of a radiology department to be noticeably increased, while providing ergonomic
comfort and ease of use. It is particularly suitable for the field of paediatric radiology.
pital with an annual patient throughput system and 99 patients examined on the
Michel Claudon
of 30,000 for general radiography. 40% of FD system. Of these 193 patients, five
these imaging examinations are emergency categories of examinations were evaluated;
Professor and Chief
Department of Radiology cases with the patient throughput remain- chest, abdomen, pelvis as well as upper and
Children’s Hospital ing at a stable level in recent years. There lower extremities. The examinations were
University of Nancy are two general radiography rooms. The further divided into those with a single
France
digital flat detector radiography system is exposure and those with two exposures
Co-authored by installed in one of them while the other (where frontal and lateral projections are
Luc Guillaume, Thomas Joris, room has a conventional radiography unit standard). Throughput and average exami-
Bernd Weber, Damien Mandry and with a Computerised Radiography (CR) nation time of these procedures were also
Laurent Kammacher imaging system. The study focussed on the measured. Additionally, each examination
comparative evaluation of the FD system was broken into three phases to analyse
and the CR system with regard to three where the most benefits were experienced.
key indicators: patient throughput, chang- The three phases were:
T
here are numerous factors that es of workload within the rooms and user • Positioning phase: Patient position-
drive a radiology department to satisfaction. ing and placement of detector or CR
adopt digital imaging technology. The equipment that allowed the radio- cassette for each respective system.
The use of the Picture Archiving and Com- luminescent plate system to be tested is the • Execution phase: Execution of the imag-
munications System (PACS) and hospital Siemens (with a free-floating table and of ing process including exposure, access to
managements' need to optimise operat- variable height) installation (ceiling-sus- patient data, CR cassette processing and
ing costs for higher efficiency are only two pended installation), connected to a PCR visualisation of image for FD system.
examples. AC 3000 Philips RLMS system. • Acquisition phase: Consisting of
With these factors and the impending The tested DR system is an Axiom archiving via PACS for the two
obsolescence of the existing conventional Aristos FX Siemens installation (Erlangen radiographic systems.
radiography system in some regions, the – Germany) with a flat panel (Trixell, Moi- The comparison of the different times
radiology department (University Hospital rans – France), large screen (43 cm x 43 for each step of the execution of the action,
of Nancy, France) decided on a fully au- cm), with a matrix of 3000 pixels x 3000 then by anatomic area explored was done
tomated digital flat detector radiography pixels. Movements of the panel and the by comparison to averages, using the t test
system. Reasons for this decision were the X-ray tube are completely automatic. The and the Mann-Whitney nonparametric
preference for a Flat Detector (FD) system computer interface is provided by means test (SPSS 11.0 software).
that delivers a high level of automated sys- of a syngo platform running on Microsoft The second focus of the study assessed
tem movements. Numerous independent Windows. the workload distribution of patients to
studies have proved that flat detector im- the two different radiographic rooms over
aging systems improve productivity and Methods and evaluation the one year study period. Activity curves
deliver significant dose-saving advantages. The first part of the study focussed on the were created to allow a time comparison of
comparative evaluation of overall patient results and an evaluation of stability over
Comparing FD and CR systems throughput. A total of 193 patients were the long-term.
This study was performed in a paediatric evaluated during the study, with 94 pa- Changes in organisation and division
radiology department of a university hos- tients examined on the conventional/CR of duties among technicians occasionally
D ia g nostics
involved in the installation of the DR were of patients were assigned to the room with reception, hygiene regulations and track-
likewise studied. the installed flat detector radiography sys- ing images for archiving and distribution
Finally, a satisfaction survey was carried tem. This is largely due to preference of to clinicians. On the other hand, this
out among fourteen technicians of the pae- the new technology by the users for its requires a minimum of two, even three,
diatric radiology department, for a total of image quality, dose savings of up to 40%, technicians to ensure continuous use of
16 persons. To find out the opinion of the and reduction in mAs values while achiev- the installation when there is an overflow
users regarding ease of use, speed of exami- ing identical image density and contrast. of patients.
nation, image quality and user-friendliness Eleven of the 14 users surveyed pre- However, the flat panel system, in its
of each of the two systems the following ferred the flat detector system on all per- current configuration, may not always be
valuation system was used: formance criteria while three users found able to completely handle the activity of
• +2 for DR much better than RLMS the flat detector and CR systems to be two radiology installations. The dimen-
• +1 for DR better than RLMS similar for one criterion each. sions of the panel do not allow for use
• 0 if the two systems are equivalent in patient beds or on a stretcher. As with
• -1 for RLMS better than DR Discussion any motorised system, manual movement
• -2 for RLMS much better than DR The values demonstrated during the time of the suspended system supporting the
measurements are unambiguous. The flat X-ray tube proved to be difficult and re-
Results of comparison panel system technology is significantly quired significant physical effort of the
Comparative evaluation of the complete faster in the three examination phases. staff. Placement of the bed in the radiol-
patient treatment time found a 30% re- These results allowed us to quantify our ogy room, moreover, is not easy, taking
duction from 403 seconds to 266 seconds technological choice of a DR system in into account the installed examination
with the FD system compared to the CR a paediatric radiology department with table. These drawbacks cause a significant
system. The patient treatment time was much regular and emergency activity decrease in patient care, which exceed the
defined as the time when the patient ar- (40% of the total activity), rather than time needed with a conventional system
rived at the waiting room to the time the justify to the institution the benefit of the and cancels out timesavings. Areas of ex-
acquired image was available on the inter- investment. ploration greater than 43 cm (legs and
nal network. On an average, time savings During the film phase, the flat-panel femurs of adolescent patients, teleradiog-
between 48% and 59% were achieved system allows the image to be visualised raphy of the spine and lower extremities)
for the various examinations from chest within 6 seconds after exposure, while it will soon be examinable by means of mul-
to pelvis, with the greatest time savings takes 35 to 55 seconds for reading based tiple exposures and image-fusing software.
for pelvis examinations. It was also mea- on the size of the screen for the RLMS sys- However, performing teleradiography of
sured that on an average, 55% time sav- tem. The presetting of the opening of the the spine or lower extremities will still re-
ings could be achieved for single exposure diaphragms as well as automatic marking main impossible for patients with multiple
studies and 51% for double exposure considerably reduce the time of the image handicaps requiring time for short expo-
studies. While the time requirements of handling phase. This leaves the installation sure, thus the use of a single exposure.
the installation phases were comparable, part, which, due to its automation, allows In addition, parallel to this study, dosi-
most timesavings occurred in the film ex- a considerable savings of time with regard metric studies confirmed that it was possible
ecution phase and especially in the image- to the placement of the material. The “all to decrease the number of necessary mAs by
processing phase with timesavings values in one” system which offers the flat panel 40%, while still maintaining identical den-
of 42% and 83% respectively. It should system allows a large savings of time in sity and contrast, which proved satisfactory
be noted that a distance of about 15 me- personnel movement, as opposed to the to radiologists and clinicians. This lowering
ters between the room connected to the RLMS system which requires technicians of the applied dose is a major advantage for
RLMS reading system requires an average to move back and forth between the radio- paediatric X-ray departments where radio-
movement of the technician of about 15 diagnostics room and the plate reader. protection is a constant concern.
seconds, with sometimes a waiting time if The speed of visualising a quality image
the other room is in use. and the system’s ergonomic design make it Conclusion
The time of the undressing phase was a pleasure to use. The paediatric radiology The flat panel system is a new technology,
measured at an average of 40 seconds, staff is making the utmost attempt to have which allows for a considerable savings
while the phase following the transfer of the patients, parents and staff from clini- of time in standard examinations.
the image to the Intranet via the PACS cal departments accompanying the child The future availability of software for
took 95 seconds for both systems. Con- benefit from this technology, which allows performing teleradiography could fur-
sequently, a total of 135 seconds on aver- waiting time to be reduced. ther expand the uses of the system. It has
age were reserved for handling a paediatric The productivity increase of the sys- been demonstrated to be particularly
patient outside of the specific execution of tem frees up technician time and requires effective for the management of a
X-ray activity. a different way of thinking about patient high number of patients in a paediatric
For workload distribution, it was ob- care. This has enabled the staff to de- department, including an important ratio
served that by the end of the study, 84% vote more time to the quality of patient of emergency cases.

D ia g nostics
Advances in Breast Imaging

Impact in Asia Pacific
While the technology is relatively new, digital mammography and CAD have already entered.
A large part of this growth has come from the rising level of awareness and education on the
importance of breast screening. The continuous efforts in organising breast cancer awareness
programmes as well as promoting breast health screening, where patients enjoy subsidies in
mammogram screening, has created a demand for better and faster mammogram services.
cost of investment is up to 4 times higher Digital advantages

Frost & Sullivan than the film version, digital mammogra- Since the images can be stored and sent
Singapore phy offers several advantages such as; electronically, the immediate benefits that
Higher accuracy for certain patients one enjoys include:
Digital mammography offers significantly • Ease in access, transmission, retrieval,
better results in early detection of breast and storage of images
B
reast cancer is ranked the number cancer than film mammography in screen- • The image is immediately available for
one cancer among women, world- ing women who are pre-menopausal, or diagnosis
wide, and is the fifth most com- who have dense breasts. This includes • Digital mammograms are likely never
mon cause of cancer deaths. It is known younger women (under age of 50) who to be lost
to occur as a result of either inherited or tend to have dense breasts, which have The digital diagnostic tools that are
spontaneous gene mutations. Accord- a lot of gland tissue compared to fat. available can significantly increase the
ing to the WHO, more than 1.2 million Digital mammography may detect 15 to 28 productivity of the reporting radiologist,
people will be diagnosed with breast can- percent more cancers in women possessing due to:
cer each year, worldwide; the good news any of the above characteristics. • The ability to “zoom in” on to suspi-
is that if detected early, breast cancer is Better image clarity cious areas for clearer diagnosis
highly curable. A major advantage that digital mammog- • Manipulating an “underexposed” film to
Detection is facilitated by mammography offers is the clarity of the image, adjust the contrast and signal-to-noise
raphy an imaging technique that uses which shows higher resolution and clearer ratios, thereby, helping reporting radiolo-
low-dose x-rays to examine the breast for contrasts. This is particularly important, gist ‘see’ certain breast tumours that are
cancerous tissue. While this process may as tumors in dense breasts do not show up currently difficult to visualise on film.
cause some discomfort, it is considered as well on the film as they do on the digital This improves the workflow of the en-
vital to undergo this screening regularly, mammograms. tire diagnostic process, with fewer women
for women aged 40 and above, as mam-
mography is currently the only diagnostic
procedure that has been proven to reduce Typical Workflow of Digital Mammography
mortality from breast cancer.
Patient
Digital Mammography - New Registration
technology in the market
Mammography is one of the last mo-
dalities to enter the digital arena, where Reading and Storage Image
most diagnostic imaging procedures that Reporting Management Acquisition
include standard radiographs, MRI, CT,
ultrasound, are already being performed
using digital means.
With digital mammography, the image
Image Processing
of the breast is acquired electronically and and Quality Check
stored directly in a computer. While the Source: Frost & Sullivan Figure 1
D ia g nostics
needing to return for extra views, as digital rural area and have the images transmit- digital mammography and CAD have al-
images are available almost instantly upon ted and interpreted at a remote medical ready entered the region, with installation
being acquired. In addition to allowing center, which allows quicker access to sites in Singapore, Malaysia, Australia,
better cancer detection, digital mammog- expert advice and second opinions as Japan, South Korea and Thailand.
raphy examination requires less compres- opposed to getting the same through A large part of this growth has come
sion of the breasts, hence is less painful mail, courier and related delivery from the rising level of awareness and
than film mammography. Most impor- services. education on the importance of breast
tantly, digital mammography uses less While the file size of digital mam- screening by various government agen-
radiation than film mammography, with mograms is relatively large, transmission cies and NGOs.
no compromise in diagnostic accuracy. of these images over long distances is still The continuous efforts in organising
Spell Checker for digital mammograms possible over broadband Internet or breast cancer awareness programmes as
Another development in the field of breast through wireless networks (such as well as promoting breast health screen-
imaging is Computer Aided Detection through satellites). A study conducted ing, where patients enjoy subsidies in
or CAD. CAD acts as ‘a second pair of by Dr. Alan R Melton of the mammogram screening, has created a de-
eyes’ in reviewing digital mammograms by New York Presbyterian Hospital, mand for better and faster mammogram
using sophisticated pattern recognition to Columbia University Medical services.
search for abnormalities that may indicate Center, demonstrated the transmission Boost of medical tourism in the region,
the possibility of cancer. These findings of digital mammogram through Internet due to the hospitals intending to draw
are then highlighted to the reporting (in a secure environment) to an inter- foreign patients is also boosting the
radiologist for further examination / preting workstation 110 miles away, with adoption of digital mammography.
interpretation. each image transmitted in less than 45 With increasing activities and
seconds. programmes promoting breast health
Tele-Mammography awareness in the region, the market for
With digital mammography, one can Rising adoption in Asia Pacific digital mammography technology is only
have a mammogram performed at a While the technology is relatively new, likely to grow.
OchreDesignLab

T E C H N O L O GY , E Q U I P M E N T & D E V I C E S
are typically measured in nanometers, i.e. in

a scale of 10-9 meters. Nanoobjects as com-
pared to other objects of the living world are
shown in figure 1. Nanoscale indeed refers
to biological dimensions and should, thus,
be ideal for application to medical devices.
Following developments of the electron-
ics industry in miniaturising devices such as
electric circuits etc., it is not a surprise that
other areas of technology would follow. The
number of scientific publications on nano-
technology and its applications in life sci-
ences is rising exponentially. Consequently,
governmental institutions and private equity
companies are investing in research and de-
velopment of nanoproducts for application
in construction, biotechnology and medi-
cal devices. Expectations for a turnover in
nanotechnology in the year 2015 count on
US$ 15 billion worldwide. Is this hype jus-
tified and where are the most active groups
working on nanotechnology? Figures on the
number of patents applied may provide the
Small is Beautiful first answer to this question: Following an

analysis of Ernst & Young from 2007, about
Nanotechnology for 5,340 patents have been granted till 2004
in the USA, 2,559 in Europe and 1,220 in
medical devices Asia. Countries leading in nanotechnology
in Asia are Korea and Japan. We can as-
sume that the number of granted patents
in nanotechnology will further increase and
Medical devices and their components are currently more and more areas, such as construction,
being scaled down to molecular levels and successfully biotechnology and life sciences will profit
from developments in this field. Further,
applied in diagnostics and clinical therapies. most of the innovative companies dealing
with R&D in nanotechnology are small
and middle-sized enterprises with less than
30 employees. This implies a permanent
need for financial support, investments and
M
any of us might know continuous patenting.
Isaac Asimov´s science fiction Jörg Vienken “NanoScience is the study of phenome-
novel “Fantastic voyage” from Professor na and manipulation of materials at atomic,
BioSciences
1965. Here, a submarine has been scaled molecular and macromolecular scale, where
Fresenius Medical Care
down to the size of a microbe and includ- Germany properties differ significantly from those of
ing a miniaturised crew, has been injected larger scales.” …and… “Nanotechnology
into the blood stream of a scientist. These is the design, characterisation and applica-
scientists were able to successfully remove a and exploited for research and device tion of structures, devices and systems by
blood clot in the brain of a famous physicist, application. controlling shape and size at the nanome-
and by this, guarantee his survival. During In the 60s of the last century, both, the ter scale!” defines the Royal Academy of
the days when Asimov wrote his novel, novelist and the physicist, would have never Engineering in London in 2004.
Richard Feynman, the famous physi- dreamt that part of their fantasy and ex- Applications in drug delivery (>50%),
cist and Nobel laureate further stated: pectations would have partially come true. in vitro and in vivo diagnostics (>25%)
“There is plenty of room at the bottom!” Medical devices and their components are and implant technology (>20%) are
Feynman believed that new and yet unpre- currently being scaled down to molecular currently the preferred and successful
dictable material properties on the level of levels and successfully applied in diagnostics realms of nanotechnology application.
atoms and molecules should be explored and clinical therapies. Atoms and molecules What are the tools and structures used in
T E C H N O L O GY , E Q U I P M E N T & D E V I C E S
nanotechnology for the application in life modification. A controlled attachment of may also stimulate pathways of oxidative
sciences or in medical device technology? nanoparticles with defined chemical proper- stress and thus lead to inflammatory reac-
Regularly shaped cages, which are made up ties may be used for the analysis of optimal tions at low levels. Clusters of nanoparticles
of a network of hexagonally and pentago- structures to either repel bacterial cells or may also prevent the correct association
nally arranged carbon atoms may serve as promote protein absorption and thus help of nerve cells in vitro. As a consequence, a
tiny reservoirs for drugs. They are named the bioengineer to identify the most promis- case-by-case approach is needed in order to
after its discoverer Richard Fuller as Fulleren ing biomaterials. Quantum dots are a novel predict reactions caused by nanostructures,
Cages. Liposomes or other polymeric mi- class of inorganic fluorophores which are which renders the establishment of safety
celles are used as drug transporters once they gaining widespread recognition because of regulations for nanoparticles difficult.
have been modified with specific ligands. their exceptional photophysical properties. A further pitfall is the still lacking and
Conjugated ligands modify the surface of They are nanometer-scale semiconductor worldwide accepted regulatory rules for
such nanocarriers in such a way that they crystals which are engineered to emit light at approval of nanodevices. Prerequisites for
are able to pass the blood-brain barrier and a variety of precise wavelenghts from ultra- approval procedures are widely accepted
thus, deliver drugs to the tumour targets violet to infrared. The narrow emission and terminologies for medical, health and per-
hidden behind this barrier. Oligonucleotide broad adsorption spectra of these dots makes sonal care applications of nanotechnol-
modified gold nanoparticles can be used for them well suited to multiplexed imaging, in ogy. As long as no clear rules for approval
intracellular gene regulation. These particles which multiple colours and intensities are are available, companies hesitate to further
are less susceptible to degradation by cellu- combined to encode genes, proteins and invest in the development of nanodevices.
lar enzymes and exhibit greater than 99% small-molecule libraries. They are ideal tools Fortunately, efforts are currently made all
cellular uptake and were, at least under the for future tumour diagnostics, drug delivery around the world to solve this problem
conditions studied, non-toxic to the cells. systems or body-imaging processes. Figure and therefore, nanotechnology remains one
Further application stems from 2 provides an overview of possible applica- of the most promising innovations in life
nanofibres obtained through electrospin- tions of nanotechnology in life sciences. sciences today.
ning. These fibres may serve as stable or The interested reader is already con- Hans Christian Anderson, the famous
biodegradable scaffolds in bioreactors, as vinced about the advantages of nantechnol- Danish author of short stories published
reinforcing structures for blood vessels, ogy application in medical device technol- the “The emperors’ new clothes” in 1837.
biodegradable compounds for wound ogy outlined here by only a few examples. Here, two scoundrels, who had heard
healing or as a coverage for otherwise bioin- However, questions may still arise regarding of an emperor’s vanity, pretended to be
compatible materials such as stainless steel the possible pitfalls of these highly promis- extraordinary tailors and offered him
for drug-eluting stents. ing applications? Nanosized particles may a cloth so light and fine that it looks
Nanotechnology also offers promising give rise to cellular uptake or at least inter- invisible. As a matter of fact it was invisible
tools for surface modification of biomaterials action with cellular structures in the body. to anyone, who is too stupid and incompe-
through coating with nanoparticles and thus They may act as catalysts or nuclei for the tent to appreciate its quality. The emperor
achieving an optimal blood and cell-com- induction of protein fibrillation and thus took it for granted and presented himself
patibility. Such biomaterials are currently increase the risk for toxic clusters, e.g. in virtually without clothes. A child finally
used in procedures, such as hip implants or amyloid formation. Nanoscale surfaces can unmasked the situation by stating: “…look,
bioartificial blood vessels. Extracorporeally act as platforms for protein association, but he is naked!” Nanofibres applied today,
applied medical devices, such as membranes depending on its chemical composition, however, are indeed invisible to the naked
for hemodialysis or tubing systems for drug may also prevent fibrillation of proteins. eye. The old story of Anderson might have
delivery, also profit from this kind of surface Uptake of nanoparticles by biological cells finally come true.
Nanotechnology and Structures:

The Nanoscale - A Biological Scale -Potential medical applications-
Figure 1 Figure 2

F acilities & operations mana g ement
Healthcare
Design
The need for
consumer-driven
research
Nicholas J Watkins, Director, Research, Cannon Design, USA
The pivotal role of healthcare design in the

improvement of healthcare delivery has become
widely accepted under the rubric of evidence-
based design. However, there is a need for
consumer-driven, comprehensive programming
methodology applicable to healthcare design
projects in Asia and the United States.

T
he sheer number and magnitude It has been argued that healthcare or-
of healthcare challenges in Asia ganisations have seen a decrease in nosoco-
offer a compelling argument for mial infection rates, medical errors, length
conducting research with findings applica- of stay and nurse turnover by adopting basic
ble to the structure and design of health- EBD principles like private patient rooms,
care organisations. China’s gross domestic family zones and nurse respite areas. EBD
product has grown at 8% the last 25 years, permeates organisational structure and
but this has not translated into improved operations since it encourages design prin-
healthcare for the 900 million Chinese ciples that foster a patient-centered culture.
living in rural areas and who largely go For instance, it is believed that EBD fea-
uninsured (Blumenthal & Hsiao, 2005). tures like sub-nursing stations improve staff
Overall, there are not enough healthcare and patient relationships and the efficiency
facilities located in the right places. of healthcare delivery.
Other countries in Asia fair as well. EBD’s popularity continues to rise
India supports privatised healthcare with among healthcare organisations in the
82% of all healthcare expenditure being pri- United States. The American Institute of
vate (Arellano, 2007). Though profitable, Architect’s Guidelines for Design and Con-
investing in high-tech medical equipment struction of Health Care Facilities, 2006,
and cutting-edge drugs caters to Indian ex- stipulates the use of private rooms for med
patriates and foreigners who contribute to / surge and post-partum beds. Attendance
the projected US$ 1 billion “medical tour- at the Healthcare Design ‘06 in Chicago
ism” industry. Also, a recent study of 12 In- exceeded 2,400 healthcare executives, de-
tensive Care Units (ICUs) in India found sign professionals, product manufacturers,
that device-associated infections accounted educators, students, and others (Center for
for 22.5 infections per 1000 ICU days Health Design).
(Mehta et al., 2007). Yet, EBD has not taken off at a faster
Many Asian countries eagerly adopt rate. Why? One of the first studies credited
precedents from the United States to resolve as EBD research is Ulrich’s study of the pos-
their healthcare challenges. Is the United itive impact of window views of nature on
States a good role model? It ranks 37th in gall bladder surgery patients’ recovery time
overall health performance when compared (1984). However, the study’s findings were
with 191 other countries, yet its healthcare published more than 20 years ago.
spending is 15% of gross domestic product
(World Health Organization, 2006). The Obstacles to evidence-based
United States is the primary example of how design
high-tech medical services have contributed The below table summarises some of the
to the overuse of and exorbitant cost of challenges to EBD and EBD research in
healthcare (Blumenthal & Hsiao, 2005). the United States. These challenges follow
Finally, in the United States, medical errors from a lack of goals and processes for EBD
account for 44,000 to 98,000 deaths a year research shared by designers and EBD re-
(Kohn, Corrigan, & Edelson, 1999). searchers. I will briefly explain the obstacles
listed in the Table 1.
Evidence-based design research EBD research is “lost in translation”
offers solutions between research findings and their ap-
Healthcare organisations in the United plication to building projects. The “lost in
States have taken strides toward improving translation” obstacle could be for a variety of
all aspects of healthcare. The pivotal role of reasons including little consensus over the
healthcare design in the improvement of definition of EBD, the lack of EBD research
healthcare delivery has become widely ac- findings, and a history of EBD research that
cepted under the rubric of Evidence-Based does not use proven research methodologies
Design (EBD). Evidence-based healthcare (Watkins & Keller, 2007).
designs, “...are used to create environments Second, despite the growing interest
that are therapeutic, supportive of fam- in EBD research, most building projects
ily involvement, efficient staff performance involve a separation among researchers,
and restorative for workers under stress” designers, clients and end consumers
(Hamilton, 2003). like patients and healthcare staff
Director of Research with literature search-

es and data collection. Such partnerships
assure future designers become sympathetic
to research and know how to apply it.
Research could have a greater impact
by including characteristics that interest de-
signers and administrators (Kuo, 2002). For
greater impact, EBD research should:
• Clearly define its audience. The audience
can include hospital administrators, nurs-
es, staff and others
Figure 1
• Be shared in a trusted and persuasive for-
(McCormack & Shepley, 2003). As a re- their use (Kong, 2007). Also, results from mat such as a newsletter, at a conference,
sult, end consumers have minimal or no say conjoint analyses are appealing to clients part of an exhibit or part of an instruc-
in design decisions. and marketers, but do not measure the tional video
These obstacles reflect a conflict over impact of design since the research relies • Identify design interventions that affect
EBD research’s role in the United States on consumer preference and is performed the audience’s practices. These can in-
healthcare design market and one that is outside of healthcare settings. clude nursing unit configurations, nurs-
evident with medical tourism in Asia. Sim- Theoretical differences between designing station types, sustainable systems, and
ply put, should healthcare design be mar- ers and researchers pose an obstacle to the electronic medical records (EMR)
ket-driven or research-driven? (Watkins growth of EBD. Traditionally, researchers • Prioritise design interventions. For in-
& Keller, 2007) For an example of how are taught positive theory. According to stance, statistics might demonstrate the
research can influence the market, design positive theory, there is an objective reality client would be wiser to invest in sustain-
practitioners cite studies of window views that can be tested, explained and predicted able design before sub-nursing stations
and healing gardens when promoting EBD by revealing causal links (Groat & Wang, Overall, research should be value-based
to clients. However, these studies and their 2002). On the other hand, designers are where value is defined as the ratio of qual-
findings might be too broad for designers trained with normative theory. As such, de- ity to cost (Evans, 2006; Porter & Teisberg,
who need to know whether an enclosed signers use facts based on intuition, conven- 2004). For example, staff retention can stand
or exterior healing garden is better for a tion and experience. for quality. The expense to promote and
specific facility. Positive and normative theories foster maintain patient safety through design can
Research that is entirely market-driven two different mindsets. Researchers want to stand for cost. Thus, value can be a useful and
can forego rigour for quick and dirty re- contribute to existing knowledge, advance objective measurement of performance.
search findings that might not hold water, existing knowledge and reveal new findings. Designers and EBD researchers have
but capture interest (Rostenberg, 2007). Findings should be publicly accessible for different standards for successful research.
For example, currently there are no peer-re- the greater good of society (Fisher, 2004; Designers judge research as either “good”
viewed, published findings of same-handed Kuo, 2002). On the other hand, design- or “bad” depending on its applicability to
patient rooms. Yet, it is easy to find sources ers want to make a profit from novel ideas. a project and whether it wins commissions.
that make strong arguments for or against Designers might prefer research methods Researchers often judge research based
and findings kept in- on the limitations of its methods. For ex-
Challenges to Goals and Processes Shared By Design and house and copyrighted ample, a study with a thorough literature
Research in the United States of America as intellectual property. review, large sample size, patients randomly
Definitions of Terms for Evidence-Based Design Academia-industry assigned to control and experimental groups,
partnerships could im- and with a pre and post-occupancy format
Gap among Consumers of Healthcare Design
prove the relationship would get a lot of attention from EBD
Market-Driven Research versus a Research-Driven Market
between design and researchers.
Positive versus Normative Theory research. For instance,
Proprietary versus Shared Information the author’s healthcare Overcoming obstacles
Academic-Industry Partnerships design firm continues EBD research should be integral to design
Value-Based Research to support an annual process so that research findings translate
healthcare design stu- into superior building projects. Under this
Research versus Design Standards (Including)
dio at the University of premise, a building project becomes a value-
“Good” or “Bad” Judgment of Results versus Limitations of Method
Illinois, Urbana-Cham- based entity with which design practitioners
Purpose of Research and Methodology paign. Also, the firm’s maximise the client's return on investment.
Generalisable versus Project Specific Research Findings staff includes a master’s With this aim, EBD research should ad-
Immediate versus Long-Term Results level architecture stu- vance towards a methodology that resolves
dent who assists the the obstacles listed in table 1 and assists
Table 1

• Research and researchers assume a me-

diary role among designers, clients, staff
and patients throughout programming.
• Theoretical differences between design
practitioners and researchers are resolved
• Inferential statistics help establish causal
relationships among several design fea-
tures and outcomes (e.g., medical errors)
• Pre-occupancy measurements can estab-
lish a solid baseline with which to com-
pare post-occupancy measurements
• Mixed methods using quantitative (e.g.,
questionnaires) and qualitative (e.g., fo-
cus groups) tactics support one another
• Research findings inform immediate and
long-term solutions
Centralized Based on prior comprehensive pro-
gramming efforts, the author’s healthcare
design firm devised project-specific design
solutions. These solutions considered nurs-
ing units as consolidations of several inter-
Clustered acting design features. See Figures 2 and 3
1:6 or 1:8 for examples.
Currently, the author’s healthcare design
firm uses aspects of comprehensive program-
Decentralized
1:1 or 1:2 ming to evaluate infusion area designs, trans-
lational research facility designs and human
interactions with sustainable systems.
Figure 2
Evidence-based design research
in Asia
with functional programming. By address- ket by advocating the needs of users (e.g., EBD-related research findings have already
ing all these obstacles, the programming patients, staff, etc). To strike a balance, EBD made an impact on healthcare design in
methodology can be designated as compre- research should investigate users as consum- Asia. The Alexandra Hospital in Singa-
hensive programming. ers of healthcare. Consumers make deci- pore will be able to respond effectively to
Comprehensive programming should sions on healthcare and are impacted by epidemics and disasters with thermal scans
be market-driven to reflect the healthcare experiences during a hospital visit. The em- at the entry to its emergency department.
organisation’s interest in attracting market phasis on consumer driven, comprehensive Also, the hospital will dedicate two below
share. Also, research should impact the mar- programming offers several advantages: grade floors to an autonomous treatment
facility with its own mechanical and elec-
trical system (Gifford, Green, & McCarter,
2006). Ongoing research in Taiwan of mall-
like healthcare complexes demonstrates that
“normalising” entire healthcare facilities at-
tracts market share by appealing to patient’s
wants without sacrificing patients’ needs
(Kuo & Wang, 2007).
These and other research efforts dem-
onstrate that Asian countries have every
opportunity to achieve design solutions by
performing rigorous EBD research. With
the continued development of method-
ologies like comprehensive programming,
Asian healthcare organisations can devel-
op novel solutions tailored to healthcare
Figure 3 market needs and the standards of research.
Desperately
Seeking Safety
Creating integrated
Bill Rostenberg surgical/imaging
Principal and
Director
Research
environments that
Anshen+Allen Architects
USA do less harm
Paul Barach
Visiting Professor
Anesthesia & Emergency The need for healthcare facilities designed for safety and the
Medicine
Center for Patient Safety convergence of surgery and imaging are resulting in new types
Utrecht University Medical of space where medical technology is complex and where safe
Center
The Netherlands environments are essential.
H
ealth care is plagued by an in- large disconnect between designers and fa- facilities designed for safety, and the conver-
surmountable abundance of cility users with the result that little formal gence of surgery and imaging are resulting
medical errors. It is estimated knowledge is implemented in preventing in new types of space where medical tech-
that over 100,000 preventable deaths oc- patient harm by better building design. nology is complex and where safe environ-
cur each year in the US hospitals alone. This disconnect is particularly apparent in ments are essential.
This is equal in magnitude to a 747 jumbo designing peri-operative settings (i.e., pre-
jet liner crashing every three days with op, surgical operating room, interventional Errors and accidents common
no survivors aboard. While there are only procedure suite, recovery room). in surgical and imaging
limited data identifying the role that the Additionally, medical advances are caus- environments
built environment contributes to medical ing some traditional departmental boundar- Researchers have found that approximately
errors, this knowledge is on the increase as ies to disappear, yielding new types of pro- 10.5% of all adverse medical events and
part of a growing area of interest known cedural spaces in which modern medicine 19.7% of all serious adverse medical events
as evidence-based design (EBD). It is clear is practiced. This in turn is changing medi- may be related to surgery while many others
that facility design has an impact on safety— cal culture as specialists collaborate in ways are related to medical imaging. Categories
either beneficial or detrimental—depend- that differ from past tradition. Nowhere of medical errors and safety include wrong
ing on how each particular facility is de- is this change more apparent than in the site surgery, wrong person surgery, radia-
signed. convergence of surgery and interventional tion exposure, magnetic resonance imaging
At the same time the world is in the radiology. accidents and hospital-acquired infections.
midst of the largest hospital construction The epidemic of preventable medi- While the majority of these errors may
boom in half a century. There remains a cal errors, the growing need for healthcare not be directly related to facility design,

knowledge of how the built environment Some surgical suites are being outfitted with that cross paths of traffic. Wireless devices
affects safety and medical outcomes is es- control rooms (similar to those found in may also reduce the need for cables and
sential in designing healthcare facilities that diagnostic imaging departments) adjacent wires. In addition, there is growing interest
do not further contribute to unnecessary to the operating room anticipating the in- in illuminating operating rooms with green
iatrogenic outcomes (a condition that has creased frequency and complexity of radia- colored lights, as research by the US Navy
resulted from treatment, as either an un- tion emitting devices being used within the has demonstrated improved visualisation
foreseen or inevitable side effect). operating room. of data on flat panel monitors while still
maintaining a relatively high illumination
Handed or universal rooms Magnetic resonance imaging level throughout the room. Green surgi-
One theory among practitioners of evi- safety cal lights are another seemingly good idea,
dence-based design is that if all operating Accidents related to ferrous objects inappro- with insufficient data, to prove or disprove
rooms and other procedure rooms are con- priately brought into an MRI suite are one its efficacy.
figured identically (sometimes referred to of the top ten safety concerns of healthcare
as handed or universal rooms) the rooms executives. While very few deaths caused by Conclusions
would be safer because during an emer- ferrous objects pulled into a magnet have Surgical suites and imaging suites are both
gency staff would intuitively know where to been documented, accidents of this nature areas where medical errors can occur com-
look for supplies and instruments because are known to occur frequently. As a result of monly and where the built environment has
they would all be in the same place regard- one fatality in 2001 the American College a profound impact on injuries to patients
less of which room they were in. While this of Radiology (ACR) developed a white pa- and staff, medical outcomes and overall
hypothesis seems logical there’s no quanti- per with guidelines for designing safe MRI safety and well-being. When the practices of
fiable evidence supporting this conclusion. suites. While these guidelines are relatively surgery and imaging are integrated into one
Furthermore, if all rooms look alike, they easy to apply to MRI suites used for diag- comprehensive area as is becoming increas-
might actually contribute to an increase of nostic imaging it is challenging to incorpo- ingly more common designing these spaces
wrong person surgery due to the lack of rate them into the design of intra-operative for safety and improved medical outcomes
visual cues, such as distinctive landmarks MRI (I-MRI) suites. This is because intra- becomes increasingly more complex and
in the room providing guidance to which operative MRI procedures often require costly.
room, and thus which patient, the staff is surgical instruments that are attracted by Design is more complicated because
attending to. Therefore, if operating rooms magnetic field to be used in close proximity each medical specialty has different tradi-
are “handed” some form of distinguishing to the magnet itself. Therefore, the design of tions of work flow, different regulatory
accent or landmark should be provided. intra-operative MRI suites requires particu- guidelines that govern how they perform
lar attention be placed on safeguards such as medical procedures and they often use dif-
Radiation protection metal detectors, that alert staff when metal ferent instruments and supplies (i.e., dis-
Radiation emitting devices continue to be- objects are brought into the general vicinity posable versus reprocessed instruments).
come safer. However, permissible accumu- of the magnet. Therefore, designers of integrated surgical
lated levels of radiation exposure are rapidly and imaging facilities need to prioritise the
becoming more conservative. As a result, Lighting and tripping hazards importance of safety as an essential concern
radiation shielding requirements continue Minimally invasive surgery (MIS) is typical- in their designs. Understanding the impact
to become more stringent, even as most ly performed in operating rooms with very that designs have on patient well-being is
radiology equipment is becoming more reli- low levels of illumination, in order to better essential.
able. In addition, there is growing interest visualise anatomical information. Because Key safety issues to consider include
in associating the long-term effects of radia- as the name suggests minimally invasive reducing nosocomial infection rates, help-
tion exposure with an increased incidence of surgery is not an “open” surgical procedure. ing prevent wrong site and wrong person
survivor cancer. While most imaging facili- The flat panel monitors are the essential procedures, protecting people from unnec-
ties are designed to ensure adequate radia- “eyes” of the surgical team and provide a essary radiation exposure and helping pre-
tion protection, surgical facilities are not al- multitude of indispensable data to guide vent MRI accidents. Several organisations
ways designed with this in mind. As surgery the procedure. provide information about reducing medi-
becomes increasingly dependent on image Performing complicated procedures cal errors, improving healthcare safety and
guidance, adequate radiation protection in a dark room in and of itself is danger- learning more about evidence based design.
becomes more critical. For example, many ous leading to staff tripping accidents, mis- These include: the Institute for Health-
operating rooms where x-ray technology is communication and degradation in perfor- care Improvement (IHI) www.ihi.org, The
used typically rely on small ceiling-mounted mance. Cables, tubes and wires connecting American College of Radiology (ACR)
lead shields and surgical staff wearing per- various medical and information manage- www.acr.org, The American College of Sur-
sonal radiation protection. However, dedi- ment systems create additional tripping geons (ACS) www.facs.org, The American
cated space is rarely provided for technolo- hazards. Therefore, it is advisable to mount Society of Anesthesiologists (ASA) www.
gies that control the imaging equipment to devices on walls and ceilings wherever asahq.org. and The Center for Health
work within a radiation controlled zone. practical when this can eliminate cables Design www.healthdesign.org.
I N F O R M A T I O N T E C H N O L O GY
RFID in Healthcare
Enabling patient safety
With the size and costs of RFID tags decreasing, their incorporation in surgical sponges,
endoscopic capsules and endotracheal tubes is creating potential benefits in patient safety
and diagnostics.
simultaneously through through materials, while better and higher

Remko van der Togt physical barriers and from a frequencies can process more data. Based on
Consultant distance, RFID has an ad- these and other characteristics like the risk
Geodan Mobile Solutions vantage compared to read- of electromagnetic interference or the object
The Netherlands
ing barcodes that require of interest, the most suitable RFID system
‘line-of-sight’ and active can be applied. In order to track patients or
user interaction to access medical equipment through your facility, an
the enclosed information. active or semi-active RFID system could be
RFID systems exist of three appropriate. For inventory control or blood
main parts: (1) the tag, product patient matching at the Operating
which is the identification Room (OR) a passive RFID system might
device attached to the ob- be sufficient. In the pilot, a semi-active
ject being tracked, (2) the RFID tag with a temperature sensor was
reader that recognises the used for tracking blood products.
I
n 2005, the Dutch Ministry of Health, presence of a tag and reads and processes
Welfare and Sport initiated a project the information which is stored on the tag RFID at the AMC
with RFID in healthcare. Capgemini, and (3) the antenna, which is part of the The application of RFID at the AMC in
Geodan, Intel and Oracle implemented communication between tag and reader. Amsterdam were conducted in a large-
three applications at the Academic Medical Tags are also called transponders and scale pilot that was carried out at the Op-
Center (AMC) in Amsterdam. The applica- basically exist of three types. First, pas- erating Rooms, the Intensive Care Units
tions were based on the use of active and sive tags do not have a battery and derive (ICU) and Blood transfusion laboratory.
passive RFID tags. The Geodan Movida their power from the radio frequency sig- The purpose of the pilots was to show
platform managed all identification, loca- nal broadcasted by the reader in order to the added value of RFID in Healthcare,
tion and other attribute information. Next be able to transmit their data. Second, ac- with a special focus on patient logis-
to these applications the project created an tive tags have a battery and a transmitter, tics, patient safety and disposables ef-
overview of best practices and standardi- and do not rely on the power derived from ficiency. The goals of the first pilot were
sation issues of RFID inside and outside the reader to operate. Third, semi-active (or (1) to acquire insight into the patient’s
Europe. semi-passive) tags have a battery and use journey through the OR-complex and
Applications that facilitate logistics and the radio frequency signal broadcasted by (2) to understand movement in and out
inventory management of expensive medi- the antenna to be activated in order to com- of the operating room. The second pi-
cal equipment appear particularly promis- municate. Semi-active tags can also contain lot addressed the issue of location and
ing in the healthcare industry. And because sensors (i.e. temperature or humidity) that temperature monitoring of blood dur-
the size and costs of RFID tags are decreas- can be used as data-loggers. The tag ‘wakes ing the entire transportation and stor-
ing; their small size permits incorporation up’ at pre-defined times to update the data age process. The third pilot focussed on
in surgical sponges, endoscopic capsules collected by the sensor. Activation by an the accurate measurement of the use of
and endotracheal tubes with potential ben- antenna is not required. expensive disposables.
efits in patient safety and diagnostics. RFID systems operate at frequencies The central software system Geodan
Essentially, Radio Frequency Identi- ranging from low frequency (LF) at 125 Movida, collected and processed data of the
fication (RFID) systems collect informa- kHz to microwave at 2.45 GHz. The latest ID and location of patients, blood prod-
tion about physical objects automatically. one is also known as the technology used ucts and disposables. It also provides alert-
Because information about tagged objects for Wireless Local Area Networks (WLAN). ing capabilities, to prevent, for instance, the
can be transmitted for multiple objects Lower frequencies are able to penetrate administration of the wrong blood product

Resource management in a hospital environment based on indoor location services. The picture shows four pieces of equipment in the emergency
floor of a medium size hospital.
Source: Macchi Hospital in Varese (Italy). Figure 1
to patients. The system presents real-time • Blood quality: ‘Where is the blood for especially the active RFID infrastructure
insights in patient flows, blood products this patient? And what is the tempera- is important. When readers or anten-
and equipment use. The data stored and ture profile in the last 10 hours?’ nas are too close to each other tags can
collected during the pilots were the basis By combining the processed ID and be picked up by several readers simul-
for deriving information on the usefulness location data of patients, blood products taneously and might produce wrong
of RFID and the assessment of the accu- and disposables, patient safety and the ef- information, like the wrong location or
racy and completeness of the collected data. ficiency of these processes can be improved. otherwise. Besides these technical
Besides the functionality that was used in For instance, personnel at the operating challenges other points of interest are edu-
the pilot at the Academic Medical Center, room are warned when a blood product cation of users, a clear insight of the pro-
Geodan Movida offers a portfolio of loca- might be administered to the wrong pa- cesses that will be supported by RFID and
tion, identification and RFID services for tient. Second, hospitals can register the use privacy issues.
healthcare, such as: of disposable material and equipment per
• Expensive equipment tracking and main- patient automatically and more accurately. Conclusion
tenance: ‘Where is the EKG?’ (Figure 1) This also induces a variety of new possibili- RFID can provide tangible benefits in
• Patient safety: ‘Does this blood product ties on the level of the individual patient. the healthcare industry especially when it
match with this specific patient?’ Within the pilot, special care was taken comes to:
• Patient flows: ‘When did patient Brown of electromagnetic interference of RFID • Establishing safe working environments
leave the department?’ equipment on medical equipment. Strict for patients and physicians
• Medical staff safety: ‘Nurse Jensing re- tuning and organisational measures are • Improving workflow and logistic pro-
quests urgent assistance in Room 3A45.’ needed to establish an infrastructure that cesses by tracking and tracing of patients,
• Patient logistics: ‘Did Mr Jones already does not cause interference but at the same physicians, blood products, equipment
arrive?’ time provides complete and accurate RFID and so on
• Material use: ‘How many pieces of prod- data processing. • Providing patients and their relatives
uct X have we used today in the surgery First, all medical equipment that could with better services
theater?’ be influenced by the electromagnetic fields In order to support this, innovative
• Equipment availability: ‘There is an in- broadcasted by RFID was tested for elec- applications of mature technologies,
sufficient number of wheelchairs in the tromagnetic interference by RFID. Second, based on platforms of proven quality and
ER department!’ the adjustment of the radio fields of, reliability are already realised.
EMR in a Large Healthcare

Organisation
Development and implementation
The YUHS planned a new EMR system that integrated pre-existing systems within the new
system. The philosophical objective was to achieve first class medical services with safety,
reliability and convenience through IT.
several information systems in last 10 years, to do, because there are too many patients
Yong Oock Kim such as Order Communication System (OCS, for individual clinicians to take care and too
Professor same term with computerised patient order many medical records to write in a limited
Department of Plastic & Reconstructive entry), Picture Archiving & Communica- time. This situation makes many clinicians
Surgery tion System (PACS), Human Resource hesitate to use the electronic recording sys-
and System (HRS). The YUHS planned a new tem. They are afraid that they may not fin-
Director HIS that integrated pre-existing systems and ish their work in proper time and may not
EMR committee
Yonsei University Healthcare System
newly-developed systems, such as Enterprise have positive return on investment (ROI)
Korea Resource Planning (ERP), Groupware (GW), consequently. Therefore, the development
Activity-Based Cost analysis (ABC), Clinical and implementation of EMR system in
Data Repository (CDR), Disaster Recovery Korea meant more than the development of
E
very healthcare organisation always (DR) systems on basis of new system that in- the system itself.
tries to deliver better services for its cluded renovation OCS and EMR systems. The EMR system had to be a real-
customers. Information Technol- istic one that is fast enough to use, easy
ogy (IT) can be a representative tool for Objectives and master planning enough to learn, and also cost-effective.
enhancement of healthcare services. The YUHS planned for an effective and ubiqui- It also has to keep basic pre-requisites of
scope of IT can be a simple one to more tous HIS. The philosophical objective was to EMR system, such as standardised termi-
complex one. However, in case of medical achieve first class medical services with safety, nology system and Clinical Document
healthcare system any application of IT has reliability and convenience through IT. To Architecture (CDA) that are necessary
to have the fundamental philosophy of “pa- achieve this objective, YUHS planned the for future sharing of information and in-
tient-oriented care”. To fulfill this philoso- EHR system as a core system, which was be- tegrity of documents. This is not easy to
phy, the application process of IT should be yond a simple order exchange system. There- realise. Therefore, many clinicians should
creative and innovative for individual health fore, the master plan focussed on renovation give their knowledge and efforts, and all
organisation. The best adaptation of IT to of OCS, development of EMR system and departments should change their working
individual health organisation will guaran- then the integration of these two systems. process under the new digital environment.
tee the best ‘care processes’ for their patients. The prime objective of the EMR system was The acting groups were organised
According to the scope of IT applica- the security of data and the privacy protec- into several working groups (WGs). There
tion in the organisation, the objectives and tion. On the basis of these objectives, the were terminology WG, clinical docu-
process of development and implementation system has developed with the strategic con- ment WG, User Interface (UI) WG, Au-
would vary. sideration of standardisation, customisation, thentication WG, Security WG, Nursing
Yonsei University Healthcare System and authentication principles. The standar- WG, CDR WG, Equipment interface
(YUHS) is a healthcare organisation with disation was done from code to the clinical WG, and CDR WG. All working groups
four hospitals, three colleges and two gradu- document. The customisation focussed on comprised clinicians, nurses, paramedi-
ate schools. YUHS has 2,500 beds and is the user interface and special needs of end users. cal personel and IT engineers. These
first westernised health organisation in Korea The authentication was done by adoption of WGs were focussed on their specific in-
since 1880. Sixty four specialised medical new technology. terest, such as standardisation of termi-
departments are involved, and 600 clini- nology, unification of data, maximum
cians and 8,000 employees are working in Considerations customisation of UI, job-defined authen-
the main hospital. With respect to Hospital For many clinicians, EMR system, instead tication, nursing process, and security and
Information System (HIS), YUHS has used of paper recording, is regarded as a hard job private protection.

Process of standardisation Document Generator (CDG) that can cre- signature, and the other is a storage into the
The standardisation of terminology was ate XML formatted clinical document forms database of individual value of MR item.
accomplished by clinicians and nurses inside by simple selection of MR items (See Figure XML file storage maintains the interoper-
the organisation. Simultaneously, all codes of 1) This innovative process of clinical docu- ability and integrity of medical record, and
previous system were gathered from all the ment generation makes possible convenient database storage of MR item enables more ef-
departments and unified between depart- use and fast adaptation of the EMR system ficient use of the information for the research
ments. This work of standardisation can among clinicians. and management of hospital. As next steps
provide the basis for a successful EHR sys- of implementation, we included the Disaster
tem implimentation. Codes consist of codes Basic architecture of the EHR Recovery (DR) system into the basic archi-
of accounts, resource, medicine, laboratory, system tecture for the security of data at six months
operation/treatment and departmental codes After the establishment of SSTD and data- later, and built the Clinical Data Repository
that are managed separately by each depart- base of MR items, we mapped terms of SSTD (CDR) at 22 months later for better clinical
ment. The standardisation of terminology and MR items with terms of the internation- research and hospital management.
was done by accumulation, analysis, classifi- ally accepted terminology system, to achieve
cation, and new concept creation of terms. future global sharing of information, such as, Development of specialised
All record items with entered value were SNOMED-CT, ICD-10 ICD-9CM, ICNP, functions of EHR system
defined as Medical Record (MR) items and NINDA, NANDA, NOC. On the basis of We decided to develop several specialised
were gathered from the 926 paper-based above terminological architecture, all clinical functions that reflect the organisation’s
clinical documents. As a result, MR items document forms were created by CDG. The unique situation and culture, in order to en-
(15,092 items), Standardised Severance formation of document can be done by clini- hance the safety and security of patient. They
Terminology Dictionary (SSTD; 62,232 cians themselves and recorded. All recorded are as follows. Drug Adverse Effect Report
terms) and medical images (1,445 images) data is stored into the file server and database System, Insurance Acceptance Guide System,
have been classified after a filtering and map- server for 22 months until now. ( Figure 1) Diagnosis Guide System, Antibiotics Dosage
ping process. On the basis of intra-organisa- All clinical documents are stored in two Control System, Child TPN Support System,
tional terminology, we develop the Clinical ways. One is a storage of XML file with Nursing Process System, Patient Information
Architecture of Clinical Documents U-Severance System
Electronic Clinical Documents ABC EIP

DB SEM CRM
EMR
Storage
XML File
Storage Medical Record Items u
Integrated S
Mobile HP
HIS & CDR M DW
Standardized Severance Terminology Dictionary A
PACS R
T Integrated
926 Paper-based Clinical Documents Homepages
ERP
Severance PACS (GE)
Dental OCS
Severance OCS
Yongdong OCS
SNOMED-CT, ICNP, ICD-10, ICD-9CM, 3N Cardiovascular cine PACS Sister
PI Hosp
Dental PACS (Infinit)
Medical Terminology Order, Account,
(CC, Dx, Tx, etc.) Resource Terminology OA GW KM
Yongdong PACS
Architecture of clinical document & terminology in U-SMAET Figure 1 Scematic diagram of U-Severabce & U-SMART system Figure 2
Control System, Specific Disease Marker The process of maximum customisa- knowledge and have a strong interest for further
System, Patient Education System, Double tion of UI is also important to the successful development and better utilisation of the
Check System with Barcode and RFID. implementation. The customisation process system. This kind of organisational upgrade
These special functions were the results of ac- of UI is a continuous interaction between fi- was another result from the hard work put
tive participation of clinicians and nurses in nal users and IT engineers. Post implementa- into the development of the EHR system.
the project. Therefore, these functions can be tion, µ-SMART provides information to the
the most ideal functions for the YUHS. Af- other information systems, such as Enterprise Perspectives
ter implementation, feedback from the users Resource Planning (ERP), Activity Based Already 23 months have passed after the im-
of these functions was obtained to improve Cost analysis (ABC), Groupware (GW), plementation. Now no clinicians and nurses
and further develop functions to accom- i-Severance (homepage), Parking system, can imagine working without µ-SMART
modate the users continuously. As for the Smart Card system (Figure 2). As a whole we system. Also we have found evidence of
authentication part, an ID-password system have the system as ‘µ-Severance system’. evolution, like the self standardisation of
was developed. The smart card system with terminology, faster innovation of clinical
Public Key Identification (PKI) was adopted The lessons document formation, better quality of record-
to verify the right individual for viewing and Getting the clinicians to participate was a ing, better working process and voluntary
recording the data. This system is connected tough task during the development. They participation of new HIS projects. The eco-
with the human resource system (HRS) of don’t want to change their working process nomical effect and the Return on Investment
YUHS; therefore, change in job status can abruptly, and sometimes they cannot catch (ROI) is still under investigation, however,
directly change the authority of medical re- what they have to help or how they partici- we can be sure that there are many positive
cording. Finally, we named this core EHR pate. Same as clinicians, there can be conflicts ROIs of EHR system. Further reports will be
system ‘µ-SMART’ (Severance Medical among paramedical departments due to their prepared in near future. We also have to
information Archiving & Retrieval System). working boundaries. These situations can be keep the value innovation of EHR system to
aggravated because nobody can show the fi- improve quality of care and to enhance the
Implementation (Go-live) nal result intuitively until the end of develop- research capability, and also have to keep the
After 12 months of development, the Go-live ment. However, it can be safely said that the technical innovation to integrate IT into the
plan was initiated and the final implemen- most important thing during the process was individualised home care of health.
tation was accomplished after 16 months of to continuously encourage of participation In conclusion, I am sure that the EHR
development. Go-live planning is crucial to with passion. Any health organization has its system improves clinical working process,
the successful implementation of the system. unique culture and special working process- patient’s safety and active utilisation of medi-
The plan consisted programmes of educa- es. As a result of participation, the individu- cal information. And it will realise ubiqui-
tion, simulation, and rehearsal with mock als can know the strong and weak points of tous environment of medical service in near
patients. The most important process was the organisation and their working processes. future. The results of current EHR system
the education of end users. We planned three Only active participation can overcome any will be another foundation for the sophisti-
education programme; key user’s program, difficulties and can make the most effective cated EHR system of the future, and knowl-
individual repetitive program and group EHR system. When everyone participates, edge-based medical services will become a
program according to position, job and it helps in learning more about the HIS reality. However, we should remember that
department. itself as every participant can share his/her people are always at the centre of the system.

Applying Path Innovation

Seeking revolutionary HIT
Healthcare requires a revolution in the way we deliver care by utilising IT in new and
innovative ways. Path innovation allows experts to work together in the development of
workflows that best leverage HIT.
cal mishaps, the US experienced about Time for a revolution

Barry P Chaiken 75% more deaths than the average OECD Revolution is defined as a “drastic and far-
Associate Chief Medical Officer country (Figure 2). reaching change in ways of thinking and
BearingPoint Don Berwick, an international leader behaving.” Healthcare systems require a
and in healthcare quality improvement ob- Health Information Technology (HIT)
Fellow of HIMSS
served that “every system is perfectly de- revolution, a drastic change in the way
USA
signed to get the results it gets.” Building on we deliver care by utilising IT in new and
Dr. Berwick’s notion, other experts have innovative ways. Aggressively deploying
defined insanity as doing the same thing IT, to replicate the processes and work-
over and over again and expecting differ- flows that currently deliver disappointing
N
o country in the world spends ent results. results on so many measures, only guaran-
more of its GDP on healthcare Perhaps for some of us, deployment of tees continued sub-optimal and unaccept-
than the US Compared to other healthcare IT is our expression of insanity. able outcomes.
countries in the Asia Pacific region, the US Many organisations, led by dedicated and Touted as a source of great efficiency
spends anywhere from 33 to 500% more, intelligent professionals, successfully im- and effectiveness, information technol-
and when compared to other Organisa- plement—as defined by technical specifica- ogy currently offers limited healthcare
tion for Economic Co-operation and tions—a variety of healthcare information examples of significant and documented
Development (OECD) countries it spends systems only to discover that their process gains. Considering the millions of dollars
50 to 100% more (Figure 1). Yet accord- and outcomes measures change little. Un- spent on healthcare IT by organisations
ing to a report published by the California fortunately, without changing the under- around the world, these results are quite
Healthcare Foundation in May, 2007, the lying processes and workflows that existed discouraging. To best understand why our
US ranked last or next to last on 9 of 10 before the implementation of healthcare IT, gains from IT investments have not
measures of healthcare delivery. On the little change in those measures should be materialised, let’s look at other industries
measure of deaths due to surgical or medi- expected. as models.
Healthcare Spending as a % GDP, 2003 Deaths Due to Surgical or Medical Mishaps per 100,000 Population in 2004
Source: WHO. The World Health Report, 2006; Commonwealth Fund. Figure 1 Source: J. Cylus and G.F. Anderson, Multinational Comparisons of Health Figure 2
Healthcare spending and Use of IT in OECD Countries, May/June 2006. Systems Data, 2006 (New York: the Commonwealth Fund, april 2007).

Early investment by other businesses in isolation is to miss the true lesson to be expertise inherent in each silo of knowl-
in information technology delivered very gained from their experiences. Early on, edge.
unsatisfactory results through the early the deployment of IT was viewed as the The failure of clinical IT tools to de-
1990s. Executives, expecting computer solution. Only after companies recognised liver safer and more efficient care is due to
systems to provide increased efficiencies it to be just a tool, did they formulate the many factors; yet all of them have origin in
and worker productivity, realised few, if real solutions based upon revised processes the concept inherent in the phrase “path
any, benefits from investing is these systems. and workflow which then provided much innovation.” Although the theories and ex-
The idea of a paperless office never of the benefits. pertise that form the basis of path innova-
materialised as many workers printed out tion are not new, their interaction with and
each and every email message, handling Focus of revolutionary IT subsequent impact on clinical IT is.
correspondence as they would a mailed let- Revolutionary HIT requires a focus on
ter or an interoffice memo. three key areas: 1) processes and work- Three key factors of path
Then sometime in the mid-1990s, that flows, 2) information technology tools and innovation
all changed. Rather quickly, over a three- 3) healthcare provider tasks, duties and re- Path innovation is dependent upon three
year period, using computers to communi- sponsibilities. key factors: 1) Process improvement or re-
cate, transact purchases and transfer docu- Solutions come from an indepth un- engineering, 2) Clinical guidelines, clinical
ments became normal business practice. derstanding of tools and creative think- paths and evidence-based medicine, and
Developers and users together conceived ing around what healthcare professionals 3) IT system design. Although subject
more and more activities that could be can do and how best to use their indi- matter experts exist in all these areas, it is
conducted online. vidual skills. Bringing together experts in unclear how well these experts historically
Across most industries that deployed clinical medicine, information technology worked together in the design and imple-
IT, a lag period occurred where quality and process redesign creates an environ- mentation of clinical IT systems.
and costs savings did not appear. As frus- ment where the best processes and work- Process improvement experts under-
trating as this period was, companies that flows effectively leverage the new HIT stand how processes impact outcomes
continued to invest in IT, slowly began to tools. Such diverse working groups allow and what analytical steps are needed to
experience the jumps in productivity and meaningful knowledge transfer and the de- evaluate processes. They are able to sug-
profit that were long expected. Each or- velopment of solutions that transcend the gest changes in processes and predict
ganisation reached a tipping point where the potential improvements such changes
processes and workflow evolved to take will deliver. Experts in clinical content un-
advantage of the new IT tools to derstand what various clinical paths
deliver unprecedented re- deliver as outcomes. They are
sults. To look at the able to link various in-
benefit of IT on terventions with
these companies probabilistic
results.
Designers of IT systems understand the system design phase, clinical and process Currently patient delivery relies upon
flow of digital information within com- design experts share their understanding an unreliable system of poorly integrated
puter systems and the user interfaces that of their discipline with the IT system de- and highly variable healthcare profession-
receive and deliver data to users. They are veloper. als. Revolutionary HIT solutions provide
able to conceptualise how a data point can During the implementation phase, the needed support tools that increase
be stored or reformatted with other data IT system designer and the clinical content the reliability of the human components,
points. expert act as consultants to the process re- while integrating these components
designer to develop new processes that are through effective processes and efficient
Experts worked independently both radically different from existing pro- workflows.
Almost universally, these experts work and cesses and that could only be implemented Revolutionary HIT fundamentally
apply their expertise independently of each utilising functionality made available by changes what physicians, nurses and oth-
other. IT system designers develop clinical the new clinical IT system. In addition, er healthcare professionals do. Physician
IT systems using specifications developed the clinical content expert can use this activities become more challenging on a
by product managers who attempt to bridge functionality to conceive of clinical paths cognitive level as other routine tasks such
IT with healthcare. These product manag- impossible without this digital healthcare as drug dose recall, use of best practice or-
ers are rarely experts in clinical medicine or capability. der sets, and drug-allergy checking become
clinical processes. Clinical content experts Although path innovation builds upon automated. Physician expertise is assigned
develop clinical content focussed solely existing approaches, it reflects a new way to more important tasks including solving
on clinical issues, rarely incorporating IT of thinking and approaching problems. difficult diagnostic problems, devising cus-
system design or clinical process consider- Instead of looking at how an existing pro- tomised patient treatment plans, and influ-
ations in their work. This is evident in the cess could be modified, path innovation encing patient adherence to chronic disease
effort invested by many organisations to requires the birth of brand new processes, care regimens.
modify existing guidelines to fit their new- formerly impossible in the institution be- Work for nurses and other healthcare
ly implemented clinical IT systems. Their fore the installation of the new clinical IT professionals changes dramatically too.
reported struggles are indicative of the dif- system. To accomplish this, organisations These professionals, guided by intelligent
ficulty of this type of work. processes and workflows that
Process redesigners often ap- include meaningful HIT,
The failure of clinical IT tools to deliver
pear on the scene late in implemen- complete more tasks formerly
tations, if at all. Working within safer and more efficient care is due to done by physicians or other
the environment as presented to many factors; yet all of them have origin healthcare specialists.
them, they try to change existing in the concept inherent in the phrase Revolutionary HIT places
processes without the advantage “path innovation.” the right professional, with the
of being able to change the inputs right knowledge in the right
(e.g., clinical path) or tools (e.g., process, utilising the right
clinical IT system and its functionality) of need to identify subject matter experts who workflow to d liver the best evidence-
the processes. are also able to achieve a basic understand- based care to the patient. Care delivery
To implement and effectively leverage ing of the disciplines of their expert col- is focussed on the patient and their
clinical IT systems, a new approach in the leagues. Then together, these experts work needs rather than the requirements of
use of experts is required. Path innovation to create new processes that incorporate the unchanged, ineffective workflows estab-
integrates different subject matter experts needs of the institution with the promise of lished before the dawn of information
in unique ways to leverage their expertise new IT systems and clinical content. technology.
throughout the design and implementa- Valued solutions offer these profession- For information technology to play
tion of clinical IT systems. Even for sys- als HIT tools that leverage their unique a valuable role in reducing healthcare
tems already built, path innovation can be skills, while organising the processes and costs while enhancing quality of care,
used to better leverage existing functional- workflows to deliver a consistently high it must be deployed in a revolutionary
ity in these clinical IT systems. It can help quality, safe and efficient healthcare out- way that completely reinvents how care is
enhance outcomes while reducing the come. delivered, professionals provide the care,
probability of unacceptable results such and technology is leveraged throughout
as system related medical and medication Need to Change care delivery. In addition, if we embrace
errors. Inherent in revolutionary HIT is the need path innovation, and incorporate it
for change; change in what professionals proactively into our deployment of
Form a path innovation team do and how they do it. Therefore, effective healthcare information technology,
Path innovation requires the formation change management techniques must be we will then be able to accrue the huge
of a team of subject matter experts that utilised to facilitate the acceptance of the increases in quality, patient safety
apply their skills during an entire new processes and workflows, in addition and efficiency we expect from these
clinical IT system project. During the to any new responsibilities and duties. revolutionary tools.

Broadband
Naoki Nakashima
Assistant Professor
Department of Medical Informatics
Medical Network
Shuji Shimizu
Chairman, Medical Working Group of
in Asia Pacific
Asia-Pacific Advanced Network and
Associate Professor, Department
of Endoscopic Diagnostics and
Therapeutics
Koji Okamura
Associate Professor
Computing and Communications Center
Kyushu University Hospital, Japan
we established multiple stations during and

after each APAN meeting by adding new
institutions /countries (Figure 1).
How it was achieved

We used public optic submarine cables for
international connections and for domestic
research and educational networks in Asia
Pacific countries. From Japan, we con-
nected the QGPOP (domestic) network
and the Korea Advanced Research Network
(KOREN) via the Asia Pacific Internation-
al Infrastructure (APII) (1 Gbps), which
uses the KJCN. In China, we connected
to the China Education and Research
Network (CERNET) through the KOREN-
The Asia-Pacific Advanced Network (APAN) can CERNET submarine link (155 Mbps). In
transmit high-quality moving images over broadband Taiwan, we used the Academic Service
Network (ASnet), with the connection from
Internet lines. This network system is being extended
Super SINET or Asia Pacific Advanced
to the entire Asia-Pacific region to promote the Network-Japan (APAN-JP) at 1 Gbps
exchange of medical knowledge and standardisation. through an optic submarine cable, which
was prepared by ASnet. In Thailand, we
connected to the Thai Social Scientific, Aca-
T
he Asia-Pacific Advanced Network Korea-Japan Cable Network (KJCN) for demic and Research Network (ThaiSarn)
(APAN) is a network communi- medical purposes. AQUA (Asia-Kyushu via Super SINET (45 Mbps). The United
cation system that can transmit Advanced medical network) joined the States was connected through the TransPAC
real-time, high-quality moving digital video Asia Pacific Advanced Network (APAN) network. Australia’s Research and Educa-
(DV) images over Internet Protocol (IP). We consortium in January 2004 (APAN-Ho- tion Network (AARNet) was connected
are now able to use international submarine nolulu). After three subsequent demonstra- to Abilene from APAN-JP. We did not
fiber-optic cable networks in the Asia Pacific tions of telemedical conferencing during have a direct connection with Singapore;
region for broadband transmission. The dis- APAN meetings, which are held twice a thus, we used a combination of the Japan-
tribution of medical information by means year, the medical working group was for- Taiwan connection and the ASnet-Singapore
of DV over IP beyond national borders mally approved by APAN by a vote during connection (155 Mbps), using the
makes medical staff keenly aware of differ- the APAN-Taipei meeting in August 2005. Advanced Research and Education Network
ences in medical services between countries We met many medical doctors/researchers (SingAREN) in Singapore.
and uncovers the relative advantages and at each APAN meeting and therefore built Trans-Eurasia Information Network
disadvantages of each. a human network to help expand our proj- 2 (TEIN2), which was launched in 2006,
ect. We also gained partner institutions in made connections to South Asian and
History Asia-Pacific countries through our atten- European countries easier. We connected
In February 2003, Japanese and Korean dance at each APAN meeting by asking Vietnam, Hong Kong and Indonesia in
medical groups collaborated to use the different institutions to the stations. Thus, the summer of 2006 and the Philippines,
Malaysia and India in the winter of 2007. procedure to hundreds of specialists in the
We also changed the route to Singapore and field in different countries. For example,
Thailand in 2006, because we were able to we connected the venue of the 94th An-
directly connect to these countries via Japan nual Meeting of the Japanese Urological
Gigabit Network 2 (JGN2) from Japan. Association in Fukuoka, Japan, and an
Additionally, we used the Asia Broadband operating room at Hanyang University
program line (ASIA-BB) for the connection Hospital in Seoul, Korea. We transmitted
to Thailand starting in late 2005. a live endoscopic urological surgery to the
venue, where more than 700 urologists
Medical-quality moving images were present. The urologists were able to
and security learn about the procedure and discuss the
Since the beginning of the project, we have surgery with doctors and the surgeon at
thought that high-quality moving images the Korean station.
are essential for medical purposes. We have This project has played two roles
used DV over IP in this network for trans- with respect to satisfactory growth of the
mission of moving images with standard network in the Asia Pacific region. First,
definition. We usually use the Digital Video it has served as the hub of the telemedi-
Transport System (DVTS) over IP. DVTS cal network within the Asia Pacific region.
is open source freeware, downloadable from While the project promoted the exchange
a Web site. Thus, terminal stations are in- of medical knowledge only between
expensive enough to be set up throughout The numbers in columns are the number of Japan and Korea in the first year, after
the Asia-Pacific region. We also transmit stations per event. The number of multiple-station our involvement in several APAN meet-
events has increased every year. Connected
High Definition Television (HDTV) im- countries are shown by abbreviations (JP: Japan, ings, many more Asia Pacific countries
ages compressed by Mpeg2 on the network. KR: Korea, US: United States, AU: Australia, CN: have participated in the project. We have
The quality of transmitted moving DVTS China, TW: Taiwan, TH: Thailand, SG: Singapore, already connected 13 countries and a total of
images is as good as that of the original dig- VN: Vietnam, ID: Indonesia, PH: Philippine, MA: 274 stations, and we plan to expand
Malaysia, and IN: India). The position of each
ital video. A frame rate of 30 per second was country on the graph shows the time of incited throughout the Asia-Pacific region. Sec-
obtained by 30 Mbps bandwidth, and the participation. ond, it has functioned as the commu-
Figure 1
images were smooth and not sluggish. The nication center for medical knowledge
sound was clear, however, audio jitter was and network technology. Those in the
sometimes present during the entire course number of events has increased gradually medical field want to use advanced informa-
due to packet loss. The time delay was less every year (Figure 1), the total number of tion and communication technologies for
than 0.3 sec between Japan and Korea and stations involved in each event has increased multimedia and high-speed transmission
slightly longer for other countries (maxi- more rapidly (14 stations in 2003; 50 in of high-quality moving images to exchange
mum 1.0 sec), which made for minimal 2004; 59 in 2005; 89 in 2005; 86 between medical knowledge with their colleagues
to no stress at each endpoint. During live January and March 2007). in remote places. However, such con-
transmissions, we used the AR550S (Allied tact has either been sporadic or not well
Telesis Co.) VPN router at each station as a Interactive communication integrated.
security system to protect patients’ privacy. between hundreds of doctors The online and offline activities of
For effective teleconferencing, we always this project function to close the IT gap
Multiple stations for each event transmit moving images and voice in both between the well-served and underserved
We conducted an increasing number of directions, and we use additional transmis- areas. In the future, we will add other tech-
events over the past 4 years, for a total of 96 sion to show other images. Usually, the nologies to our system to improve telecom-
by March 2007 (Figure 1). The percentage surgeon has a high level of experience with munication efficiency.
of multiple-station events (three stations or regards to the technique being presented or For example, we want to facilitate
more) increased each year—reaching 50% in is using a cutting-edge device. The surgeon transmission of high definition moving
2006—although the technical level of these can hear and talk to other stations during images, and try stereoscopy images and
events is higher than that of peer-to-peer the procedure if he/she allows it. Thus, image processing. In conjunction with par-
connections. When an event has multiple we can communicate interactively with ticipation in APAN meetings, we have es-
stations, we often use a QualImage/Quatre the surgeon from remote areas. Another tablished a high-quality video transmission
system (Information Services International- use of transmission of live images is tele- system over IP throughout the Asia Pacific
Dentsu, Ltd., Tokyo, Japan) that can inte- mentoring. region that is easy to use, reliable and eco-
grate four DV signals into one digital image We have transmitted live demon- nomical. This useful system is a promis-
without analog conversion. At the APAN- strations of medical procedures in actual ing tool for the standardisation of medical
Manila meeting in January 2007, we con- patients to international academic meet- systems and medical procedures in the
nected eight stations in eight countries. The ing venues. We are able to introduce a Asia Pacific region.

Commoditising
Healthcare IT
The next wave
H
ealthcare and Information
Technology (IT) have been
linked for decades. Some of
the earliest uses of IT in healthcare were
for the creation of Artificial Intelligence
and Expert Systems—such as MYCIN
and CADEUS—in the 1970s. These early
implementations were heavily influenced
by mathematics. Their implementation
was labour-intensive as they utilised be-
spoke development techniques. They
were complex to use and monolithic in
structure. Monolithic systems are gener-
ally unique to clinical domains and are:
• Costly to develop and maintain
• “Closed loop”: not designed for easy
integration with other systems
• Tightly-bound to the requirements
of the clinical domain they service: it
would be easier to write an entirely
new application than to reapply the
functionality
Monolithic systems also have other, less
obvious, implications:
• They impede the diffusion of technol-
ogy innovation within healthcare be-
With the costs of healthcare rapidly increasing, cause systems development is slow and
the monolithic model of HIT is no longer expensive
• They waste capital expenditure as they
sustainable. HIT commodity capability that
cannot easily be reused
provides a new level of convenience and • Patient safety is compromised because
serviceability to the healthcare environment it is difficult to change system interfaces
to comply with clinical domain or area
while being cost-effective.
standardisation requirements
As the field of Healthcare Informa-
tion Technology (HIT) has progressed,
our ability to manage, manipulate and
invent Information Technology (IT) solu-
tions outside of HIT has grown at a rate
Werner van Huffel
comparable to Moores’ Law. Our under-
Health and Social Services Industry Strategist
Regional Public Sector Group standing of architectural frameworks,
Microsoft Asia Pacific such as Enterprise Application-centric
Singapore schemas (e.g. Zachman, TOGAF and
others), has grown to incorporate more
loosely defined capabilities such as those
covered within Service Oriented Archi- of HIT operates within silos—informa- others are actively attempting to facilitate
tecture frameworks. These architectural tion exchange is disjointed and collabo- interoperability through the definition
strategies are based on the implemented ration is limited. This is a legacy of the of standards. However, implementation
technologies: rules processing engines, history of healthcare itself, as well as the of collaborative capability in HIT still
workflow and document process man- uses and implementation of IT within depends on technologists and technol-
agement systems, databases and develop- healthcare. ogy companies working in concert with
ment environments. While these should healthcare professionals.
all be part of the core IT infrastructure, Where are we going? The key to commoditised HIT is for
many domain-specific solutions are still In some respects, technology in healthcare technology companies to further embed
developed within the monolithic model has not come very far in the past 40-odd HIT requirements as capabilities within
(i.e. reproducing these core software ca- years. There are many reasons for this; their products and architectures. Those
pabilities as bespoke components). some studies have shown that poor com- requirements will include:
To the objective observer, HIT has munication between healthcare profes- • increased use by vendors of frameworks
progressed very slowly in most areas and sionals and the IT systems they use may that support dislocated applications,
very quickly in others. As the clinical en- be a contributor. Many developments such as Software as a Service(SaaS) and
vironment has become more complex, the within healthcare still utilise the legacy Service Oriented Architecture
data storage and processing requirements method of monolithic, bespoke develop- • creation of standards-agnostic (not
of the clinical domains have also increased. ment similar to the era of MYCIN and atheistic) systems that extend capa-
The data explosion caused by the advent CADUES—consuming substantial devel- bility directly to the desktop through
of genomics, large scale requirements for opment and infrastructure resources and the addition of modular, user-friendly
electronic medical / health records and the delivering little interoperability capabil- functionality to enable the clinical
widespread use of electronic documents is ity. information worker to exchange clini-
straining existing monolithic systems. Generalised technologies such as cal documents without the need for
No one system will do everything for processing engines, databases and uni- costly and complex software
healthcare, ever. One has only to review fied communications have begun to pen- • introduction and penetration of
the sheer number and the complexity of etrate healthcare. There is a growing un- systems which deliver high-end value-
systems in a healthcare institution’s infra- derstanding that technological rigidity is added capabilities, such as Electronic
structure to realise that “one size does not not always the best approach to solving Medical / Health Records, as a com-
fit all”. Furthermore, the rapidly increas- healthcare problems. To be fair, IT is not moditised unit of production rather
ing costs of healthcare means that the as mature as healthcare and is still coming than an ad-hoc amalgam of systems
monolithic model of HIT is no longer to terms with the mechanics of change in • healthcare domain-enabled search, as
sustainable. areas other than itself (such as clinical do- opposed to generalised search
mains). Standards can facilitate transfor- • creation of platforms for interoper-
What is a HIT commodity? mation, but standards change. When this ability in which the entire background
A HIT commodity is a cost-effective capa- happens, standards can initiate the very infrastructure of an operating system
bility that provides a new level of conve- confusion that they attempt to alleviate. or physical architecture can be geared
nience and serviceability to the healthcare In order to be effective in the future to facilitate healthcare information
environment. From general experience, a and have an impact in healthcare IT, sys- exchange
commodity is also a capability which has tems need to be: Many enterprise-scale and niche pro-
become ubiquitous, to the extent that it • modular (be able to plug-and-play with viders are working in collaboration with
becomes background “noise” to the stan- varying clinical domain requirements) clinicians to understand the requirements
dard operation of an environment. In • user friendly (to increase their reach for such healthcare solutions. This will
other words, successfully commoditised and minimize pushback from clinicians deliver greater choice in HIT and can im-
IT implementation becomes transparent around data collection and monitoring prove the chances of an organic resolution
to the people using its functionality. The systems perceived as ‘Orwellian’ initia- of the issues plaguing HIT, rather than
transition from monolithic to commodi- tives) the present dipolar battle that appears to
ous models is an ongoing, ever-increasing, • commoditised (cost-effective with high be raging.
drive within HIT. societal usefulness) As more and more healthcare domain
In HIT, the technology implement- The work done by standards bod- requirements are embedded onto the op-
ed in healthcare has been undergoing ies is an attempt to bring collaboration erational substrate of IT, proof of their
continuous commoditisation since the and information interchange capabili- applicability and suitability increases.
earliest initial bespoke implementations. ties to the healthcare domain in usable This will in turn create more of a market
This is primarily because, in many cases, chunks. In many respects, standards for commoditisation. This ability to meet
we understand the requirements of pure bodies are leading attempts to drive and further commoditise HIT require-
technology implementations better than commoditisation of IT in healthcare. ments, without detrimentally impacting
we understand those of healthcare. Much Global bodies such as the IHE, HL7 and the delivery of care, is the next wave.

Interview
RFID in
Healthcare
RFID is helping hundreds of healthcare
facilities across UK, US and Germany
to improve overall safety and
operational efficiency as it operates
without line-of-sight while providing
read/write capabilities for dynamic
item tracking.
Prashant Agrawal
Chief Executive Officer
Orizin Technologies Pvt. Ltd.
India
1. The Indian healthcare sector is evolv- hospital. We feel, as we go along, RFID Philippines, South Korea, Japan, UAE and
ing. In this scenario how has RFID been would be more ubiquitous than barcode as other technology leading countries.
received by the healthcare providers? it makes lots of applications possible. We
RFID is generating significant interest in cannot track patient and assets in real-time 4. What all applications are possible with
the marketplace because of its robust ap- using barcode but it’s very much possible RFID? Which departments of a hospital
plication capabilities. RFID is helping with active RFID technology could benefit from its application?
hundreds of healthcare facilities across RFID is moving from retailers to hos- RFID can bring lots of benefits in health-
UK, US and Germany to improve overall pitals, manufacturing and other sectors. It care in managing various resources like
safety and operational efficiency because would be adopted faster than barcode due blood samples, assets and patients.
it operates without line-of-sight while to its obvious benefits. RFID is considered as a key technol-
providing read/write capabilities for ogy in eliminating some of the major
dynamic item tracking. 3. Countries like the US have led bottlenecks in hospital management and
We receive lots of queries from CIOs the way in using RFID, how have improving process efficiencies. In one of
of the top Indian Hospitals to know more India and other Asian countries fared the major surveys in the US on benefits of
about RFID solutions and their benefits to in comparison? the RFID technology in healthcare, 70%
healthcare. Some of the hospitals have al- Although adoption of RFID in India has cited the patient safety as the major factor
ready implemented RFID based “Dynamic been slow (due to lack of awareness) the to implement RFID. Using RFID active
Queue Management” solution for regular number of inquiries is increasing these RFID wristband tags like the ones provid-
patients to reduce the wait time for lab test- days mainly for patient and asset tracked by Orizin, a patient can be easily tracked
ing. We plan to install the solution at some ing. In India, the general tendency is to across hospital and their movement can be
of the major hospitals in India this year. follow the adoption rather than lead the controlled to un-wanted places.
revolution. Singapore and other neighbor- Asset tracking and utilisation is
2. Given the potential of its applications, ing countries are doing much better. Some another bottleneck in hospital manage-
are hospitals in India likely to take to of the major hospitals in Singapore like, ment that RFID promises to eliminate. In
RFID like the Retail sector has? Alexandra Hospital, and The National Uni- an emergency situation, locating crucial
Definitely! If we go back five years, bar- versity Hospital, Singapore General Hospi- equipment like a ventilation pump could
codes were visible only on products like tals had implemented RFID technologies be a challenging task, which could be
garments and that too mostly on imported to track patients, staff and assets. The solu- easily facilitated by RFID. Moreover, a
ones. Today it is in the main stream and tion was a huge success during SARS out- major number of equipment in hospitals
noticeable everywhere whether one buys break. Similarly it is seen that there are lots is rented and it becomes very difficult to
a coke or gets a routine check-up at a of implementations in countries like China, estimate the usage and maintenance.
standard to communicate with exist-

ing healthcare solutions. Lack of this
standard could poise a real-challenge in
implementation.
There are minor challenges like ac-
commodating RFID devices in the exist-
ing infrastructure, as it requires ethernet
and power connectivity and a hospital
may need to upgrade the facilities. This is
acceptable. We are also launching Wi-Fi
based RFID sensors that could easily fit in
hospitals existing infrastructure. Unlike,
other segments, RFID does not demand
change in existing business process when it
comes to hospital.
Please provide your opinion on the
second part of the question related to the
cost aspect.
6. How do you see the future of RFID in

healthcare shaping up, globally as well
as in India?
We are very much upbeat with the
Some of the benefits as observed by the Clinic are equipped with RFID chips so potential of RFID in healthcare seg-
actual users are mentioned below: to prevent any confusion or mix ups in ments. As per some of the major reports,
• Virginia Hospitals in US has deployed regard to blood transfusion and blood healthcare vertical’s consumption of RFID
a RFID network to track mobile treatments. In the first phase, almost tags and services will rise from US$ 90
medical equipment at three Virginia thousand bags of bloods are being la- million this year to US$ 2.1 billion
hospitals operated by Bon Secours beled. The solution makes sure that cor- in 2016. We feel what we see today is
Richmond Health System. The three fa- rect blood is given to each patient. just the tip of the iceberg; the best is yet
cilities are St. Mary’s Hospital, Richmond to come.
Community Hospital and the Memorial 5. What challenges exist in the imple-
Regional Medical Center mentation of this technology in Indian 7. Any other comments you would like
• Birmingham hospital NHS trust in UK hospitals? How important a factor is to make?
has tagged patients with RFID chips to cost? I would like to share an excerpt from the
improve safety and ensure that correct We don’t see any major challenge in report “RFID in Healthcare: Poised for
operations are carried out on the right implementing active RFID technology, Growth”, a survey of health care execu-
patients. as the it is robust and stable. We follow tives, by Bearing Point and the National
• Blood bank supplies at Saarbruecken HL-7 protocol, a widely used industry Alliance for Health Information Technol-
ogy, November 2005.
Very Somewhat Not
Important N/A How hospitals rate RFID’s
Important Important Important
business benefits
Achieve compliance with policy 26% 30% 27% 7% 10%
The top four business benefits expected by
Antitheft/anticounterfeit/antitampering 42% 22% 25% 4% 7%
using RFID are: improved patient safety,
Improve asset visibility 37% 28% 22% 5% 7%
patient flow management, productivity
Improve business processes 45% 30% 16% 2% 7% and business processes. The majority rated
Improve patient flow management 48% 25% 15% 1% 11% achieving compliance with policy as only
Improve patient safety 67% 14% 11% 1% 7% “somewhat important” as opposed to “very
Improve productivity 48% 31% 15% 1% 6%
important.” (Table 1)
Most facilities are in the discovery and
Improve security 44% 28% 19% 2% 7%
information gathering stage in evaluating
Precision location 36% 30% 24% 3% 7% RFID. In 12 months, most expect them to
Reduce inventory 34% 26% 26% 6% 8% be in the experimentation test phase, and
Reduce labor costs 42% 22% 23% 6% 7% in 24 months the majorities are expected
to have projects deployed.
Table 1

Products & Services
Company Page No. Company Page No.
Diagnostics Mediaid (Singapore) Pte Ltd 34

AsiaGen Corporation 46 Shimadzu (Asia Pacific) Pte Ltd 32
Inverness Medical Innovations, Inc. 14 Synthes Asia Pacific OBC OBC3
Synthes Asia Pacific OBC3 Unomedical Pty Ltd 26
ZOLL Medical Corporation 4
Facilities & Operations Management
Synthes Asia Pacific OBC3 Surgical Speciality
Unomedical Pty Ltd 26
Shimadzu (Asia Pacific) Pte Ltd 32
Healthcare Management Synthes Asia Pacific OBC3

B. E. Smith 8
Technology, Equipment & Devices
ChinaMed IBC2
AsiaGen Corporation 46
Evolution Holidays Pte Ltd 16
Bloodline S.p.A 30
Frost & Sullivan 2
Electrolux Professional IFC1
Information Technology Fotona d.d. 28
Srishti Software Applications Pvt. Ltd 59 Inverness Medical Innovations, Inc 14
ZOLL Medical Corporation 4
Shimadzu (Asia Pacific) Pte Ltd 32
Medical Sciences Synthes Asia Pacific OBC3
AsiaGen Corporation 46 Unomedical Pty Ltd 26
Bloodline S.p.A 30 ZOLL Medical Corporation 4
Suppliers Guide
Company Page No. Company Page No.
AsiaGen Corporation 46 Inverness Medical Innovations, Inc 14

www.asiagen.com.tw www.determinetest.com
B. E. Smith, Inc. 8
www.besmith.com Mediaid (Singapore) Pte Ltd 34
www.optosystems.com.sg
Bloodline S.p.A. 30
www.bloodline.it Shimadzu (Asia Pacific) Pte Ltd 32
ChinaMed IBC2 www.shimadzu.com
www.chinamed.net.cn Srishti Software Applications Pvt. Ltd 59
Electrolux Professional IFC1 www.srishtisoft.com
www.electrolux.com
Synthes Asia Pacific OBC3
Evolution Holidays Pte Ltd 16 www.synthes.com
www.evolutionholidays.com
Unomedical Pty Ltd 26
Fotona d.d. 28
www.fotona.si www.unomedical.com
Frost & Sullivan 2 ZOLL Medical Corporation 4

www.frost.com www.zoll.com
To receive more information on products & services advertised in this issue, please fill up the "Info Request Form" provided
with the magazine and fax it, or fill it online at www.asianhhm.com by clicking "Request Client Info" link.
1. IFC: Inside Front Cover 2. IBC: Inside Back Cover 3. OBC: Outside Back cover


Ahhm 14

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ahhm 14

Uploaded by

Copyright:

Available Formats

Healthcare Management Medical Sciences Diagnostics Information Technology Surgical Speciality

Issue 14 2007 £12 €18 $25 www.asianhhm.com

Where knowledge talks business

Patient Safety and Quality

Truth in Ethics, Truth 29

FACILITIES & operations

INFORMATION TECHNOLOGY Asian Hospital & Healthcare Management is published by

EMR in a Large Healthcare Organisation 58

Yong Oock Kim, Professor, Department of Plastic &

Applying Path Innovation 62

John Leifer, President

 Asian Hospital & Healthcare Management ISSUE-14 2007

Traditional Healthcare Consumer-Driven Healthcare infinitely more complex and difficult to

 Asian Hospital & Healthcare Management ISSUE-14 2007

Transparency in today’s globalised healthcare world has impressed

Patient Safety and Quality

10 Asian Hospital & Healthcare Management ISSUE-14 2007

Acute Care Quality Indicators develop measures to monitor care, train

Patients Discharged on CareMaps® They can begin to hold clinicians accoun-

Prioritization Matrix (Importance of Governance)

Governance/Board of Trustees (is it Aligned with the Vision)

Finance (i.e., Cost) / Budget

Benchmarking (Is it Used / Recognized by CMS, IHI, JCAHO, DOH)

Operation (How We Treat Patients/Delivery of Card)

Evidence-Based Medicine (Benchmark for Excellence of Care / Opportunity for Improvement

Trending in Negative Pattern

Compliance (Is it a Deviation from Practice)

Patient Satisfaction Surveys/Patient Complaints

Malpractice Rates/Insurance Premiums

is to ask the people closest to the problem

12 Asian Hospital & Healthcare Management ISSUE-14 2007

16 Asian Hospital & Healthcare Management ISSUE-14 2007

What can the Operating Room

18 Asian Hospital & Healthcare Management ISSUE-14 2007

20 Asian Hospital & Healthcare Management ISSUE-14 2007

Several challenges ahead

1. More details of which can be found on the NICE

22 Asian Hospital & Healthcare Management ISSUE-14 2007

Treating Lung Cancer

New treatment modalities such as immunotherapeutic

been shown to be overexpressed in many

24 Asian Hospital & Healthcare Management ISSUE-14 2007

Therapeutic lung cancer vaccines in clinical development

Autologous/Allogeneic tumor cells

1 Number of lung cancer patients on trial. 2 Clinical or immunological responses. Table 2

h in capable of being either

the word ‘true’, when used in ethical

sivist, I say that it is true that it is wrong to

torture innocent children just for the fun of

wrong to torture innocent children just for

s truth in sition, but merely to express an attitude.

30 Asian Hospital & Healthcare Management ISSUE-14 2007

32 Asian Hospital & Healthcare Management ISSUE-14 2007

34 Asian Hospital & Healthcare Management ISSUE-14 2007

36 Asian Hospital & Healthcare Management ISSUE-14 2007

Surgical Skills Simulation

There is an increasing evidence emerging that

attentional resource that is required can be

Three Ss of Best Care

38 Asian Hospital & Healthcare Management ISSUE-14 2007

i.e. the PSM, commences in the diagnostic • Multi-scale modelling

Modules of a Surgical Assist System

Images WF and Devices/

Asian Hospital & Healthcare Management ISSUE-14 2007

Asian Hospital & Healthcare Management ISSUE-14 2007