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

c o m 
 Asian Hospital & Healthcare Management ISSUE-16 2008

Online PHRs
Bridging the information divide
Online PHRs can overcome the geographical limitations of existing EMR systems,
while encouraging patients towards selfcare.
A
patient’s health record is perhaps the most
important, yet most scarcely shared, aspect of
the healthcare process. Whether in primary care
or emergency, a doctor having access to the patient’s
medical history is better equipped to provide the right
care at the right time. As it happens, patient informa-
tion is bound by the geographical reach of a hospital’s
Electronic Medical Record (EMR) system.
The internet has enabled an innovation that has the
potential to change the scenario—placing patient records
online and giving patient the control over their health
information. Sensing the potential of this consumer-
centred innovation, companies like Microsoft, Google,
IBM and Intel—to name a few—have already taken to
online Personal Health Records (PHRs) in a big way.
While Microsoft launched HealthVault in early 2008,
Google introduced Google Health in June 2008. These
services are in their initial stages and issues such as data
security are still being sorted out. Since these services
are provided free of cost, providers will have explore
the right business model for the long run. However,
there are no apprehensions whatsoever regarding their
potential benefits.
The data in an online PHR is built and managed
by the patient. Given the ubiquity of the Internet, this
data can be accessed from anywhere at any time. This
is a blessing for both the patients—who have become
increasingly Internet savvy and mobile—and for health-
care providers. With the entire patient history being
available at the click of a button, a doctor, even if treating
the patient for the first time, can be helped to a quicker
and accurate diagnosis. As a consequence it is the
patients who will gain most from PHRs.
Foreword
Patient-doctor relationship stands to gain from online
PHRs. Patients can exchange data with their doctor on
a daily basis, which could result in reduction in visits
to the clinic. More importantly, it allows the doctor to
monitor the patient’s health and take corrective steps
if necessary.
In this issue’s cover story, we present to you insights
into this promising trend in healthcare. It also features
interviews with experts who have pioneered research in
the field. This includes views from Bill Crounse, Senior
Director of World Health at Microsoft, Claudia Pagliari,
Senior Lecturer in Primary Care at the University of
Edinburgh and John Halamka, Chief Information Officer
and the Dean for Technology at the Harvard Medical
School.
By allowing the patient to control the health data,
online PHRs could play a catalytic role in improving
patient participation in healthcare. Designed with
the patient in mind, online PHRs encourage selfcare.
A typical PHR website provides health-related informa-
tion to patients maintaining records on that website. It
can also incorporate the principles of social network-
ing on the Internet, thus enabling patient-to-patient
interaction. Online PHRs have the potential to fill the
information void that has existed on the patient’s side
for so long.
Akhil Tandulwadikar
Editor
w w w. a s i a n h h m . c o m 
 Patient Records Online 38
Shared access for quality care

Prasanthi Potluri Akhil Tandulwadikar

Editor Editor
Asian Hospital & Healthcare Management

Online Health Information 45

Accuracy, quality and privacy

Celia Boyer Mayoni Ranasinghe

Executive Director Research Assistant
Health on the Net Foundation (HON), Switzerland

HEALTHCARE MANAGEMENT MEDICAL SCIENCES

Health Tourism 6 Chronic Pain Management 20

The growth phenomenon
Integrated with primary care
Luigi Bertinato
Marilee Donovan
Director
Regional Coordinator
Marina Canapero Pain Management / Clinical Nurse Specialist
Health Communications Consultant
Lindsay Kindler
International Health and Clinical Nurse Specialist
Social Affairs Office
Kaiser Permanente, USA
Department of Health and
Social Services, Italy
Slow Medicine 24
Emerging concept in elderly care
Knowledge Transfer and 13 Sridevi Prekke
Human Resource Development Member, Editorial Team, Asian Hospital & Healthcare Management
in Medicine Cardiac Death Predisposition 27
CME and beyond New tools for early detection
Alexander v Smekal Ivana I Vranic
CEO, Meditrainment GmbH, Germany
Specialist in Internal Diseases
Cardiologist and Assistant Professor
Medical School University of Belgrade Private Clinic HERTZ, Serbia

Surgical speciality
Interruptions 16
at the Workplace Bariatric Surgery 31
A risk worth managing Experience with medical tourism
Gerry Armitage
Arun Prasad
Senior Research Fellow, Patient Safety
Senior Consultant and Academic Coordinator
Bradford Institute for Health Research
Minimal Access & Bariatric Surgery, Apollo Hospitals, India
Bradford Teaching Hospitals Trust, UK

 Asian Hospital & Healthcare Management ISSUE-16 2008

 Contents
diagnostics
Radiology Beyond Anatomy 33
Baylor 68
New value chain for personalised medicine Emergency
Frederik Lars Giesel Department
Physician Providing the
Department of Radiology state-of-the-art services
National German Cancer Research Centre Todd C Howard
Heidelberg, Germany President, t. howard + associates, USA
Hans-Ulrich Kauczor
Professor and Chairman Quality and Safety 72
Department of Radiology Creating a supportive culture
University of Heidelberg, Germany Philip Hoyle
Director, Clinical Governance
technology, EQUIPMENT & DEVICES Northern Sydney Central Coast Area Health Service, Australia

Medical Device Market 49

Mega trends in Asia Benchmarking and 75
Jennifer Lau
Industry Analyst Measuring Patient Safety
Frost & Sullivan, Singapore The Medway model
Jacqueline McKenna
Director, Nursing and strategic Planning
Medical Products 52 Medway NHS Planning, UK
Manufacturing in India
Getting ready for growth
INFORMATION technology
G S K Velu
Managing Director
Trivitron Group of Companies and Challenges in 80
Metropolis Health Services India Ltd.
India
Managing Chronic
Diseases
EMRs enable better care
Medical Devices 54 Gregory Larkin
Meet Consumer Electronics Chief Medical Officer
Revolution in healthcare delivery Indiana Health Information Exchange, Indiana
Alison Burdett
Director Semantic Web and Translational Medicine 83
Technology, Toumaz Technology, UK Creating the next generation
healthcare enterprise
FACILITIES & Operations Vipul Kashyap
management Clinical Informatics R&D
Partners Healthcare System, USA

Sustainable Hospital Design 58 Telemedicine and Remote Monitoring 87

Beyond the numbers Improving COPD patient care
Russell A Sedmak Michael Hansen-Nord
Vice President Chief Physician, Odense University Hospital
Heery International, USA Hospital of Svendborg, Denmark

The Hospital of the Future 62

Isn’t…
Insights into 90
Role of architects Healthcare IT
Gary M Burk Transforming
Principal healthcare in Asia
Terrie L Kurrasch H Stephen Lieber
Senior Associate President and CEO
RATCLIFF, USA HIMSS, USA

w w w. a s i a n h h m . c o m 
 Issue 16 2008

Editors : Akhil Tandulwadikar

Prasanthi Potluri
Consulting Editor : P Sudhir
Editorial Team : Sridevi Prekke
Vandana Wadhawan
Language Editor : G Srinivas Reddy
Art Director : M A Hannan
Visualiser : Sk Mastan Sharief
Graphic Designers : K Ravi Kanth
Ayodhya Pendem
Copy Editor : Omer Ahmed Siddiqui
Prity Jaiswal
Production : Suresh Giriraj
Head - Sales : Naveed Iqbal (Tele Sales)
Rajeev Kumar (Field Sales)
Sales Manager : Sunita John
Sales Associates : Vinod Kumar P Sirwani
Sylas Makam
K Vikas
David Nelson
Max Miller
Bhasker Josyula
Kiran Narra
Compliance : P Bhavani Prasad
CRM : Rajkiran Boda
Yahiya Sultan
Savitha Devi
Murali Manohar
G Vijay Kumar
IT Team : Shadaan Osmani
Ifthakhar Mohammed
Azeemuddin Mohammed
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w w w. a s i a n h h m . c o m 
healthcare management

Health Tourism
The growth phenomenon
More affordable international travel and major Luigi Bertinato
Director
advances in medical science, medical or health Marina Canapero
tourism is becoming less of a novelty and more Health Communications Consultant
International Health and Social Affairs
of a global trend. Office, Department of Health and
Social Services, Italy

I
n 2007, over half a million Americans
travelled abroad to receive medical
treatment and since 2003, 1.29
million Britons aged 16 to 64 had dental
treatment outside the UK because it
was more economical. These are not
isolated trends. Every year, increasing
number of patients from around the
globe seek healthcare abroad either for
economic reasons or to find better quality
treatment and overcome long waiting
lists. The picture that emerges is of
increasing mobile patients with greater
choices of where to receive quality
treatment at competitive prices.
Worldwide tourism growth
According to the World Travel and
Tourism Council (WTTC), tourism is
a key driver of 21st century’s economic
activity and is the largest creator of
jobs, wealth and investment around the
world.
Travel and tourism is the largest
industry in the world and the
US alone contributes US$ 3.5
trillion to the world’s GDP and
US$ 1.2 trillion to its GDP.
It is also the world’s largest export
earner with foreign currency receipts from
international tourism outstripping exports
of petroleum products, motor vehicles,
telecommunications equipment, textiles
or any other product or service.
In 2007, international tourist
arrivals rose by 6 per cent reaching a
new record figure of 898 million and
overtaking 2006 figure by over 52 million
arrivals. One significant feature of 2007
was the continuing healthy performance
of emerging destinations backed up by
one of the longest periods of sustained
economic expansion.

 Asian Hospital & Healthcare Management ISSUE-16 2008


Traditional and emerging source
markets 2007
Globally, world tourism flow shows a
significant shift from traditional source
markets (Western Europe, USA, Canada,
Japan) to alternative ones (Central
and Eastern Europe, China, Republic
of Korea, Singapore, Middle East,
Mexico, the Russian Federation, India
etc.) Tourism growth has been driven by
emerging destinations in Asia, Pacific,
Africa and the Middle East, while the
more ‘mature’ regions of Europe and
the Americas show a more moderate
pace.
The increasing trend of
health tourism
The increasing trends of tourism coupled
with health treatments abroad have
led to a growth in the health tourism
phenomenon. Health tourism (also called
medical tourism, medical travel or global
healthcare) is a term initially coined by
travel agencies and the mass media to
describe the rapidly growing practice of
travelling across international borders
to obtain healthcare. Such services typi-
cally include elective procedures as well
as more specialised surgeries such as
joint replacement (knee / hip), cardiac,
International tourist arrivals
Traditional and emerging source markets 2007
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
China Russian India
International Tourism Expenditure (US$ Million)
Source: UN World Tourism Organization 2007 (UNWTO)©
dental and cosmetic surgeries. Travel
and leisure aspects typically associated
with tourism are now being offered in
the form of all-inclusive health tourism
packages.
In 2007, 51 per cent of all inter-
national tourist arrivals (430 million)
were motivated by leisure, recreation
and holidays. Business travel accounted
for about 16 per cent (131 million),
and 27 per cent represented travel for
other purposes such as visiting friends
and relatives, religious reasons and /
or pilgrimages and health treatment
(225 million). Travel for the purpose
of undergoing health treatment abroad
is clearly on the rise.
Health tourism - An age old
concept
The concept of health tourism is not
new. The first recorded instance of
health tourism goes back to thousands
of year when Greek pilgrims travelled
from all over the Mediterranean to the
small territory in the Saronic Gulf called
Epidauria. In the Middle Ages, pilgrims
in need of care relied on a network of
monasteries providing free, even if basic,
care as they made their way slowly to
centres such as Santiago de Compostela
USA Germany UK Japan France
No. of trips abroad Emerging source markets
Graph 1
healthcare management
in what is now called Spain. In eight-
eenth century England, Mediterranean
travellers visited spas as they were places
with health-giving mineral waters, treat-
ing diseases from gout to liver disorders
and bronchitis.
The situation nowadays is very
different. First, many people are cross-
ing borders, not on foot or horseback
but by trains, cars and increasingly by
low-cost airlines. Second, the scope of
healthcare has changed beyond recog-
nition with increasingly sophisticated
pharmaceuticals and technology allowing
many people to survive and in many
cases to lead perfectly normal lives.
Health tourism today - Driven
mainly by costs
Highly competitive prices of medical
treatment offered abroad continue to
attract most medical or health tourists.
According to the United Nations World
Tourism Organization (UNWTO),
depending on the location and proce-
dure, a medical vacation can cost up to
50 per cent, 30 per cent, or even 10 per
cent of what one would normally pay
at home country.
The cost of surgery in India, Thailand
or South Africa can be a tenth or even less
of what it is in the US or Western Europe.
For instance, a heart-valve replacement
costing US$ 200,000 or more in the US,
can go for US$ 10,000 in India includ-
ing return airfare and a holiday package.
Similarly, a metal-free dental bridge worth
US$ 5,500 in the US costs US$ 500 in
India, whereas the total cost of a standard
filling ranges from € 156 in England to
€ 8 in Hungary. The total cost includes
x-rays, materials, drugs and overheads,
as well as the dentist’s time. Cosmetic
surgery savings are even greater: a full
facelift that would cost US$ 20,000 in
the US costs about US$ 1,250 in South
Africa. A US$ 40,000 hip replacement
in the US can cost US$ 6,600 in Costa
Rica or US$ 4-5,000 in Cuba. Estimates
of the value of medical tourism to India
are as high as US$ 2 billion per year by
2012.
w w w. a s i a n h h m . c o m 
healthcare management
In 2007, 77,000
UK travellers went to abroad
Source: International Passenger Survey
43 per cent of the travellers
sought Dental Care
Source: Agency Treatment Abroad
Over half a million
Americans travelled abroad to
Medical and Dental
treatment
Source: Wall Street Journal NBC Survey
The increasing costs of medicare
in the US
Consequently, each year more people
from the most industrialised nations
such as the US are looking for healthcare
treatment abroad either for economic
reasons or to find better quality treat-
ment and avoid long waiting lists. In a
Wall Street Journal-NBC Survey almost
50 per cent of the American public said
that the cost of healthcare is their number
one economic concern. More and more
US citizens are looking beyond their
borders for cheaper and more timely
healthcare. In 2007 alone, over half a
million Americans travelled abroad to
receive medical and dental treatment.
Part of the reason for US citizens not
covered by a universal healthcare system
seeking medical care abroad lies in the
increasing costs of medicare and private
health insurance packages. Nearly 43
million Americans are uninsured and
surveys show that the primary reason
for this is the high cost of health insur-
ance coverage. Almost 25 per cent of
the uninsured reported to change their
way of life significantly in order to pay
medical bills.
Countries promoting
health tourism
Popular medical travel destinations
 Asian Hospital & Healthcare Management
worldwide include: India, Brunei,
Cuba, Colombia, Hong Kong, Hungary,
Jordan, Lithuania, Malaysia, Philippines,
Singapore, South Africa, Thailand and
recently, Saudi Arabia, UAE, Tunisia
and New Zealand. On the other hand,
much sought after cosmetic surgery
travel destinations include: Argentina,
Bolivia, Brazil, Colombia, Costa Rica,
Cuba, Mexico and Turkey. In South
America, countries such as Argentina,
Bolivia, Brazil and Colombia lead in
plastic surgery medical skills relying on
their experienced cosmetic surgeons.
Colombia also provides advanced
care in cardiovascular and transplant
surgery. New EU accession countries
such as Poland, Hungary and Slovenia
offer competitive dental tourism pack-
ages particularly to British, German,
Austrian and Swiss nationals who can
take advantage of budget air travel and
cut costs. South Africa is taking the term
‘medical tourism’ literally by promoting
their ‘medical safaris.’
The growth of so-called
‘5-star hospitals’
Most of us are familiar with the
star-rating system for hotels, but there is
also a growing phenomenon of privately-
run ‘5-star’ rated hospitals around
the globe in such far-flung places as
Bangkok, Singapore, Manila, Kerala
and Dubai. These hospitals operate in
a highly competitive market and are run
along the lines of 5-star hotels. They
claim to offer not only medical expertise
and state-of-the-art medical technologies,
but also first-rate and modern facilities
and a wide range of specialised medi-
cal and diagnostic services covering all
medical disciplines, while guaranteeing
more affordable and high quality care
for patients.
Increasingly mobile patients
A ‘new’ kind of European and World
Citizen is slowly emerging where for
instance, a citizen lives and works
between two or more countries. This
is the case of stockbrokers, bankers and
ISSUE-16 2008
The expansion of the
Schengen Area to 24
Member States in December
2007 runs alongside the
movement of Citizens for work,
tourism and study reasons
across Europe.
managers who live in financial capital
cities during the working week and
return home to another country at the
weekend or go on holiday to a third
country. The term ‘Nylon’ (short for
New York-London) has been coined to
describe over 400,000 super-commuters
who live and work between New York
and London (6,500 km, about 5 hours
flight), and the term ‘NylonKong” (short
for New York-London-Hong Kong)
describes commuters, often financial
service executives, who commute regu-
larly between London, New York and
Hong Kong. There are no less than 187
direct flights that leave London for New
York every week and 28 weekly flights
from Hong Kong to New York. This
category of upwardly mobile profes-
sionals on the move is a major target
for health tourism.
The increasing mobility of pension-
ers in Europe is also an emerging trend.
Europeans are increasingly
looking beyond their national
borders to receive more
timely and economical
treatment in another Member
State and combining the medical
treatment with tourism and
residing for long periods in the
host country. This is the case of
800,000 pensioners
from Northern Europe
migrating to the South
during the cold season.
w w w. a s i a n h h m . c o m 
healthcare management
Northern European retirees are taking up
residence in South European countries
and the Mediterranean for part of the
year during the coldest winter months
of the year. They are estimated to be
over 800,000 annually in the European
Union (EU). In the Lake Garda area of
the Veneto Region in Northeast Italy,
there are over 3,500 permanent residents
from Northern Europe. According to
the UK Office of National Statistics, one
million Britons have decided to move
overseas after retirement, with Spain
being their popular choice. In the last
10 years, over 75,000 British pension-
ers have moved to Spain to establish
permanent residence.
Challenges to patient mobility and
health tourism
The increasing mobility of citizens in
the EU and the growth of global health
tourism present a number of challenges.
Firstly, standards are important as far
as healthcare is concerned and issues
concerning international health accred-
itation, evidence-based medicine and
quality assurance need to be addressed.
In the US, Joint Commission and in
the UK and Hong Kong, the Trent
International Accreditation schemes
provide certain guarantees of standards
and quality of healthcare of affiliated
hospitals and healthcare institutions.
However, there is still a long way to go
before such accrediting bodies can cover
the vast range of healthcare providers
worldwide.
With the progressive introduction of
the European Health Insurance Card in
Europe on 1st June, 2004, EU citizens
could obtain essential medical treat-
ment while staying abroad temporarily
or exercise their right to better quality
and more timely planned care in another
Member State if waiting lists force them
to seek alternative treatment abroad.
Treatment is provided in accordance
with the rules of the Member State
being visited and costs are reimbursed
in line with the tariffs applied in that
Member State.
10 Asian Hospital & Healthcare Management
The impact of tourism
CaseStudy
on the Veneto Region, Italy
The Veneto Region in its capacity as a highly popular tourist
destination, makes a very interesting case study of patient mobility and
health tourism in Europe. The significant flow of tourists brings with it
a series of healthcare challenges that regional healthcare services have
to deal with, in some cases by organising specific services to respond
to the high demand of seasonal tourist flows and long-term foreign
residents and ensuring their good health.
During the last decade, the Veneto Region of northeast Italy has become
famous as a major tourist destination, thanks to three main attractions:
Venice, as a city of art and culture along with Verona, Padua and Vicenza,
the Mediterranean beaches of the Adriatic sea; the lake region (Lake
Garda); and the Dolomite mountains. Economically, tourism has become
one of the Veneto’s main resources. In 2006, spending by foreign visi-
tors in Veneto totalled € 3,845 million—15.9 per cent of total spending by
foreign visitors in Italy.
Nowadays, visitors to the Region can in case of a medical emergency
choose from a wide range of health services provided by its Local Health
Authorities (LHAs) in close collaboration with the Department of Health
and Social Services and the Department of Tourism of the Veneto Region.
The Veneto Region ranks number one among the Italian regions in terms of
tourist flows (see Table 1).
National and international tourist flows
to the Veneto Region, year 2006
Origin of No. of overnight Average no.
tourists
Arrivals % %
stays days of stay
Italians 5,259,736 39 25,093,862 42 4.77
Foreigners 8,179,099 61 34,266,727 58 4.18
Total 13,438,835 100 59,360,589 100 4.40
Source: Veneto Regional Statistics Office data based on ISTAT 2006 Table 1
Looking at the tourist flows to the Veneto Region in 2006, we can
clearly see the following: Foreign tourist arrivals are mainly from Germany
(1,888,235), Austria (642,886), the UK (592,926), France (521,043),
Spain (387,330) Non-EU countries. The USA (818,262), Japan (280,601)
and Australia (118,053) make up the greater proportion of total overnight
stays amounting to over 59 million.
ISSUE-16 2008
w w w. a s i a n h h m . c o m 11
healthcare management

Purchasing across the
European Union
The first English patients to go to France for
hip-replacement therapy, paid for by the NHS
Cataract
NHS .................................... £880
Private ........................... £2,000
France . .......................... £1,000
Hip
NHS ................................ £3,900
Private ........................... £7,600
France . .......................... £4,000
Knee
NHS ................................ £4,400
Private ........................... £8,500
France . .......................... £3,000
Source: European Observatory on
Health Systems, McKee 2006
The right to safety and quality care
is an essential element for all patients in
Europe. Each individual has the right
to choose among different treatment
procedures and providers in various
Member States and to receive treatment
without any delay. This is true within
national healthcare systems in accord-
ance with article 22.2 of EC Regulation
1408/71 and to further rulings of the
Court of Justice. The question is whether
of the Veneto Region in Italy outlined
below) is a clear example of the extent of
the tourism phenomenon, which implies
actions at different levels (regional,
national and European), further imply-
ing particular legal, organisational and
regulatory approaches.
Health tourism to the
Veneto Region
The Veneto Region’s health services are
facing challenges mainly from mass tour-
ism, which brings with it a sudden and
significant increase of demand on health
services, particularly in the summer with
different priorities depending on the
type of tourism, for example cultural,
seaside, agro or adventure tourism.
Seaside tourism is marked
by large and seasonal
concentrations of tourists,
which affect facilities and
services set up to respond to
the increased demand. Each
year in the Veneto Region,
preparations for the summer
season commence in March
with the selection of multilingual
health staff. A similar practice is
carried out in ski resorts.
Since 2003, a special ‘task force’
has been formed in the Veneto with
the aim of broadening the knowl-
edge of the tourism phenomenon and
patient mobility, and to cope with
the underlying administrative and
Luigi Bertinato is the Director of International Health and Social Affairs
Office, Department of Health and Social Services, Veneto Region,
Venice-Italy. He is involved in a number of European health and social
A u thor
organisational problems. Its aim is to
collect and provide data on the magni-
tude of the phenomenon of patient
mobility between the Veneto Region
and other regions or Member States and
to analyse the impact of cross-border
health demand and related health issues
at the regional level.
Conclusion
Trends clearly point to a continued
expansion of medical tourism in the
coming years. However, there is an
urgent need to provide and compare
private and NHS health services for tour-
ists, and to be aware of the risks involved
and the legal implications resulting from
medical complications that may arise
on the patient’s return to home.
Furthermore, international standards
of quality assurance and health accredi-
tation need to be established to protect
citizens worldwide and ensure them their
rights to the best healthcare possible at
the most competitive prices.
We are now at the dawn of a new
era in health tourism worldwide, where
citizens have more options as regards
where they choose to be treated and
how to spend their money.
By 2015, the health of the so-called
Baby Boomer generation will have started
to decline. With more than 220 million
Baby Boomers in the US, Canada,
Europe, Australia and New Zealand,
this represents a significant market for
cost-effective and high-quality medical
care, and has enormous potential for
global health tourism.

care projects, in the area of health policy, e-health, health promotion

it always works in practice. and patient mobility.
Accessing healthcare in another
European country should theoretically Marina Canapero is the Health Communications Consultant, International
be a straightforward process, but it often Health & Social Affairs Office, Veneto Region. Since 2003, she has
creates problems both for patients and been collaborating part-time as a consultant in the International Health
& Social Affairs Office of the Veneto Region in Venice, liaising with
the healthcare systems involved. The various departments of the Regional Health Ministry in various European
experience of certain European areas health projects.
with heavy tourist flows (as is the case

12 Asian Hospital & Healthcare Management ISSUE-16 2008


Knowledge Transfer and
Human Resource Development
in Medicine
CME and beyond
HR development could play a key role in providing quality healthcare. Care providers
need to dedicate more resources to devise their HR policies and strategies.
Alexander v Smekal
CEO
Meditrainment GmbH
Germany
T
he ongoing developments in
medicine and healthcare present
a continuous challenge for all
stakeholders. Besides technical and struc-
tural changes, adequate education and
training of employees, supply of medi-
cine and healthcare are critical factors for
growth. Educational and training
programmes need to be adapted
to regional and global healthcare
requirements. The industry is
facing high demand for training
due to new markets and modern-
ised equipment and technol-
ogy. Hospitals are desperately
searching for well-trained staff,
while the healthcare professionals
are looking for suitable opportunities
to enhance their knowledge and
skills.
The concept of Continuing Medical
Education (CME) has been introduced to
help physicians update their knowledge
and develop skills. Apart from the USA,
Europe (European Accreditation Council
for Continuing Medical Education
(EACCME) and other countries have
taken to CME and developed their
interpretation of it. In some states, CME
is mandatory for physicians. However,
it is unstructured and limited to medi-
cal content and the main focus of the
system is to raise awareness of the need
for lifelong learning. For individuals,
the term Continuing Professional
Development (CPD) better describes
a structural approach from the point-of-
view of a professional. Both programmes
do not address the needs either of the
healthcare system or of the employers
and employing institutions.
The healthcare industry is facing
high demand for training due to new
markets and modernised equipment
and technology.
To understand the actual needs and
optimise medical education and training,
one has to look at the present situation in
terms of the requirements of the market
and the demographic changes.
Varying healthcare conditions from
one country to another mandates health-
care providers to take a global view,
which ultimately leads to medical tour-
ism. The success of medical tourism
healthcare management
depends upon the terms of mobility
of all involved stakeholders. Mobility
and flexibility in global market place
in reality are affected due to various
ethnic, cultural, social, religious, indi-
vidual, political and monetary factors.
Possible changes of these factors may
highly affect business models. Hence,
all these factors have to be considered
seriously while planning to develop
healthcare structures and Human
Resources (HR).
To meet the growing demands
of healthcare due to demographic
changes, the countries need to
either attract foreign health-
care professionals and serv-
ices, or send their people who
need healthcare abroad.
However, it appears that they
have not come up with any
definite plan to deal with the
situation.
The ongoing speed of
technical and structural development
is faster than the duration of studies
and training programmes in medicine
and healthcare. Therefore, continuous
or lifelong learning is mandatory in
these fields. The development of trained
medical personnel is much slower
than the construction of hospitals
and getting technical infrastructure
in place.
w w w. a s i a n h h m . c o m 13
healthcare management
Medical education and training is
mostly focussed on the medical key
competences. Knowledge and skills in the
different specific medical domains domi-
nate education and training. Especially in
Europe, training in communication, lead-
ership, service orientation and business
skills is not part of the medical education
process. However, consolidation of the
hospital and healthcare service market
necessitates the need for medical profes-
sionals with broadened key competences.
Hospital administration in the past was
often divided into medical and admin-
istrative branches and competences,
which worked in two parallel worlds.
Modern hospitals, however, are led by
an overall united administration with a
clear strategy. This change is not reflected
in education and training of healthcare
professionals. There is, in most cases, no
sustainable policy or strategy for HR
development in hospitals or hospital
groups.
14 Asian Hospital & Healthcare Management
As stated above, both CME and CPD
approaches have limited themselves to
lifelong medical learning that focuses
solely on the medical domain and the
individual physician’s needs. The aspects
and needs of a regional or global health-
care market are not reflected through
these approaches. These aspects have to be
addressed by the employer or employing
organisation. It sounds curious, but HR
development is rarely applied to medicine.
Therefore, understanding structures
and tools for HR development in medi-
cine are underestimated and underde-
veloped.
A close look at two major healthcare
markets reveals the problems they face in
the development of HR in medicine.
• Due to the increasing growth in the
hospital buildings and infrastructure
in Middle East, there is great need
for well-trained healthcare profes-
sionals. The strategy to overcome
the shortage was to engage foreign
ISSUE-16 2008
specialists. Rarely was a sustainable
training programme organised in
the region. As a result, the special-
ists stayed only for a short period of
time. When they leave the place, they
take their skills and know-how with
them. The structures they build do
not survive and therefore no sustain-
ability is given
• In Eastern Europe, healthcare infra-
structure is growing, supported by
partnering programmes. Advanced
medical technologies, as in diagnostics
or therapy, are being installed but
there is no tradition to buy know-
how or soft skills. Regional health-
care professionals seek to enhance
their knowledge and skills abroad.
The knowledge transfer back home
is limited.
In both situations, the desperate
need for strategic HR development in
medicine and healthcare is evident. But
what are the consequences?
 healthcare management

Implementing HR development
in healthcare
First step is to increase the awareness
and understanding of the specific
situation, the needs and the possibili-
ties. This also includes the possibility
of training the staff. In most cases,
change management helps to under-
stand and value soft skills, workforce
and communication. Untrained teachers
who are not aware of modern learning
and technology will not succeed if they
are not carefully guided and trained.
An overall policy and strategy has to
be developed to create a sustainable
solid base for training. The transfer of
information, knowledge, skills, and
finally competence requires
training in a face-to-face setting,
and technology-enhanced learn-
ing. Blended learning, combina-
tion of Self Directed Learning
(SDL) and face-to-face train-
ing, including Information and
Communication Technologies
(ICT) is the way to build
up structural and strategic
education.
The scenario of e-learning has to be
based on a modern learning environ-
ment. Modern in this sense includes
technical and learning aspects. Web 2.0
and 3.0 inspire technology-enhanced
learning in terms of flexibility, inter-
activity, community aspects, knowl-
edge management, open interfaces
and mobile learning. New technology
opens new ways of learning, but all the
stakeholders have to learn how to make
best use of it. Our learning approach at
Meditrainment is very much influenced
by ‘microlearning’. Based on the ideas
of Theo Hug, Professor, Department
of Educational Sciences, University
Innsbruck/Austria, we developed a
concept of small learning units as the
by personal reasons and motivation,
never by technology. Technology can,
however, act by different means as a
motivator. We experience this right now
in mobile learning. An overwhelming
number of possibilities are offered, but
only a few are accepted by the user.
The technology can be used to make
the learning unit interesting, easy and
interactive.
Based on a learning environment, all
aspects of learning have to be addressed
to the learner. The learner should be
able to acquire and share knowledge,
skills and competence. All of this needs
to be evaluated and tested. In learn-
ing scenarios, simulation in learning
Sharing of competence in the
sense of developing problem-based
solution utilising knowledge
and skills is the Holy Grail of
educational transfer.
as in testing is an essential feature.
In medicine, some simulators already
exist to train skills. Sharing of compe-
tence in the sense of developing problem-
based solution utilising knowledge and
skills is the Holy Grail of educational
transfer. A combination of face-to-face
training and self-directed learning with
interactive media and simulators can
help to reach this goal. Important and
essential for the success of such an
approach is the interactivity, the amount
of repetitions made by the user, and
most of all, the persistent motivation.
Community and game-based learning
A u thor
will also play an important role in such
scenarios.
For strategic and policy-driven
approaches to learning, all of the above
mentioned aspects have to be addressed
in a technical as well as structural way.
Therefore, moderation and change
management are the key to success.
An external consultant should have a
broad experience and understanding of
the domains of medicine, healthcare,
human resource development, manage-
ment and interdisciplinary develop-
ment. A person or team is rarely found
speaking the same language as an
IT-specialist, healthcare professional,
administration, constructor, politician
and patient.
In the growing market,
device makers, universities,
IT-Industry, and national agen-
cies try to gain market share.
So far though, collaboration
or moderation for the sake
of a regional problem has not
been seen. Most of them have
very specific key competences
and underestimate the inter-
disciplinary aspects. Mediating and
consulting roles have to be given to
specialised companies in the field of
education and training in medicine
and healthcare.
HR development in medicine and
healthcare will play an increasingly
important role in the development
of regional and global healthcare.
More attention needs to be paid
and more resources have to be all
cated to devise policies and strategy
in this field. HR development is
the key to continuously providing
healthcare for all.

Alexander v Smekal is the Cofounder and CEO of Meditrainment

base of individualised strategic learn-
ing scenarios in a personalised learning
environment. We believe that each has
his own way to learn. Therefore, tech-
nology has to be utilised to empower
the individual. Learning is always driven
GmbH, Germany. He is a board member in radiology and
nuclear medicine, emergency care and sports medicine, studies
of healthcare science, occupational activities in medicine, research
and lecturing in universities in Germany, Austria, Switzerland,
Netherlands and USA. He is trainer and consultant for human resource
development in medicine and healthcare.

w w w. a s i a n h h m . c o m 15
healthcare management

T
he Harvard Medical Practice
study published in the New
England Journal of Medicine in
1991 created a groundswell of interest
in patient safety. Though not the first
study of its kind, it was the first large-
scale randomised approach to patient
safety. The impact of the Harvard study
was felt outside the US and eventually
in the UK as well. As part of govern-
ment-led modernisation program, clini-
cal governance was introduced to the
British National Health Service (NHS)
to promote quality, reduce risk and real-
ise clearer lines of accountability. It was
envisaged that making chief executives
of NHS organisations directly account-
able for maintaining quality would
force them to produce better patient
outcomes. Organisational learning was
central to the mission of governance.
It was not surprising that a flurry of
related policy directives followed. ‘An
Organisation with a Memory’ was the
British Department of Health’s first dedi-
cated, strategic policy document focussed
entirely on patient safety and adverse
Gerry Armitage
Senior Research Fellow
Patient Safety
Bradford Institute for Health Research
Bradford Teaching Hospitals Trust, UK
events. It was based upon advice of an
expert group, which drew on human
error theory and their already estab-
lished application to aviation and other
high-risk industries. Human error theory
accepts the inevitability of error, moving
organisations and individuals away from
blame and towards learning, while firmly
acknowledging accountability.

Interruptions
at the Workplace
A risk worth managing

While it is known that they can lead

to errors, interruptions can also be
imperative in high-risk domains such
as healthcare, where patient safety
and medical error reduction is now
paramount. Human error theory can
explain the concept of error and how
errors occur at different levels in an
organisation.

16
16 Asian Hospital & Healthcare Management ISSUE-16 2008
 healthcare management

What is human error theory? Consequently, slips are potentially a A third category of error is a mistake—
James Reason, Emeritus Professor of part of all routine behaviours. Donald an action proceeds as planned but does
Psychology at Manchester University Norman reminds us that they also tend not achieve its intended outcome
has explained that human error stems to take predictable forms, and are likely because the original plan was wrong.
from the interplay of various contribu- to be experienced by experts rather than For example, a junior doctor may
tory factors that exist at the level of novices (the latter being less able to decide he doesn’t need to consult his
individual performance (known as active automate), which has implications for formulary for the dose of a previ-
failures), the immediate environment the familiar assumption that new staff is ously un-encountered antibiotic so
(or local workplace factors) and at a less reliable. Experts are further compro- he chooses the wrong dose due to
broader, organisational level (systems mised by the mental storage of many lack of information. The key element
failures). Active failures include slips, more pre-programmed instructions (or is the decision—he has made a judge-
lapses and mistakes. A slip is observable schemata) than their junior colleagues. ment but it has not led to the desired
and unintended and not uncommon in A lapse is simply forgetting something. outcome.
a busy environment. Slips are essentially For example, a doctor knows well that Local workplace factors are the
errors in the human automation process a patient requires pain relief at four- phenomena that surround practition-
where there is no conscious control and hourly intervals but forgets to prescribe ers and sometimes merge to increase
a normal routine is disturbed. the analgesia at the times required. the likelihood of an error. They include
unworkable processes, an inappropriate
skill mix and poor documentation.
Interviewees’ opinion about interruptions
Systemic failures such as chronic
“When an incident happens, you look at the factors leading up to it, I think gaps in supervision or shortfalls in main-
interruption, nine times out of ten is there …you just can’t concentrate on doing tenance are examples that will originate
your medicines and nothing else… the way we do our medicines on here, the in human decisions but, as Professor
way we work, we work in three teams. We’ve got four qualified nurses on a shift.
Reason has written, they are made at
The senior nurse will be in charge and then there’ll be three trained nurses taking
charge of nine or ten patients each. So there’s three nurses crowding round one a strategic level. At this level, differ-
trolley, all trying to do their medicines at the same time.” ent influences stemming from group
Staff Nurse, Acute Medicine dynamics and—as witnessed in the US
challenger disaster—from structural and
“Your managers are one of the first who’ll sit down and say, ‘Right, we have to cultural sources such as production pres-
tackle these drug errors. Let’s put tabards on to stop you from being interrupted’,
but they’re the first ones who are on the phone saying, ‘Actually, no, can I speak sures and bureaucratic accountability,
to her now.’” might exist. Certain upstream decisions
(GA) Do you find that in any way frustrating? Don’t let me stop you.
can then lead to numerous error-produc-
ing factors downstream.
“I was just thinking, I mean, it’s not just your managers. Obviously you’ve got
to think of all the other interruptions you get on the phone. Surgeons will phone,
they always want to speak to the Sister. It’s slightly different if you’re a staff Research study
nurse, obviously. So they all want to speak to me and if I actually told them all, In a recently completed study, I exam-
say, ‘No, I’m on a medication round,’ it’s just...”
ined the contributory factors in medica-
(GA) Difficult? tion errors and their reporting in a large
“…extremely difficult, yeah. It wouldn’t happen. And also it would make my job a teaching hospital. Data were collected
lot harder as well, in some respects, if I said, ‘ I’ll ring you back,’ to every single from a retrospective, random sample
person I got a phone call from.”
of just under 1,000 definitive drug
Staff Nurse, Surgery
error reports submitted over a period
“I think another defence is you should have a tongue in your head and you know of five years. This was followed by 40
how to say to somebody, just leave me alone while I do this, I’m doing some qualitative interviews with a volunteer
medicines, I’ll talk to you about your tea-break later, you’re obviously working a and multi-disciplinary sample of health
medication out or you’re doing your drugs, you’ve got the drug chart there and
professionals. Of particular interest were
somebody comes in and starts chatting about Saturday night. Well, I’m always
one to have a good natter, but you can imagine management, well, why weren’t the interview participants’ accounts of
you concentrating? Well, I was talking about my Saturday night out... the contributory factors in medication
I mean I’ve more recently sort of turned round to people and stopped what I’m error from which a hierarchy of impor-
doing and actually said, yeah, it was really good, I’ll come and talk to you about tance emerged (See Table 1). In line
it in a little while, just let me do this. But not in a confrontational way.” with much of the literature on medica-
Senior Nurse, Paediatrics tion errors, the participants elucidated
Table 1

w w w. a s i a n h h m . c o m 17
healthcare management
a whole range of contributory factors.
Interruptions and distractions, a rela-
tively rare factor from the drug error
report analysis, were far more promi-
nent in the interview data. This may
be related to an inclination to present
written accounts in a particular style.
Some implications
Twenty four years ago, Gilbert and
Mulkay examined the way scientists
described their experiments. They
established a clear difference in content
between written reports and interview
data concerning the same scientific proc-
esses. Their documentation portrayed a
world firmly governed by scientific laws,
where the scientist’s actions are neutral.
However, when interviewed about
the very same experiments, they gave
quite a different view of their various
activities and judgements, admitting
that their personal behaviours and
social positions also exerted a tangible
influence. They added that all sorts of
variables impacted on actions.
The literature on interruptions as a
contributory factor in medical error is
compelling and like the factors previ-
ously discussed, is a multi-disciplinary
problem. Furthermore, policy makers
such as the US Institute of Medicine
(IoM) have highlighted the phenom-
enon as significant. Interruptions lead
to specific types of error usually slips,
which may then contribute to errors of
omission—and can be significant—such
as failing to give a medication or wash
one’s hands.
Nevertheless, interruptions may
serve a function. Donald Norman and
colleagues have explained that if inter-
rupted, the human functions of stor-
ing, retrieving and processing thoughts
are usually suspended. Consequently,
recovering the original activity, if a
new one is introduced, can be diffi-
cult. Interestingly, Mohammed Walji
and colleagues at NASA have actually
argued that interruptions are critical
cues in multi-tasked environments
such as healthcare and even promote
18 Asian Hospital & Healthcare Management
productivity. Yet, to avoid interrup- be deliberate (or intentional) being
tions being seen as an accepted element a psychosocial rather than cognitive
of practice, Walji has identified three factor. Interruptions require two parties.
conditions for what might be termed as Of course, the person being interrupted
‘effective interruptions’. First, the person by a social question may not wish to
being interrupted must be interrupted at be interrupted. Their inability to say
the right time, the task they are undertak- ‘no, not now’ may similarly hide away
ing should not be spoilt as a consequence organisational weaknesses, but may also
of interruption, and the interruption be strongly suggestive of a lack of error
process should be carefully executed to wisdom. It is clear from this data that
enhance its persuasiveness. However, a interruptions are a cause for concern.
notable caveat is supplied by Tucker and It may also be that reporting, if care-
Edmondson who, on the basis of their fully structured, may be one means of
multi-centred observational studies, have identifying their role in causation and
proposed that (ostensibly) resourceful their effects.
and highly adaptable staff who normalise
interruptions simply serve to hide away So what can we do?
organisational weaknesses. To gain a better understanding of
My interview data exposed another problems such as interruptions, which
type of interruption. Categorised here are essentially local workplace factors,
as social interruption, and rather like we have the asset of human error theory.
violations in comparison to slips, the First, we know that interruptions
social interruption is more likely to can cause particular error types. This
Clinical Staff Task Management
Drug Dispensing, Prescribing
and Administration
Provides Clinical Reports Situational Professional
and Handovers on Drug Awareness Style
Therapy Thorough preparation Abides by professional code
Outlines plans and Anticipates therapy and Aspires to high performance
differences updates drug documentation Stays conscientious and flexible
Allocates tasks Makes contingency plans for Remains Self-aware and seeks
Seeks input problems feedback
Checks understanding Keeps broad perspective
Teamwork Workload Drug Handling
Balances rank authority Recognises high workload Ensures that it is safe, effective
Flexible and shows respect Takes or makes time and efficient
Actively monitors and Deals with overloaded priorities Follows and amends overall
supports prescription
Avoids distraction and
Thinks independently distracting Is aware of side effects and
contra-indications
Manages errors, reports near
misses and adverse events for
learning
Communication Decisions Applied Knowledge
Shares information / ideas Identifies problems / issues Technical
Actively listens Involves others if needed Guidelines
Assertive when required Evaluates outcomes Protocols
Admits mistakes and doubts Uses structure in new
situations
Table 2
ISSUE-16 2008
 healthcare management

knowledge can then provide a system-
atic trail from the outcome—a missed
medication dose—to the likely contribu-
tory factors. Consider a practitioner slip
alongside a problematic way of working
like giving all patient medications when
one team of nurses hands over to another;
a point when staff availability is probably
low and interruptions are high.
Based on the above knowledge, we
could then change practice but healthcare
will never be interruption-free, indeed
this would be counterproductive. Lessons
can be learnt from the aviation indus-
try where interruptions are conditional.
Work I carried out with a British airline
has led to the development of a drug
Effective team work also means that
whatever the seniority of colleagues, they
do not have an unconditional right
to interrupt. As the skills list states,
practitioners must be ‘assertive when
required’. One’s professional style also
demands that social interruptions do not
interfere with critical activities. We
cannot afford social interruptions to be
normalised. This, however, demands
cultural—not just procedural—change
and is not easy. Effective leadership
is crucial.
Gerry Armitage worked as a registered nurse for 13 years in both
A u thor
Interruptions are a risk worth manag-
ing, but managers may not find staff detail-
ing the risk in incident reports, unless
of course they are encouraged to think
more carefully about the impact of local
workplace conditions on their perform-
ance. This might be achieved through
more analytic reporting tools, which we
are currently developing at the Bradford
Institute for Health Research. Oh! and
watch out for the expert practitioners, the
spontaneous demands on their expertise
means they make errors too!

junior and senior posts. Following this he spent a similar length

therapy skills list to combat medica-
tion errors (Table 2) stemming from
a pilot skills list. It acknowledges that
interruptions can be distracting and they
require avoidance, especially if they cause
overload for the recipient.
of time working in higher education where he led undergraduate
nursing programmes and developed new courses with the NHS,
independent sector, and outside the UK. In 2007 he completed a
3 year research study funded by the Department of Health which
culminated in the introduction of a drug error reporting scheme for
an acute hospitals trust.

w w w. a s i a n h h m . c o m 19
medical sciences
N
umerous studies conducted in
countries all over the world have
shown chronic pain to be a prev-
alent and costly problem. The American
Pain Foundation states that Americans
get affected by pain more than diabe-
tes, heart disease and cancer (American
Pain Foundation). Another study suggests
that the costs of healthcare for patients
with chronic pain exceed the combined
costs of treating patients with coronary
artery disease, cancer and AIDS (Turk,
2002). The impact of chronic pain in the
Northwest Region of Kaiser Permanente
(a Health Maintenance Organisation in
Chronic Pain
Management
Integrated with primary care
With the number of individuals in need of assistance for
chronic pain increasing each year, only a small fraction
of patients with chronic pain are treated directly by the
Pain Clinic.
In recognising the scope of the
problem, in terms of prevalence, cost
and human suffering, the KPNW
Pain Management Clinic has created a
programme to meet the needs of patients
and care providers, all while keeping
down costs of the overall organisation.
Throughout the design and imple-
mentation of this pain programme,
the KPNW Pain Management Clinic
(PMC) has based its services on two facts
of chronic pain care. The two facts are:
1) Research on chronic pain manage-
ment has consistently demonstrated the
20 Asian Hospital & Healthcare Management
the Pacific Northwest, United States) has
proven to be just as significant. Kaiser
Permanente Northwest (KPNW) has iden-
tified 67,000 members with chronic pain.
In 2003, the organisation did a survey of
members with various chronic diseases and
found that those with chronic pain showed
the highest impairment and reported the
most significant negative impact on their
quality of life. Members with chronic
pain are hospitalised more, make more
emergency visits and outpatient visits
than an average Kaiser Permanente
member, even those with other chronic
illnesses.
need for a multidisciplinary approach Marilee Donovan
for effective long-term results. 2) With Regional Coordinator
the number of individuals needing Pain Management /
Clinical Nurse Specialist
assistance for chronic pain each year,
Lindsay Kindler
only a small fraction of patients with Clinical Nurse Specialist
chronic pain can be directly treated Kaiser Permanente, USA
by the Pain Clinic. With these facts in
mind, the KPNW Pain Management
Clinic devised a programme that
has consistently worked to accomplish
two goals—to help members with chronic
pain get their lives back and to help
primary care providers treat members
with chronic pain more effectively.
ISSUE-16 2008

Programme overview
As suggested earlier, the KPNW Pain
Clinic firmly believes in the value of a
multidisciplinary team. Starting with three
anaesthesiologists working part time, one
nurse, one clinical nurse specialist and one
social worker in 2000, the programme has
grown dramatically. A team composed of
four anaesthesiologists, one physiatrist, two
internal medicine physicians, a psychiatric
nurse practitioner, four social workers,
two clinical nurse specialists, three phar-
macists, three advice nurses, two triage
nurses, procedural nurses and medical
assistants provide care. The team provides
support to all services of the pain manage-
ment programme. Services offered by
the KPNW Pain Management Clinic
consist of several interrelated compo-
nents. Each of these components works
to meet the needs of the individual patient
while providing assistance to the primary
care provider responsible for ongoing
management of the patient’s overall
care. All consultations performed by
PMC providers include an accompany-
ing chart note to the patient’s primary
care provider specifying recommenda-
tions or suggested services in order to
Model of multimodality care adapted by KPNW
Cognitive Behavioral Therapy
Examples: knowledge about pain,
realistic goals, quite smoking, pacing
(use of timer, pedometer), counseling,
mediation, relaxation techniques,
treatment of depression
Co-management of
addictive disease
Patient Self Care
Physical Modalities
Examples: exercise/stretch q1h;
start where you are and go slow;
positioning; aids (walker, splint), TENS,
heat and cold, self massage trigger point
therapy
medical sciences
enhance a team-oriented approach. The
clinic’s anaesthesiologists and physiatrist
make recommendations and implement
advanced pain management procedures
from blocks to radio frequency procedures
to implantation. The internal medicine
physicians and pharmacists consult their
patients and their primary care provid-
ers to either implement or recommend
medication management plan for patients
with complex medication needs. The clinic
has one physical therapist that helps
design treatment plans in collaboration
with physical therapists throughout the
KPNW system. Social workers, clinical
nurse specialists and the psychiatric nurse
practitioner consult Pain Clinic physi-
cians or primary care providers for the
management of patients with complex
psychosocial needs and help develop treat-
ment plans that optimise the resources and
services of Kaiser Permanente. The clinic
has three nurses devoted to patient advice.
They answer patient questions, provide
ongoing patient education by phone or
email and assist in titration of medication.
Two nurses triage more than 400 incom-
ing referrals per month and ensure that
the patients are directed to the service that
Medical Therapies
Examples: medications,
procedures, surgery, implantation
Complemental Therapy
Examples: acupuncture, hypnosis,
chiropractic, herbals, elimination diet,
energy work, Ayurvedic naturopathy
Figure 1
w w w. a s i a n h h m . c o m 21
medical sciences

Growth of pain clinic 1990-2008 primary care clinicians on their office

computers. Every month at least one
25000 from the team consisting of physician,
clinical nurse specialist, pharmacist, social
20000
worker or physical therapist is involved in
15000 educating practitioners through clinic in-
services, department meetings or regional
Number of visits / year

10000
continuing medical education activities.
5000 The most effective education occurs on an
individual basis through the discussion
0
of care of patients dealing with complex

Improve Access

Exceed Capacity Again

Block Clinic

Add Groups

Merge Block & Groups

Vohs Award

National Work

Add Medication
Management

Add Complemental

Add Salem Clinic

Add Washington Clinic

bio-psychosocial needs. This communi-
cation is accomplished through e-mails
via KPNW’s electronic medical record;
phone conversations and multidisciplinary
patient care conferences. Consultations
with the PMC staff regarding complex
1995 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 cases allow primary care providers to feel
Major steps in evolution supported in their daily work and assist
Figure 2 in the development of care strategies in
future.
best meets their needs. The clinic also has the first seven weeks presents new ways
a partnership with a growing Integrative to manage chronic pain, emphasising Outcomes
Medicine Program that consists of practi- the need for a multidisciplinary, multi- Over the years, PMC has tracked a
tioners offering acupuncture, training in modal approach. In the final eighth variety of outcomes—pain relief, improved
self-hypnosis, energy healing, ayurvedic visit, a Pain Clinic practitioner and the function and reduced healthcare utilisa-
medicine and neurostructural integration. patient work together to devise an tion. The electronic medical record now
For the sub-population of patients with individualised treatment plan. This allows us to graph pain severity, func-
both addictive disease and chronic pain, plan serves as a guide for the patient tional interference over time (using the
the clinic works closely with Addiction and is also sent to the primary care Wisconsin Brief Pain Inventory which
Medicine. provider as a way to enhance the working is embedded in the electronic medical
At the core of the KPNW Pain Clinic relationship between the patient and record) (Daut, CLeeland and Flanery,
are the multidisciplinary group visits that provider. 1983). Because KPNW has had an elec-
help patients learn how to manage their tronic medical record since 1997, health-
pain on a day-to-day basis. Forty series Services for the primary care care utilisation data is relatively easy to
of eight structured group visits are avail- provider obtain. The initial evaluation of the pain
able to members each year. These group While the PMC serves less than 10 per management programme indicated that
visits help the primary care provider cent of patients with the most complex for patients who completed the series
bring evidence-based pain manage- care needs, the primary care providers of pain management group visits, the
ment to members within their local area. manage the majority of patients with utilisation decreased by approximately
These visits help members try a variety of chronic pain. In order to optimise US$ 1,000 per patient each year.
therapies in order to develop an effective chronic pain care to all individuals, the Evaluation of five years indicates that
individualised multimodal treatment plan PMC is committed to help primary this improvement in utilisation persists
(See Figure 1). care providers, give more effective, for many patients. It was hypothesised
The groups are also co-led by PMC evidence-based pain management care. that this reduced utilisation occurred
nurses, social workers, clinical nurse To accomplish this goal, the staff of the because patients improved their skills to
specialists, pharmacists, the psychiat- PNC offers continuous education on pain deal with their pain and felt more confi-
ric nurse practitioner and the physical management, consults individually via dent about their ability to manage the
therapist. Because of the commitment telephone or electronic messaging on pain and changes in the pain over time
to multidisciplinary care, all groups are questions of care, and provides tools and (Donovan, Jacobs and Blake, 2002).
co-led by a team composed of group information to primary care providers. External pressures have often deter-
leaders from two disciplines. Each of These tools are readily available to the mined other outcomes that need to be

22 Asian Hospital & Healthcare Management ISSUE-16 2008

 medical sciences

considered. For instance, in both the

states of Oregon and Washington (where
KPNW provides care), it is required that
all patients taking opioids for chronic pain
have a signed consent and opiate therapy
plan. The current method of producing
list of patients who need this document
produced and signed will soon be replaced
by a reminder that is generated electroni-
cally in the medical record when an opiate
therapy plan is required. With growing
concern about the adverse effects of meth-
adone and high dose opioids in general,
pharmacy records are being reviewed
to determine the outcomes related to
these medications. As the demand for
pain management has grown faster than
resources to provide services needed, the
waiting time for a patient from the date
of his / her referral to consultation has
become a critical outcome. The number
of patients who complete the series of
group visits is compared to that of patients
who were initially appointed. In 2008, it
has become clear that the cost of fuel is
resulting in far fewer patients attending
the group visits. The Pain Management
team proposed developing a DVD of the
pain management group visits that could
be used with telephone coaching as an
alternative to group visits when patients
cannot afford to attend the group visits
in person.
Growth and future directions
Owing to the success of the PMC’s serv-
ices and the growing recognition of the
need for aggressive pain management
and the ageing of the population, the
Pain Clinic has expanded to meet the
growing needs of the KPNW population.
Not only has the programme increased
its staff by 500 per cent in eight years,
but also the number of visits and their
Pain management clinic - hub and spoke model
North
Westside
INTG East
CON
GROUP
VISITS CORE MED
MGT
PROC
Goal is comparable services in all PCSAs;
Ellipses indicate no services yet Salem
Figure 3
regional primary care providers, and offer KPNW electronic medical record makes
services specific to local needs. The PMC it easier to do the right thing, but it is
Multidisciplinary Groups have used this not essential. The essential components
model of delivering Pain Management are: a commitment to help the patient
Clinic services at the site of the local clinic in becoming an active partner using
with great benefit over the years. The Pain multiple modalities of care each day;
Clinic currently offers some services at a providing care as close as possible to the
section of the region with a goal of being patient by supporting the primary care
able to provide most services closer to efforts; basing care on scientific evidence
patients. (Figure 3) whenever possible; flexibility and ongo-
ing development of the programme
Conclusion in response to internal and external
The KPNW Pain Management Clinic needs; and patience and persistence—the
approach has many components that energy to persevere because it is the right
are transferable to other settings. The thing to do.
Marilee Donovan has spent most of her career dedicated to
improving pain management. She is co-founder and Regional
Coordinator of the Kaiser Permanente Northwest Pain Management
A u thor

kinds has increased dramatically.
The PMC believes that the best care
is delivered closer to the place of the
patient and the primary care provider.
Moving more services to regional locations
Program.
Lindsay Kindler has been a Clinical Nurse Specialist with the KPNW
Pain Management Program since 2004. She is also a doctoral
student at the Oregon Health Sciences University.

will offer decreased travel distances for

patients in pain, offer greater opportunity
for collaboration among PMC’s staff and

w w w. a s i a n h h m . c o m 23
 from a measured approach. This could
involve understanding their problems,
medical and others, their values, their
life, their choices and their living circum-
stances. For elders, Slow Medicine could
be a gateway to conventional treatments,
provided it is of their choice.
Slow Medicine is a philosophy and
also a practice. It demands time and
regular attention. Many elements of
the philosophy and the practice of Slow
Medicine can be applied to help anyone
approaching life’s end. The philosophy and

Slow Medicine
practice of Slow Medicine serves elders
well because their journey of late life is
more complicated than that of middle age.

Emerging concept Factors like patient’s age, strength and the

severity of the ailment play a vital role in

in elderly care the practice of Slow Medicine.

If one were to define a ‘successful
outcome’ in Slow Medicine, accom-
plishing a patient’s preferences would
Slow Medicine advocates less-aggressive and be apt. According to Dr McCullough,
compassionate approach towards the elderly patients. “A successful outcome is one which
reflects, on repeated re-assessment over
Despite many ethical and professional apprehensions, time, the choices of the elder and his or
a start has been made. her family.”

especially for elderly patients. The elderly
not only suffer due to ageing problems
such as failing minds and bodies, but
Sridevi Prekke also because of an ill-equipped social
Member
Editorial Team
healthcare system. The Slow Medicine
Asian Hospital & model is rooted in the presumption that
Healthcare the choice of the elderly regarding their
Management care should be appreciated.
Unanimous decision
The concept of Slow Medicine calls
for the involvement of the patient
and patient’s family in taking a deci-
sion concerning the treatment that the
patient should undergo. The principles
of Slow Medicine include communi-
cation with elders, their family and
doing one’s best to take decisions
based on complete understanding

N
ature knows best. Less is more.
These two are the thoughts
surfacing recently in elderly care
through the concept of Slow Medicine,
pioneered by Dr Dennis McCullough,
a geriatrician and a faculty member at
Dartmouth Medical School and the author
of My Mother, Your Mother Embracing
“Slow Medicine”: The Compassionate
Approach to Caring for Your Aging Loved
Ones. Slow Medicine is a less aggressive,
family-centred and less expensive way
of care that slots in all the requirements
to be pursued for a quality end-of-life,
Philosophy and practice
The philosophy of Slow Medicine is to
protect comfort of the patient rather than
cure of an ailment. Slow Medicine shares
with hospice care the approach of paying
a great deal of attention to patients and
their specific problems and needs. The
difference, according to Dr McCullough,
is that while hospice care focusses more on
the very last days or weeks or months of
care, Slow Medicine can be practiced over
years or perhaps, in some cases, a decade
or more. It is largely based on the belief
that the best decisions about care come
of the patient and the situation the
patient is in and maximising his / her
comfort. So, patient’s consent and
acceptance are vital to practicing Slow
Medicine.
For example, a person in his seventies,
suffering from an ailment may not be
willing to undergo intensive medical treat-
ments; rather he /she would be seeking a
quality life for the time left over. Another
patient, in the same condition might like
to extend his / her life as much as possible
from the available resuscitating therapies.
Thus, the patient’s perspective is always

24 Asian Hospital & Healthcare Management ISSUE-16 2008


Dennis McCullough
Geriatrician and Faculty Member
Dartmouth Medical School
USA
How can Slow Medicine help in solving the
problems of elderly patients?
In late life, the elder, the elder’s circumstances and
the problems the elder faces require that we not
push for a fast decision, but allow time to help the
elder; the family and healthcare providers achieve
a deeper and truer understanding of what they
must decide and provide. This is often not easy
because it may require facing conflicts and differ-
ences of opinion and approach. It is expected that
there will be continuing periods where there may
be uncertainty about these choices and choices
must be re-visited as needed.
What are the circumstances that prompt the patient
to choose Slow Medicine rather than conventional
treatment?
For elders, Slow Medicine can be a gateway to
conventional treatments, when that is the elder’s
choice. However, the practice of Slow Medicine
may also lead to choices of ‘alternative medicine’
or ‘traditional medicine’ treatments or perhaps to
‘wait and watch’ approaches that simply focus on
symptom relief and comfort (and commitment to
whatever approach is chosen).
essential to the practice. Speaking about
the patient’s perspective, Dr McCullough
says, “The patient’s perspective must be
sought through emotional and other
physical responses—for instance, inter-
est in eating, in relationships, etc. at this
time of life.”
The family and healthcare providers
need to achieve a deeper and truer under-
standing of what they must decide and
provide. Dr McCullough points out that
How can one assimilate a patient’s perspective in
choosing Slow Medicine?
The patient’s perspective is always central to the
practice. Even if an elder is partially disabled, for
example, by a stroke or some cognitive impair-
ment, the patient’s perspective must be sought
through emotional and other physical responses—
for instance, interest in eating, in relationships, etc.
at this time of life.
Do you think patient will be capable of taking
a decision regarding what treatment he should
undergo?
In those instances where an elder may clearly be
unable to participate in making a decision, the
burden falls to those (family, friends, health profes-
sionals) who have sought to understand the elder
over the late life period.
Slow Medicine doesn’t focus on saving the life
of a patient; rather it focusses on quality of life
and comfort of the patient. Then, is it proper to
conclude that Slow Medicine is not an approach
which can be practised in an emergency situation
for an elderly?
Although there are some emergency situations
where Slow Medicine might not be practised to
its full extent, there are always principles of Slow
Medicine practice (communication with elder
and family, kindness, doing one’s best to make
this understanding arises through discus-
sions and reflections by elders themselves
along with their ‘circle of concern’—fami-
lies, other intimates and friends.
In the whole exercise, it is imperative
that healthcare professionals must be open
to the whole idea of Slow Medicine as they
are the essential drivers for Slow Medicine.
They should be ready to involve the
patient and his /her family. They should
discuss the condition of the patient, the
medical sciences
decisions based on as complete an understand-
ing of an elder and their situation, maximising
comfort) that still hold true. If one has practised
Slow Medicine along the way, emergencies as they
occur are almost always better understood by the
elder, the family and support persons and health-
care professionals.
A patient in his 70s is advised to undergo an open
heart surgery, only to prolong his life for few more
years, of course, with all the risks that he faces
during the first three months after surgery. What
do you advise in such a situation?
Perhaps the most important part of this process
is that there is a clear understanding of the real
risks of this surgery and the potential benefits and
the patient and his or her advisers have enough
time to really think about them and discuss them,
repeatedly, if necessary. Then, the answer usually
emerges. For an otherwise healthy person, at the
relatively young age of 70, the decision might
be straightforward; for the patient over 80 with
other problems, it could be a very difficult deci-
sion which should be explored over time. I have
had patients decide both ways, which is perfectly
in keeping with Slow Medicine. The important
work here is to allow the patient to make the best
decision possible for him or herself, aided by
thoughtful and patient professional and family
counsel.
available alternatives and the pros and
cons of the alternatives. The milieu of
the patient should be well known to the
patient himself and his family.
Put on the brakes
In an effort to extend the life of the
patient, family and physicians opt for
intensive care, even if it means that the
treatment could cause serious side effects.
Some treatments hasten the downward
w w w. a s i a n h h m . c o m 25
medical sciences
course of patients’ health leading to
prolonged period of dependence. Most
of the elderly are afraid of the side effects
of intensive care. Dr McCullough advo-
cates a less aggressive alternative in such
situations. For example, a manual breast
exam is preferable to a yearly mammogram
for the very old and home tests for blood
in the stool to the draining routine of a
colonoscopy.
Slow Medicine encourages physicians
to slow down when considering aggres-
sive care that may cause high risks and
limited rewards for the elderly. It is a
return to the personal doctoring in an age
of high-tech medicine. It edifies patients
and families how to avoid hospitalisation
and emergency room trips proposed for
those with treatable ailments, not the usual
downturn due to advanced age. And, the
periphery of the treatment confines to
the known surroundings of the patient,
unlike the typical medical ambience which
they resist the most.
Ethical edge
Aggressive care in some cases saves life. A
number of doctors opine that intensive
care definitely prolongs life. This percep-
tion might not hold true in all cases. Still,
mentioning only the cases of death would
be biased and vice versa. Dr McCullough
argues that “the decision to practice Slow
Medicine can sometimes run contrary to
what the ‘system’ wants most, which is a
decision taken quickly to assure that high
efficiency for the system occurs.”
Slow Medicine is described as a less-
expensive way of providing care. This
gives rise to the ethical question of valu-
ing human life. Furthermore, estimating
the time left approximately considering
the circumstances—which could differ
from case to case—may prove the assess-
ment wrong. So, choosing Slow Medicine
is ultimately the choice of the patient
and the patient’s family. In that case,
the question arises: how can the doctors
allow the patient to take such a critical
decision?
Regarding the ethical side of the
concept, Dr McCullough says that Slow
26 Asian Hospital & Healthcare Management
Medicine blends the ethics of individual-
ity i.e. autonomy, benevolence, truthful-
ness and non-malfeasance which focus
on the empowered individual in making
decisions with the ethics of character and
commitment. These ethics emphasise the
importance and value of ‘staying with’
an elder though all the ups and downs.
He comments, “This ethical approach,
‘commitment to the very end’, in a
partnership between elder, family and
healthcare providers is presently less
emphasised in our acute care-oriented
medical systems.”
Every patient and his / her circle of
concern would wish a long life, but at
what cost and what kind of life would
that be? These are the questions that cross
through the minds of those involved in
the process of decision-making.
The resistance
The concept of Slow Medicine might
not hold good in an emergency. But,
Dr McCullough advocates the prac-
tice and states that though there are
some emergency situations where Slow
Medicine might not be practiced to its full
extent, the principles of Slow Medicine
practice still hold true. He says, “If one
has practiced Slow Medicine along the
way, emergencies as they occur are almost
always better understood by the elder, the
family and support persons and healthcare
professionals.”
Not only the ‘circle of concern’ of
the patient, but physicians too tend to
have a mindset of ‘what all can be done,
shall be done’ to save and prolong the life
of a patient at any cost. Their etiquette
doesn’t allow them to think beyond the
physical existence of their loved ones.
They would always like to try out all
the available options to extend the life
of the patient. Hence, Slow Medicine
may not be an easy option.
All said, the idea of Slow Medicine is
still foreign to many physicians who are
proponents of aggressive treatments for
patients’ ailments. In the process, medi-
cal care has grown almost tantamount
to technology-oriented care.
ISSUE-16 2008
Resistance to change is common and
it is the case with slow medicine too. But,
as the patient population desiring this
kind of care is increasing, the chances
of sustainability of the concept are more.
Time alone can prove how it nurtures the
requirements of both the patients and
the doctors.
BOOK Shelf
My Mother, Your Mother:
Embracing “Slow Medicine,”
the Compassionate Approach to
Caring for Your Aging Loved Ones
Author : Dennis McCullough
Year of Publication : 2008
Pages : 288
Publisher : Harper
Description
My Mother, Your Mother will help you learn
how to:
• Form an early and strong partnership with
your parents and siblings;
• Strategize on connecting with doctors
and other care providers;
• Navigate medical crises;
• Create a committed Advocacy Team;
• Reach out with greater empathy and
awareness; and
• Face the end-of-life time with confidence
and skill.
Although taking care of those who have
always cared for us is not an easily navigated
time of life, My Mother, Your Mother will
help you and your family to prepare for this
complex journey. This is not a plan for getting
ready to die; it is a plan for understanding,
for caring, and for helping those you love
live well during their final years. And the time
to start is now.
For more books, visit Knowledge Bank
section of www.asianhhm.com

Cardiac Death Predisposition
New tools for early detection
Those who die a sudden death, probably are never aware of the potential risk they carry.
Recently, new tools for diagnosing those prone to SCD have been introduced. This marks a
key milestone in the detection of sudden cardiac death signs among healthy individuals.
Ivana I Vranic
Specialist in Internal Diseases
Cardiologist and Assistant Professor
Medical School, University of Belgrade
Private Clinic HERTZ
Serbia
S
udden Cardiac Death (SCD) contin-
ues to be an important medical
challenge in Asia as well as in the
developed countries—apart from Europe
and the US. Since sudden cardiac arrest
is no respecter of geographic boundaries,
identifying individuals who are at risk and
responding in time to those who suffer
from this catastrophe far from hospital
are the major problems.
A generally accepted definition of
SCD is natural death due to cardiac causes
preceded by abrupt loss of consciousness,
which lasts for an hour from the onset of
acute cardiac symptoms. Epidemiological
studies remain challenging because
of persisting inconsistencies in data,
variations in clinical recognition and
its pathophysiological mechanisms of
development.
Epidemiology
Approximately 50 per cent of all Coronary
Artery Disease deaths are sudden and
unexpected. They comprise half of
all SCDs. The other half that is not
CAD-related have very low incidence of
0.1-0.2 per cent per year. Low incidence
of disease in the other half is due to inher-
ited conditions such as channelopathies
(long QT syndrome, Brugada syndrome,
catecholaminergic ventricular tachycardia,
and similar disorders), and hypertrophic
cardiomyopathy as well as arrhythmogenic
right ventricular cardiomyopathy.
In an attempt to subcategorise the
duration of symptoms preceding SCD,
Kuller and colleagues showed that if the
duration of symptoms is less than one
hour between onset and death, 91 per
cent of unexpected natural deaths were
found to be due to cardiac arrhythmias.
But, if the duration is two hours, only 12
per cent of deaths were sudden and due
to cardiac causes. However, if the dura-
tion increased to 24 hours, 32 per cent
of deaths were found to be sudden.
Causes of SCD
The causes of SCD vary with the age of
the patient and are enhanced by complex
interplay between genetic polymorphism
and environmental factors. Therefore,
virtually any pathologic process that
involves the heart may lead to it. The high-
est incidence of sudden death is between
birth and six months of age (sudden infant
death syndrome) and between 45 and
75 years of age. The incidence is 100-
fold greater in adults older than 35 years,
than in young adults less than 30 years
old. Men are more likely to die suddenly
than women, possibly because of lack of
oestrogen protection.
It is interesting, though, that among
other causes of death, cases with ‘no
findings’ on autopsy encompass almost
one-third of all sudden deaths in the
population younger than 30 years of
age. It suggests that there was no prior
medical sciences
warning sign and that death was the first
and usually the only sign.
Risk for SCD
The risk of sudden death among the
general population aged 35 years and
older is in the order of 1-2 per 1000 per
year. Between the age of 40 and 65, there
is a marked increase with CAD being
the most important cause. In patients
with a high-risk status, the risk of sudden
death may be as high as 10-25 per cent
per year. In adolescent and young adult
populations, the risk is about one per
cent (of that of the general adult popu-
lation) and familial diseases, such as the
congenital long QT syndrome, hyper-
trophic cardiomyopathy, arrhythmogenic
right ventricular dysplasia and Brugada
syndrome, play a preponderant role.
Arrhythmogenic right ventricular
dysplasia
Among others, Arrhythmogenic Right
Ventricular Dysplasia (ARVD) is of
special interest. It is the cause of sudden
death in young athletes and otherwise
healthy people during vigorous physi-
cal effort or even during rest and sleep.
Unfortunately, valid World Health
Organisation (WHO) criteria during last
14 years failed to detect ARVD at its early
stage and recommended diagnostic meth-
ods were shown to have low sensitivity
for majority of patients even in its overt
phase (because of a lack of scoring system).
Investigation of this population is further
complicated by disease rarity and lack of
large databases. Newly published research
w w w. a s i a n h h m . c o m 27
medical sciences
V sign pathognomonic of ARVD on ECHO
Figure 1
data give priority to vectorcardiography
and ultrasound.
The recent results published by
Dr Jeff Safitz clearly demonstrate that
patients with ARVD are 10 times more
susceptible to mechanical stretch and
electrical force than normal cardiomyoc-
ites, explaining why those patients are at
risk for early and massive apoptosis.
The possible explanation for this
might lie in the existence of specific place
in the heart exposed to most physical
forces during cardiac cycle. Nevertheless,
this place is the locus minoris rezistentiae
during contraction and relaxation of the
heart. It is presently the focus of ongoing
clinical studies regarding two aforemen-
tioned methods in detecting early stage of
ARVD / C. It is also registered by WIPO
as SOPHIE methodology (suggesting
wisdom to detect).
Both of the aforementioned mecha-
nisms are clearly present in ARVD. It is
a genetic disorder followed by peculiar
RV involvement and its structural and
functional abnormalities (due to the
replacement of myocardium by fatty and
fibrous tissues), and electrical instability
that precipitate ventricular arrhythmias
and sudden death. However, all non-inva-
sive and invasive methods of evaluating
RV structure and function have inherent
limitations, which are due to the complex
anatomy of RV. Evaluation of the RV
28 Asian Hospital & Healthcare Management
T sign pathognomonic of ARVD on ECHO
can provide important insights due to its
complicated structure and the fact of being
divided into three parts: inflow, outflow
and the crescent-shaped, truncated main
body. Not to mention the right ventricu-
lar free wall, which also has a variable,
trabecular pattern that in combination
with its retrosternal position limits precise
measurement of cavity size and wall thick-
ness. Nevertheless, Tricuspid Anterior
Plane Systolic Excursion (TAPSE) has
been shown to correlate with its overall
function (in adults), particularly in systole,
as assessed by ejection fraction, that can
be objectively estimated by radionuclide
ventriculography (done in a standard
way). The recognition of mild, fruste, or
localised forms of the disease remains a
clinical challenge. It is difficult to diag-
nose ARVD in patients with minimal
right ventricular abnormalities by echo or
contrast angiography examination. So far,
only V sign and T sign (Figure 1 and 2)
by Dr Ivana I Vranic have been attributed
as pathognomonic in ARVD but no other
signs have been reported yet. Standardised
diagnostic criteria have been proposed by
the ISFC, however this condition may
be overlooked by the insufficiency of its
signs at the early stage of disease.
New perspectives
Database started in 1998 in Serbia, (which
encompasses 96 ARVD patients up till
ISSUE-16 2008
Figure 2
now), was discovered and has been inves-
tigated by Dr Ivana I Vranic, provides
with some interesting new insights in
relation to vectorcardiography (Figures 3
and 4). This database made it possible to
discover a new pathognomonic sign in the
early phase of SCD-prone patients when
no other technique is able to detect. Very
soon, this technique could be incorpo-
rated in a new medical equipment (used
for risk stratification of SCD).
Autonomic nervous system
The concept that neural activity exerts
a potent influence on arrhythmogen-
esis in late 1970s has received strong
affirmation in recent literature. Some
important and fascinating new insights
have been gained regarding the mecha-
nisms of neurocardiac interactions and
important practical tools from emerg-
ing concepts have been developed for
human studies on neural influences on
heart rhythm in health and disease. These
elements provide basis for risk stratifica-
tion in inherited arrhythmogenic diseases
and implication for therapy. The entire
neural control of the heart is enriched
by afferent information, relayed centrally
through vagal and sympathetic cardiac
afferents. This sensory system, besides
signalling haemodynamic changes through
cardiac mechanoreceptors provides the
basis for arrhythmia genesis.
w w w. a s i a n h h m . c o m 29
medical sciences
Heart rate variability
The analysis of heart rate variability could
also provide valuable inputs for the estima-
tion of the risk for SCD. The influence of
autonomic nervous system on heart rate
has been studied by employing the tool of
Heart Rate Variability (HRV). The study
Increasing degree of right bundle branch block
(a) Normal QRS-vector and T loop; (b), (c), (d)
Different degrees of incomplete right bundle branch
block; (e) complete right bundle branch block
Figure 3
Type A right ventricular hypertrophy
A u thor
(a) ASD, SOVS, VSD; (b), (c) ARVD Figure 4
30 Asian Hospital & Healthcare Management
has shown that parasympathetic activity
influences higher frequency component,
whereas sympathetic nerve activity
exerts lower frequency component. This
parameter is capable of stratifying risk
for mortality after myocardial infarc-
tion, or chronic cardiomyopathy, but
has not been tested in myocarditis or
other inherited arrhythmogenic diseases
until recently by Dr Ivana I Vranic in
ARVD patients.
Heart rate turbulence analysis
Heart Rate Turbulence (HRT) is a
new method for evaluating the risk of
sudden death in patients with heart
diseases (Shmidt et al., 1999). Earlier,
it was the most powerful risk stratifier
in patients with ischemic heart disease,
diabetes mellitus, congestive heart fail-
ure, and idiopathic dilated cardiomy-
opathy, Chagas disease and in healthy
adults. But this kind of studies has never
been conducted with inherited arrhyth-
mogenic diseases until recently by
Dr Ivana I Vranic in ARVD patients.
Turbulence Onset (TO) is the
percentage difference between the heart
rate immediately following PVC and
the heart rate immediately preceding
PVB.
Here A and B are the first two
normal intervals preceding the
Ventricular Premature Beat (VPB) C
and D the first two normal intervals
following the VPB. Turbulence Slope
(TS) is defined as the maximum posi-
tive slope of a regression line assessed
over any sequence of five subsequent
sinus-rhythm RR intervals within the
first 20 sinus rhythm intervals after a
VPB.
Ivana I Vranic is a Specialist in Internal Diseases and is pursuing her
Doctorate from the University of Belgrade School of Medicine. Her
areas of interest include Perioperative intensive care in cardiovascu-
lar surgery, ultrasound in cardiology, urgent medical diagnostics and
therapy and advanced life support and resuscitation.
ISSUE-16 2008
Inclusion criteria for HRT analysis
(G Shmidt et al., 1999): a coupling inter-
val of less than 80 per cent of the average
of the preceding five sinus intervals; a
compensatory pause exceeding 120 per
cent of the preceding sinus intervals; if
they were embedded into two preced-
ing and 15 succeeding N-N intervals;
cycle length of more than 300 ms but less
than 2000 ms; difference to the reference
interval of less than 20 per cent.
Results of HRT analysis
in Sebian database
(Normal: TO <0%, TS>2, 5ms per RR interval)
Turbulence Turbulence
Group N* Onset (TO), slope (TS),
% ms/RR
ARVD with 36 -5.8 ± 4.02 17.0 ±10.38
arrhythmia
ARVD 60 -4.08 ± 4.60 38.56 ± 22.43
without
arrhythmia
Table 1
Abnormal value of TO is high-specific
criteria for the prediction of adverse phase
of disease in patients with heart diseases.
TS < 2,5 ms per RR interval may be
used as a relatively specific tool for risk
stratification of sudden death in patients
with heart disease.
Conclusion
There is diversity of clinical presenta-
tion of SCD data, but now possibilities
abound with new methods, which can
precisely detect people who are at high
risk with recent advances in vector cardi-
ography heart rate turbulance analysis.
Sophie technology can be of much use to
a wide spectrum of populace be it cosmo-
nauts, scientists, sportspersons and high-
risk patients. It can also be beneficial to
insurance industry and professional sports
companies, which buy players.

Bariatric
Surgery
Experience with
medical tourism
E
xorbitant costs of healthcare in
industrialised nations, ease and
affordability of international travel,
favourable currency exchange rates in the
global economy, rapidly improving tech-
nology and standards of care in many
countries of the world, and most impor-
tantly proven safety of healthcare in select
foreign nations have all led to the rise of
medical tourism. More and more people
are travelling abroad as an affordable,
enjoyable, and safe alternative to having
medical, dental, and surgical procedures
done in their home countries.
Medical tourism is relatively cheaper
in developing countries than in the devel-
oped countries. Going by the ‘McDonald
index’, in India you get a burger for 40
cents at McDonalds, which would be
more expensive in the US. Similarly, the
cost of other products and services are
proportionately lower for people coming
from developed countries like the US.
Likewise, a surgery for obesity which
costs about US$ 50,000 could be done
in India for just US$ 10,000 in the best
corporate hospital using the same kind
of technology used in USA and done by
surgeons trained in the West.
Due to the current favourable Rupee
/ Dollar / Pound / Euro exchange rate,
foreign clients can take advantage of the
weak Rupee and save up to 75 per cent
over the same treatment in their own
countries with no compromise on quality.
For the average Indian, private medical
care is very expensive, but for the visitors
from other countries, it is a bargain price
considering what they would pay back
home for an elective procedure with a
top specialist. In other words, cheapness
is relative and does not mean that the
standards are in any way lower.
While the globalisation of healthcare
has given a sense of assurance to patients
that they would get quality care, accredita-
tions like that of the Joint Commission
International (JCI) and presence of
highly-trained doctors have added to
the confidence.
Treating obese patients
To start with, when an obese person
seeking surgery for his / her weight loss
decides to come to India, he / she would
have already tried all other alternatives
and would be fed up and depressed. The
first contact is usually through Internet.
S urgical specialit y
Arun Prasad
Senior Consultant and
Academic Coordinator
Minimal Access & Bariatric Surgery
Apollo Hospitals, India
Medical tourism for
obesity surgery is still in
its infancy and needs to
be taken care of.
What actually they need at that moment
is simple straight talk. The medical tour-
ism agency should understand that these
patients have to be dealt with sympa-
thy and attended in a proper way. And,
repeated questions are normal for this
category of patients.
The potential complications of obes-
ity surgery and the hassles of travelling
to a new country, which has a differ-
ent culture, can stress any one out. It is
important for the patient to have a tele
/ video conferencing with the surgeon
who would be doing the surgery.
Patients have to be counselled about
the tests that need to be done. They are
often put on a high protein low carbo-
hydrate diet that makes them and their
liver more fit for the surgery. This gener-
ally starts 2-3 weeks prior to their travel
to India.
Long travels and long waiting for
transportation may create health trou-
bles, the chief culprit being deep vein
thrombosis. I usually ask my patients to
start prophylaxis against this dreaded and
common problem from the time they leave
their home to the time they go back. One
cannot do an ‘over’ prophylaxis.
w w w. a s i a n h h m . c o m 31
S urgical specialit y
Once the patient reaches India after
enduring the long journey, which is
extremely cumbersome for a patient
weighing over 200 pounds, he / she needs
rest and time to get over jet lag. Most
of the patients suffering from morbid
obesity are shy and have very little experi-
ence of taking long flights. Never plan
to take them from airport to operation
theatre. There should be a cooling off
period of one to two days to ease out
the exhaustion and also to get over the
cultural shock (and of course the jet lag
of travelling east).
All the staff in the hospital has to be
geared to deal with these patients who
are extremely sensitive to any kind of
ridicule that may come from the igno-
rant. The problem of obesity is generally
misunderstood in a developing country
such as India as a self-inflicted problem of
affluence and overindulgence. As a result,
patients who come for the treatment are
often ridiculed. However, the patients do
not expect such insensitive behaviour from
the staff of a professional hospital. For
instance, a patient of mine was not upset
hearing a snide remark from taxi driver
about a possible flat tyre, but a ridicule
from a ward boy, who was deliberately
panting while taking her on a wheel chair,
brought her to tears.
Not just buying a bariatric operation
theatre table will be enough to perform
the operation. There are many other facili-
ties that need to be upgraded like wheel
chairs, toilet seats, room chairs, beds and
all other infrastructural amenities. The
entire team of nurses, ward boys, staff
of the food and beverages department,
dietician, physiotherapists, receptionist
and junior medical staff need training
and workshops on how to deal with these
patients. Only after this, comes the more
difficult job of detecting complications
which though serious, manifest in a very
mild manner that can go undetected till
it is too late.
Patients are sensitive to overcare.
Various department in-charges have the
habit of popping into patient’s room
unannounced while he / she is trying
32 Asian Hospital & Healthcare Management
to sleep. They tend to drop their cards that there is proper communication
and proudly say, “call me any time if you between them. The nurse who checks the
have a problem”. The biggest problem is temperature should reassure the patient.
disposal of these cards and trying to figure She should not dash out of the room to
out who is who. This act of pampering complete the record. I once had a panic
is often seen as an invasion of privacy phone call from a patient, who thought
by the patients. that something was terribly wrong with
The members of the staff who deal his blood pressure as the nurse dashed
with patients directly should ensure out after recording it.
The right approach
• Adherence to predicted time and estimated cost are a few things at which Indians
are extremely poor. This lapse is seen as unprofessional behaviour and can be
very upsetting for the patient and also lead to loss of credibility. Do not create
unrealistic expectations on these fronts. It is always better to make honest realis-
tic statements.
• Admission and discharge procedures should not be time consuming. Transport
from reception to room and within the hospital should be swift and comfortable.
• Food requirements should be special and good coordination is needed between
the surgeon, endocrinologist and dietician. It is very confusing for a patient to
hear different advices on one issue from these three departments. A standardised
and mutually agreed diet chart should be formulated.
• Physical activity, breathing exercises, physiotherapy should be well agreed
upon and appropriate to the medical needs of these patients. Junior doctors are
totally untrained to deal with patients of another country especially with obese
patients. They need to be sensitised to the needs of this special group of patients.
Psychological care is as important as the medical care.
• Cleanliness and infection control is the biggest nightmare of all these patients.
Repeated assurances about the equipment used, sterilisation and usage of gloves
is necessary. The surgeon in charge is the best person to address this concern.
• Postoperative pain control, communication and reassurance is needed. If possi-
ble, video conferencing with a close relative back home can do wonders in boost-
ing the morale of these patients. Avoid overcautious approach as this could raise
suspicions of something being wrong and something being hidden.
• Billing and discharge procedures have to be smooth and reading material on
postoperative care is very useful. Patients should not be abandoned at this stage
and should be escorted to a hotel for recovery before they fly back. An email of
good wishes and enquiry is always welcome.
Medical tourism for obesity surgery is still in its infancy and we need to realise that
this infant has special needs that need to be catered to if we want it to be a healthy
adult.
A u thor
Arun Prasad belongs to the first generation of laparoscopic
surgeons from the time it started in the UK. Experience of over 5000
laparoscopic surgeries that include over 3500 cases of laparoscopic
cholecystectomy, 1000 laparoscopic hernia surgery and rest
advanced laparoscopic surgery including Thoracoscopic and
Bariatric Surgery for weight loss including Gastric Banding, Roux en
Y Gastric Bypass, Sleeve Gastrectomy and Mini Gastric Bypass.
ISSUE-16 2008
 diagnostics

Radiology Beyond Anatomy

New value chain for personalised
medicine
Radiological imaging is capable of providing ‘functional’ information for biomedical
characterisation of disease beyond volumetric visualisation of structure with high spatial
resolution. Improved technologies enable further transparency beyond imaging interlinked
with important economical aspects, such as Six Sigma for improved and efficient patient care.

by multislice CT enable a real volu- Imaging (MRI), provide whole body

Frederik Lars Giesel
Physician
Department of Radiology
National German Cancer Research
Centre, Heidelberg, Germany
Hans-Ulrich Kauczor
Professor and Chairman
Department of Radiology
University of Heidelberg, Germany
metric approach. The large number of
source images represents an incredible
amount of work for the radiologists and
is unacceptable for clinical partners.
This requires the extraction of infor-
mation from high-resolution volumetric
CT and has driven the development,
implementation and integration of
dedicated Computer Assisted Diagnosis
(CAD) applications. They provide
coverage and are useful to assess systemic,
generalised diseases, e.g. M-staging in
tumours and atherosclerosis.
Information extraction
Apart from extraction of information
from a single series, steps such as fusion,
matching and registration of images and
extracted information from different
modalities (PET, CT, MRI), e.g. colour-

H
ealthcare providers in devel-
oped countries are facing the
challenge of improved and effi-
cient hospital management focussed on
a bottom-up approach for patient flow
and management. Patient management
relies on best medical care right from the
hospital entry point. This first contact
and the subsequent hospital care are
crucial and require expertise of high-level
professionals and economic expertise.
Today, imaging presents the opportu-
nity for guiding the further diagnostic
and therapeutic pathways and thus
leads to dedicated and personalised
medicine.
enhanced view of structure by multi- coded parameter maps, are necessary to
planar reformations, thin- or thick-slab exploit the potential of complementary
maximum-intensity-projections, volume image information.
rendering, and virtual endoscopies. The MRI enables high spatial resolution
sophisticated tools that have wide- and the detailed visualisation of struc-
spread application include detection ture with high spatial resolution and
and volumetry of pulmonary nodules T1- or T2-weighting. The application of
(Figure 1) and virtual colonoscopy. T1-, T2- proton- or diffusion-weighted
Both CT and Magnetic Resonance sequences aims at the visualisation of
Tumour assessment using RECIST, WHO and volumetric analysis of
pulmonary nodules on axial slices and 3D

Structural and volumetric

visualisation
Computed Tomography (CT) is one of
the leading imaging modality to visu-
alise the structure of tumours. Novel
volume acquisitions with almost isotropic
voxels in sub-millimetres as provided
Figure 1

w w w. a s i a n h h m . c o m 33
diagnostics

special properties of the tissue of interest,
such as fluid or cellularity.
Functional imaging, which relates
mainly to volumetric imaging that gener-
ates a large number of images (Figure
2 and 3), is also called 4D imaging.
Dedicated software and software engi-
neering is required to extract the informa-
tion, which is ‘functional’ in a broader
sense. Time resolved series acquired during
contrast applications enable morphological
and functional insights of small and large
vascular structures—so called magnetic
resonance angiography (MRA)—and its
territories and branches.
‘Perfusion’ MR imaging aims to
capture tissue microcirculation by using
endogeneous contrast or iatrogenic appli-
cation of contrast agents (extra-cellular or
intra-vascular) or even different contrast
compartment mechanisms (one-, two- or
multi-compartment model) on the basis
of both T1-weighted or T2*-weighted
sequences.
From such 4D-series (3D + time),
perfusion is assessed qualitatively by
visual evaluation, semi-quantitatively
by analysing Signal Intensity (SI) or
Signal to Noise Ratio (SNR) curves
over time or by quantitative approaches
that make use of more sophisticated
pharmacokinetic modelling provid-
ing surrogates for microvessel density
and vascular permeability. Both are
regarded as indicators for the angiogenic
potential of the tumour. Similar analy-
ses are possible by contrast-enhanced
CT (perfusion CT) that has entered
clinical routine for stroke diagnostics
and recently through the rapid improve-
ment in CT-Scanner for cardiac
imaging.
Motion imaging is looking into
cardiac and respiratory motion including
the compliance of the myocardium (hypo-
kinesia) and vascular walls. Appropriate
triggering, e.g. by ECG or a respiratory
belt is required. In aortic aneurysms the
lack of compliance of the aortic wall
might serve as a predictor of the risk of
rupture. On other occasions, resolved
image acquisition protocols allow
for the assessment of respiratory
motion and especially the mobility of
neoplasms, which might have substantial
effects on high precision radiotherapy
planning.
Another novel functional MR
technique is Diffusion Weighted
Imaging (DWI), which provides addi-
tional insights into the microstruc-
ture of tissues simply by measuring
the amount and direction of the diff
sive Brownian motion of water mole-
cules. It can be used for tractography
(Diffusion Tensor Imaging or DTI)
in the brain demonstrating the loca-
tion and orientation of fibre tracts or
visualization of recurrent cancer, espe-
cially in head and neck tumours, as it
provides information on cellularity and
perfusion.

MRI-based perfusion map MRI-based perfusion map in

in breast cancer malignant pleural mesothelioma

a) High perfusion indicated by high amplitude and exchange rate before chemotherapy a) Marked hyperperfusion before chemotherapy

b) No spot of increased perfusion after chemotherapy, indicating ‘complete remission” b) Increased perfusion indicated by
high amplitude and exchange rate after
chemotherapy, size (RECIST) unchanged,
representing ‘progressive disease”

Figure 2 Figure 3

34 Asian Hospital & Healthcare Management ISSUE-16 2008


Integration
Multidimensional imaging comprises
targeted molecular imaging of individual
tumour types and characteristics on the
one hand and downstream surrogates
of tumour biology, such as results from
perfusion MR imaging, i.e. microcir-
culation and permeability that play a
major role in oncological radiology on
the other. The implementation of surro-
gate markers is a major challenge within
the multidisciplinary concept of tumour
diagnosis and treatment follow-up during
dedicated therapies.
Once achieved, it will reduce the
need for specific molecular imaging.
Improved and increasingly sophisti-
cated approach will integrate imaging
and non-imaging surrogates, and will fuse
different worlds within the life sciences.
Future radiology will supply detailed
structural and functional information,
such as perfusion or metabolism as a
3D coverage of two different volumes
(1) ‘whole body’ volume for staging and
(2) ‘whole lesion’ volume for assessment
of heterogeneities.
In contrast to molecular biology,
which mainly is unidimensional, and
histology, which provides 2D information,
radiology provides information regarding
localization and extent in 3D. This situ-
ation demands for integration for such
markers in large databases to enable a
multidimensional matrix for prediction
of prognosis or treatment response.
Impact on treatment planning and
personalised care clinical setting, especially neo-adjuvant or
Continuous advances in therapeutic
approaches necessitate new concepts in
non-invasive image-based assessment.
Nuclear medicine techniques, especially
Positron Emission Tomography (PET),
have recently gained importance with the
combination of structural high resolution
imaging from radiology (64-MSCT and
higher) with a PET scanner (Figure 4).
diagnostics
In contrast, new functional imag-
ing approaches such as dynamic contrast
enhanced MRI (DCE-MRI) or Perfusion
Computed Tomography (Perfusion CT)
enable an additional tissue characterisa-
tion. These 4D (3D + t) high-resolution
(spatial and temporal) imaging techniques
are complementary to nuclear medicine.
While PET enables assessment of meta-
bolic activity 4D imaging using CT or
MRI enables non-invasive insight of
microvascular status in diagnosis of stroke
or oncology. Perfusion imaging method-
ologies are of particular importance in the
adjuvant radio-chemotherapy in cancer
including anti-angiogenesis. The combi-
nation of all these modalities enables a
high level of individual patient care. The
current transition to bio-medical imaging
in radiology empowers medical profes-
sionals to respond more precisely to the
individual disease status and predict the
outcome.
w w w. a s i a n h h m . c o m 35
diagnostics

CT-PET image fusion in liver metastasis Economic perspective

for planning RFA treatment and follow-up

a) CT-PET image fusion
b) Treatment planning of liver lesions in
3D-surfcce rendering on the basis of CT
and PET data
Today, healthcare providers in the devel-
oped countries are facing the heavy
burden of healthcare costs, which are
mainly caused by increased technologi-
cal standards and the demographic chal-
lenges. At the same time, healthcare is
one of the biggest and most promising
industry worldwide and is experiencing
a major change from public service to
private patient-focussed care (so called:
personalised medicine). Particularly,
the major terms like ‘individual patient
care (diagnostics and therapy decision
path)’, ‘process optimisation’, ‘market
positioning’ and ‘Six Sigma’ play a major
role for department heads and hospital
managers. In particular, Six Sigma is
one of the important tools in healthcare
management to rule out deficits in serv-
ice quality and performance on different
levels that affect the total patient clinical
value chain. Therefore, we would like to
make the reader familiar with the term:
The term Six Sigma is derived from the
electronic industry and often focusses
on three important indicators in particu-
lar to healthcare providers - Access to
services, Service cycle time, and Cycle
time associated with result reporting and
discharge. In Six Sigma, higher sigma
numbers correspond to fewer defect
rates. At the Six Sigma level, there are
only 3.4 errors per million opportuni-
ties, which is nearly error-free. Striving
towards the Six Sigma level involves five
major steps:
1. Defining a problem
2. Measuring what is important
3. Using statistical tools to analyse the
root causes for variation in quality and
performance
4. Working together as a team for making
improvements and implementing them
over time
5. Monitoring and controlling the success
and sustainability of the solutions.
Clearly defined measures and data
analysis allow for additional benefits to
manage the hospital processes effec-
tively to increase individual patient care.

Conclusion series from different image modalities,

Apart from volumetric structural visu-
alisation with high spatial resolution CT
and MRI, these modalities are capable
of providing ‘functional’ information for
individual characterisation of disease.
Adding the dynamic temporal compo-
nent to such acquisition allows generating
4D maps (3D structure + time). Two
important tasks have to be solved by
c) RFA of target lesions CAD (1) registration of different image
and (2) extraction and integration of
quantitative surrogates that can be used
for characterisation, therapeutic deci-
sion-making, image-guided procedures
and efficacy evaluation. This personalised
medical value chain brings benefits to
patient care from individual non-invasive
3D / 4D imaging-based surrogates and
enables improvement of healthcare with
innovative tools cost-effectively.

Frederik Lars Giesel is physician at the National German Cancer

Research Centre, Department of Radiology, Heidelberg, Germany.
Giesel is also working as a honorary visiting lecturer at the University
of Sheffield, United Kingdom. His research focusses on pharmacoki-
A u thor

netic and molecular imaging. He holds several patents for contrast

media, undertakes various clinical trials and has broad expertise in
industrial cooperation. Recently, he gained an international MBA
degree to extent his expertise from medicine to economic.

Hans-Ulrich Kauczor is a Professor and Chairman of Radiology at

the University of Heidelberg, and Medical Director of Diagnostic
and Interventional Radiology at the University Hospital Heidelberg.
He is the CEO of the Steinbeis-Transferzentrum ‘Radiological
Imaging: Consulting and Training.’
Figure 4

36 Asian Hospital & Healthcare Management ISSUE-16 2008

w w w. a s i a n h h m . c o m 37
 Allows patients to access their health information from
Functions and Advantages
any place at any time, so that they can easily monitor
and manage their health and enables them to get better
treatment for their ailments and diseases
PHR contains medical and health information, drug
information, family history, medical / health contacts,
general health and demographic information, diseases
and conditions, hospitalisations, surgeries, injuries,
lab tests / results, screenings, health insurance
information etc.
Allows doctors to deliver better care to patients
38 Asian Hospital & Healthcare Management ISSUE-16 2008
Reduces cost by avoiding the duplication of tests with
proper maintenance of reports
PHR helps in improving healthcare communications
between patients and doctors
Helps in scheduling appointments with the doctor
Provides drug interaction, online prescription request and
refills, and preventive service and appointment reminders.
Manages information like identification and demography,
personal contact, medical insurance, pharmacy insurance
and contact with the medical care provider.
Patient Records Online
Shared access for quality care
Online Personal Health
Records signal
a paradigm shift in
the management of a
patient data. By allowing
easy access to patient
information, online health
records can enhance
patient care and create
a healthy doctor-patient
relationship.
Prasanthi Potluri
Editor
Asian Hospital & Healthcare Management
Akhil Tandulwadikar
Editor
Asian Hospital & Healthcare Management
I
n healthcare, information, especially
the one related to a patient’s health, is
key to the care provided. Faulty treat-
ments, in most cases, can be attributed to
improper communication of critical data.
The adoption of information technology
by healthcare providers has resulted in
reducing many of these errors. However,
amidst all these developments, the patient
has in some ways been left out. The data
related to one’s own care is either not
available with the patient or is beyond
his / her comprehension. As a result,
the patient is completely dependent on
the doctor when it comes to making a
decision regarding his / her treatment.
However, the Internet has changed this
scenario drastically. Today, information
about diseases, treatments and medicines
is available at the click of a button.
Storing medical records online
Electronic Medical Records (EMRs) have
made the storage and management of
large volumes of health data electroni-
cally possible. Since, EMRs served only
doctors, a tool to help patients manage
their health information was still miss-
ing. This scenario changed with the
introduction of online Personal Health
Records (PHRs). Like in industries such
as banking, the Internet is empowering
consumers by enabling them to take
control of their health information.
This movement is a part of the ongo-
ing trend of consumer-driven services
that has been driving healthcare for the
past few years.
Unlike EMRs, a PHR is created and
managed by patients, their caregivers
or family members. Other key play-
ers involved in PHRs are healthcare
providers, medical equipment providers,
insurers, pharmacies, employers and
organisations providing health-related
information.
Drivers for PHRs
Not surprisingly, doctors have been
endorsing PHR by switching over to
digital and online records. The response
to PHRs has been most visible in Europe
and USA, where the move to consumer-
centred healthcare is taking place at
a rapid pace. “In the US and Europe
A US survey in 2005 by the Markle Foundation
found that 60 per cent of respondents
supported the creation of a secure online
personal health record service.
major private healthcare organisations
have come to recognise the potential
value of PHR for improving customer
satisfaction and loyalty, and as a mecha-
nism for reducing and raising revenue,”
says Dr Claudia Pagliari, Senior Lecturer
in Primary Care, School of Clinical and
Community Health Sciences, University
of Edinburgh, UK.
Also, many IT companies have
shown interest towards providing
online PHR services. Organisations like
Kaiser Permanente, Microsoft, Google,
IBM, Intel etc. have already made their
services available. More companies are
likely to jump into the foray as the
w w w. a s i a n h h m . c o m 39
 Bill Crounse
Senior Director
Worldwide Health, Microsoft Corporation, USA
How do you think PHRs will affect Patient care?
I see it as a very positive impact on patient care,
I myself as a physician, practiced for more than
twenty years before joining Microsoft and I have
always believed that patient’s who are powered
and engaged with their physician can have an
enhanced dialogue and share information with
their physicians, actually are people who end up
with healthier outcomes and get better care. I
think ideally we want our patients to be informed
and to be copartners with us in managing their
health. And PHR is one very important way to
do that. Also, there are obvious advantages that
can help speed workflow. Many of the scenarios
for PHR involve being able to get that informa-
tion, share that information with who ever you
want to share it with. That of course includes
your physician or your hospital meaning that
in many cases properly configured, you won’t
have to be filling out similar paper work every
where you go because you can grant a doctor
or a hospital access to your information. That’s
the way we designed our Health Vault system.
Microsoft’s Health Vault here in United States,
is to give that functionality so the consumers
really in control of the information and can grant
access to a healthcare provider organisation
or healthcare provider or a family member and
they really have complete control on that infor-
mation.
How has the response of patients been to online
PHRs?
I can speak certainly for what are the experi-
ences with Health Vault. We are very pleased with
numbers of people who are establishing Health
Vault accounts and availing themselves of the
services, whether that is search for information
or upload their medical information or connect
with partners and services and devices that are
made accessible through the Health Vault. So,
we are at the beginning of a long journey; this
won’t happen overnight. I should be clear, that
Microsoft is not the only company this going to
be the space. There will many others including
provider organisations and payer organisations.
But, I must add that I am extremely pleased be
associated with a company that has put a firm
foot in the water and has developed a service
that people are so excited about.
40
40 Asian Hospital & Healthcare Management
How are PHRs likely to evolve in the coming
years?
If I may use the analogy of the Automated Teller
Machine (ATM) if you think about early ATMs,
when quite frankly nobody got too excited about
them, originally they were ways that you could just
go and look at information, you could look at your
bank balance but you really couldn’t do very much.
In a way, today’s rudimentary PHRs are a bit like
that. In many ways today what asking consum-
ers to sort of aggregate their own information and
enter in to a Health Vault account or store it in a
Health Vault or other kind of repository and there
are not a whole lot of transactions going on. But, I
think where we are moving, and you are suddenly
be seeing this an announcement coming forward
from our company and I am sure others, that it will
become much more fluid much more transactional,
in the same way that my banking accounts or my
brokerage accounts today are highly transactional
and the data is uploaded, downloaded data, but all
of the partners that I work with in the ecosystem
are exchanging data through this systems. That
it would become much more automated when it
does, then we will truly a have arrived at a point I
think people will understand and avail themselves
of the patient health records. Because today, I
mean it’s going to be the highly engaged, highly
motivated consumer who is going to want to
manually to track down their health information
and then upload it into some repository. The more
idea system is, put in some information, but, my
doctor contributes to that information, my dentist
and hospital might contributes to that repository.
So, that’s what we need to move.
How will this affect the current healthcare
scenario?
I think what you are going to find around the world,
and I’ll start-off speaking to developed countries
around the world, developed economies that we
hear more and more about consumers / patients
demanding more transparency in healthcare;
transparency in pricing, transparency in quality,
transparency in services. I think that comes hand-
in-hand with notion that government and payers of
healthcare around the world are putting more and
more responsibility on the consumers. If consum-
ers of care are going to be put in that position, then
they do indeed deserve greater transparency. And
one of the ways we can deliver that transparency
is through online services and through personal
health records. And in the same way, I think the
personal health records, in many ways, makes
the patient or consumer more transparent to the
healthcare provider because he / she has at his /
her fingertips the data that they need to take care.
So, I think it really benefits all sides of equation. And
ISSUE-16 2008
2008
I think in the, let us say, in less developed countries
I think even where medical resources may be less
available or scarce or difficult to access, there’s all
the more reason that it’s extraordinarily important
for people to have a record of their information.
And, it’s uncommon, I mean I know in many coun-
tries around the world, the norm is that there is a
expectation that the patient is actually responsible
for keeping their health record, the health system
doesn’t take it upon itself to be the arbitrator or the
repository for the health record, it’s for the patient
who owns the data and actually it makes a lot of
sense.
Could there be any unintended consequences of
making PHRs available online?
I think the unintended consequence would come
should there be breaches in security or privacy,
which is why I would implore any one contem-
plating developing a service ore repository of this
kind of information, to be extraordinarily cautious
about privacy and security. We hold this informa-
tion dearer than even our financial information.
Indeed I think, and rightfully so, consumers need
to be cautious, I think they need to be wary, I
think that there’s a good reason to be concerned,
particularly as we get into the area of genomics
and DNA analysis and so forth and in risk assess-
ment, you know science moves so forward that
we start predicting disease states and people.
We certainly don’t want people put in jeopardy
being discriminated against on the job front or in
the society. So, these are all things that patients
in healthcare organisations and Governments and
everyone needs to give deep thoughts to that we
are prudent in developing systems with appropri-
ate privacy and security because nothing is more
important.
Are the current data safety standards enough?
One could argue that what has held us back in
healthcare is not the lack of standards but may
be too many standards. And that our standards
bodies have moved too slowly and sometimes
have been at odds with each other. We need to
sort through that. Here again I think that technol-
ogy and web services and XML is taking us where
we need to go. You’ve also probably read about the
investments Microsoft is making for example with
technology called the () which we acquired, which
is very good at aggregating lots of different kinds
of data from lots of different kinds of sources and
making it highly usable to end-users and the ability
to analyse that data and make sense of it and turn
data into information, information into knowledge
and knowledge into wisdom. So, yes we need
standards, there is no doubt about that, but I think
that we are making good progress.
presence of PHRs spreads. This augurs
well for patients as well as healthcare
providers.
The potential benefits of PHRs
in Asia are numerous. Compared to
their western counterparts, health-
care consumers in Asia have little or
no control over their health informa-
tion. “In the developing countries PHRs
have the potential to become a trans-
formative technology by balancing the
power differential between consumers
and providers of healthcare,” opines
Dr Pagliari. Giving people control
over their information could not only
improve their awareness towards health-
The Networked PHR
Specialist Doctor
Hospital
System Data Hub
Laboratory
Pharmacy X
Hospital A
School Nurse
care, but also encourage them towards
self-care. Though there are some online
PHRs in Asia, they are far and few in
number. With sustained efforts from
the IT companies, this scenario is likely
to improve. Ubiquity of the Internet
permits the patients to easily access their
health records any time, online.
Perspectives
A typical PHR website helps the patients
in recording their health information
and sending health data from their EMR
to a doctor or a healthcare provider. It
enables patients to actively participate in
maintaining their own health checkups
Pharmacy Q
Hospital B
Pharmacy Y
Specialist Doctor
Home
Monitoring Devices
Payer Data Center
(Health plan Medicare)
by providing information on diseases,
prognosis, causes, symptoms, treatment,
diagnosis, prevention, complications,
etc. It also provides health management
tools—assists a patient with the infor-
mation contained in their record, helps
the patient in booking appointments
online with doctors and allows patients
to choose home-based self-monitoring
medical devices. “Integrated PHR
systems that enable online appoint-
ment booking or results collection
can enhance patient convenience and
satisfaction,” adds Dr Pagliari.
Microsoft’s HealthVault, for exam-
ple, offers a way to connect, store and
share the entire patient’s information
in one place, without being tied to a
closed, siloed database. Online PHRs
also allow patients to interact and share
experiences, which could further encour-
age self-care.
A website providing PHR services
also provides information about diseases
and treatments. The availability of
information on various diseases, condi-
tions and treatments on the Internet has
made patients more aware and demand-
ing. This information, sourced mostly
from organisations and focussed on
research in these areas, is more reliable
as it comes from a credible source. By
giving the patient control over infor-
mation related to their disease, PHRs
add another dimension to this change
underway in healthcare.

Scenario in India Doctor-patient relationship

Perhaps the biggest change that an
There has been an impressive growth in India’s healthcare sector. “Well–informed
online PHR would bring to health-
patients are now demanding their doctors in India to treat them with more respect and care is in the patient-doctor commu-
be more transparent,” says Dr Aniruddha Malpani, Medical Director, HELP – Health nication. “Increased access to and
Education Library for People, India. However, EMRs are yet to become a part of the control of personal data may raise
mainstream. Medical records are maintained mostly in the form of hand written text as patients’ motivation for self-care and
in doctor’s consultation or typed text on paper. improve doctor-patient communica-
Whilst healthcare records are being made online and few companies are getting into tion and shared decision making,” says
developing online PHRs, India still has a long way to catch up with the technology Dr Pagliari. With their ease of use,
and advancement in healthcare services. “In developing countries much patient care PHRs help in getting the patient
remains at the paternalistic end of the spectrum, increasing the potential of PHR to involved in the treatment he receives.
become a transformative technology by balancing the power differential between It allows the patient to report even the
consumers and providers of healthcare,” says Dr Claudia Pagliari. minor problems he or she had faced
during th treatment to the doctor.

w w w. a s i a n h h m . c o m 41
 Claudia Pagliari
Senior Lecturer, Primary Care
School of Clinical and Community Health Sciences
University of Edinburgh, UK

How will PHRs affect the doctor-patient relation-
ship?
The issue of electronic health records often attracts
public concern about the privacy and security of
personal data. However emerging research indi-
cates that giving patients access to their records
can improve trust in doctors and healthcare
organizations by increasing transparency and
enabling the individual to question the data that
are held about them. PHR also provide opportuni-
ties for patients to organize their own records and
thoughts about their illness patterns, which can aid
communication and shared decision making during
the consultation. At the same time, integrated PHR
systems that enable online appointment booking or
results collection can enhance patient convenience
and satisfaction.
How will this affect the current healthcare scenario
where doctors are not sharing patient information,
especially in developing countries?
Most western nations have seen a marked shift in
attitudes towards the roles of doctors and patients
over the last 10-15 years, accompanied by a move
from the traditional paternalistic model of health-
care to a more patient-centred and collaborative
one. This reflects wider societal trends towards
consumer empowerment, which encompass
greater freedom of information and flexible serv-
ices. Personal Health Records are entirely consist-
ent with these trends, offering the promise of
convenient access to one’s own data, the right to
critically evaluate this information, and the opportu-
nity to become a partner in the healthcare process.
In developing countries much patient care remains
at the paternalistic end of the spectrum, increas-
ing the potential of PHR to become a transforma-
tive technology by balancing the power differential
between consumers and providers of healthcare.
While variable access to online PHR could increase
the digital health divide, two factors offer hope that
this will not be the case. Firstly, PHR are becoming
available in multiple formats, including via mobile
phone and wireless internet, and access to such
services may be good even in areas where other
technological infrastructure is underdeveloped.
Secondly, early evidence from the USA indicates
that the most economically disadvantaged groups
may derive the greatest benefits from such tech-
nologies, which can ameliorate limitations in
access to healthcare through supporting health
self-management and offering cheaper opportuni-
ties for remote care. PHR also have the potential to
increase the globalisation of healthcare; for example
by enabling migratory workers to maintain access
to their records and their healthcare providers via
the internet; while multifunctional and interactive
PHR also offer opportunities for the purchase of
cheaper or higher-quality care from providers in
other parts of the world.
How have the healthcare IT companies responded
to this?
Personal Health Records technology is a commer-
cial growth area. In the United States and Europe
major private healthcare organizations have
come to recognise the potential value of PHR for
improving customer satisfaction and loyalty, and
as a mechanism for reducing costs (e.g. through
fewer insurance claims) and raising revenue (e.g.
through online consulting). This has lead to the
growth in online, interactive PHR systems, such as
Kaiser Permanente’s Health Online. Other commer-
cial providers have stepped in to develop portable
record management tools, such as the MedicAlert
E-HealthKey which stores multiple records that
can be viewed by an emergency healthcare team
with the relevant software, as well as by the
patient themselves using a home computer. In the
United Kingdom commercial operators are offering
patients access to their primary care record via
USB smartcard and waiting room kiosks, as well
as via the internet. It is unclear how this market
will be influenced by the development of free online
PHR systems, such as HealthSpace in the UK and
iHealthRecord in the USA, although the differing
needs of healthcare consumers will undoubtedly
create multiple product niches.

Aniruddha Malpani
Medical Director
HELP – Health Education Library for People, India

Why is there a need for taking PHRs online?
The healthcare industry is a service industry which
was designed to keep people in good health. Today,
unfortunately, it has deteriorated to becoming a
sickness industry, which specialises in taking care
of diseases. There are many reasons why matters
have come to such a sad pass—and one of the
most important of these is the fact that people
have no control over what healthcare services
they receive. It’s high time the industry re-discov-
ered its focus and put people back in control of
their healthcare, by designing a consumer-driven
healthcare industry. One of the key ingredients for
this is the Personal Health Record.
What are the benefits of making Personal Health
Records available online?
While paper records and online records are
complementary, online records offer many advan-
tages.
1. Much less expensive to setup
2. Easier to update
3. Easier to access 24/7 from anywhere in the
world
4. Do not get lost
5. Can be referred to in an emergency by a family
member
6. They allow people to setup online communities
and network with and share information with
other people who have similar medical problems
7. The biggest benefit is that they allow data inter-
operability; so that in the future, the patient’s
health record is automatically updated when
the doctor’s or hospital’s medical records is
updated, so that there is no need to enter the
data multiple times

42
42 Asian Hospital & Healthcare Management ISSUE-16 2008
2008
By doing this, the possibility of the
condition spiralling out of control
can be checked and eliminated. The
doctor can decide the course of action
that needs to be taken and, if needed,
an appointment can be fixed. Clear
communication between the doctor
and the patient helps build confidence
into the relationship. “PHR greatly
enhances the doctor-patient relation-
ship,” says Dr Bill Crounse, Senior
Director, Worldwide Health, Microsoft
Online PHR System
GoogleHealth
HealthVault
My HealtheVet
myPHR
WebMD
ER-Card
LifeSensor
Corporation. This transparency would
lead to reduction of medical errors.
“Greater transparency of information
may also enable the identification of
errors by patients, which has potential
to improve patient safety by highlight-
ing unrecorded allergies, outdated diag-
noses or inappropriate medications,”
opines Dr Pagliari.
Further, as the patient’s health
information is recorded in the online
PHR, the data would remain intact
Provider
Google
Microsoft
U.S. Department of Veterans Affairs (VA)
American Health Information Management
Association
WebMD Health Corp.
ER Card, LLC
InterComponentWare Inc.
CaseStudy
even when the patient changes his /
her primary care physician. The record
provides the doctor with the patient’s
medical history, which helps the doctor
get an overview of the case and plan
treatment accordingly.
In case of emergency, the treating
doctor would have ready access to all
the necessary information about the
patient—thus avoiding possible medi-
cal errors. This is a dramatic change
over what exists today in the EMRs,
which may not be accessible across
different networks.
Privacy, confidentiality…
The major challenge facing online
PHRs is to chuck out security, privacy
and confidentiality threats. The top
concern of the consumer is the poten-
tial misuse of data from their health
record. A few companies that offer
PHR services, for example, could share
the data with third-party firms without
the patient’s consent.
The privacy concerns, therefore,
revolve around the ones who have an
access to the information. An indi-

Vendor Created, Clinic Hosted

vidual who signs up for an Internet-
based service with password controls
an untethered PHR. The privacy of his
John D Halamka data depends on how best the service
Chief Information Officer and Dean for provider is able to guard the informa-
Technology Harvard Medical School, USA tion. Potential threats from hackers also
cannot be ignored. Individual provide
MyChart is the EHR product, developed by US based Epic Systems with The Palo Alto their health information or sends perti-
Medical Foundation (PAMF). The functionality requirements for a PHR were integrated
nent documents to the PHR vendor to
with their EHR. PAMF became the first customer of MyChart, which was implemented
at the end of 2000. Since then, over 90,000 patients have used PAMFOnline. Across be filed in the record. Service provid-
the US, 2.4 million patients are using MyChart. MyChart enables the patients to view ers, therefore, are making all possible
their diagnoses, active medications, allergies, health maintenance schedules, immuni- efforts to meet existing data security
sations, test results (including graphical display), radiology results, appointments, and standards, even as new ones are being
demographics. put in place by various government and
In many cases, relevant health educational resources are automatically linked to key non-government organisations.
terms or phrases in the patient’s medical record, such as a diagnosis of Diabetes. In the US, for example, an online
PHR system should at least have
In addition, patients can communicate with the physician’s office to request an appoint-
privacy measures equal to those in
ment, request a prescription renewal, update demographic information, update immu-
nisation status, or update a health maintenance procedure. The patient can also request
Health Insurance Portability and
advice from an advisory nurse or from his or her own physicians. The most popular Accountability Act 1996 (HIPAA).
features of the integrated PHR are access to lab test results and communication with The National Committee on Vital and
physicians. As of September 2007, 26,000 patients login to PAMF’s MyChart each Health Statistics (NCVHS) subcom-
month, sending 20,000 secure messages. mittee has been conducting hearings
on privacy and confidentiality and

w w w. a s i a n h h m . c o m 43
 the Nationwide Health Information
Network (NHIN), and additional
recommendations will be forthcom-
ing. Standards should cover all the key
areas in making the PHR implementa-
tion easy and reliable. In response to
the threat concern from health plan,
employer or provider organi-
sations handling data due to
lack of portability, AHIP and
the BlueCross BlueShield
Association (BCBSA) of US
have undertaken an initia-
tive to adopt standards for
the essential data content of
PHRs as well as for messaging
among them in order to make
PHR data transportable among health
plans. The standards from The Health
Information Technology Standards
Panel (HITSP) will be used as a part of
Commission on Certification of Health
Information Technology (CCHIT)
44 Asian Hospital & Healthcare Management
certification criteria for Electronic
Health Records (EHR) and PHRs
over the next three years.
In UK, Commons Health
Committee is working on the develop-
ment of the national electronic record
system.
Online PHRs could solve the
information needs of doctors at
all levels of treatment.
Canada Health Infoway and the
Canadian Standards Association
have signed a cooperative agree-
ment to advance health information
technology standards in managing
PHRs.
ISSUE-16 2008
The result…
Though there are concerns, healthcare
consumers have shown interest in moving
their PHRs online as it gives them a
sense of control and involvement. PHRs
could also play a vital role in improving
healthcare delivery, promoting wellness
and disease prevention.
The journey towards creating
online medical records—from
unstructured medical records to
paper-based medical records to
computerised records and then on
to online medical records now—
has been charted over a period of
almost a decade. Online PHRs
could solve the information
needs of doctors at all levels of treatment.
Interoperability, the major hurdle to
the proliferation of EMRs, could be
a thing of the past with the Internet
and the presence of universal guidelines
for PHRs.
Online Health Information
Accuracy, quality and privacy
Several e-Health initiatives are underway to empower the patient with the right information.
The Internet, with its vast amounts of information, is a key player in turning the patient into
an ‘informed patient’.
Célia Boyer
Executive Director
Mayoni Ranasinghe
Research Assistant
Health on the Net Foundation (HON)
Switzerland
T
he ever-growing fields of science
and technology have advanced
the quality of human life in leaps
and bounds in all aspects, from Internet
banking to eco-friendly cars.
The health domain has also been
influenced in this wave of development
in various aspects with discoveries in
the field of research, new and improved
diagnostics and minimally invasive proce-
dures, to name a few. As always, there
is room for improvement. The Patients’
and Citizens Task Force of the European
Health Telematics Association (EHTEL)
describes several possible ventures.
One such improvement is through
the use of Electronic Health Records
(EHR). The patient should be master
of the EHR as consent for information
sharing on the EHR would be given by
him / her. This consent should be taken
at the onset, following which reviews
would be done upon considering new
conditions. If the patient suspects any
information abuse, he / she would have
the right to intervene and call for action.
The patient would also have the right to
restrict information sharing (but should
be made aware that this may affect care)
and would not be discriminated or
refused care as a result of this. Electronic
communications and a log book facility
are essential in such a record to enable
proper information sharing in addition
to providing a record of all such transac-
tions. Also, cross-border issues should
be addressed by the EHR, thus enabling
the patient to access it regardless of
his / her geographical location.
Authenticating info-systems
Another foreseen venture is the infor-
mation system within a clinical setting
(which encompasses the EHR). Unlike
new medications or devices, many infor-
mation systems are not tested thoroughly
before implementation, thereby increas-
ing the risk of errors. Information systems
to be implemented in the clinical sector
especially require vigorous and independ-
ent testing before actual implementation,
as well as the proper training of all who
use it, to ensure that errors, such as faulty
data entry and accidental security breach
are minimal. The Internet has brought
a wealth of information to the patient
and provided a way to research aspects
of medication and alternative manage-
ment strategies. Indeed, the patient can
often have more time to spend on this
issue than a pressured and time-limited
professional. This empowers the patient
and provides greater control over his /
her health. The concept of the ‘informed
patient’ is one that needs to infiltrate
the existing consultation and treatment
regime. The views of the patient need
to be listened to and respected.
Focus on homecare, safety
Patients requiring homecare can also
benefit from the aspects of eHealth.
Homecare is usually provided for the
elderly and those with severe disabili-
ties or debilitating diseases. Like in all
other aspects of healthcare, in homecare
as well, patient safety is paramount. To
ensure this, patient should be informed
about the benefits as well as the risks
of homecare. The patient must be in
control and privacy should always be
respected. Any homecare technologi-
cal device should be easy to use and
developed bearing in mind the elderly or
those with limited mental ability. Patients
also require appropriate education and
training in the use of such technology.
The risks or benefits of the technology
should be clearly defined and patients
should have an option of declining any
technology. Respect and sensitivity are
vital to the success of homecare and
should be constantly observed.
Patient perspectives can bring new
and practical solutions to eHealth issues.
eHealth has to take into account the
needs of all major stakeholders; the
patient being one of these should be
recognised as a key player.
Personalised Information Platform
for Life and Health Services (PIPS)
PIPS is an e-Health integrated project
w w w. a s i a n h h m . c o m 45
 health professional-directed information
The PIPS system will enable: access, which has been tailored as much
as possible to the individual patient with
• Professionals to deliver just-in-time personalised healthcare services according to
regards to personal content, language,
the individual’s personal health state, preferences and ambient conditions
intellectual / emotional capacity and
• Individuals to make informed decisions about therapies and nutrition at any time /
locality, is being evaluated in the US
place according to the real-time evaluation of their health state
and initiated in the UK.
• Healthcare authorities to improve risk management in the healthcare systems as well
This is based on the argument that
as to get access to and generate valuable information assuring the global sustain-
ability of the system.
patients should be empowered with
information so that they are able to make
better decisions about their health and
aimed at the provision of innovative knowledge and support action lifestyle and also take a more active role
services to support the patient in his / • Trust Infrastructure - which aims to in managing their health. Also, due to
her daily life. Started in January 2004, integrate security protocols to protect the information overload on the Internet,
within the 6th Framework Program of sensitive information patients should ideally be directed to
the EU, it will be finalised in June 2008 • User Interaction - where the aim is correct information sources, so that they
and involves 17 partnering organisa- integrating a new generation of multi- are not overwhelmed. Parts of the medi-
tions from five EU member states, media personal assistance devices (e.g. cal advice or information provided by the
supranational organisations and other home telecare equipment, Internet- healthcare professionals are forgotten by
countries, such as Canada, China, Israel enabled home appliances). the patients (40-80 per cent), while the
and Switzerland. The aim of PIPS is to In fact, PIPS is a virtual assistant rest of the information remembered is
create a new Health and Life knowl- supporting the individual in every mostly incorrect. Therefore, it is essential
edge and services support environment, moment and in any environment. It that medical information be delivered
improving current modes of health- also provides interactive multimedia at the right time and at the place of the
care delivery using the latest innova- and multi-platform services tailored to individual. The objectives of Information
tions in Information Technology. Its their intellectual capacity and include Prescription are: to support the patient
services are personalised according to services for children which create a in self-care and disease management,
the individual profile and are based on healthier lifestyle through edutainment improve health literacy (the ability to
preventive / predictive medicine. The (education through entertainment); make sound health decisions in the
system is designed to develop innovative support in daily life through personal- context of everyday life) and to empower
technological solutions ranging from ised nutritional advice, shopping lists, the patient in decision-making regarding
continuity of care to education and technological assistance like the Smart his / her health.
impact on lifestyles. Shopping Cart; personalised motiva-
tion for physical activity through the Information for every need
Bringing personal care to the fore use of various technological systems; The type of information provided also
The scope of PIPS is to create a dynamic drug compliance support with real time varies, as it not only caters to individu-
knowledge environment that gives value detection of drug intake and verification als with varying needs but also to the
added feedback for personalised knowl- with prescriptions and self-monitoring same individual with different needs
edge and services to improve the public through the continuously available and at different times. The different styles
welfare. Services are personalised and pervasive support for risk level controls include practical information and
based on medicine, ranging from drug of chronic disease management. advice on healthy lifestyles, informa-
compliance to continuity of care. The PIPS healthcare delivery model tion on treatment options and outcomes,
The technical infrastructure presents addresses societal challenges by facilitat- advice on long-term self-care, local care
these significant core parts: ing the shift from treatment-oriented and self-help and social care through
• Knowledge Management - where the medicine to prevention-oriented health- peer support. The key concepts of
aim is to transform heterogeneous care for individuals. PIPS will be utilised Information Prescription are: it provides
information sources into a trusted by three levels of users: professionals, appropriate and targeted information at
homogeneous valuable knowledge external experts and the end users. the right time to meet the needs of the
base individual in sound decision making;
• Decision Support - where the aim is Empowering patients with targeted it is issued by professionals at strate-
to use intelligent technology to gener- information gic points in care pathways; it usually
ate new personalised user-oriented Information prescription, defined as points to sources of information and

46 Asian Hospital & Healthcare Management ISSUE-16 2008

w w w. a s i a n h h m . c o m 47
 and which cannot. Established in 1996
The PIPS system
as a non-governmental organisation,
HON implements one of the most well
Over the past 11 years, HON has accredited close to 6000 websites consisting of over known codes of conduct. The HONcode
a million Web pages in 32 different languages and has grown to become a house- made up of eight principles to which the
hold name, not only amongst webmasters, but also the general public. HON grown website would have to adhere, in order
in terms of implementation of services, it has also increased its liaisons worldwide to be accredited and thus be deemed
to include the World Health Organization (WHO) and the United Nations (UN), where
as trustworthy. It is free of charge and
it has consultative status to the Economic and Social Council of the United Nations
(ECOSOC). In view of its pioneering work and long expertise, the HON Foundation has though given voluntarily (webmasters
been chosen by the HAS (Haute Autorité de Santé or the French National Authority for request for accreditation of their website),
Health) to implement the certification of French health websites according to the French it is in high demand because of the seal
bill passed on the August 13, 2004. This certification is performed by HON through of quality and trustworthiness that it
the implementation of the HONcode. Now, more than ever, the HON Foundation and the confers onto a site.
HONcode play a vital role as new and extended treatment modalities come into play,
such as the empowering of patients through provision of information. Making information user-friendly
Due to the vast amounts of information
available, it is imperative that quality
knowledge only (where these informa- Health On the Net - Current information be filtered from this informa-
tion sources would be accredited for initiatives tion pool for the benefit of the public,
reliability and trustworthiness); and it The Internet, with its vast quantities of which will in turn educate them and thus
does not display or hold any informa- information is now the largest global result in a better-informed and respon-
tion. Information Prescription would database and offers an immense amount sible patient. i.e. a resourceful patient.
be in the format most convenient for of information on every topic conceiv- With a usage growth of 250 per cent
the patient and could include printed able. The domain of health is no different in seven years (2000 to 2007) and 1.1
information, SMS (reminders, encour- from all the rest and is filled with various billion Internet surfers in the world, the
agement), email (reminder, follow-up), websites advising the public on how to Internet continues to change the relation-
DTV (targeted programming) and Web keep their diabetes in check, detoxify in ship between the health professional and
references. one week, eat well balanced nutritious the patient by making them co-players
Information Prescription systems meals...the list is endless. This infor- in the game, thus replacing the teacher
are currently being initiated in the mation overflow can be overwhelming / pupil relationship of old. These few
UK where patients are sign-posted to to an individual who would not know examples present solutions which take
relevant information at different stages what information to trust and what to into account the current situation i.e.
of the care pathway such as the diagnosis disregard. a situation where the patient is able to
and treatment. The mission of the Health On the access information related to their medical
In the USA, doctors are provided Net (HON) foundation is ascertaining condition and can then take their own
with customised prescription pads which health websites could be trusted, decisions regarding their medical care.
containing the list of websites of
the National Library of Medicine.
The patient would be given such a
Célia Boyer is the Executive Director of the Health On the Net
prescription with advice on the websites Foundation, has been serving at the HON since it’s inception in
relevant to his / her condition. Off 1995. She is recognised as an expert in quality assessment of
course, one of the obstacles, which medical information on the Internet and has taken part in several
projects and conferences-both European and International and has
have to be overcome, is regarding
A u thor

authored more than 50 scientific articles on the subject. Célia has a

the authenticity of the information degree in Science and Applied Physics from the University of Luminy
provided. Guiding patients to reliable of Marseilles, France and an engineering degree from the Federal
Polytechnic School of Lausanne, Switzerland.
online information is of paramount
importance and thus websites, which Mayoni Ranasinghe is a Research Assistant of online health
have already undergone rigorous testing information at the Health On the Net Foundation for the past year.
Before that, she was a clinician in Paediatrics, Surgery, Internal
and have been accredited according to a Medicine and Sexually Transmitted Diseases in her native country,
specification or code of conduct, would Sri Lanka. Mayoni obtained her medical degree (MBBS) from the
be provided as sources of information Medical College of Medical Sciences, Pokhara, Nepal.
for patients.

48 Asian Hospital & Healthcare Management ISSUE-16 2008


Medical Device Market
Mega trends in Asia
Faced with an increasingly ageing society and rising healthcare costs, countries in Asia
Pacific are expecting cost-effective medical devices to be developed by local companies.
Jennifer Lau
Industry Analyst
Frost & Sullivan, Singapore
D
espite the fact that Asia has 60
per cent of the world popu-
lation providing large market
potential, Asian* healthcare expenditure
constitutes only 15 per cent of the global
healthcare expenditure. In 2007, the
total global healthcare expenditure was
at US$ 4.981 trillion. With a growth
rate of 6.2 per cent as shown in Figure
1, the total healthcare expenditure of
Asia is expected to be at US$ 791.7
billion by 2008.
While some parts of Asia are expe-
riencing high population growth, other
countries such as Japan and China
are facing the problem of accelerated
ageing population. For instance, Japan
is estimated to have 22.0 per cent of
its population above 65 years by 2012
as compared to 20.6 per cent in 2007
(Figure 2). With the current Asian
lifestyle, the prevalence of chronic
diseases such as diabetes, cancer, obes-
ity and cardiovascular diseases has
increased significantly. Other diseases
that threaten the region include
auto-immune diseases, infectious diseases
and neurological disorders. Accelerated
ageing population and increasing
prevalence of chronic diseases are the
key drivers that contribute towards the
increase in total healthcare expenditure
on medical devices in the region.
Transformation in
device industry
Zero-Defect reliability
When it comes to medical devices,
reliability and safety are very criti-
cal. This is an industry where qual-
ity and reliability of the devices
cannot be compromised. Even a low
device-failure is unacceptable to the
patient and the healthcare providers.
For example, a current leakage of as
little as 10µA (10-6 A) on a pacemaker
will cause a microshock to patient,
which will eventually bring death to
the patient in minutes. Therefore, reli-
ability is critical for medical devices.
Unreliable readings given by devices
might lead to misdiagnosis, further
leading to delay in treatments or
false alarms.
Total Healthcare Expenditure (Asia*), 2007-2008
800
790
Healthcare Expenditure
780
(USD Billion)
770
760
750
740
730
720
Asia* – Countries included in the statistic are Philippines, Malaysia, India, Indonesia, China, Thailand,
Singapore, Taiwan, South Korea, Hong Kong and Japan.
technolog y , equipment & D evices
the medical To ensure zero-defect reliability of the
medical devices, manufacturers use the
Failure Mode and Effect Analysis (FMEA)
tools. FMEA is used to evaluate the risks
associated with the devices produced and
to develop strategies to overcome them.
Using flexible circuits instead of rigid
circuits in medical devices is yet another
option that could be employed by the
manufacturers to increase the reliability
of devices.
Miniaturisation
Technology advances have made it possi-
ble to use smaller and thinner integrated
circuit boards. Self-monitoring devices
such as blood glucose meter and wrist
blood pressure monitor now come with
more functions that are smaller in size
due to availability of denser and thinner
printed circuit boards. Miniaturisation of
791.7
CAGR : 6.2%
745.5
2008 Year
2007
Source: Frost & Sullivan
Figure 1
w w w. a s i a n h h m . c o m 49
technolog y , equipment & D evices
Percentage of population above 65 years (Asia), 2007-2012
Philippines
Malaysia
India
Indonesia
China
Thailand
Singapore
Taiwan
South Korea
Hong Kong
Japan
0 5 10
Percentage (%)
devices has made it possible to save space
in the operating theatres or intensive care
units that have limited space.
Improved power sources
Power sources are critical for medi-
cal devices such as hearing aids and
neurostimulators of a pain control
therapy device. Batteries for these devices
must be small, of right weight, easy to
replace or recharged and have a reason-
ably long life span. For example, the
rechargeable battery of a neurostimu-
lator has 10 years of lifespan. Other
batteries under development include
biothermal battery that uses body heat
to generate low current source of power,
and nuclear microbatteries that use
the decay of tritium and nickel-63 to
generate power.
Enhanced performance and features
In order for medical devices to be
more marketable in the increas-
ingly competitive market, these
devices need to have breakthrough
technologies. Medical devices are increas-
ingly coming up with enhanced features
and performance such as connectivity
through wireless solution or LAN.
Devices such as cochlear implant
can be programmed wirelessly, and
ultrasound images can be transferred
from a patient’s bed to the nearest
workstation through LAN or Wi-Fi.
50 Asian Hospital & Healthcare Management
2007 2012
15 20
Source: Frost & Sullivan
Figure 2
Medical device market drivers
Large population and increasing
population in Asia
Asia with its large population, is consid-
ered as a lucrative market for device
makers . Further, accelerated ageing popu-
lation in few developed countries, such as
Japan, Korea and Taiwan will eventually
increase its healthcare expenditure.
Growth in economy amidst slowdown in US and
Europe
Asia continues to experience economic
growth amidst slowdown in the US and
Europe.
Investments in healthcare infrastructure
Realising the importance of disease
prevention, the Asian governments
invested billions of dollars annually to
improve their healthcare infrastructure.
For instance, the Ninth Malaysia Plan
(2006-2010) is to work ‘towards achiev-
ing better health through consolidation
of services’ whereby emphasis has been
placed on sustainability, upgrading and
maintenance of existing facilities and
equipment, and improving the quality
of healthcare.
China announced its Healthy China
2020 plan in January this year, which
aims to provide safe, effective, conven-
ient and low-cost public health and basic
medical care to both rural and urban
citizens by 2020. Some key goals of the
ISSUE-16 2008
plan include making public medical
institutions ‘non-profit’; reducing the
involvement of hospitals in the sale of
drugs, increase the role and responsibil-
ity of government and establish basic
medical care network for all Chinese citi-
zens. These policies clearly showed the
eagerness of the government to provide
better healthcare infrastructure with better
medical devices and facilities.
Increased healthcare awareness
In recent years, the medical industry has
experienced a paradigm shift from sick-
ness care to healthcare. Higher priority is
given to prevention rather than to cure.
This phenomenon is also seen in Asia,
25 where finding cures and fighting infec-
tious diseases have become the priority.
Asians are becoming more aware of their
health, especially people in China, Hong
ageing Kong and Singapore, which were hit by
SARS and Avian Influenza several years
ago. Both the governments and people
in Asia are now more receptive towards
medical technology and encourage home-
based monitoring.
With advanced technology and
communication systems available in most
of the countries in the Asia, people now
have access to the information resources
available and are more demanding in
seeking healthcare options. On the other
hand, direct-to-customer marketing
strategies of some pharmaceuticals and
medical device companies have indirectly
educated Asians on the healthcare options
available to them. Employers, in their
effort to increase company’s efficiency
are becoming more aggressive in pushing
for preventive care. This paradigm shift
has increased the demand for medical
devices in the healthcare industry.
Emergence of private sector
High participation from private health-
care providers in developed countries in
Asia promotes healthcare expenditure.
For instance, Taiwan has fairly high
participation of private healthcare, which
contributes 65 per cent of Taiwan’s total
hospital beds. Private involvement has
enabled efficient healthcare delivery
to the people, which could be clearly
 technolog y , equipment & D evices

seen in the case of Taiwan. This private
participation was driven by Taiwanese
comprehensive National Health Insurance
scheme, which has eventually helped to
increase the healthcare quality.
Market challenges
Government purchases depress price
Most hospitals in the Asia rely heavily
on government subsidy, and in most
cases government purchases control the
prices of medical devices. For instance, in
Taiwan, huge pressure is put on National
Health Insurance to reduce its account
deficit, which leads to stricter medical
examination. Unnecessary health screen-
ing such as MRI and blood screening
are excluded from the insurance cover-
age, which leads to reduction in device
purchase. Government restric-
tion discourages the installa-
tion of medical devices that are
considered by it as non-critical
items. This causes initial barri-
ers in introducing new medical
technology into the region.
Varying regulations
In addition to government
control over the price, Asian countries
have started to implement regulations
following the increased concern of prod-
uct safety when imported into these coun-
tries. Increased healthcare regulation has
brought varying regulations in different
countries. Most of the countries in the
Asian region are now implementing
and adopting different medical device
standards. Some of these countries, such
as China and Japan have taken a step
further to develop their own regulations
that suit their local requirement. These
complicated regulation structures in these
countries pose challenges to investors.
Increased distribution and service costs
Distribution costs in Asia have increased
in recent years due to continuing high oil
Competitions from local companies
Increased involvement of local medical
device companies in countries such as
Korea and China is a threat to the multi-
national companies. These companies,
supported by their governments, are
able to provide medical devices that
suit local requirements at a price far
lower than that offered by multinational
medical device companies.
Shortage of healthcare providers
In most of the Asian countries, the ratio
of medical professionals to patients is
still critically low. For instance, in
Malaysia inadequate human resources
in healthcare services were due to chang-
ing demographics and the emigration
of skilled workers from government
hospitals to private hospitals. On the
Even a low device failure is
unacceptable to the patient and the
healthcare providers.
other hand, China faces imbalanced
human resource distribution with short-
ages at central level and overstaffing at
periphery due to its uneven popula-
tion distribution across the country.
Imbalanced human resource distribu-
tion makes rural areas short of essential
medical devices, while urban areas are
over-equipped.
Geographic vastness of Asia
Geographic vastness of the Asian region
poses challenges to distribution, logistic,
communication and promotion activi-
ties of medical device companies. In
most of the Asian countries such as
Jennifer Lau joined Frost & Sullivan Asia Pacific Healthcare team
A u thor
Thailand, Vietnam and Indonesia, the
well-equipped hospitals are in the urban
areas and rural residents barely have
an access to medical services. Lack of
penetration to rural part of Asia is due
to poor transportation systems in these
countries. Healthcare infrastructures in
these countries are not well developed
and may take another two decades
to reach such a level. Vast geography
with poor transportation increases the
delivery time and operation costs. These
factors have hindered the growth of
medical device market.
Market potential of medical device industry
The full potential of Asian markets can
be realised by establishing key part-
nerships and alliances with the local
companies, keeping mind the market
drivers and challenges posed by
the region. The fastest way to
penetrate these highly protected,
untapped Asian markets is
through effective joint ventures
with the emerging medical
device companies of Asia.
Geographically big Asian
countries provide great oppor-
tunity for telemedicine and teleradiol-
ogy. In view of the poor transportation
facilities in parts of Asia, telemedicine
and teleradiology could help in provid-
ing more efficient and timely medical
care in rural areas.
Companies should consolidate their
distribution function throughout Asia
in order to be more cost-effective and
efficient in product delivery. In order
to stay competitive in the local market,
emphasis on Research & Development
of medical devices should be combined
with the manufacturing of medical
devices.

as an Industry Analyst. She focusses on monitoring and analysing

prices and inflation. Labour charges too
have increased over the years compared to
a decade ago, with the increasing demand
for labour. Although the overall cost is
still lower than Europe and US, the effect
of the increase is significant.
emerging trends, technologies and market behaviour in the Medical
Devices, Medical Imaging and Healthcare Information Technology
industry in Asia Pacific. Prior to this, Jennifer had 5 years of working
experiences in Medical Devices Distribution environment in Malaysia
and Brunei. She brings with her medical devices knowledge and ex-
perience of marketing strategies.

w w w. a s i a n h h m . c o m 51
 G S K Velu
Managing Director
Trivitron Group of Companies and
Metropolis Health Services India Ltd.
India

52 Asian Hospital & Healthcare Management ISSUE-16 2008


Medical Products
Manufacturing
in India
Getting ready for growth
What made you choose India to build
your medical equipment park over other
Asian countries?
India, over the last five years,
has been growing in the areas of
Electronic Component manufacturing,
Mechanical Fabrication, Biotechnology,
Pharmaceuticals and Information
Technology. These industries, in one
way or the other, provide inputs to
medical product manufacturing. As a
result, India today is an attractive low
cost destination for Medical Technology
manufacturing. Soon India will be able
to demonstrate its capabilities as an
alternate manufacturing destination
to China for many medical products.
Taking this trend into consideration,
Trivitron is in the process of building its
first medical technology park in India.
In its first phase, this park will be able
to manufacture medical technology
products cost-effectively to cater to the
fast growing Indian medical technology
market and also to several emerging
markets across the globe.
What is driving the growth of Indian
medical devices market?
Access to healthcare is improving in
India because of the rapid growth of
private healthcare providers and an
increase in expenditure by the central
and state governments on the provision
technolog y , equipment & D evices
of healthcare. Privatisation of insurance
sector has opened avenues for several
private healthcare insurance companies.
These are the two major factors driving
the growth of Indian medical device
market.
Do you think the medical device indus-
try in India is adequately regulated?
Indian medical device industry has not
been regulated appropriately as of now.
However, the Government of India is
has taken an initiative to regulate the
market through the formation of the
Central Drug Authority on the lines
of the USFDA.
Advanced medical technologies have a
higher cost. In what way will hospitals
benefit in such a scenario?
Since advanced medical technologies
are unaffordable for a major segment
of the population in India, there is an
Soon India will be able
to demonstrate its
capabilities as an alternate
manufacturing destination
to China for many medical
products.
urgent need for indigenisation wherever
possible. This will make these technolo-
gies affordable to all segments of the
population.
What scenario do you envision for the
Indian medical equipment Industry in
the future?
Indian Medical Equipment industry has
a bright future in India with most of the
segments experiencing Compounded
Annual Growth Rate (CAGR) of over
15-20 per cent.
What role can India play in the global
medical equipment market considering
its low cost advantage?
India has an abundant talent pool in
the areas of medicine, engineering and
information technology. This, combined
with infrastructure and labour arbitrage,
will make India a preferred destination
for Medical Equipment manufacturing
for many global companies. India has
always been a preferred destination for
the low–volume, high-mix category of
manufacturing. With its English-speak-
ing labour force and academic excellence
in the areas of medicine, engineering,
information technology, India can be
a very good value proposition for top
multi-national companies to manufac-
ture their medical technology products
for global requirements from India.
Will mergers and acquisitions help the
growth of Indian medical equipment
industry?
There are several small size Indian
companies with long presence and tech-
nical expertise. Trivitron is looking at
mergers and acquisitions as an option
to consolidate Medical Technology
industry in the country.
Will the low cost of manufacturing in
India translate into lower healthcare
costs?
Low cost manufacturing should defi-
nitely translate into lower healthcare
delivery cost in India in the next 5-10
years time.
w w w. a s i a n h h m . c o m 53
technolog y , equipment & D evices
Medical Devices
Meet Consumer Electronics
Revolution in healthcare delivery
Advanced semiconductor technology is transforming healthcare. At the vanguard is an
entirely new way of monitoring the human body—wirelessly, intelligently and at low cost.
Microchip-sized wireless body monitoring systems are offering quality of life for users and
providing critical data for healthcare professionals.
Alison Burdett
Director of Technology
Toumaz Technology, UK
A
revolution in healthcare delivery
is on its way. Advanced semicon-
ductor technology is transforming
the medical services market by enabling
a new generation of technology solutions
that leverage the economies of scale of
consumer electronics, while delivering
the robustness and medical compliance
normally associated with expensive capital
equipment. At the forefront of this new
generation of healthcare technology is
an entirely new way of monitoring the
human body—wirelessly, intelligently
and at low cost. Breakthrough silicon
technology is enabling the develop-
ment of new wireless devices, with its
application across a vast array of health-
care management scenarios. Intelligent
microchip-sized wireless body monitoring
systems are set to enable a wealth of new
healthcare applications, offering quality
of life for users and providing critical
physical, bio-chemical and genomic data
for healthcare professionals.
The New Wave – Pervasive and
personalised healthcare
Demands on healthcare throughout the
world are changing. As a result, there
54 Asian Hospital & Healthcare Management
is now huge demand for new systems
which improve productivity, cut costs
and support the shift of healthcare from
hospital to the home and community
settings.
The global demographic trend
towards ageing populations, coupled
with less active lifestyles and fast-food
diets, is leading to higher probability and
earlier onset of chronic conditions such
as Type 2 diabetes and cardiovascular
diseases. This, in turn, is translated into
a substantial increase in the proportion
of resources required for a long-term,
continuous care and a growing burden on
healthcare infrastructures. Today, 75-80
per cent of healthcare expenditure is spent
on chronic diseases, placing an unsus-
tainable strain on healthcare providers’
Wireless Body Area Network
•Brathing
•Activity
•ECG
•Heart beat
•Blood pH
•Glucose
•Dissolved oxygen
•Carbon dioxide
•Insulin Pump
•Temperature
ISSUE-16 2008
resources including hospital beds.
With healthcare budgets already over-
stretched and few care takers—profes-
sionals and non-professionals—being
available to meet the increased needs,
forecast additional demands are simply
unsustainable using current practice.
Continuous monitoring has shown
to enable more effective treatment of
chronic disease, deliver improved patient
outcomes and reduce the requirement
for hospital visits and admissions. With
the prevalence of chronic conditions set
to escalate in coming years, the ability to
harness non-intrusive, proactive health-
care monitoring and 24x7 diagnostic and
intervention capabilities—at acceptable
system cost levels—is becoming a key
priority for healthcare providers.

Sensium
Application
Oracle Lite DB
Sensium enabled
Digital Plaster
Digital Plaster
Converging on a new vision
The impetus for the emergence of the
new global digital medicine market is
convergence. Digital information stand-
ards now enable X-rays and scanned
images to be stored, retrieved, commu-
nicated and analysed using Picture
Archiving and Communication Systems
(PACS).
The development of interoperability
standards for Electronic Medical Records
(EMR) is also opening the way for greater
patient / physician access to data and
the provision of patient choice. Through
interoperable EMRs physicians, phar-
macies and hospitals can share patient
information and deliver timely, patient-
centred and portable care.
In parallel, the ubiquity of wireless
and mobile cellular networking is driving
the clear trend for ‘unwiring’ the health-
care world and the increasing demand for
mobile-based solutions, both in general
ward hospital environments and in out-
patient and care home scenarios.
Now, disruptive semiconduc-
tor technology is enabling all these
convergent trends to come together and
create a nexus for major innovations in
treatment, diagnostics and interven-
tion. The transfer of this ground-
breaking technology allows the
advantage of economies of scale that
semiconductor industry now enjoys to
be passed onto healthcare markets for
the first time.
technolog y , equipment & D evices
Sync Client WiFi or Web Server
(mSync) GSM (Apache HTTP)
Oracle HTB
Intelligent wireless body
monitoring – Platform for a digital
revolution
Health research has shown that our
bodies are not constant. Nearly every
physiological process fluctuates with
our internal circadian rhythms; the
body’s temperature, immune function
and hormone levels vary according to
the time of day or night. In addition,
many diseases have daily rhythms, with
symptoms more severe at certain times.
As a result, taking data at single set time
points provides limited insight into a
condition or an individual’s overall health
status. A growing recognition and under-
standing of the body’s sensitivity to time-
of-day helps in improving the efficiency
and safety of drug delivery.
In every healthcare scenario, the abil-
ity to continuously—and remotely—
acquire data necessary to undertake a
more holistic clinical assessment of an
individual is the key to defining highly
personalised treatments and delivering
improved outcomes.
New ultra low-power system-on-chip
technology lies at the heart of the digital
medicine revolution. This technology
enables a new generation of low-cost,
non-intrusive wireless vital signs monitors
that can continuously monitor multi-
ple vital signs in real-time, allowing
healthcare providers to remotely monitor
patients via standard mobile devices such
as PDAs and cellphones. With the ability
Sync Server HTTP Physician's
(Mobile Server) Web browser
Mobile Server
Repository
to deploy simple, reliable and affordable
remote body monitoring devices, whole
new areas of the medical services market
are being created, including point-of-care
diagnostics, tele-monitoring and the abil-
ity to self-manage chronic conditions. For
healthcare professionals, this innovation
is opening a completely new window
on patient physiology enabling unprec-
edented levels of analysis and unlock-
ing entirely new areas of knowledge and
understanding into disease progression,
diagnosis and therapies.
Intelligent wireless infrastructure
for healthcare and lifestyle
management
New ultra low power system-on-chip
technology is enabling a new generation
of low-cost, non-intrusive body-worn
wireless vital signs monitors for medical
and professional healthcare applications.
This breakthrough technology provides
the complete wireless infrastructure to
allow healthcare providers to remotely
and intelligently monitor the human
body in real time, via standard mobile
devices such as smartphones and PDAs.
The technology provides an intelligent
data acquisition platform and a complete
integrated solution for patient care –
enabling the ubiquitous monitoring of
physiological inputs from ambulatory
and non-ambulatory patients, in both
general ward and out-patient or telecare
scenarios.
w w w. a s i a n h h m . c o m 55
technolog y , equipment & D evices
Together with appropriate external
sensors (for example, electrodes, 3-axis
accelerometers, temperature sensors,
pressure sensors, strain gauges, ampero-
metric sensors and so on), this platform
technology allows continuous, intelligent
monitoring of multiple vital signs—such
as ECG heart rate, body temperature,
respiration and activity level—in real time
allowing earlier detection and prediction
of adverse events such as heart attack,
falls or hypoglycaemia.
Powered by low-cost thin batteries,
body-worn monitors can process and
extract key features of the data and intel-
ligently integrate it into an electronic
medical record (EMR) via a base station
device using a power-optimised wireless
operating and networking system. For
healthcare professionals, this delivers
unprecedented possibilities for proac-
tive monitoring and improved quality
of care at dramatically reduced cost.
Traditional healthcare models are simply
not able to offer this level of continuous
care except in expensive ICU settings.
This new technology unlocks a higher
quality system of individualised patient
care throughout the treatment and diag-
nostic cycle—from the hospital ward
to the home.
For patients, this transforms the
opportunities for lifestyle-compatible,
personalised healthcare as well as better
therapeutic outcomes.
Wireless Body Monitoring
Infrastructure
In a Wireless Body Area Network
scenario, one or more devices can
continuously monitor key physiologi-
cal parameters on the body. These
small body-worn monitors can capture,
dynamically process and filter ‘prob-
lem’ event data—such as irregularities
in heartbeat or blood pressure—and
report it wirelessly to a basestation device
plugged into a PC, PDA or smartphone
via an ultra low-power short-range radio
telemetry link (much lower power than
alternative short-range technologies such
as Bluetooth or ZigBee). The data can
56 Asian Hospital & Healthcare Management
The key enabling benefits of new platform technology
• Gathering real-time information, not raw data
√ On-chip signal processing to intelligently extract critical information from
sensors
• Ultra-low-power
√ Patented AMx technology coupled with low-power radio and intelligent
information handling results in non-intrusive, continuous monitoring
• Low-device cost
√ Ultra low-power and low voltage operation leads to devices powered by
simple, low-cost “printed” batteries
• End-to-end system
√ Provides the low-power radio link from the patient to the telecommunications
network and into the healthcare provider’s database/system
be further filtered and processed by be integrated with existing health infor-
application software. mation systems, thereby becoming a
Using ultra low-power advanced total patient care package and clinical
mixed signal processing algorithms, repository of data. In the general ward
these devices requires only a very small, environment, vital signs data is transmit-
low-cost battery, enabling them to be ted either to the bedside monitor (in
body-worn with complete freedom of the case of non-ambulatory patients) or,
movement. The system can be incor- for ambulatory patients, to the nearest
porated into a wide variety of lifestyle- basestation via the ultra low-power wire-
compatible form factors depending on less link. Data from multiple basestations
market application and requirements. is then delivered over Ethernet or WiFi
For example, a disposable monitor— to the software-based server, which can
offering days’ to week’s lifetime and be integrated seamlessly into the existing
requiring no battery change—or a non- hospital IT system or database.
disposable body-worn device. In telecare or home monitoring envi-
ronments, vital signs data is acquired
End-to-end Solution – Towards from the mobile patient and transmit-
management of care by exception ted to a standard mobile device (cell-
Toumaz and Oracle Corporation are phone or PDA), which acts as a network
currently working together to link real- node. From there, it can be sent over
time vital signs information acquired the standard cellular network to the
by the Sensium system to the electronic server before being integrated into the
patient record, using Oracle’s Health hospital IT system. All acquired data
Transaction Base (HTB)—an infor- can then be made available to hospital
mation system designed specifically staff via the nurse’s station or wirelessly
for healthcare markets and integrated to a doctor’s PDA or Mobile Clinical
with the first international standard for Assistant (MCA).
storing and sharing health informa-
tion: the Health Level Seven Version 3 First metre healthcare – System
(HL7 v3) Standard. architecture for Wireless Body
The integrated end-to-end system Area Networks
will allow key physiological data taken By converging the IT system onto the
from multiple patients—both in general individual and bringing the network
ward and out-patient care settings—to into the ‘first metre’, intelligent inte-
ISSUE-16 2008

grated platforms are creating a unique
opportunity for the development of
end-to-end telemedicine and health
information systems that can meet the
rapidly growing need for analysis and
decision-making based on real-time
data—offering the potential to deliver
greatly improved healthcare outcomes
at dramatically reduced cost.
As a platform technology, this tech-
nology provides a viable cost model
for long-term, preventative care that
is also compatible with patient lifestyles,
ushering in a new era of healthcare
opportunities. The ability to continu-
ously and wirelessly monitor makes
24-hour observation and analysis of
an individual’s response to treatment
possible, supporting recalibration of
dosage quantity and timings. In future
scenarios, by allowing two-way flows of
information (for example, an uplink
of raw or processed data and a down-
link of requests or activation signals),
intelligent wireless body monitoring
platforms could offer further use in
closed loop systems to control drug
delivery and maintain key physiologi-
cal parameters, such as blood pressure,
within an optimum range. Adaptive
treatment responses are crossing into
other fields such as pharmocogenomics,
which holds the promise that one day
drugs might be tailor-made for indi-
viduals, or adapted to each person’s
environment, diet, age, lifestyle and
genetic make-up.
Personalised healthcare,
boundless possibilities
As witnessed by the digitisation of the
telecom industry, convergence creates
unimagined technological opportuni-
ties. Today, popular social networking
sites such as MySpace and Facebook
are already changing the human fabric
of the Internet. This evolving social
networking model may even open the
way to new healthcare dimensions in
the future. Aggregating data from these
sites or search engines like Google, and
making this available or accessible from,
technolog y , equipment & D evices
Cellular
connection to
sensium Server
Sensium
Server
Basestation
User's existing
iF
i
IT system
r W
e to i or database
Sensium rn iF
he (Optional)
Et orW
Senium et
Wi-Fi rn
wireless link he
Bluetooth Et Nurse's
to mobile of Station
Etc.
PDA
Identical devices to
monitor at home and PDA/MCA
integrate data with
hospital records
or within, EMRs could see the emer- healthcare delivery. The ultimate goal is
gence of new online communities that for ill health to become largely predict-
enable people to select medical thera- able and capable of being managed,
pies, personal training or recuperation with the focus on prevention rather
programmes, and even access lifestyle or than symptomatic or event-driven
rehabilitation mentoring partners. therapeutics. This technology is now
With a growing focus on low-cost providing the platform for healthcare
preventative care models, demand for professionals to work in an embedded
personalised healthcare and continuous matrix of information, with patients
body monitoring is set to experience becoming partners in managing their
exponential growth. We could well see own health.
the emergence of a new breed of service As we move towards this digital
provider organisation set up specifically medical future, the trends are very clear:
to deliver integrated patient information the market opportunity created by a
and bio-sensor network monitoring serv- merging of the consumer electronics
ices to the professional healthcare and and healthcare industries is vast; and
wellness market. These services could this is certainly just the beginning of a
incorporate a wide range of solutions, global healthcare revolution.
including monitoring, clinical data or
alarm services, links to dedicated call Trademarks
centres or SMS and email functions. Toumaz Technology Ltd. retains title
Developments in wireless body and ownership of the following registered
monitoring are already changing atti- trademarks: Sensium® the Toumaz® logo;
tudes and assumptions about health and and AMx™
Alison Burdett was a senior lecturer in the Department of Electrical
A u thor
and Electronic Engineering at Imperial College before joining Toumaz
Technology. Her expertise is in the design of high frequency analogue
and wireless integrated circuits. She has designed commercially suc-
cessful silicon chips for Mitel (now Zarlink Semiconductor) and LSI
Logic as well as collaborating on research projects with a number
of semiconductor companies including Ericsson Microsystems,
Philips Research Laboratories Redhill, Panasonic System LSI Design
Europe (PSDE) and Nortel plc.
w w w. a s i a n h h m . c o m 57
 I
t’s getting harder to read a
newspaper or watch the television
without seeing news about the
impact of global warming. While the
debate about cause and effect is certain
to continue, it is clear to a growing
number of people that we must reduce
the consumption of natural resources
and the emissions of carbon into the
atmosphere.
Without question, building construc-
tion has a significant impact on the envi-
ronment, not only in terms of how it
alters the landscape, but also in terms
of material and energy consumption
and waste generation. Consider these
numbers: over 65 per cent of the US’
electricity is consumed by building
construction and occupancy. Globally,
more than 40 per cent of the earth’s raw
materials are consumed in the name of
building construction and occupancy.
58 Asian Hospital & Healthcare Management
Statistics like these are responsible
for the world’s burgeoning interest in
sustainable design and construction.
Individuals and corporations are making
a concerted effort to learn how to create
buildings utilising sustainable technol-
ogy, renewable resources and systems
designed to reduce energy consumption
and carbon emissions.
There’s no better place to implement
these principles than in the design and
construction of hospitals and other
healthcare facilities. Hospitals gener-
ate vast amounts of waste material in
the form of food, paper and plastics,
the majority of which is not recycled.
As a building type, hospitals are rela-
tively heavy users of materials, energy
and water. Not only does this heavy
usage drive up the cost of construc-
tion of most hospitals, it also results in
increased operational expenses over the
ISSUE-16 2008
lifetime of the building, especially as
the cost of natural resources continues
to skyrocket.
Of course, research has also shown
that environment aids the healing proc-
ess. Healthier buildings lead to healthier
patients and staff.
A growing number of hospitals are
becoming more interested in a sustain-
able approach to healthcare design. There
seems to be a lot of uncertainty, however,
about implementing it. Concerns typi-
cally revolve around initial costs, sched-
ule and return on investment. With an
educated and organised design approach,
implementing sustainable methods is
not only becoming less costly, but also
more the rule than the exception.
The United States Green Building
Council (USGBC) has developed a
sustainable building guideline and
rating system known as Leadership
 F acilities & operations M anagement

Sustainable
Hospital Design
Beyond the numbers

The new trend to design and build hospitals using sustainable

technology, renewable resources and systems designed to
reduce energy consumption and carbon emissions is making
it possible to achieve higher building performance in terms of
reduced energy consumption, improved indoor air quality and
a supportive healing environment.

Russell A Sedmak
Vice President
Heery International, USA

in Environmental and Energy Design
(LEED). This system and the USGBC
staff serve as a technical resource for
the design and performance of all
building types. Recently, the
organisation completed LEED guidelines
specific to healthcare facilities. These
resources allow architects, engineers,
and owners to make informed design
and operational decisions about
the design and planning of hospital
facilities.
While several hospitals have achieved
LEED standards using office building
guidelines, only two have achieved a
LEED Gold Certification, and none
yet have achieved Platinum. A third
hospital, currently under review for
Gold Certification using the new health-
care guidelines, is the Medical Center
of the Rockies (MCR), in Loveland,
Colorado.
MCR, a 595,000 SF, 136 bed critical
care facility, with combined centres of
excellence in cardiac and trauma care,
is an innovative example of a large new
specialty hospital. Its 40-acre campus
was developed from a vacant site and
master-planned to ultimately accom-
modate a tripling of its initial size.
Few hospitals have the opportunity to
take advantage of the outdoor spaces like
MCR does. A nature trail and wetlands,
located directly in front of the facility,
serve as part of the healing environment.
However, even hospitals located in the
tightest urban areas can take advantage of
outdoor spaces by using concepts such as
hardscaping, which requires less planting
and maintenance and is more useful to
patients, family and staff.
There are ways to zone a site in terms
of the intensity of plant material, and
the degree of maintenance and irrigation
required if the facility sits on a large tract
of land. What’s important to note is
that not every part of a hospital’s open
space requires a manicured lawn or
trees in order to create a high-quality
outdoor environment. In fact, a diverse
landscape adds interest and context to
most sites.
Regardless of site location, thoughtful
storm water collection and flow manage-
ment provides an opportunity for sustain-
ability and protection of neighbouring
land. Stored water on site can potentially
be used for irrigation. In some climates,
however, open, standing water can pose
health risks, especially if left untreated.
A new wetland was created at MCR to
filter run-off before discharging surface
water into a nearby wildlife sanctuary.
Another important site considera-
tion is the building’s placement and
position, and the locations of public,

w w w. a s i a n h h m . c o m 59
F acilities & operations M anagement
1 2
4 9. Gift Shop
4 6
Public Circulation 7 10
8 9
Patient / Staff Circulation
service and ambulance entries to best
take advantage of solar orientation. Even
in low sunshine climates, buildings have
a warm side and a cold side. Wind is
also something to be considered because
it is another factor that contributes to
energy consumption, maintenance costs
and user comfort and safety.
Building orientation also impacts
daylighting. How the sun penetrates a
building and how designers manage that
direct solar access is extremely important
for practical purposes, and can influence
LEED credits. Not only does the use of
natural light in patient care and staff
support areas reduce energy consump-
tion, it also provides an important
connection with nature and supports
a better healing environment.
Outdoor ventilation is a considera-
tion in most climates, although it can be
difficult to manage from a temperature
60 Asian Hospital & Healthcare Management
MCR Layout
3
4
5 8. Volunteers
6
11
12
control perspective. Most new hospitals
have thermostats for every patient room.
If the zone control is compensating for an
open window on a hot or cold day, the
overall system load is only affected at the
room with the open window. The physi-
cal and psychological benefits gained by
allowing fresh air to come into a patient’s
room are tremendous. Additionally, fresh
air can improve indoor air quality.
Interior areas without access to an
outside wall can benefit from the use of
task lighting versus overhead fluorescent
lights. In a patient unit hallway for exam-
ple, there’s no reason to design for more
than 25 foot-candles. A reduced lighting
level in corridors not only saves energy
but creates a sense of calm and comfort
for patients and their families. It also
tends to lower voices in the halls and in
nurse stations. Another benefit is lower
eye strain and reduced fatigue.
ISSUE-16 2008
1. Emergency
2. Diagnostic Imaging
3. Clinical Laboratory
4. Admin. / HR / M.I.R
5. Physician Services
6. Outpatient Cardiology
7. Chapel
10. Education / Offices
11. Main Lobby / Atrium
12. Main Entrance
Proper use and preservation of
water in design can be an integral part
of sustainability. Water is a powerful
healing element and the symbol of
life. Should a facility opt to incorporate
water elements, it’s critical to pay close
attention to design and engineering to
minimise water consumption, leakage,
maintenance and algae.
Sustainable architecture also involves
the use of renewable materials and
products with lower Volatile Organic
Chemical (VOC) emissions. This idea can
also be taken one step further by using
recyclable building materials wherever
possible, because eventually these materi-
als and their finishes will be replaced.
Non-recyclable materials ultimately end
up in a landfill.
Durability and ease of maintenance
are the two factors that impact sustain-
ability and operational costs of the
 F acilities & operations M anagement

facility. Spending a little more money on
higher-quality and eco-friendly finishes
such as terrazao and stone, is often the
most cost-effective decision. These types
of materials are easy to maintain with-
out chemicals. Typically, they last the
lifetime of the building. If the project
cannot afford products like terrazao in
procedure areas, resilient sheet goods such
as linoleum, which have low VOCs and
are made from renewable resources, can
be substituted. PVCs and vinyl flooring
products should be avoided.
Construction site recycling plays a
major role in conservation and can gener-
ate LEED points. Until recently, many
construction sites recycled only a small
portion of their scrap material because
there was neither a large market for recy-
cling, nor the environmental conscious-
ness to drive the process. That is changing
quickly as recycling options for wood
and drywall are becoming more available.
During the construction of MCR, for
example, a local pig farmer purchased
the crushed gypsum from wall board
scraps to mitigate the effects of animal
waste on his land. MCR recycled over
75 per cent of its construction waste
as a result of a concerted team effort
established at the project’s inception.
Enforcement by the owner and contrac-
tor, JE Dunn, was also critical to the
recycling programmes' success.
Design innovation creates additional
opportunities for achieving sustainable
design goals. With critical input from
the owners, it’s possible to create an ideal
floor plan that maximises flexibility and
minimises circulation and wasted space.
In hospital design, it is critical to create
a circulation pattern to separate public
from private zones which complicates
the idea of efficiency. But by locating
these two zones, or spines back-to-back
and placing them at the core of the facil-
common. Vertical stacking reduces the
building footprint and allows more natu-
ral light into the building. It is not only
important from an operational and cost
standpoint, but also because it reduces
waste and demolition. A properly stacked
hospital also reduces energy consumption
by reducing the length of utility runs and
reducing the building footprint overall,
making it more efficient to operate and
allowing a more efficient use of land.
Ultimately, the twentieth century
trend of building cheaply and quickly
and prematurely disposing of worn struc-
tures will be replaced by the use of higher
quality, longer lasting building materi-
als and methods. This is great news for
design professionals and the people and
communities these facilities serve.
More attention is being paid to the
idea of green roofs. Not only do they
impact sustainability, but also provide
user comfort by allowing patients to
look out of the windows to see grass,
pavers, benches and people, instead of
just equipment and roofing material. The
environmental and energy savings utilis-
ing this form of building covering are
substantial, and will eventually outweigh
the concerns for the costs that incur in
building structure, waterproofing, and
landscape maintenance.
Marketing and public relations can
also play an integral role in educating the
population, particularly in areas where
there are several healthcare options. A
sustainable facility can impact a hospi-
tal’s perception in the marketplace.
Sustainable hospital design does have an
impact on governmental approval proc-
esses, where development is more tightly
controlled, especially as communities
demand a higher building standard with
less impact on the environment.
A u thor
In designing sustainable healing
environments, it is also important to
look at the elements which go beyond
the simple numbers. It is vital to look at
customer expectations and the ability of
people to choose a healthcare provider.
In order to provide high quality of care
patients expect, hospitals have to be able
to recruit and retain the best doctors,
nurses and support staff. It is the ability
of the hospital’s design to integrate all
these needs in a way which is flexible and
adaptable over its lifetime, so that it can
continue to serve its mission, without
substantial reconstruction. These are the
most critical elements of a sustainable
hospital.
Overall, the future of sustainable
hospital design is very bright. We have
much ground to uncover in an effort to
reverse the environmental trends of the
last century, particularly in our most
populated and industrialised countries.
But with exceptional vision and leader-
ship by architects, engineers and building
owners, and with governmental support
in each country, we can build a healthier
and more sustainable world.

ity, they can be made shorter and work
more effectively, even as the facility grows
over time.
As land value and land scarcity
increases worldwide, vertical stacking
of hospital floors will become more
Russell A Sedmak has spent the majority of his 23 year architec-
tural career as a leading healthcare facility planner and designer for
Heery International. Of the firm’s many notable projects, he has most
recently directed the planning and design effort for Medical Center
of the Rockies (MCR), a 590,000 square foot regional tertiary care
hospital specialising in cardiac and trauma services.

w w w. a s i a n h h m . c o m 61
F acilities & operations M anagement

The Hospital
Role of architects
of the

Gary M Burk
Principal
Terrie L Kurrasch
Senior Associate
RATCLIFF, USA

N
o administrator, patient or
doctor today would recognise
the hospital of the future. It
isn’t a healthcare facility, as we know it.
As a result of changes in technology and
the general delivery system, consolida-
tion, amalgamation and an ever-chang-
ing regulatory environment, the hospital
of the future will not be the resource-
intensive and richly utilised organisation
as it is today. Instead, the hospital of
the future is likely to be smaller, less
expensive to construct and operate, and
sustainable in design, utilisation and
energy efficiency. It will most likely be
part of a distributed healthcare deliv- Centrally located in the Alta Bates Summit Medical Center campus in
Oakland, California, the Breast Health Center is just footsteps from the
ery system, rather than a stand-alone main entrance to ease wayfinding for patients and their families.
organisation. As part of the anticipated
healthcare reform movement, hospitals
of the future will be resource-appro-
priate and their utilisation rates will will affect the health and welfare of Architects contribute to the
be proportionate and relative to their hundreds of millions of people. Four solutions
demographics. armies are battling to gain control: the Do design professionals have responsi-
As renowned author Regina health insurers, hospitals, government bilities within this era of reform? Most
Herzlinger points out in her 2007 book, and doctors. Yet you and I, the people certainly. In the recent past, healthcare
Who Killed Healthcare, ‘The US health- who use the healthcare system and who architects and hospital planners have
care system is in the midst of a ferocious pay for all of it, are not even combat- focussed on the issue of universal access
war. The prize is unimaginably huge— ants. And the doctors, the group whose and the implications of that on utilisa-
US$ 2 trillion, about the size of the interests are most closely aligned with tion and hence, building size. The larger
economy of China—and the outcome our welfare, are losing the war.’ problem confronting this society now

62 Asian Hospital & Healthcare Management ISSUE-16 2008

 F acilities & operations M anagement

Future Isn’t…
The concepts for what
the hospital of the future
‘is likely to be’ and ‘isn’t’
include distributed services,
the ‘hospital at home’
project, ‘wearable hospital’
telemedicine innovations, ‘lean
design’ principles and ‘cellular
care.’ These concepts dictate
the design professional’s
responsibilities within an era of
healthcare reform.

and well into the future is cost. In the
healthcare field, cost drivers are multi-
faceted and generally include most or
all of the following:
• Labour and Benefits
• Capital Expenses
• Materials / Supplies
• Services / Operations
• Facilities Development
• Reimbursement
• Uncompensated Care
• Compliance and Unfunded
mandates
Architects can and should take an
active role in the discussion about the
kind of facility the hospital of the future
would be. They could do it by:
• Working with hospital leadership to
understand the patient base of the
future
• Seeking to design and build less expen-
sive facilities
• Designing facilities that are efficient
to use and access and that cost less
to operate
• Committing to design buildings with
net zero carbon footprints by 2030
• Designing facilities that make life
easier for caregivers and healthier
for patients.

w w w. a s i a n h h m . c o m 63
F acilities & operations M anagement
Hospital utilisation trends
Another way for hospital architects to
expand their sphere of influence is to
understand and educate clients about
key utilisation trends. Hospital resource
utilisation results from both access
and availability. Information from the
Dartmouth Atlas of Health Care showed
that the amount of time patients spent
in a hospital varied greatly depending on
where they lived and practice patterns
of the local physician community. For
instance, the patients who were chroni-
cally ill in Bend, Oregon spent only
10.6 days per year in the hospital, while
those in Manhattan spent 34.9 days
annually.
Additionally, the Dartmouth study
illustrates that physicians adapt their
practice styles to the resources avail-
able to them, which can cause huge
variations in healthcare costs. Medicare
spending for chronically ill patients at
the Mayo Clinic in Minnesota was only
US$ 34,372 per patient, but that figure
rose to US$ 64,900 at the University
of California-Los Angeles (UCLA)
Medical Center. This is because utili-
sation rates and physician visits were
markedly higher at UCLA than at the
Mayo Clinic (11.6 ICU days vs. 4.2
ICU days and 53 physician visits per
stay vs. 24 visits per stay, respectively). In
both these cases, enrollment in hospice
care programmes was greater in Oregon
and Minnesota than in Manhattan and
Los Angeles, an obvious factor in the
utilisation of hospital resources.
Current trends in hospital manage-
ment and construction cannot be
sustained by the US economy. Without
comprehensive community planning,
the boom in US hospital building is
replacing many outmoded facilities and
adding beds to respond to the perceived
needs of an ageing population. This trend
aggravates and sustains the utilisation
and practice patterns identified in the
Dartmouth study. Higher utilisation
results in higher costs due to greater
expenditure of resources such as energy,
capital and supply chain materials.
64 Asian Hospital & Healthcare Management
Impact of healthcare policies
We all recognise the influence of
policies and policymakers on the design
of healthcare facilities, including the need
for eight-foot corridors, one-hour fire safe
corridors in nursing units, and accessible
design that provides safe ergonomics for
disabled and non-disabled staff alike. But
these are just a few of the reasons that
the hospital of today got to where it is.
To fully appreciate the current state, one
only has to reflect on legislation such as
the Hospital Survey and Construction
Act (also known as the Hill-Burton Act)
of 1946 that provided federal grants and
guaranteed loans to improve the nation’s
hospital system and help to achieve a
goal of 4.5 beds per 1,000 in population.
These grants did not sunset until 1975
and every hospital in the country had
benefited from this funding source.
Before Health Maintenance
Organizations (HMO’s) began providing
insurance coverage, there was indemnity
insurance—hospitals were paid what it
‘cost’ to provide care. Length of stay
was not an issue and patients were
routinely admitted to a hospital bed
the day prior to a surgical procedure to
complete their pre-surgical lab work and
imaging. There were of course, Health
Systems Agencies (established in 1975) Realising the hospital of the future
to provide local direction and control through design
of healthcare planning. The local agen- Hospital designers need to join the
cies developed health systems plans that ‘ferocious war’ described by Harvard
mandated the number of beds, operating economist, Herzlinger. Designers can
rooms, ED stations and so on for each advocate for changes in their clients’
planning area. Some would argue that practices, push for smaller concentrations
their effect was limited in terms of curb- of healthcare resources and urge client
ing and controlling growth. Certificates groups to disperse their services to be
of Need (CONs) were created in 1974 more accessible throughout the commu-
to help control how hospitals spent their nity. Using their influence to educate
money; capital expenditure was limited policymakers and benefit consumers,
and expansion plans had to fit into the designers may assist in making many
local Health System Area (HSA) plans. of the following concepts a reality.
Most states that had CONs have let them The Advisory Board Company, an
sunset because they, too, generally failed industry based think-tank in Washington,
to meet their intended aim of reducing DC, proposed that because of the uncer-
spending and expansion of services. These tain regulatory and reimbursement
and other regulations helped to bring scenarios ahead, the hospital of the future
about the current state of the healthcare will specialise in key services. This new
delivery system. organisational structure may result in
ISSUE-16 2008

Cellular care concepts
Few care stations, many activities per station
Cells configured with multidisciplinary care
teams to produce measurable milestone
outcomes in care pathway
Little patient movement required
Cells do not ‘own’ the areas they work in
and they can expand / contract their areas
of service with patient demand, minimising
process redundancy
Cells are viewed as production centers
Optimisation of the whole hospital
lifting of the moratorium on physician-
owned hospitals and slowing the growth
of stand-alone comprehensive healthcare
facilities. Instead, it will encourage the
growth of ‘Centres of Excellence’ that
can deliver patient care within existing
facilities, dispersed throughout a commu-
nity without the need to construct new
Departmental care realities
Many care stations, limited activities per station
Departments configured for specialisation,
outputs not specifically coordinated with other
events in care pathway
Extensive patient movement required
Departments ‘own’ their space, thus they
are fixed in a location, forcing redundancy of
processes such as scheduling, registration and
queuing
Departments are viewed as cost centers
Optimisation of sections of the hospital, not the
whole
Table 1
buildings. Other futuristic healthcare
delivery options include:
• Distributed Hospital, featuring broad-
ening access points like a freestand-
ing emergency department, a short-
stay hospital, a ‘super’ medical office
building and a variety of speciality
hospitals
The Cardiology Family Resource Center offers a
multimedia resource library, business center, two
private counselling rooms, discrete waiting areas,
and a hospitality room.
• ‘Hospital at Home’ where patients
with certain diagnoses (such as conges-
tive heart failure) are discharged from
the ED and are accompanied by a
nurse or MD home for the first 8-24
hours. Subsequently, a nurse or MD
would visit the patient daily until he is
discharged. This concept was studied
by Johns Hopkins Hospital in 1996
and significantly lowered costs and
patient’s length of stay
• ‘Wearable Hospital,’ which utilises
remote patient monitoring. This
concept has resulted in a 23 per cent
reduction in diabetes patients’ hospi-
talisation rates in a recent Veterans
Administration study. While current
technology requires patient activation
to send data to the monitoring station,
clinical trials are underway for wear-
able, automatic patient monitoring
w w w. a s i a n h h m . c o m 65
 As patients move past the Breast Health
Center admitting desk, they enter a waiting
room finished in a rich gold patina.
systems that eliminate the patient’s
role in transmitting the data.
• Other ‘innovative disruptions’ on
the horizon of healthcare delivery
that are gaining momentum are
medical tourism and retail clinics
(e.g. doctor’s offices located in busy
shopping centers for easy access).
David Chambers at Sutter Health has
developed a number of concepts for
moving the industry towards a better
future and sees architecture as one of
the key means to achieve both better
hospitals and lower costs. Under his
guidance, Sutter Health has initiated
a programme to develop a prototype
hospital using tools for planning and
design advocated by Chambers. A
description of this process follows.
Lean design
Architecture is central to the discussion
of ‘lean design’ for the hospital of the
66 Asian Hospital & Healthcare Management
future. It literally can remove the walls
in a healthcare setting that cause silos
between staff and fragmentation of care
delivery. By designing patient units that
allow for single bed service line adaptable
environments, architects can facilitate
the achievement of measurable mile-
stone outcomes, create opportunities
for care providers to work differently
(in multidisciplinary care teams) and
minimise patient movement.
The ‘five big ideas of lean’ outlined
here can be embedded into healthcare
design and project delivery to remove
waste in the capital programme:
1. Collaborate, really collaborate
2. Increase the connections of the partici-
pants
3. Develop a network of commit-
ments
4. Optimise the whole and not the pieces
/ departments
5. Couple learning with action
ISSUE-16 2008
Planning for optimised patient care
delivery offers a multitude of operational
benefits, such as the reduction of steps
and cycle times, elimination of patient
handoffs, enhancement of the predict-
ability of workflow and commitment
to the ‘lean’ process, reduction of staff-
ing requirements and improved quality
of patient outcomes. It also equates to
less facility space required, fewer dedi-
cated or specialised function spaces
and the dissolution of departmental
fragmentation.
Cellular care
Cellular care (also known as multi-
disciplinary team care) is likely to be
the operational model for the hospi-
tal of future. Table 1 illustrates the
efficiencies and outcome improvements
to be gained by this new paradigm in
comparison to the current healthcare
delivery model.
 F acilities & operations M anagement

California’s hospital of the future configuration based on cellular care

Sutter Health, headquartered in
Sacramento, California has embarked on
a plan to implement and open prototype
hospitals embodying the principles of
lean design and cellular care. In order to
break from the conundrums of current
delivery methods, Sutter shared its
models and objectives with multiple
architectural teams. In the process, it
split the design project delivery process
into a competitive planning and pre-
design stage followed by implementation
by the ‘winning’ teams. As the owner,
Sutter prioritised the drivers for each
project and they are: patient safety, staff-
ing efficiency, cost project adaptability
and flexibility.
Project teams (including members
from operations, programming and
design and build firms) were assembled
prior to proposing to participate in this
collaborative process. Three teams were
selected to compete for the opportu-
nity to design Sutter Health’s prototype
hospital and each team was awarded
US$ 500,000 to develop their proposals.
In the kick-off meeting, all the three
teams were involved in determining
the project’s metrics and actual deliv-
ery schedule.
The prototype hospital objectives
were outlined as:
• Improve workflow efficien-
cies by 40 per cent (gained by
reduced cycle times, elimination of
unnecessary redundancy in
patient flow and revisions to care
concepts)
• Reduce facility area per adjusted
patient discharge by 30 per cent
(realised through the elimination of
unnecessary redundancy in patient
flow, reduction of excess queues and
spatial configuration of services for
cellular care delivery to eliminate
fragmentation in care model)
• Reduce overall construction costs per
bed by 50 per cent by developing
design sets oriented toward high value
to cost ratios
• Reduce energy use per area by
25 per cent
Sutter now has four prototype
hospitals in design production and
expects to bring them online
within the next few years. They all
appear to have met the objectives
set out by the owner, and should
be among the most cost-effective and
efficient hospitals in the country upon
completion.
Conclusion
Healthcare designers and planners
have ample opportunities for
thought leadership in this arena.
The hospital of the future most
likely will include distributed services,
a hospital at home prototype, wearable
hospital telemedicine innovations,
‘lean design’ principles and ‘cellular
care’ concepts. Instead of focussing on
what the hospital of the future ‘isn’t’,
architects.

Gary M Burk has been responsible for project and client management
of healthcare facility planning projects, including utilisation analysis,
facility assessment, space programming, user group interviews,
planning standards development and master planning. He has more
A u thor

than four decades of professional experience, working as a practi-

tioner in major architectural offices.

Terrie Kurrasch has an extensive background in facility planning and

healthcare administration. She has worked exclusively within hospi-
tal and healthcare organisations, and as a healthcare management
consultant. Terrie came to Ratcliff after managing the implementation
of the merger of Alta Bates and Summit Medical Centers.

w w w. a s i a n h h m . c o m 67
F acilities & operations M anagement

Baylor
Emergency
Department
Providing
state-of-the-art services

68 Asian Hospital & Healthcare Management ISSUE-16 2008


The Baylor University Medical Center’s Emergency
Department in Dallas, Texas has been operating at
near capacity for almost 10 years. The high number
of patients combined with the dearth of resources
lead to an inevitable and unwelcome decline in
service. To correct this issue, Baylor brought in local
architect t. howard + associates and North Carolina-
based architect FreemanWhite to perform a 75,000
sq.ft. renovation and addition to the ED. This more
than doubled its capacity to care for patients and
tripled the footage of the ED.
Todd C Howard
President
t. howard + associates, USA
CaseStudy
T
he Baylor University Healthcare
System is a Christian ministry
of healing that serves patients
by providing exemplary healthcare,
education, research, and community
service. It was founded on the princi-
ple of improving community health by
addressing identified needs. The Baylor
University Medical Center Emergency
Department (BUMC ED) located in
downtown Dallas, Texas has been oper-
ating near capacity for almost 10 years.
The high number of patients combined
with the dearth of resources made provid-
ing top-notch healthcare more difficult.
To correct this issue, Baylor brought
in North Carolina-based architect
FreemanWhite and local architect t.
howard + associates to perform a reno-
vation and addition to the ED.
Healthcare coverage for Texans ranks
among the worst in the US, largely
because so many Texans go uninsured
each year. Twenty five percent of all
Texans have no health insurance, which
precludes them from having regular
check-ups that could catch illnesses
before they magnify into emergencies.
Other insured workers have no medi-
cal leave, which leaves them with little
opportunity to visit a physician regularly.
These translate into high levels of ED
traffic. In fact, a third of individuals
in the US visit an emergency depart-
ment each year. The Dallas Metroplex’s
population has enjoyed nearly 30 per
cent growth rate over the past decade
and is still growing steadily. This adds
to the number of people visiting the
ED each year.
When emergency strikes, few centres
in Dallas are able to provide levels of
patient care equivalent to the The Baylor
University Medical Center Emergency
Department (BUMC ED). It is one of
only two Level One Trauma Centers
in the North Texas Trauma Network.
This designation signifies that the centre
provides the highest of level of surgical
care to trauma patients and maintains
capable personnel in-house 24 hours
a day, seven days a week for prompt
w w w. a s i a n h h m . c o m 69
F acilities & operations M anagement

diagnostics and treatment of the most

critically injured patients. The increased
demand on the BUMC ED over the
years has caused the ED to outgrow its
space, thus requiring larger work areas
to alleviate overcrowding in order to
maintain the high standards of efficiency
and patient care. Prior to the ED expan-
sion, patients sometimes had to wait for
more than three hours to see a physician.
One of the end goals was to significantly
reduce the waiting time.
With the aim of improving patient
service, the BUMC board of trustees
began planning the new ED in early
2005. FreemanWhite and t. howard +
associates (THA), architectural firms with
a strong healthcare focus, were brought
on board to help fulfil the trustee’s vision
for the project. The ED went under the
knife for a renovation and expansion
of the existing department to increase
patient volume and improve quality of
care and staff retention for a comprehen-
sive cost of US$ 53 million. The design
team strategically planned to expand the
area of the department from 33,000 sq.ft.
to 78,000 sq. ft., more than doubling
its patient capacity. The total number of
beds increased from 34 to 87, majority Furthermore, imagine patients needing facility have a modern and approach-
of which are now private. A large trauma to visit the ED and being able to call able appearance. Visual monitors featur-
area was built to accommodate up to their doctor ahead of time and ask him / ing calm virtual aquariums are spread
eight injured persons. her to meet at the hospital. Patients who throughout the larger waiting area. In
One of the challenges the design have doctors with practicing privileges times of high activity, the monitors
team faced was making a noisy, bustling at Baylor are permitted to the use of a transition to a dedicated Baylor channel
emergency room tranquil without new physicians' waiting area and are with nature scenes and soothing music.
disrupting workflow. A large waiting able to meet with their caregivers in a Terrazzo flooring is one of the lowest
area was broken into several parts allow- more efficient manner. This reduces the maintenance solutions available and can
ing families to congregate in relative number of patients in the general wait- survive the heavy scrubbing required
privacy, while sub-waiting areas spread ing area. Treatment rooms are orientated in the ED. With lower maintenance
throughout the ED provide the family around centralised care team stations to finishes, patients and staff aren’t subjected
comfort and proximity. The private assist with operational efficiency during to the constant noise of cleaning, waxing
patient rooms, all equipped with enough non-peak hours. The new silence in the and buffing.
seating for family members, a television, ED will help alleviate stress in both staff To make the experience more
and a phone, helped speed the treat- and patients alike. personal, the Baylor Foundation focussed
ment process while increasing the care Baylor wanted durable finish that on bringing in artwork from local artisans
quality and sanitation. The orientation added an inviting and professional look for the ED. Individual art pieces can be
and equipment provisions are typical in to their facility, without requiring a lot found in each of the treatment rooms
each treatment area. Dimmable lighting of maintenance. The ED is designed and numerous three-dimensional wall
allows maximum comfort and in place to welcome the patient through careful art pieces can be found throughout the
of privacy curtains, electrostatic glass selection of colours. The wood elements facility, adding a feeling of brightness to
becomes opaque at the flip of a switch. and stainless steel used throughout the the ED. Artists were commissioned to

70 Asian Hospital & Healthcare Management ISSUE-16 2008


One of the challenges the design team faced was making a noisy,
bustling emergency room tranquil without disrupting workflow.
paint one-of-a-kind watercolours featur-
ing local landmarks. In addition to being
visually stimulating add-ons to the ED,
they also assist in wayfinding.
Even though the ED is large, the
design is simple. The care team pods
are located in the centre of the facility
with the treatment rooms lining the
perimeter. These facilitate communica-
tion and increase efficiency among the
staff. There are strong visual connec-
tions throughout the ED, so staff can
clearly see inside the patient rooms
and also from one care team station
to another. In order to help patients
and staff find their way easily, different
The ED also benefits from cutting-
edge technology upgrades: four X-ray
units, two CT scanners, an Ultrasound,
a Lodox and upgraded lab services are
now available within the department.
Computers are located in every patient
room, which increases the amount of
time staff can spend with patients.
With a large decontamination room,
containment room and showers, the
ED is prepared to face disasters and
biological threats. A total body digital
imaging system, Lodox Statscan is located
Todd C Howard is the President and Founder of t. howard + as-
A u thor
CaseStudy
in the trauma area allowing the trauma
staff immediate access to the imaging
equipment.
In the unfortunate event of a patient
passing away, a body viewing room is
incorporated into the design. This small
divided room allows patients’ families
to view their loved ones when they
are prepared and allows the staff space
to speak with the family in seclusion
without interruptions. The design
team has incorporated vinyl flooring
resembling wood, soft wall paint covers
and furniture. The result is far preferable
to a chaotic trauma room or a sterile
morgue.
It was important that the ED remain
fully functional during the renovation
and addition. Construction was carefully
phased so as not to disrupt the ED’s abil-
ity to care for patients and the ED was
able to treat 110,000 patients during the
seventeen-month construction period.
Other departments that had previously
been located in the ED’s new space were
seamlessly relocated within the hospital’s
footprint without adversely affecting the
hospital’s patient load capability. The
design began in December 2005 and
the final construction was completed
in January 2008.
Now, the waiting room in the
ED is no longer overflowing. Patients
aren’t subjected to wait for three
hours. Baylor’s trustees and staff can
comfortably accommodate additional
increase of patients. This state-of-the-
art department rivals any ED in the
country. The completion of the new
ED will help the Baylor system to
better serve their patients as well as the
community.

colours are used for each care team pod.
The design team helped cut down on
visual chaos by creating niches in the
corridors for drug distribution machines
and crash carts. With everything having
its own dedicated space the hallways get
much calmer.
sociates architects (THA). He received his Bachelors degree in
architecture from Texas A&M University and specializes in health-
care, educational, and not-for-profit design. Todd is an active mem-
ber of numerous professional organisations, such as the American
Institute of Architects, serving as the Dallas branch’s President Elect
for 2008, Texas Society of Architects and the Dallas Architectural
Foundation. Todd is also a passionate community volunteer. This
year marks THA’s 10th anniversary.

w w w. a s i a n h h m . c o m 71
F acilities & operations M anagement
Quality and Safety
Creating a supportive culture
A process-oriented approach, which sees care as both social and technical, naturally
supports a positive quality improvement strategy and aligns the major subcultures.
Philip Hoyle
Director
Clinical Governance, Northern Sydney
Central Coast Area Health Service
Australia
C
onsider a typical senior
management meeting, and
how care—which is, after all,
the core business—is talked about. Care
is typically talked about as delays, costs,
issues, liabilities and perhaps, revenue
or market share. Its beneficial purpose
generally remains implicit. Conversely,
consider a typical clinical meeting. Here,
the ‘system’ is seen as a block to good
ideas and a waste, with its positive role
in coordination, resource allocation
and system improvement unremarked.
Similar fault lines can be observed in
quality improvement. Official quality
and safety strategies often boil down
to exhorting clinicians to ‘please try to
not harm people’, rather than a positive
view of doing things well. Conversely,
clinicians can be reluctant to buy into
broad system issues beyond their own
immediate sphere of influence or even
their own profession.
This divergence matters because,
given the link between resource and
clinical outcomes, the clinical and
managerial cultures must come together
if real progress is to be made. The
challenge is therefore to recruit the
organisation—not just its formal
72 Asian Hospital & Healthcare Management
structures, but also its culture and
practices—to continuously improve
care. Given that one must start with
the culture one has, rather than the
desired one, the practical problem is
how to link subcultures in a common,
positive project of improving care.
Where are we now?
The quality of healthcare remains highly
variable. While excellent results are the
norm, the reliability of healthcare proc-
esses generally remains low, with unreli-
ability being estimated by the Institute
for Health Care Improvement (IHI)
at 1:10. That is, healthcare processes
generally deliver the intended result
only nine times out of ten. This esti-
mate is corroborated by the thousands
of avoidable deaths and injuries that
happen each year, as well as by struc-
tured record audits. While there are
major exceptions (consider the safety
improvements in anaesthesia) even the
best health systems perform well below
what might be expected.
Technical complexity is necessarily a
factor, but as Gaba had noted, reliability
in healthcare is also limited by cultural
factors such as lack of accountability,
structural secrecy, cultures that blame
and, tellingly, the ‘normalisation of devi-
ance’—the acceptance of poor quality
as normal. AHRQ’s description of a
high reliability organisation—safety as a
top-level priority, recognition that activi-
ties are error prone, blame-free report-
ing, development of solutions through
collaboration and resources directed to
ISSUE-16 2008
safety concerns—gives further insights
into why reliability remains low.
Improving our capacity for quality
and safety is not just a matter of going
out and setting up new quality systems.
First, there is little evidence that quality
interventions as such make a material
difference. While this may reflect the
difficulty of demonstrating cause and
effect in complex evolving systems,
it should give policy-makers a pause
before making further large investments.
Second, safety culture is a facet of the
broader culture, and quality will be best
improved by addressing broader cultural
issues, in particular, how all participants
in the health system, whether clinician,
consumer, manager, funding agency or
regulator, can collaborate to ensure the
right care is delivered reliably in the
right way.
Cultural limits to quality and safety
improvement
While there are exceptions, health
services generally remain organised
around professional relationships,
resource inputs, external reporting
lines and historical arrangements. A
discourse centred on effective, integrated,
efficiently resourced care does not arise
naturally in these conditions.
As Degeling and his colleagues
have shown, the major sub-cultures
often have conflicting values about
important things. For example, most
medical clinicians are deeply sceptical
of teamwork (unless they happen to
lead the team), while nurses generally
 F acilities & operations M anagement

see teamwork as essential. Similarly, their little party and they’ve got their gains, these are tiny compared to the
clinical doctors and nurses see quality little set-up nice so, stepping on toes is gains from optimised care systems.
as a private professional matter rather not my thing because you know you’re The challenge is, therefore, to move
than belonging in the public domain not going to get support further up, so from the ‘anti-negative’, to the ‘positive’,
while managers see (clinicians’) quality why do it? It’s just too difficult and it’s from ‘don’t harm’ to ‘let’s do the right
as a proper matter for the public record. real shame…” said a Nurse Manager. thing’. This is more than a rhetorical
Clinical doctors and clinical nurses The implications for clinical leaders gesture—to make the transition, it
generally reject resource constraints as are profound. Unless middle manag- requires a rethinking of who ‘we’ are,
the basis for an individual care decision, ers are ‘authorised’ to lead by both what we manage, and how.
while managers are more willing to base the followership and those ‘above’, Healthcare nearly can be described
decisions on available resources. The key and unless senior management gives in terms of processes—a sequence of
point is that very powerful groups have consistent support through difficult actions and events that tend to be
polarised views on the very issues that times, energy is diverted into survival repeated in similar circumstances.
must be dealt with if quality and safety rather than taking the system forward. Typical examples are treatment of
are to be improved, namely, teamwork, The challenge is to engage and recruit community acquired pneumonia, an
quality, evidence and the basis of divergent cultures in a common task of elective surgical admission or normal
resource allocation. improving care. childbirth. While such processes have
a technical dimension, namely what
is done in what order, they also have
So, what can be done? a social and cultural dimension—the
Given the polarisation of values, three broad options are: values, expectations and interactions of
those involved, whether nurse, doctor,
consumer or manager.
1. Find a value that all share. This only works to a limited extent. For example, while
in most healthcare systems everyone is committed to patient care, consensus falls
It follows that if operations are
apart when it comes to “which patient” and “what care”, especially if resources are based on care processes, the various sub-
scarce. cultures can be linked because it is clear
who is involved, in what capacity, using
2. Impose an “official” value set. Prominent examples are “doctor knows best”, and what resources, to what effect, with what
“financial reality”. This approach can briefly optimise one element, but to an extent variation. Furthermore, a process-based
alienate those who don’t agree, to the extent that they may not participate at all or only system promotes organisation around
emerge from the cave to throw rocks. the care produced rather than history,
profession and resource inputs. Even
3. Harness the diverse sub-cultures. Recognising and harnessing diversity can positively
more fundamentally, the values around
link the various sub-cultures. While this is an attractive option and works well in some
individual units, it is not easy to achieve at a broad organisational level which the system is built resonate with
those involved: quality discourse can
move from a post hoc source of guilt
This dissonance is not theoretical. Harnessing diversity – to a prospective responsibility, from
Middle managers, whether clinical or The centrality of process ‘what went wrong’, to ‘what must we
general, are subjected to pressures from Official strategies aimed at improving do right’. This re-orientation is more
above to avoid patient harm, to conserve quality and safety tend to be couched than sleight of hand. As Quinn points
money and to retain the workforce. They in what might be called ‘anti-negative’ out, purpose-centred thinking—that
also experience pressure from below to terms—for example ‘please stop kill- is, what must be done to achieve the
protect their unit from outside pressure ing / infecting / poisoning / tripping desired result—can greatly enhance
and to procure new resources and oppor- people’. While such approaches play leadership.
tunities. This can create great personal well in senior management and politi-
stress and even alienation amongst the cal circles, and indeed close loops on A goal of quality and safety
very people whose support is needed to much ‘guilty’ knowledge (falls reduc- While it is simple to state, ‘quality and
ensure a safe, reliable system. A nurse tion, anyone?), they tend to be less than safety are our highest goal’, as Marais
manager’s comment reported in a recent inspiring to clinicians, who soon tire of points out, there is usually conflict
study of a major hospital is revealing: straining against system limits and top- between safety and performance goals,
“… I know a lot of the systems could down mandates. While increased vigi- and in practice, a choice must be made
work a lot better, but they’re playing lance and error trapping can make safety between optimising performance and

w w w. a s i a n h h m . c o m 73
F acilities & operations M anagement
optimising safety. Furthermore, a
wide range of external factors affect
that choice as also internal influences,
ranging from overt politics to mandated
targets to the personal ambition of
decision makers.
In health services, there are inter-
esting and complex ethical issues
surrounding such choices. First, while
the careers and reputations of decision
makers may be at risk, the lives that are
most affected are not usually involved
in the discussion, at least at a policy
level. Second, at a societal level, the
tensions between access to services,
quality and funding usually remain
undiscussed: unrealistic expectations
abound, and quality / performance
trade-offs remain implicit. Third, in the
absence of a societal consensus and overt
policy, the burden of decision-making
is typically passed down to clinicians
and patients, whose marginal resource
decisions are constrained by a system
that neither the clinician nor patient
feels able to influence.
As Marais points out, the chal-
lenge is not to proclaim one goal to
the exclusion of others, but to assess
the risks and to know how much risk
is acceptable.
A simple example from my own
organisation is our approach to improv-
ing inpatient nutrition. Earlier in-house
research had shown avoidable problems
with inpatient nutrition, with a signifi-
cant impact on vulnerable patients. The
typical approach in the past has been
the ‘anti-negative’—one of developing
a set of detailed policies and procedures
designed to avoid the problem (in this
case, malnutrition), with the hope that
the staff would have the time, inclina-
tion and resources to follow.
The positive approach is subtly, but
crucially different. Rather than being
a set of error-trapping procedures,
the policy comprises a set of positive
evidence-based standards, developed in
consultation with consumers, clinicians,
food service providers, managers and
funders. Each standard is a positive
74 Asian Hospital & Healthcare Management
A positive vision
Once the conceptual breakthrough of a positive, as opposed to an anti-
negative vision, is made, it is relatively a simple task to reorient formal quality
improvement. A typical set of positive quality goals, suitable to inform business
planning might be:
Quality outcomes are recognised as a high level objective
Best practice care is delivered
Staff have the skills to deliver or support high quality care
The organisation is a learning organisation
Quality improvement is a valued activity
Quality and Safety is integrated into operational systems and methods
Policies support quality and safety
Explicit care processes are systematically improved
Risks are identified, assessed, communicated and managed
Consumer expectations and needs are understood and our operational activities are informed
There is internal accountability
There is external accountability
Quality & safety problems are found and understood
Adverse events are identified, investigated and prevented
There is positive engagement with the broader system
statement, such as ‘the ward environ- now known as opposed to be buried, can
ment will be conducive to eating’, be formally and accountably managed by
with a set of subsidiary statements. Of acceptance, elimination or control.
course, extensive subsystems are now
being developed (e.g. risk screening) but Conclusion
once again these are couched in terms Quality, Safety and Improvement
of positives, rather than negatives. requires a supportive culture, but we
The approach does not ‘wish away’ must get started. We can start with the
constraints on achievement, such as culture we have to create the one we
resources. Rather, it allows them to be want. This requires an understanding
effectively risk managed. If, for exam- of our cultures and a practical way to
ple, a ‘standard’ in the nutrition policy engage them in a shared positive vision
cannot be met, then the risk, which is of where we need to be.
A u thor
Philip Hoyle is a Director of Clinical Governance for Northern
Sydney & Central Coast Area Health Service. Responsibilities within
that role include quality, safety, risk management, policy systems and
accreditation, as well as executive responsibility for research and
disaster management. Philip’s obsession is the prospective design
of health systems, so that clinical staff, consumers, managers and
funders can combine to ensure the right care is delivered, first time.
ISSUE-16 2008
 CaseStudy
Benchmarking and
Measuring
Patient Safety
The Medway model

The Medway Nursing and Midwifery

Accountability System (NMAS)
is a model that calls nurses and
midwives to account for their
performance in relation to nursing
care and patient safety.

Jacqueline McKenna
Director
Nursing and strategic Planning
Medway NHS Planning, UK

T
he Medway NHS Foundation
Trust is situated in Kent,
approximately 40 miles east
of London and 40 miles west of the
coast of England. It is a large district
general hospital and has regional serv-
ices including Vascular and Neonatal
services. It also has the busiest accident
and emergency department in the county
with over 80,000 attendances / year.
The senior nursing team is stable and
has worked together for a number of
years. The Trust has been voted as one
of the Nursing Times’ top 100 employ-
ers of nurses in the country for the last
three years.
In 2004, the Director of Nursing
developed a system to measure the nurses’
performance. She had been inspired
by reading the ex-mayor of New York
Giuliani’s book Leadership (2003). In
one of the chapters, Giuliani explains
how he helped New York become safer
using a system called Compstat. The
three criteria of such a system are:
• Having an agreed set of indicators to
measure the performance
• Regular collection of data
• Holding regular meeting to review
the performance of the staff.
It was thought that these criteria
could be used as the basis of a perform-
ance improvement for nurses in the
Medway NHS Foundation Trust. The
Director of Nursing devised a proposal
for the nursing staff. This proposal set
out indicators that should be collected
and discussed on a weekly basis. The
proposal was sent to the Heads of
Nursing, the matrons and the senior
sisters for comment during the summer
of 2004. There were many comments
about the proposal, but by September
an agreed model was ready to be imple-
mented. Table 1 provides the list of indi-
cators that were agreed upon when it
commenced.
Work flow matrons followed in
collating data based on indicators
for four years from the beginning
of September, 2004
WEDNESDAY
Data is fed into a central database
and then disseminated
FRIDAY
Meeting held to discuss the data
and performance
MONDAY
Data is presented to the Director
of Nursing

w w w. a s i a n h h m . c o m 75
F acilities & operations M anagement

Orthopaedic Documentation SEPTEMBER 2004

110.00%
Number of patients with MRSA / Cdiff
100.00%
Bed days lost due to closure
90.00%
Hours lost due to short term sickness
< three days
80.00%
Documentation review
70.00% Current
Mean Nurses not wearing uniform properly
60.00% 86.22%

50.00% Hours of agency used

Sept 04 Feb 05 Aug 05
Documentation Result Mean UCL LCL Number of people with pressure sores
Graph 1
Number of nursing complaints
Trust Agency Table 1
600 Every week, two or three matrons
Current were asked to discuss their data for the
500 Mean
last eight weeks for each of the indica-
236.33hours
400 tors. Those presenting were accompa-
nied by the senior sisters in the area. If
300 their performance improved, they were
200 asked to share how they led the improve-
100
ment. This enabled their colleagues to
learn different techniques and allowed
0 good practices to be shared across the
organisation. If their performance over
the last eight weeks deteriorated, they
Sept 04 Feb 05 Jul 05 were called to account for the situa-
Hours Agency Used Mean UCL LCL
tion and explain why things did not
Graph 2
improve and what they would do in
future to rectify the performance. Once
Trust Agency the matrons present the data, the Trust
evaluates and scores each of the indica-
140
tors. The matrons who did not present
120 that week understood whether they have
contributed positively or negatively to
100 the overall performance.
On the request of the matrons, the
80 performance indicators were reviewed in
April, 2005. The revised indicators are
60 presented in Table 2. It was agreed that
the indicators for MRSA, Clostridium
40 Difficile and Pressure Sores would be
more useful if they were classified
20
according to those patients admitted
with them—those acquired in the week
0
in hospital and those who acquired them
Hours Agency Ud Mean UCL LCL in hospital more than a week ago. The
Graph 3 Trust made progress by reducing the

76 Asian Hospital & Healthcare Management ISSUE-16 2008

 F acilities & operations M anagement

CaseStudy
involvement of the agency nurses so that
Trust Bank the matrons could start measuring the
4500 use of bank nurses. They also thought
that sickness should be counted within
4000
seven days rather than the first indica-
3500 tor of within three days. In September
3000 2007, the indicators were reviewed once
again and the fall in the number of
2500 patients was added as an indicator.
2000 The graphs demonstrate some of
the initial achievements the organisation
1500 had in relation to the indicators. Graph
Current 1 shows the progress of the orthopae-
1000
Mean
3047.17hours dic wards in improving the standard
500
of documentation. The decrease in use
0 of bank nurses in the general surgical
Apr 05 Jun 05 Sept 05 wards can be seen in Graph 2. Graph
Hours Bank Used Mean UCL LCL 3 demonstrates that there was a drastic
Graph 4 decrease in the use of agency nurses
across the Trust. The straight line in
Graph 4 shows that there was improve-
ment in the performance during late
Nursing & Midwifery Strategic Direction 2005. However, it is important to know
where performance is stagnant (a straight
Monitoring & Audit Productive line) because it shows that the inter-
Observation Ward
Procedures ventions that have been made did not
Patient
Multi Disciplinary Shadowing have the desired effect and, therefore,
Working
EOC Care required corrective actions.
SfBH Planning The Medway NHS Foundation
Education Efficiency
Essence of Care Trust is now implementing phase two
Infection Control Service
Saving Redesign of NMAS. This involves integrating
Lives HCC
Budgets all the nursing initiatives under a new
CNST
NHSLA Clinical strategic direction and identifying the
Productivity Appraisal
Expertise performance indicators for all the aspects
Working with
Performance
based on the original NMAS model.
Estates & PEAT Working Recruitment Management The strategic direction, which aims at
Housekeeping to make a and Retention
Defference Clinical
an excellent patient experience, involves
Staff
Infection
Environment Experience Supervision following aspects:
Control Staff survey • Competent staff
Clean / Recruitment
Tidy Areas Customer Care • Clean environment
Audits NT Acute Trust • Customer care
Trainig &
Top 10 Development • Productivity
Programmes
Patient • Staff experience.
Monitoring surveys Service
Star Succession Each one of these aspects has a
Complaints Planning number of actions for each of the senior
Patient
sisters. The senior sisters have 24 hour
Involvement Good responsibility for the areas they manage
Dignity Attitude
in Care and have also had their levels of author-
ity agreed and clarified so that in the
Figure 1 majority of their role they are able to
act without having to ask line manag-
ers first. This is very important if they

w w w. a s i a n h h m . c o m 77
78 Asian Hospital & Healthcare Management ISSUE-16 2008
 F acilities & operations M anagement

CaseStudy
quarterly basis and, therefore, is not
APRIL 2005 Usual NMAS Indicators
effective.
1. Admitted Environment Environment audit Agreed objectives: The indicators are
Number of patients agreed upon by the nursing staff and
2. Acquired Commode audit
with MRSA not imposed on them. As described
3. New this week Handwashing audit above, the indicators have also been
Patient’s view on clean
changed in response to the suggestions
4. Admitted
environment of the staff.
Number of patients
5. Acquired Focussed on performance: The model
with CDiff Clinical expertise Observations audit
6. New this week allows nurses to spare some of their time
Patient’s perception of to focus on improvement and update
pain management
7. Bed days lost due to closure their knowledge of their respective
Patient’s level of trust in areas.
8. Registered nurses
Hours lost due to Weekly meeting: Weekly meetings
short term sickness 9. CSW Patient’s view on whether with the senior nurses are considered
<7 days staff work together
beneficial to everyone. It is a very good
10. Others
Customer care Protected meal times forum for not only discussing perform-
11. Documentation review Patient’s perception of ance but also to share good practice
respect and dignity and focus the attention on the patient
12. Nurses not wearing uniform properly Productivity Budget experience.
Accountability: The purpose of
13.Hours of agency used Annual leave management
NMAS is to improve nursing care and,
Saff experience Vacancy rate patient safety. It also ensures that the
14. Hours of bank used nurses are accountable for the patient
Appraisal rate
Number of people 15.Admitted
care in the concerned area.
Mandatory training Transferable to other systems: The
with pressure sores
16. Acquired attendance
model proved successful in other systems
Mentors/ward as well. The model has been adapted in
17. New this week
Staff perception of various systems in diverse organisations
18. Number of nursing complaints leadership ranging from US police to UK nurs-
Table 2 Table 3 ing homes. In the UK, the model has
been successfully adapted in acute care
are to be held accountable for their that the system is not at all rigid and hospitals, thereby proving that it can
performance. This is a major change can change as the local or national be effectively used in community and
in phase two—the senior sisters rather healthcare agenda requires. The Trust mental health organisations as well.
than the matrons are now held account- has changed the indicators four times Improved patient safety: By improving
able for performance. For each of the since its commencement to meet the the performance in relation to each of
five aspects of the strategy, there are needs of the staff. the clinical indicators, patient care has
ways to measure performance. These Relevant data: The data is collected become safer.
indicators have been added to the usual and discussed on a weekly basis. To summarise, NMAS has become
NMAS indicators (Table 3). These indi- Therefore, the nurses have to account totally embedded in the nursing culture
cators not only cover factual figures on for current performance. In many of the organisation. It gives the nurs-
performance but also the patient’s and performance review systems, the data ing staff a framework for continuous
staff ’s feedback on care and leadership is reviewed on a monthly or sometimes improvement.
in the concerned area. The strategy is
illustrated in Figure 1 below.
A u thor

Jacqueline McKenna is the Director of Nursing and Strategic

To conclude, the Medway NHS Planning at the Medway NHS Foundation Trust, a post she has held
Foundation Trust has seen many benefits since 2000 having previously been Director of Nursing at Southmead
from implementing NMAS. Some of NHS Trust in Bristol. She was awarded the Health Service Journal
patient safety award in 2005 for her innovative Nursing and Midwifery
them are: Accountability System which is a performance improvement tool for
Flexibility: It has been demon- senior sisters and matrons.
strated through the above description

w w w. a s i a n h h m . c o m 79
 The majority of healthcare
expenditure worldwide is
spent towards treating chronic
diseases like diabetes. Electronic
Medical Records could prove
effective in the management of
chronic diseases, facilitating the
delivery of quality healthcare to
the patients.

I
n global healthcare industry, it is
worth mentioning that incomplete
patient information often leads to
errors, misdiagnoses, patient safety issues
and cost inefficiencies. While serious
efforts are made to reduce error rates
and increase levels of patient safety, IT
solutions such as the Electronic Medical
Record (EMR) are emerging as enablers
of high-quality, cost-effective healthcare
delivery.
But the question is, can EMRs really
save money in both transaction-based
and non-transaction-based healthcare
systems?
Let’s start with the landscape of EMR
adoption. It’s no secret that the EMR
adoption of 20 per cent in US is well
behind that in most European countries
rt as well as China, Japan and Australia,
Hea e
e as just to name a few.
Dis
Last year, the Wall Street Journal
Online / Harris Interactive indicated
that a majority of Americans believe
Cancer that EMRs can reduce healthcare costs
Diabete
s while improving patient care. Yet, the
number of US physicians using an EMR
still hovers below 20 per cent.
Stroke
However, a question still remains
unanswered—can EMRs really reduce
costs and improve outcomes? In my
Chronic
Respiratory
Disease
80 Asian Hospital & Healthcare Management ISSUE-16 2008

Challenges in
Managing
Chronic Diseases
EMRs enable better care
Gregory Larkin
Chief Medical Officer
Indiana Health Information Exchange
USA
opinion, an EMR is a partial, but impor-
tant element in addressing global health
costs and concerns.
Implementation of a clinic-based
EMR requires significant financial
resources and can initially cause signifi-
cant disruption in an office’s established
patient flow processes. Additionally, the
typical installation of an EMR provides
a new medical record system void of
historic patient care data (which remains
within the replaced paper-based system).
To fully realise the potential of EMRs,
their complexities need to be reduced,
installation costs need to be lowered
and historic care data needs to be easily
captured.
Health Information Exchange (HIE)
HIE is one way to resolve these complex
issues. HIEs serve as a community-wide
electronic warehouse, which gathers
healthcare information from a broad
array of providers: physicians, labora-
tories, pharmacies, hospitals and imag-
ery centres (Xrays, MRI, CT etc). A
HIE securely aggregates and accurately
delivers lab results, reports, medication
histories, treatment histories in a stan-
dardised, electronic format to healthcare
providers.
I nformation technolog y
The data thus integrated and in the US have unmet informational
presented in a user-friendly standard needs that are available elsewhere. HIE
format, helps physician interpret the can help fill these gaps, creating an inte-
patient’s medical history easily. grated clinical IT environment.
In the US, this ability to provide The technology is feasible and is
an integrated patient medical record working in several metropolitan areas
is considered important. According in the US. A recent report by the State-
to the Journal of the American Society Level Health Information Exchange
for Information Science and Technology Consensus Project found that more
(JASIST), 66 per cent of clinical visits than 75 per cent of states have begun
Chronic Diseases - A growing concern
The majority of healthcare expenditure worldwide goes towards treating chronic
diseases. Chronic diseases such as heart disease, stroke, cancer, diabetes and chronic
respiratory disease are responsible for more than 60 per cent of deaths globally and are
projected to account for 47 million deaths annually in the next 25 years.
One chronic disease that is playing a leading role in complications and deaths is
diabetes. Although the US is expected to experience a far more rapid increase in
diabetes, according to estimates from researchers at the World Health Organization
(WHO) and several European universities, the greatest relative increases will be in the
Middle East, Sub-Saharan Africa and India.
The economic consequences of the worldwide rise in diabetes are alarming. The WHO
estimates that during 2005-2015, income loss (in international dollars) due to diabetes
could rise to as much as US$ 558 billion in China, US$ 237 billion in India, US$ 33
billion in Russia and US$ 33 billion in the UK.
According to the Milken Institute, the cost of treatment and lost productivity caused
by chronic illnesses in the US is more than US$ 1.3 trillion per year and if the similar
conditions prevail the costs could reach US$ 6 trillion by 2050.
w w w. a s i a n h h m . c o m 81
I nformation technolog y

developing some form of HIEs. The
Office of the National Coordinator for
Health IT is leading the development
of the Nationwide Health Information
Network, a secure, nationwide, interop-
erable health information infrastructure
that will connect providers, consum-
ers and others involved in supporting
health and healthcare. The Center for
Information Technology Leadership
estimates that a nationally standardised
and interoperable HIE can save US$ 77
billion per year in the US.
In addition to being implemented in
an affordable and non-disruptive fashion,
HIEs must also demonstrate value. In
Indianapolis, Indiana, a metropolitan
area in the US, it is estimated that the
system saves US$ 26 per emergency
department visit by not only eliminat-
ing duplicate tests, but also allowing
the physician to make better and more
informed care decisions. For example,
the savings could reach US$ 450 billion
a year nationally by helping physicians
pick optimal therapies and alerting physi-
cians to potential drug interactions.
Other countries, too, are looking at
implementing similar HIE solutions.
China, Canada and the UK are some of
the leading examples of countries that
are supporting their national infrastruc-
tures to bring in interoperability among
their HIEs.
Benefits of implementing HIEs
For patients and physicians across the
globe, the benefits of EMR are numer-
ous. The frustration of remembering
names of the medicines and doses for
patients would be a thing of the past.
These records could prevent unnecessary
repetition of tests and delay in access
to the information related to the test
results. The physicians will have informa-
tion at their fingertips where it is most
In addition to being essential to
realising the potential of EMRs (which
can be populated with information via
a HIE), the greater value in the data
within a community. HIE lies beyond
simple distribution. HIE may offer the
opportunity to utilise these data in new
and innovative ways, such as arming
physicians with information to proac-
tively reach out to their patients, all
without requiring expensive new equip-
ment or software packages to users. This
is where the true value of health IT lies
and offers the best opportunities for
improving outcomes and demonstrating
the value of health IT. In other words,
the community’s long-term benefit of
a viable HIE is the identification and
improved management of chronic and
disabling diseases.
Role of HIEs
HIEs hold the potential to improve
community chronic disease management
by the integration and transmission of
the patient’s care history and needs. The
concept for one such chronic disease
management programme is underway in
one US city. Physicians receive monthly
reports with the complete details of their
patients. They include details of all the
patients, chronic disease they are suffer-
ing from, the patients who receive care
compliant with the best standards and
the patients who need care interven-
tion.
From these reports, for instance,
physician could know if a patient with
diabetes recently had any test to deter-
mine the disease control and also whether
he needs a more aggressive treatment.
Thus, physician could focus on the
patients who are in need of better control
and improve the diabetic care of all his
A u thor
/ her patients. An interesting additional
benefit of this HIE-generated report is
that the details of the patients with
targeted chronic disease are constantly
updated automatically. Such dynamic
listing of the information in paper-based
systems is very problematic
Global healthcare improvements
mandate more efficient chronic disease
management due to both the high costs
and significant subsequent disabilities
and death. Chronic illness requires
historic medical data to equip the care
giver with a complete picture of the
patient’s needs. HIEs equip both the
community and the physician with the
tools necessary for a high quality of care
and optimum utilisation of healthcare
resources.
Conclusion
As a physician, I am keenly aware that
healthcare is about decision-making.
Improving the speed and accessibil-
ity of information allows physicians
to operate more efficiently, eliminate
uncertainties and make better decisions.
Technology by itself doesn’t do this, but
it does facilitate it.
The adoption of HIEs across the
globe cannot be simply viewed as
advancement of 21st century’s technol-
ogy. Instead, HIEs will be instrumen-
tal in reducing the impact of disease
burden on all communities. HIEs do
much more than simply sharing medi-
cal data; they provide patient’s history
and treatment no matter where the
patient travels and provide commu-
nity and individual disease care needs.
Undoubtedly, as HIEs’ databases
become expansive, they could play
an important role in the discovery of
life-saving discoveries.

critical—at the point-of-care. In critical Gregory Larkin was the Director of Corporate Health Services for Eli
Lilly and Company, a global pharmaceutical research and manu-
times when the patient may be unable facturing company before joining the Indiana Health Information
to communicate with the physician or Exchange as its Chief Medical Officer, He is a Fellow of the American
remember key medical information, Academy of Family Practice, and a Fellow of the American College
of Occupational and Environmental Medicine (ACOEM), and the
HIE could provide much needed help President of the Indianapolis Medical Society.
to the patient.

82
82 Asian Hospital & Healthcare Management ISSUE-16 2008
2008

Semantic Web
and Translational Medicine
Creating the next generation
healthcare enterprise
Translational Medicine, which aims to improve communication between the basic and clinical
sciences, coupled with informatics and semantic technologies will help in creating the next
generation healthcare enterprise.
Vipul Kashyap
Clinical Informatics R&D
Partners Healthcare System, USA
T
he Web has revolutionised the
way people look for information
and corporations do business.
The Semantic Web, being proposed
as the next generation web, builds on
the current infrastructure and attempts
to give information on the web a well
defined meaning. Simultaneously, the
life sciences sector is playing host to
a battery of innovations triggered by
the sequencing of the Human Genome
coupled with a more proactive approach
to medicine. There is an increased
emphasis on disease prevention and
wellness of the individual as opposed
to disease treatment and management;
and significant activity has focused on
Translational Research, which seeks to
accelerate ‘translation’ of research insights
from biomedical research into clinical
practice and vice versa.
The next generation healthcare
enterprise - A vision statement
There is a great need to get away from
the short-term goals of treating current
diseases and conditions, and focus on
long-term strategies of enhancing the
well-being and quality of life of an indi-
vidual. In fact, it is a well known fact
that adopting the approach of disease
prevention will result in reducing the
load on current healthcare infrastructure.
From this perspective, the vision of the
next generation healthcare enterprise
may be articulated as follows:
The Next Generation Healthcare
Enterprise provides services across the
Healthcare and Life Sciences (HCLS)
spectrum targeted at delivering optimum
wellness, therapy and care. These holistic
services cut across biomedical research,
clinical research and practice and create
a need for the accelerated adoption of
genomic and clinical research into clinical
practice.
A key consequence of this vision
is that not only should the healthcare
enterprise meet the current needs of a
patient, but also anticipate future needs
and implement interventions that can
potentially prevent diseases and other
adverse clinical events. This could be
done by sequencing the genome of the
patient and assessing the disposition of
a patient towards diseases and adverse
clinical events. This creates a need for
knowledge sharing, communication
and collaboration across the HCLS,
I nformation technolog y
which is indeed the underlying goal of
Translational Medicine.
Translational Medicine
Translational Medicine aims to improve
the communication between basic and
clinical science so that more therapeu-
tic insights may be derived from new
scientific ideas and vice versa. Translation
research goes from bench to bedside
where theories emerging from preclinical
experimentation are tested on disease-
affected human subjects, and from
bedside to bench, where information
obtained from preliminary human
experimentation can be used to refine
understanding of the biological princi-
ples underpinning the heterogeneity of
human disease and polymorphism(s).
The products of translational research,
such as molecular diagnostic tests are
likely to be the first enablers of person-
alised medicine.
Translation of genomic research
into clinical practice
One of the earliest manifestations
of translational research will be the
adoption of therapies and tests created
from genomics research into clini-
cal practice. Consider a patient who
suffers a shortness of breath and
fatigue in a doctor’s clinic. Subsequent
w w w. a s i a n h h m . c o m 83
I nformation technolog y

Information Flow examination of the patient reveals the

following information:
• Abnormal heart sounds that could be
Test ordering Clinical Trials represented in a structured physical
Patient Encounter 1 4
guidance Referral exam leading to the ordering of an
ultrasound
• Discussion of the family history with
5 the patient reveals that his father had
New test results Tissue-bank a sudden death at the age of 40, but
his two brothers were normal and
Genetics healthy
Decision Support Therapeutic Bench R&D • The ultrasound may reveal cardio-
2 6
guidance
myopathy based on which molecular
3
diagnostic tests (to screen genes such
as MYH7, MYBPC3, TNN2, etc.) for
Knowledge Integrated Genotypic Clinical Trials
7 genetic variations may be ordered
Acquisition Phenotypic Database Phase 1-4
• If the test is positive for pathogenic
variants in any of the above genes,
Figure 1
the doctor may recommend the test
for first and second degree relatives of
the patient and select treatment based
Information needs and requirements on the above-mentioned data
• When a patient is detected to as
Step
Information Requirement Application Stakeholder(s) a high-risk candidate for sudden
Number
death, he / she is put under thera-
peutic protocols based on drugs
Description of Genetic
1 Tests, Patient Information,
Decision Support, Electronic Clinician, Clinical Trials such as Amiadorone or Implantable
Medical Record Investigator, Patient Cardioverter Defibrillator (ICD). In
Decision Support KB
this case, molecular diagnostic tests
may indicate a risk for cardiomy-
Decision Support, Database opathy and phenotypic monitoring
Test Results, Decision Clinician, Patient, Healthcare
2 with Genotypic-Phenotypic
Support KB
associations
Institution protocol that may be indicated.

Knowledge Acquisition, Information needs and

Database with Genotypic- Knowledge Engineer, Clinical requirements
3 Decision Support, Clinical
Phenotypic associations Trials Investigator, Clinician
Guidelines Design See Figure 1 for information flow to
identify various stakeholders and their
Clinical Trials Management information needs.
4 Test Orders, Test Results Clinical Trials Investigator
Software
The aggregation of data for identify-
ing patients for clinical trials and tissue
Tissue and Specimen Clinician, Life Science banks leads to knowledge acquisition
5 LIMS
Information, Test Results Researcher
especially to create knowledge bases for
decision support. This also helps to map
Tissue and Specimen
Lead Generation, Target genotypic and phenotypic traits. An
Information, Test Results, Life Science Researcher,
6 Discovery and Validation, enumeration of the information require-
Database with Genotypic Clinical Trials Investigator
Clinical Guidelines Design
– Phenotypic associations ments is presented in Table 1.

Service-oriented architectures for

Database with Genotypic
7 Clinical Trials Design Clinical Trials Designer translational medicine
– Phenotypic associations
Each requirement identified in terms of
Table 1 information items has multiple stake-
holders, and is associated with different

84 Asian Hospital & Healthcare Management ISSUE-16 2008

 I nformation technolog y

contexts, such as: (a) domains such as

Service-oriented architecture for translational medicine genomics, proteomics or clinical infor-
mation; (b) activities, such as biomedical
research or clinical practice; (c) applica-
PORTALS R&D DIAGNOSTIC Svs LABs CLINICAL TRIALS CLINICAL CARE tions such as the EMR and LIMS; (d)
services such as decision support, data
integration and knowledge-, provenance-
related services.
APPLICATIONS LIMS EHR TRANSLATIONAL MEDICINE
The components of the conceptual
ASSAYS DIAGNOSTIC TEST ORDERS AND
ANNOTATIONS RESULTS ASSAY OBSERVATIONS TOOLS architecture, as illustrated in Figure 2,
INTERPRETATIONS are as follows:
APPLICATIONS Service
COMPONENTS
Genomic Analysis Order Entry/Fulfilment Patient Administration Creation and Portals: This is the user interface layer
Provisioning and exposes various personalised portal
views for various stakeholders such clini-
SERVICE DISCOVERY, COMPOSITION AND CHOREOGRAPHY Matadata cal researchers, lab personnel, clinical
Annotation
trials designers, clinical care providers,
hospital administrators and knowledge
Ontology Decision Knowledge Ontology
Engine
Rule Engine
Support
Medication
Management Data Mapping engineers.
SERVICES Services Services
Services Services Services Applications: The two main applica-
Ontology tions, viz. the EMR system and LIMS
Mapping are illustrated in the architecture.
DATA AND KNOWLEDGE INTEGRATION Service Discovery, Composition and
Knowledge Choreography: Newly emerging appli-
Acquisition cations are likely to be created via
DATA AND and Authoring
KNOWLEDGE
composition of pre-existing services
REPOSITORIES and applications. This component of the
Clinical Laboratory Metadata Database of Ontologies Knowledge
Data Repository Bases and
architecture is responsible for managing
Data Genotypic/
Phenotypic Rule Bases service composition and choreography
Associations Figure 2 aspects.
Services: The services that need to be
implemented for enabling Translational
Medicine applications can be character-
ised as (a) business or clinical services,
RDF representation of clinical and genomic data
e.g. medication and clinical decision
support services; and (b) infrastructural
"Mr.X" "Paternal" 1 Patient(id=URI1) 90% or technological services, e.g. ontology
and rule engine services.
name type degree has_structured_test_result evidence1 Data and Knowledge Integration: This
enables integration of genotypic and
phenotypic patient data and reference
MolecularDiagnostic
Patient ralated_to Person TestResult
information data, which could enable
indicates_disease
(id=URI1) (id=URI2) (id=URI4) clinical care transactions and discovery
of promising drug targets. Examples of
Dialeted
Cardiomyopathy knowledge integration would be merging
has_family_history associated_ralative identifies_mutation of ontologies and knowledge bases to be
(id=URI6)
used for clinical decision support.
Family History MYH7 missense
(id=URI3)
problem
"Sudden Death" evidence2 Data and Knowledge Repositories: These
Ser532pro (id=URI5)
refer to the various data, metadata and
EMR Data LIMS Data 95% knowledge repositories that exist in
healthcare and life sciences organisations.
Figure 3 Some examples are databases contain-
ing clinical information and results of

w w w. a s i a n h h m . c o m 85
I nformation technolog y

Merged RDF graph that itegrates genomic and clinical data
90%, 95%
evidence
ma
Dialated Cardiomyopathy y_s
uffe
(id=URI6)
indicates_disease
Structured Test
has_structured_
Result (id=URI4)
test_result
indentifies_Mutation
_ gen
has
MYH7 missense Ser532Pro
(id=URI5)
laboratory tests for patients. Metadata
related to various knowledge objects
(e.g. creation data, author, category of
knowledge) are stored in a metadata
repository.
Data and information integration
We will describe this with the help
of an example, an approach for data
integration based on semantic web
specifications such as the Resource
Description Framework (RDF) and
the Web Ontology Language (OWL),
to bridge clinical data obtained from an
EMR and genomic data obtained from
a Laboratory Information Management
System (LIMS). The first key step in
semantic data integration is the defi-
nition of a domain ontology spanning
across multiple domains; or creation of
inter-ontology mappings across multiple
ontologies that reflect different perspec-
tives e.g. research and practice a given
(clinical) domain.
The RDF graphs illustrated in Figure
3 represent clinical data related to a
"Mr.X" "Paternal"
r_fr
om name type
Patient related_to Person
(id=URI1) (id=URI2)
has_family_ associated_
e history ralative
Family History problem
(id=URI3)
"Sudden Death"
X’) is modelled as another node, and is
linked to the patient node via an edge
labelled name. Properties of the relation-
ship between the patient ID and person
ID nodes are represented by reification
(represented as a big box) of the edge
labelled related_to and attaching labelled
edges for properties such as the type of
relationship (paternal) and the degree
of the relationship.
Genomic data related to a patient
evaluated for a given mutation (MYH7
missense Ser532Pro) is illustrated. Nodes
(boxes) corresponding to Patient ID
and Molecular Diagnostic Test Result
ID are connected by an edge labelled
has_structured_test_result modelling the
relationship between a patient and his
molecular diagnostic test result. Nodes
are created for the genetic mutation
MYH7 missense Ser532Pro and the
disease Dialated Cardiomyopathy. The
relationship of the test result to the
genetic mutation and disease is modelled
A u thor
using the labelled edges identifies_muta-
tion and indicates_disease respectively.
The degree of evidence for the dialated
cardiomyopathy is represented by reifi-
cation (represented as boxes and ovals)
1 of the indicates_disease relationship
and attaching labelled edges evidence1
and evidence2 to reified edge. Multiple
degree
confidence values expressed by different
experts can be represented by reifying
the edge multiple times.
The end user previews them and spec-
ifies a set of rules for linking nodes across
different RDF models. These simple rules
may include: merging of nodes that have
same IDs or URIs, introduction of new
edges based on pre-specified declarative
rules specified by subject matter experts
Figure 4
and informaticians. New edges that are
inferred (e.g. suffers_from) may be added
back to the system based on the results
of the integration. Sophisticated data
mining that determines the confidence
and support for new relationships might
be invoked. This integration process
results in generation of merged RDF
graphs as shown in Figure 4.
Conclusion
There is a growing realisation that
Healthcare and Life Sciences is a knowl-
edge-intensive field and the ability to
capture and leverage semantics via infer-
ence or query processing is crucial for
enabling translational medicine. Given
the wide canvas and the relatively
frequent knowledge changes that occur
in this area, we need to support incre-
mental and cost-effective approaches
to support ‘as needed’ data integration.
Personalised / Translational Medicine
needs Semantic Web technologies to be
implemented in a scalable, efficient and
extensible manner.

patient with family history of Sudden Vipul Kashyap is a Senior Medical Informatician in the Clinical
Informatics Research & Development group at Partners HealthCare
Death. Nodes (boxes) corresponding System and is currently the Chief Architect of a Knowledge
Patient ID and Person ID are connected Management Platform that enables browsing, retrieval, aggregation,
by an edge labelled related_to modelling analysis and management of clinical knowledge across the Partners
Healthcare System. Vipul has worked on semantics and knowledge-
the relationship between a patient and based approaches for information and knowledge management.
his father. The name of the patient (‘Mr.

86 Asian Hospital & Healthcare Management ISSUE-16 2008

 I nformation technolog y

Telemedicine and
Remote Monitoring
Improving COPD patient care
The medical world is in urgent need of
providing new ways of dealing with the
challenges of the profession. IT and
sharing of competences among the
staff must be part of the solution.

Michael Hansen-Nord
Chief Physician
Odense University Hospital
Hospital of Svendborg, Denmark

E
ven though IT communication
systems like mobile phones and
Internet are well established in
most parts of the world, their usage
by the medical profession is fare from
optimal. The doctors just do not seem
to care! How come? Why do we not
take these tools, right at hand, into our
world? The obvious reasons ought to be
well known: lack of specialists, lack of
services to patients living at a distance
from hospital, growing number of elderly
people in need of chronic care and lack
of money. But other factors seem to be
the bigger challenge: the urgent, evident
need of change of culture and the need
to share competence among the staff of a
hospital. Furthermore, it has been argued
that the patients are not ready to cope
with the IT-solutions. This is far from the
truth. The fact is that if handled properly
these problems can be overcome.
The patients and the population are
ready! They already have, or will soon
get access to sophisticated communica-
tion systems and will expect the medical Image Courtesy : University of Queensland,
Centre for Online Health Work, Australia

w w w. a s i a n h h m . c o m 87
I nformation technolog y
world to go along and offer professional
support whenever and wherever they need
it. In other words we have to deal with
the growing demands of accessibility.
Organisations, who will not adapt to
these demands, will sooner or later get
into serious problems.
Care providers need to realise that
the medical world is changing from a
market of supply to a market of demand.
In other words, we have to accept a set
of guidelines that can be referred to as
the patient principles:
• That we at any given time can offer
the patients the most competent treat-
ment
• That it happens within standards and
recommendations
• That it happens within the economic
resources
• That it counts for every patient
• That health professionals adapt to the
customers’ expectations
Sharing competence is a very impor-
tant issue in adapting to IT solutions.
It is obvious that doctors must focus
on patient matters, wherever their
knowledge is needed. However, many
specialists perform consultations that
could be performed by trained nurses
just as well.
88 Asian Hospital & Healthcare Management
In my medical department, we have
worked seriously on this issue for many
years and today about 50 per cent of all
outpatients are consulting the nurses. For
5 years, we have been running out patient
clinics at a distance on a small island, 3
hours travel from our hospital.
A good example of this is patients
suffering from type 2 diabetes on a near
by island: a specialist nurse travels to the
island twice a month and takes consulta-
tions. Whenever she requires the consul-
tation of an endocrinologist, she connects
via the Internet to the hospital and gets
the doctor online for support. The doctor
then takes over the consultation, talks to
the patient and provides the necessary
treatment. A simple solution and yet the
treatment of patients with type 2 diabetes
has improved considerably. The HbA1C
has fallen from 8.7 to 7.2 per cent in the
population. This is astonishing!
Another such example deals with
patients suffering from suspected heart
failure. A specialised trained nurse goes
to the same island, equipped with a port-
able echocardiograph. She makes the
ultrasonic investigation and concludes
whether the condition is normal or
abnormal. Whenever an abnormal
investigation occurs, she connects to the
cardiologist on duty and shows him the
result of the ultrasonic investigation. The
cardiologist then makes a decision on the
issues and takes over the consultation. All
the normal investigations are afterwards
shown to the cardiologist. In the last
five years, 75 per cent of the referred
patients had a normal echocardiography
and could be discharged instantly. In
addition, the amount of medication for
heart failure rose to the expected level for
patients suffering from the disease. All
Image Courtesy: University of Queensland,
Centre for Online Health Work, Australia
ISSUE-16 2008
this is well documented in our regional
prescriptions database.
Let us turn to another issue: shar-
ing competence and assisted IT solu-
tion have proved to be of great value
in minimising the amount of ‘in days’
in the medical ward for the severely ill
chronic patients.
Several studies have proved that
Assisted Home Care (AHC) is as good as
continuing hospitalisation for about one-
third of the patients admitted because
of exacerbation of Chronic Obstructive
Pulmonary Disease (COPD).
The goal is to seek solutions that are
safe for the patients, save time for the
specialists and bring down the costs.
Our medical department, together
with MedCom International is conduct-
ing a project, which brings ICT tools into
healthcare and thus, in a cost-efficient
manner, facilitates high-quality care for
chronic patients by offering hospitalisa-
tion at home.
The objective is to compare AHC
with hospitalisation at home under
the surveillance of a newly developed
briefcase that enables the hospital to
be in contact with the patient through
ICT. The project focusses on COPD
(often referred to as smokers’ lung
disease) patients and the overall goal
is to reduce the length of hospital stays
for a patient group, to reduce cost and,
more importantly, to improve the qual-
ity of life for the patients. During the
summer of 2006, our medical depart-
ment and GITS, a Danish IT company,
developed a patient briefcase, which
makes it possible to take care of COPD
patients in their own homes. The ICT
equipment allows live images / sound as
well as data measurements from medi-
cal equipment (e.g. Spiro meter and
devices to measure oxygen saturation)
to be quickly transferred to the hospi-
tal either via the Internet or a satellite
connection. At the hospital, the doctor
can evaluate and guide the patient as if
the patient was present at the hospital.
The data transmitted from the patient’s
home enables the hospital to perform a
 I nformation technolog y

systematic monitoring and control the
quality of the treatment.
Technology used
The patient briefcase (MediSat®) is a
specially developed, portable communi-
cating item that includes video-conference
equipment, three buttons (on / off, call
me and sound adjustment) and medico
technical equipment, connections to the
specialist via ADSL / LAN or satellite,
A mobile phone with the specialist on
duty to receive calls from the patients
and a computer with electronic medical
health record at hand and videoconfer-
ence equipment.
Methodology
The population of the Svendborg Hospital
consists of five municipalities. Two of
these, (A) have made agreements with the
medical department to participate in the
project, and the other three municipals
(B) have been given the part as controls.
Every patient, admitted to the depart-
ment because of exacerbation in COPD,
is evaluated through a validated test to
part them into one of three groups:
• Group 1 is supposed to be discharged
within 48 hours
• Group 2 consists of candidates who
require invasive air support and
• Group 3 consists of those who need to
be admitted into the medical ward for
more than 48 hours and not needing
invasive air support.
Patients from group 3 are offered an
early dismissal within 48 hours supported
by the portable IT solution which enables
the patient to ask for urgent assistance
and provide for hospitalisation at home
with regular rounds by a specialist at
fixed times.
During the first 24 hours of admis-
sion, the patients are instructed in how to
use the briefcase. The aim was to include
time in the medical ward 4) savings on
economy compared with continuous
admittance / assisted home care-solu-
tions 5) experiences from the hospital
staff 6) number of patient readmitted
within the first 30 days.
The study is to be followed by a regu-
lar randomised study.
Evaluation
1. Patient’s satisfaction is evaluated by an
interview, conducted by a third party
(a department of quality) and finally
a control-visit in the outpatient clinic
four weeks after the briefcase has been
withdrawn
2. System effectiveness is evaluated by
the number of re-admittances within
the first four weeks, compared to a
control group
3. The different technologies of the
briefcase are continuously evaluated
by surveillance of reliability
4. The costs of the different solutions
Results (47 patients with the
briefcase)
1. The patients feel safe and comfort-
able at home
2. Everyone asked will participate
3. Reduction in number of patients who
were readmitted within the first month
by more than 50 per cent
4. Reduction in ‘in-days’ by 5 days on
an average
5. Improved staff-patient relations
6. Reductions in expenses
The study is still in progress.
Perspectives
Chronic patients have to be offered serv-
ices of surveillance, either by education
Michael Hansen-Nord has been chief physician at one of
A u thor
or by offers from the specialists…or both!
I believe that educational programmes
can improve the competence of these
patients and evolve them to be alert of
their own symptoms and react properly
to hard-core medical measurements. The
last part can be supported by surveyed
IT systems that makes early interven-
tion possible and thereby either improve
the everyday status or even avoid admis-
sion into hospital units. Furthermore,
the specialists can considerably improve
care by using their skills wherever needed
and not on problems which could be
handled by nurses.
Conclusions
All over the world, healthcare providers
have to deal with the growing demands
for medical services. We can do this by
developing solutions, which are cheaper
and seek solutions where the population
gets more value for money (the aver-
age in-bed time for patients in medical
departments vary an astonishing 9-7 to
4-2 days even in Europe!).
Many options are right at hand and
well documented yet they are not used.
We could, for instance, start by adapting
to the growing access to IT-solutions used
in other parts of the society.
Many IT-systems are already there for
medical purposes, but the use is limited to
hard-core fanatics within the healthcare
sector and to very local initiatives. That
is just not good enough! The doctors also
have to learn, that sharing competence
with nurses does not mean loss of pres-
tige but helps reaching the overall goal:
improving healthcare to the population
that we are meant to serve. We are in
urgent need of support from the govern-
ment and from the medical profession.

Denmark’s largest medical departments, leading a team of 84

50 patients with the briefcase at home
and 50 patients with assisted home care
solution with the controls of the patients
from the B municipals. The evaluations
focussed on 1) safety of the technology
2) patient experience 3) savings on in-
doctors, for the last 7 years. Since 2003, he and his team have been
working with the Danish Center of Health Telematics (MedCom). The
first e-health programme, they took part in was the Health Optimum,
the e-health project of 2005 in the EU. The present focus of his team
is the chronic patient with more than 2 admittances a year with the
aim of reduction of in-bed-time and re-admittances.

w w w. a s i a n h h m . c o m 89
 K
nowledge is not constrained
to national or geographic
boundaries. While we must
recognise cultural, national, societal
and other variations, best practices are
applicable everywhere.
More than 1,500 health informa-
tion technology professionals from 31
countries discussed on topics: clinical
leadership and governance, e-health,
EHR, EMR, EPR, PHR, IT strategy
and innovation during HIMSS AsiaPac08
conference.
The group of healthcare leaders and
professionals who gathered during this
event looked at the evolution of health-
care with a unified philosophy: healthcare
delivery can be improved with the use of
information technology. Following are
some of the basic principles that offer
a picture of healthcare that applies to
everyone.
Use a bottom-up approach
Dr York CHOW, SBS, JP, Secretary, Food
and Health, Government of the Hong
Kong Special Administrative Region and
Shane Solomon, Chief Executive, Hong
90 Asian Hospital & Healthcare Management
Kong Hospital Authority (HA) suggested
four key ‘factors in action’ that helped
transform the Clinical Management
System in Hong Kong. One of them was,
transformation of healthcare is bottom-
up, rather than top-down, development
process.
“Users are involved right from the
beginning and are put in the driver’s
seat throughout the design, standardi-
sation, development and implementation
process,” said Dr CHOW. “We engage
the users from the outset and allow the
whole process to be driven in a bottom-
up manner by user groups—which is
painstaking and time consuming.” He
also explained that this process is worth it
because “it secures the buy-in and owner-
ship of the users themselves to the need
for change.”
In countries where healthcare systems
are largely centralised under a govern-
mental authority, this concept can be a
challenge. When most of the planning
and IT adoption is driven by a regional
health authority or federal level ministry,
switching to a process that starts with the
end user can be difficult. Government
ISSUE-16 2008
officials must give up certain elements
of control in hope for a better outcome
through the end user’s commitment that is
secured from the bottom-up approach.
Focus on the patient
Private sector management models
have been both a source of revelation
and consternation to the healthcare
industry.
Dr TAN Yung Ming, Product
Development Manager at Health Group,
Singapore and CHEW Kwee Tiang,
Chief Operating Officer at Alexandra
Hospital explained ‘Lean Healthcare
IT Systems: The Toyota Way.’ Using
this business strategy from the Toyota
Production System (TPS), Alexandra
Hospital in Singapore has emphasised
on the following principles:
• The customer is at the heart of the
organisation’s philosophy
• The organisation continuously reflects
and learns
• The organisation sees processes
end-to-end and removes silos.
Looking at healthcare delivery
from the patient’s perspective presents

Insights into
Healthcare IT
Transforming healthcare in Asia
Healthcare delivery can be improved by focussing on clinical leadership and
governance, e-health, EHR, EMR, EPR, PHR, IT strategy and innovation.
an entirely different approach to care
because the focus is on the person, not
the process. The TPS approach uses
a value stream map that distinguishes
value-added versus non-value-added
activities. Thus, TPS is a management
philosophy that requires the creation of
an organisational culture where every-
one is involved.
A study from Tefen USA found
that this number may be even higher
for those over the age of 65 who have
more hospital stays than that of the
general population. The data from this
study reveals that elderly population has
nearly three times as many hospital days
per thousand as the general population.
In addition, 62 per cent of 50-64 year-
olds indicate that they have at least one
of six chronic health conditions: arthri-
tis, cancer, diabetes, heart disease, high
cholesterol and hypertension.
This patient-centred approach takes
on a role reversal as the population
ages throughout the world. Demand
increases for quality healthcare delivery
to manage the health and the care of
these individuals. For example, in the
H Stephen Lieber, President and CEO, HIMSS, USA
US, a recent report from the Centers for
Medicare and Medicaid Services (CMS)
predicts that unless decisive action is
taken, total US healthcare spending will
double to over US$ 4.3 trillion by 2017
or nearly 20 per cent of the nation’s gross
domestic product.
Chronic disease management is one
of the primary benefits of the EHR, but
the patient must truly be part of this
process. Shane Solomon, Chief Execu-
tive, Hospital Authority, Hong Kong,
said that “healthcare can do more,” to
help improve the delivery of care.
“We have created the passive, disem-
powered patient, waiting in hospital for
the doctor or nurse to tell them what to
do,” said Mr. Solomon. This philosophy
made sense when hospitals mainly cared
for those with infectious diseases and
patients were uneducated and unable to
care for themselves.
He suggested a co-production
approach to healthcare, where “you
should not only be able to read your
own health record, but you will contrib-
ute to creating it.” As he explained, to
do this, the patient needs information.
I nformation technolog y
The patient must also take an active role
in recording their blood pressure, weight
or blood glucose levels. “This electronic
health record will link to authoritative
sources of information for the condi-
tion, and other forms of patient support
and education.”
Mr Soloman’s vision is not unreal-
istic and in fact, as he indicated, there
are prototypes of these initiatives already
emerging throughout the world.
This changing focus on the patient in
regards to health information is evident.
The very strong historical culture of
hospital or physician ‘ownership’ of
a patient’s information is giving way
to this shared ownership concept—
slowly, but surely. Personal Health
Record (PHR) applications are in their
infancy, but there are some very powerful
proponents of these applications:
Microsoft and Google to name two. The
increase in number of these applications
will have an impact on institution-based
Electronic Medical Record (EMR)
systems and anticipation of the relation-
ship between PHRs and EMRs will be
important.
w w w. a s i a n h h m . c o m 91
I nformation technolog y
Come together on health IT
standards
Standards make interoperable exchange
of information possible and enduring.
In fact, together standards and organisa-
tions are working to develop effective
standards for healthcare.
Providing an update on global
health IT standards development, Dr
Yun Sik KWAK, Medical Informatics,
Kyungpook, National University,
Republic of Korea explains that there
are various HL7 standards, such as V2.X
and V3 that have been introduced to
help establish integrated and connected
health information systems. Dr KWAK
is also the Chair, ISO / TC215, Health
Informatics, Republic of Korea.
Dr KWAK and Audrey Dickerson,
Secretary, ISO / TC215 Health
Informatics (USA), and Manager,
Standards Initiatives, HIMSS
opined that both HL7 and
ISO are separate but collabo-
rative Standard Development
Organisations (SDOs), which
recognise that developing coun-
tries depend on standardisation
for some of their IT infrastruc-
ture in hospitals and in their
clinics, for health IT systems and
devices. In addition, telemedicine has
been used as a consultant network in
some countries, especially China, where
the network is advanced to assist local
doctors with diagnosis.
Many developing countries are
completing their initial work in health-
care IT, often seeing what other coun-
tries have done and how those successes
can be applied in their own countries.
But involvement by the healthcare
community in international creation
of standards is critical. As healthcare
becomes more of a global business,
commonality of health standards will
grow. Engagement with HL7, ISO
and other standards development
organisations will pay dividends in
the Asia Pacific and other regions as
they move further down the path of
IT adoption.
92 Asian Hospital & Healthcare Management
Quality healthcare with a local
focus
While quality is the constant in patient
care throughout the world, many other
variables change based on location,
availability of staff, medicine, hard-
ware, software, and even a building,
to provide that care.
Dr Alvin Marcelo, Director, National
Telehealth Center, University of the
Philippines, Manila, who dealt with the
problem of shortage of health workers in
the Philippines due to their increasing
migration to other countries, opines that
the biggest challenge in the Philippine
is, ‘human capacity’ not ‘infrastructure.’
As a result, open source software and
SMS / MMS telereferrals, a simpli-
fied technology that demands less tech
support, were put in place. He focussed
on capacity-building to eliminate the
Looking at healthcare delivery from
the patient’s perspective presents an
entirely different approach to care.
fear or avoidance of personal comput-
ers (PCs). He said that he was able to
expose rural health workers to “practical
applications that related directly to the
nature of their work,” a process that
allowed them to “evaluate the quality
of their data and to plan for improve-
ment.”
In healthcare, it is easy to forget,
or perhaps not recognise, that learning
how to manage technology takes time.
Dr Marcelo found that he had to invest
in the healthcare workers of his country
instead of signing an expensive licensing
agreement. And, he chose to invest in
healthcare workers.
In Asia, workforce shortage and
training issues vary from one region
to another. The valuable lesson learnt in
managing the labour shortage focusses
on the critical need to develop a culture
of continuous professional improvement,
ISSUE-16 2008
whether using expatriate workers or
developing the skills of nationals with
quality education and training. In either
case, healthcare is a complex activity
requiring many skills and extensive
knowledge. Continuing education is
an investment in the future.
How privacy works for EHRs?
Elisabeth Harding, Director, Legal &
Governance, University Hospital, Dubai
Healthcare City, United Arab Emirates,
advises healthcare professionals that it is
important to understand what privacy
of patient health information means and
how it works at the point-of-care, but so
should the patient. She explained that
“privacy legislation is not about keep-
ing things ‘private’ or ‘secret’ but about
ensuring that information is used consist-
ently with the purposes for which it was
obtained.”
The Hippocratic Oath intro-
duced in the 4th century BC,
indicates that privacy was a
concern then, and now. Physician
Hippocrates stated that, “All that
may come to my knowledge in
the exercise of my profession or in
daily commerce with men (now
people), which ought not to be spread
abroad, I will keep secret and will never
reveal.”
She advises physicians to help
patients, and healthcare employees,
understand why information is being
collected. “If people (you and I) trust
what is being done with our information,
then generally there is not a problem with
sharing our information in the course
of providing care and treatment (in its
broadest sense),” she said. She advises
healthcare providers to make sure the
patient understands why information is
being collected because, “transparency is
essential to build trust.”
Andrew M Wiesenthal, Associate
Executive Director, The Permanente
Federation, said that his organisation,
Kaiser Permanente, learnt early in its EHR
implementation process that information
technology is a strategy, not a goal.
 I nformation technolog y

Kaiser Permanente began this proc-
ess in 1970s with new applications
or technology introduced in certain
regions throughout these years. This
integrated healthcare delivery system
serves eight regions that include nine
states and the District of Columbia
with more than 32 hospitals and medi-
cal centers and more than 435 medical
offices.
In 1997, the EHR implementa-
tion process became a corporate goal
of Kaiser Permanente. In 2002, Kaiser
reassessed its progress and asked key
questions on the system needed and on
clinical and operational goals. In 2003,
one of a “complete healthcare business
system that will enhance the quality of
patient care.” That conclusion comes
from understanding the following
points.
• Deploying an EHR is a strategy, not
a goal
• Distributed development with subse-
quent integration is achievable but
very difficult and very expensive
• Interfaces to legacy system are always
more difficult than predicted
• The organisation is a healthcare
Stephen Lieber is President and CEO of the Healthcare Information
A u thor
delivery system, not a software devel-
opment firm.
All of us in the healthcare indus-
try continue to strive for the best
patient care that we can deliver with the
'how-to' equation differing on the
basis of budget to time in the day.
But technology has brought the
world together in many industries,
including healthcare. The six points
presented here offer some guidance
based on lessons learned from our peers
in the field.

the organisation introduced the Kaiser
Permanente HealthConnect™ integrated
healthcare delivery system.
Dr Wiesenthal’s assessment of what
worked—and didn’t work—has global
applications because his summation of
the electronic health record at Kaiser is
and Management Systems Society (HIMSS). Lieber also serves
on the Board of Directors of HIMSS and its two related corpora-
tions, as well as other corporate, nonprofit and coalition boards and
groups. He is one of the founders of the Certification Commission
for HIT and the Health Information Technology Standards Panel,
which are both US federally-funded initiatives supporting the US
interoperability effort.

w w w. a s i a n h h m . c o m 93
94 Asian Hospital & Healthcare Management ISSUE-16 2008
 ProductShowcase
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w w w. a s i a n h h m . c o m 95
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HealthcareEvents

August 2008 October 24 - 28

August 24 - 28 12th Asian Oceanian Congress of Radiology
SICOT/SIROT 2008 XXIV Triennial World Congress (AOCR 2008 SEOUL)
Venue : Hong Kong Convention and Exhibition Centre Venue : COEX, Samsung-dong, Gangnam-gu, Seoul
Organisers : International Society of Orthopaedic Surgery 135-731, Korea
and Traumatology-SICOT Organisers : Asian Oceanian Society
Email : congress@sicot.org of Radiology (AOSR)
Web Link : www.sicot.org Email : info@aocr2008.org
Web Link : www.aocr2008.org
September 2008
October 26 - 28
September 17 - 19
HospiMedica Asia 2008 Abu Dhabi Medical Congress
Venue : SICEC-Singapore International Convention & Venue : Abu Dhabi National Exhibition Centre,
Exhibition Centre, Suntec, Singapore Abu Dhabi, UAE
Organisers : Messe Düsseldorf Asia Pte Ltd Organisers : Institute for International Research
Email : hospimedica-asia@mda.com.sg Email : info@iirme.com
Web Link : www.hospimedica-asia.com Web Link : www.abudhabimed.com

October 2008 October 30 - 31

8th Asia-Oceania Congress of Medical Physics &
October 2 - 5
9th Asian Congress of Urology 6th South-East Asian Congress of Medical Physics
Venue : The Ashok Hotel, New Delhi Venue : CHORAY Hospital, Ho Chi Minh city
Organisers : Urological Society of India Organisers : CHORAY Hospital
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96 Asian Hospital & Healthcare Management ISSUE-16 2008

w w w. a s i a n h h m . c o m 97
98 Asian Hospital & Healthcare Management ISSUE-16 2008