I s s u e 37 2017 w w w.asianhhm.

com

Healthcare
Business Models
in Southeast Asia
Evolution is vital

Industry 4.0
Manufacturing and the
future of medical things

Dawn of the Future

IoT-driven medical devices
service enterprises

Healthcare in Southeast Asia
Opportunities and challenges alike
The Southeast Asia’s emerging countries are
expected to witness tremendous growth in
healthcare spending by 2020. These include
Indonesia, Philippines, and Vietnam which are
witnessing a widening reach and expansion of their
healthcare systems to serve thousands of patients
that have for long been deprived of proper care.
According to the Economist Intelligence Unit,
the CAGR of healthcare spending in Indonesia
and Philippines during 2016-20 is expected to
be 10.6 per cent and 10.8 per cent, respectively,
exceeding growth of the BRIC nations. These
merging economies have focused on social
health insurance to provide affordable healthcare
for low-income families. Indonesia has made a
reasonable advancement in healthcare provision
through its universal health insurance that
covered more than 65 per cent of its population
as of 2016, growing from 46.7 per cent in 2013.
Meanwhile, Vietnam has more than 77 per cent of
its population covered under universal insurance
scheme, while the coverage for Philippines was
just under 90 per cent by 2016. Implementation of
the health insurance policies was dependent on
partnership with private hospitals as government
hospitals were unable to meet demand because
of inadequate supplies and lack of proper
infrastructure.
While Singapore and Brunei are the most
developed healthcare markets in the region, the
former is looking beyond a strong healthcare
system and aims to drive healthcare innovation to
address challenges such as chronic diseases and
ageing population. In the fast maturing markets
of Malaysia and Thailand, the rise of healthcare
systems locally meant better choice of care for
patients. Malaysia in particular, has seen rise in
spending on healthcare as the health ministry
planned to spend around $350 million as of 2016
to better integrate public and private healthcare
systems by sharing of data.
Foreword
Economic growth has spurred funding in public
healthcare expenditure in the region’s emerging
countries; nevertheless private players do see a
great opportunity in the longer run and continue to
expand their services. Rising income groups and
an affluent popula ion have fueled the demand for
access to better healthcare facilities and higher
quality of care. The challenge of healthcare
delivery is being addressed through allocation
of heavy budgets for upgrading healthcare
infrastructure and closing in on the demand for
hospital beds in the regions. Myanmar is slowly
moving towards becoming a growing healthcare
market, while Cambodia and Laos have been
dependent on private players for healthcare.
These merging countries present significant
opportunities for private companies. For the
universal health programmes to sustain in the long
run, governments will look to players that finance
and deliver care by improving efficiencies through
development of generic drugs and providing
affordable healthcare. For healthcare companies,
this means widening their reach through higher
volumes of affordable products, and innovative
business models for serving middle and affluent
income groups.
In the cover story, Yoshihiro Suwa of Roland
Berger, provides deeper insight into how
private players in the region have experienced
an i ncreasingly competitive environment and
reduced margins in the recent past. While the
outlook remains optimistic, private healthcare
providers should continue to look at innovative
business models to evolve and remain relevant
for sustaining in the long-run.
Prasanthi Sadhu
Editor
 Cover Story
Contents
HEALTHCARE 16
MANAGEMENT Healthcare
06 Nurses are Expected to Embrace Technology Business
Who is there to address their woes?
Lt Col (Retd) Binu Sharma, Senior Vice President Nursing Services
Models in
Columbia Asia Hospitals
Southeast Asia
12 National Health Policy Evolution is vital
A welcome move in the healthcare industry
Suresh Ramu, CEO, Cytecare Hospitals Yoshihiro Suwa
Partner, Roland Berger
20 Becoming World Class, with Class
Jeffrey E Thompson, Pediatric Intensivist and Neonatologist
Gundersen Health System

26 ACO Meets Triple Aim and Save $millions

Peter A Gross, Chair, Board of Managers, HackensackAlliance ACO

MEDICAL SCIENCES
30 The Global Advancement of Diabetes Management
Sanjiv Agarwal, MD & Founder, Diabetacare

34 Head and Neck Cancer

Symptoms, early detection and prevention
Vikram Kekatpure, Senior Consultant, Head & Neck Surgical Oncology
Cytecare Hospitals
INFORMATION
38 Risk Factors for Development of Cardiovascular TECHNOLOGY
Disease
KATM Ehsanul Huq, Graduate School of Biomedical & Health Sciences
48 Dawn of the Future
Hiroshima University IoT-driven medical devices service enterprises
Michiko Moriyama, Graduate School of Biomedical & Health Sciences Ram Meenakshisundaram, Senior Vice President and Global Delivery Head
Hiroshima University Life Sciences, Cognizant
Pradeep Kumar Ray, Engineering Research Center on Digital Medicine and
Clinical Translation (DMCT), Shanghai Jiao Tong University 50 Data Security and Analytics
Susumu Nakayama, Graduate School of Biomedical & Health Sciences Shaping the future of healthcare
Hiroshima University
Baskaran Gopalan, Senior Vice President, IT & Projects
Md Moshiur Rahman, Graduate School of Biomedical & Health Sciences Omega Healthcare Management Services Pvt. Ltd.
Hiroshima University

54 HealthTech Innovation
Technology, Equipment Optimising telehealth services
Dave Waldrop, Co-CEO/CRO, Calgary Scientific

& Devices 58 EHR Interoperability

42 Industry 4.0 Why, what and how
SB Bhattacharyya, Head, Health Informatics
Manufacturing and the future of medical things TCS Member, National EHR Standardisation Committee, MoH&FW, Govt. of India Member
Francisco Almada Lobo, Chief Executive Officer and Co-Founder, Critical Manufacturing IMA Standing Committee for IT, IMA Headquarters

12 38 42

2 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017

 Editor
Advisory Board Prasanthi Sadhu

Editorial Team
Debi Jones
Grace Jones

Art Director
M Abdul Hannan

Product Manager
Jeff Kenney

Senior Product Associates

David Nelson
Peter Thomas
Sussane Vincent

Product Associate
Ben Johnson
Jennifer Wilson

John E Adler Circulation Team

Professor Naveen M
Neurosurgery and Director Radiosurgery and Nash Jones
Stereotactic Surgery Sam Smith
Stanford University School of Medicine, USA
Subscriptions In-charge
Vijay Kumar Gaddam

Head-Operations
Sandy Lutz S V Nageswara Rao
Director
PricewaterhouseCoopers
Health Research Institute, USA

Peter Gross
Chair, Board of Managers
HackensackAlliance ACO, USA
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HEALT HCARE MANAGEMENT

Nurses are
Expected to
Embrace Technology
Who is there to address their woes?

Historically, developed under the British rule, nursing was one of

the first profession to develop in India. This noble profession has
witnessed tremendous evolution strides in all spheres including
technology, medicine and medical equipment. From being
considered as an art based human subject, it has evolved into the
field of technology. However, the status of nursing in our country
is still a subject of debate. With organisations coming forward
in the leadership of influential public figures, will the status of
this noble profession remain the same even in 21st century?.
Lt Col (Retd)Binu Sharma, Senior Vice President Nursing Services, Columbia Asia Hospitals

H
istorically, nursing in India
had evolved under British
rule. The British Medical
Services, later known as the Indian
Medical Services, were the first to
develop nursing as a profession in
India.
Nursing as a profession has evolved
over the years from being an art based
human approach to a technology
oriented science subject. The role of
nurses has changed dramatically over
the last couple of decades. I have seen
evolution in this field from the time
I had entered this profession, exactly
40 years ago.
In any health system, the health
worker determines the nature and
quality of services provided. Data
demonstrate that most health systems
across the globe face nursing shortages,
varying across regions and rural-urban
distribution. Although nursing services
are an integral part of both preventive
and curative aspects of India's health
system, the nursing estimates of the
country shows that India has been
facing a shortage of nurses since
independence.
Earlier, nursing had little to do with
formal training on clinical practices,
infection prevention and patient safety.
A few decades back it was more about
following the doctor’s orders and
comforting the patients and counselling
them. Nursing curriculum didn’t include
training & exposure to vital aspects to
handle patients independently.Young
nurses lacked confidence in infection
control protocols, basic & advance life
support measures and doing skill based
procedures. The role of nurses was given
prime importance in terms of basic still
sets with a human touch.
However, over the last two
decades,with technology playing a key
role in healthcare and with hospitals
adopting digitization, cloud data

6 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017

 HEALT HCARE MANAGEMENT

Nurses should be considered as active

members of the health team, in terms of not
only providing services, but also as a part of the
decision-making processes, so that it is possible
for her to participate in providing holistic and
comprehensive healthcare to the patient.

storage, and electronic documentation,

nursing as a subject has become more
science and technology driven. Nurses
today are expected to hone their
skill sets on the latest technologies.
For instance, we at Columbia Asia
Hospitals are completely paperlesswhen
it comes to patient’s medical records
and other documentation. Nurses very
easily adopt technology once they are
inducted & trained in the Hospital
Information System.
This apart, now,focus is given on
imparting knowledge to the nurses along
with hands on skills in operating the
newer medical devices and equipment
for handling patients likesmart drug
infusing pumps, drug delivery pumps,
and patient’s monitoring systems.
Nurses are using newer technology for
assessing and monitoring patients
The good news here is that since
majority of the nursing professionals
belong to the younger age group, they
are flexible with the evolving systems
which never existed in earlier days.
However, we should understand
that training of nurses should ideally go
much beyond imparting technical and
medical skill sets. As nurses anddoctors
are the pillars of patient care in the
hospital, it is vital for them to work in
coordination. Thus, it is important for
nurses to get trained to enhance their
integration with the doctors. Also,
nurses and doctors should be trained
together in disease management, from
the point of medical management and
nursing management, so that they can
work as a team with a common clinical
goal which improves patient outcomes.
This helps in ensuring that they all

www.asianhhm.com 7
HEALT HCARE MANAGEMENT

speak the same language with no Standardisation of Salary for Nurses personal level to the patient and has
miscommunication when they involve in India: chances of being exposed to bodily
in patient communication. Nurses form the backbone of any fluids and contaminations. The work
Counselling plays a vital role in medical services or patient care in undertaken by nurses still has social
a nurse’s skill set today. Nurse the health sector. But in India, this stigma attached to it . This can be cited
Counsellors are trained to educate the important section of workers are as one of the main reasons behind the
patient and his family about a disease highly exploited, with lack of respect low perception held by the Indian
and how to handle it. Nurse Counsellors and dignity at workplaces and more society towards the nursing profession.
are also expected to counsel the patient’s importantly paid extremely low salaries The nurses are considered to be
family, educate them about patients’ with lack of job security. secondary in position as compared to
safety in the hospital and at home, The demand and supply ratio of other health professionals in India.
and focus on ways to maintain hygiene nurses in India is getting wider with There is a vast difference in the prestige
for the patient. These are new training trained nurses from India are settling and recognition accorded to doctors as
guidelines which go much beyond the for greener pastures abroad. For decades compared to nurses (Gill 2009). The
traditional nursing training. now, nurses are taking up jobs in nursing profession continues to be
A nurse in a private or a Middle East, many European countries, neglected in India. Some of the causes
corporate hospital has to internalise Canada, andvery minuscule numbers behind this neglect are more emphasis
communication etiquettes, are relocating with jobs in the US. on medical education, political
communication content and other The nursing profession in India lacks influence by the medical community
soft skills. At Columbia Asia, there is a high professional status, has low and and less allocation of financial resources
standard script designed for nurses for unattractive salaries, gets inadequate on health by the Indian government
all the communication that she must recognition from the community for (Rao, Rao, Kumar, Chatterjee, &
do with the patient. For instance, there the services provided by them and has Sundararaman 2011).
are exact drafted words that she should little incentives for quality performance Thus, with time and experience,
speak to a patient on hospital bed or (Gill 2009). The institutions responsible they prefer to move overseas as there
during discharge. for nursing training lack the required is respect, good compensation with
Another important factor today is physical and human resources. annual perks like free vacations, good
grooming of the nurses. Nurses hail The nursing profession is given living conditions and other benefits.
from various parts of the country, with low social status because of the In India, most of the women in
many coming from smaller towns and prevalent societal traditions. Nursing nursing would want to move to a
many of them are not comfortable in work involves rendering services on a government set-up because of job
communicating in English. Hence, they
are trained in English communication
and grooming. A little make over with
knowledge about carrying themselves
presentably, maintaining personal
hygiene, adopting pleasing manners
goes a long way in adding to their
overall personality and service offered.
They are also trained in body language
and how not be rude to the patient.
Also, training is given on computer
skills, keeping in mind the rising
standards of the hospital. Now-a-days,
apart from conventional nursing skills
and nursing procedures, a customer
also looks at a seamless experience or
approach. Therefore, nurses have to
be trained to work in integration with
other departments for establishing
inter-departmental coordination and
communication.

8 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017

www.asianhhm.com 9
HEALT HCARE MANAGEMENT

Nurses form the

backbone of any
medical services or
patient care in the
health sector.

security, accommodation and medical
benefits. They would choose to work for
a government establishment even though
there is not much professional growth,
as they get various benefits which is not
available in private sector. Experienced
nurses in India also prefer taking up
teaching jobs in nursing colleges as
they get position of assistant professors
which is of a much better social status as
compared to nurse.
It is about time that various
stakeholders seat together and decide
on a standardization, when it comes to
salary for nurses. There have been some
efforts in the last two years where FICCI
along with other stakeholders came
up with an advisory panel to reforms
nursing condition in India.We have
worked for the last two years and have
come up with a white paper for reforms
including compensation, growth,
speciality vacancies and many more.
Future of Nursing Industry Over The
Next Decade:
Since healthcare is growing,demand
for nursing as a profession is bound
to grow. However, students choosing
nursing as profession are dropping
drastically. Younger generation is not
30-40 per cent seats during enrolment
are left vacant. Hence, India is going to
struggle with availability of nurses, unless
the working condition, compensation
and social status of nursing professionals
are elevated. This calls for animmediate
change in the social framework at par
with international standards.
Strong political commitment is
required for improving the nursing
situation in India. Goodworking
conditions must be provided so that
nursing workforce can be developed
and deployed in the health services
fulfilling the recommended staffing
norms. Nurses should be considered
as active members of the health team,
in terms of not only providing services,
but also as a part of the decision-making
processes, so that it is possible for her
to participate in providing holistic and
comprehensive healthcare to the patient.
The nursing education programme
in India should be strengthened. The
Indian Nursing Council should be
vested with requisite powers, so that
it can work with in tandem with the
Author BIO
State Nursing Councils for the purpose
of regulating and maintaining standard
in nursing education and training.
The government should take initiatives
to create and empower leaders from
the nursing fraternity itself. Moreover,
there should be efforts to provide
adequate infrastructure, remuneration
and working conditions to the
nurses. Efforts should be made by the
government to retain qualified nursing
personnel in the country. Reducing
movement of nursing personnel
outside the country must form one of
the priority areas of the government.
The nurses choose migration as
a realistic option arising out the
circumstances existing in the country.
Adequate incentives, both financial
and otherwise, need to be provided in
order to retain health staff. Addressing
the issues and problems faced by the
nursing fraternity will help not only to
in reducing migration of nurses from
the country but also to some extent
it will help in reducing the nursing
shortages faced in the country.

motivated enough to take up nursing. Col. Binu Sharma is also a certified NABH assessor and the
General Secretary Infusion Nursing Society-India - an international
They rather choose a career path affiliate to INS - US. Her current role involves: Designing the nursing
with a BBA, engineering or MCA architecture and leading the team to deliver high quality nursing
degree, where life is better with good services; to facilitate nursing education and training for overall nurs-
ing management; to participate in strategic planning, budgeting,
salary to start with and a respectable resource allocation, planning & opening new hospitals.
social status. Today, as much as

10 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017

A market intelligence leader delivering
research and consultancy for the Global
Healthcare Industry
HEALT HCARE MANAGEMENT
National Health Policy
A welcome move in the healthcare industry
The revision in the national health policy is
a landmark event as this has been revised
in India after 14 years. The policy highlights
the increased spend in healthcare which will
go up to 2.5 per cent of GDP, hopefully in the
next 5 to 10 years. The policy also recognises
that there are certain types of cancers which
can be addressed early through screenings.
Suresh Ramu, CEO, Cytecare Hospitals
12 A si a n H o s p i t a l & H ea lt hcar e M an age me n t
A
health policy is a structured framework
of a set of decisions and plan of action
undertaken to achieve specific healthcare
goals within the society. These health policies
help the government to implement and monitor
various health services across the country to
ensure basic health benefits reach citizens across
all demographic and economic class. While
there are smaller health policies initiated on a
need based approach, there is a master nation
health policy in place which is essential in
defining a country's vision, priorities, budgetary
decisions and course of action for improving and
maintaining the health of its people. Most countries
have been using the development of national health
ISSUe - 37 2017

policies, strategies, and plans for decades
to give direction and coherence to their
efforts to improve health.
Such a master health plan is
paramount in India, especially due
to the fragmented socio-economic
structure and lack of education &
awareness among the large pool of the
population in the rural and small towns.
While technology and infrastructure is
slowly connecting these remote regions
to development and better standards of
living, having easy access to affordable
and quality healthcare services is still an
arduous task.
The National Health Policy was
endorsed by the Parliament of India in
1983, updated in 2002 and recently it
was largely amended in March this year,
with the focus to provide healthcare to
all, in light of the emerging challenges
arising from the ever-changing socio-
economic and epidemiological situation
in the country. The amendment in the
national health policy is a landmark
event as it has been revised after 14
years and the key goals of the policy are
expanding access to medical facilities,
providing affordable treatment to the
masses and improving the quality of
medical services. With these three
main objectives, this policy system
encapsulates preventative methods
without bounding anyone by financial
shortcomings. This shows that our
country is focused on creatinga
healthierIndia, as the PMO echoed
the same sentiment by stating that the
National Health policy marks a historic
moment in their endeavour to create a
healthy India where everyone has access
to quality healthcare.
The policy highlights the increasein
expenditure in the healthcare sector
which is expected to go up by 2.5 per
cent of GDP in the next 5 to 10 years.
The vision of the policy is to bring
about a positive and noticeable social,
economic and technological change to
strengthen India’s healthcare system.
It involves reorientation of public
hospitals where there is a cost recovery
According to the World
Health Organization, an
Indian today has over
twice the odds of dying
of a non-communicable
disease than a
communicable
disease.
approach, access to free drugs and
emergency services for people from all
strata of the society.
The NHP passed this year is
standing boldly on four pillars – clarity
in objective, clarity in design, clarity in
financing and clarity in incentives. The
policy also puts light on investment
and action in school health-by
incorporating health education as
part of the curriculum. Broadly the
policy envisages providing assured
comprehensive primary healthcare and
indicates important change for major
NCDs [non-communicable diseases],
mental health, geriatric healthcare,
palliative care and rehabilitative
care services. In addition, the policy
will look at offering free drugs, free
diagnostics and free emergency and
essential healthcare services in all public
hospitals in a bid to provide access
and financial protection. It also looks
at a three-dimensional integration of
AYUSH systems encompassing cross
referrals, co-location and integrative
practices across systems of medicines
and also will develop their grievance
redressal mechanism.
The ‘giving back to society’
initiative in the new Health Policy
extends a helping hand by providing
voluntary service in rural and under-
HEALT HCARE MANAGEMENT
served areas supported by recognised
healthcare professionals. It believes in
extensive deployment of digital tools for
improving the efficiency and outcome
of the healthcare system and proposes
establishment of National Digital
Health Authority (NDHA) to regulate,
develop and deploy digital health across
the country.
The Key Principles of This Policy
are:
• Professionalism, Integrity and Ethics
that are to be to be maintained in the
entire system of healthcare delivery
in the country, supported by a
credible, transparent and responsible
regulatory environment
• Equity: It would mean curtailing
inequality on account of gender,
poverty, caste, disability, other forms
of social exclusion and geographical
barriers. Pooling financial resources
for the poor will also come under
this
• Affordability: Access to free drugs
and emergency health services,
making medical equipment cheap is
also one of the key principles
• Universality: This includes stoppage
of exclusions on social, economic or
on grounds of current health status
• Patient Centered & Quality of
Care: Giving dignity and maintaining
confidentiality on certain issues like
gender sensitive, effective, safe, and
convenient healthcare services is
priority this time
• Accountability: Transparent decision
building and making healthcare
systems both in public and private
sectors corruption free is one most
important reason of revision of the
policy
• Inclusive Partnerships: A multi-
stakeholder approach with
partnership & participation of
all non-health ministries and
communities. This approach would
include partnerships with academic
institutions, not for profit agencies,
and healthcare industry as well
www.asianhhm.com 13
HEALT HCARE MANAGEMENT

• Pluralism: AYUSH care providers are

small extensions of the Government
where patients get themselves treated
for speedy process encouraging home
and community based practices and
thus meeting the national health goals
and objectives through integrative
practices
• Decentralisation: With practical
considerations and institutional
capacity decentralisation of decision
making to a level is a prudent
principle of the policy.
• Dynamism and Adaptiveness:
Based on new knowledge that is from
national and international knowledge
partners there is a constant need of
improving dynamic organisation of
healthcare system in India.
Clearly different from the previous
two policies; this time it is the detailed
elaboration of areas in which private
sector services will be contracted for
training, skill development, community
training for mental health, disaster
management, purchase of services
to fill gaps and preferentially for
Central Government Health Scheme
members, and primary healthcare
in urban areas. Partnership with the
private sector for infectious disease
control, immunization services, disease
surveillance and health information
and manufacture of medical devices
is taken in consideration. The policy
also pursues to take steps to improve,
upgrade and incentivize the quality
of services being provided by the
private sector in rural and remote areas
and among underserved populations
along with facilitating of diagnostic
laboratory support.
Our health system is burdened by
emerging and re-emerging diseases
like drug-resistant TB, malaria,
SARS, avian flu and the current
H1N1 pandemic. The actions taken
to protect public health of India had
witnessed many hurdles in its attempt
to improve the standard of living of
its people. Since independence major
public health problems like malaria
have been curtailed through the health
policy chalked by the government. For
the first time the policy emphasised on
, specific targets like the elimination
of certain diseases like kala-azarby
the end of this year, leprosy by next
year and lastly the most important or
rather the most challenging target of
eliminating Tuberculosis by 2025. The
policy also aims to reduce the fertility
rate to 2.1 by 2025. There is a focused
approach on AIDS awareness also and
the NHP plans to attain ’90:90:90’
global target by 2020. This means that
90 per cent of all people living with
HIV are aware of their HIV status,
90 per cent of people infected with
HIV receive sustained antiretroviral
therapy and about 90 per cent of those
receiving the therapy will have viral
suppression.
The policy also emphasizes on
early detection through screening for
certain types of cancers. To accelerate
this process ASHA workers across the
country are trained for oral, breast
and cervical cancer treatment. This is
a great initiative as it will help early
detection and reduce mortality rate
even in the lower strata of the society.
The National Health Policy has a target
to reduce premature mortality from
cardiovascular diseases, cancer, diabetes
or chronic respiratory diseases by
25 per cent and increases life
expectancy at birth from 67.5 to 70 by
2025. Another major preposition in
national health policy was to manage
costs for generic drugs and medical
devices in government hospitals, as a lot
of patients currently prefer treatment
from private institutions.
The policy also plans to reduce
the prevalence of blindness by 2025
to 0.25 per 1000 persons. To provide
a health card to every family, so that
they have access to primary care facility
as well as access to a well-defined
package of services nationwide is
also one of the aims on the NHP.
This policy seeks to reduce neonatal
mortality rate as well as stillbirth
rate by improving home based
facilities for sick newborns. Also an effort
will be aimed towards pre-emptive care,
so as to attain the most favorable levels
of adolescent health. The policy is of the
view that if they strengthen the existing
medical colleges and if converted to
new medical colleges it could increase
the number of specialists and doctors
in regions where there are a deficit

14 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017

 HEALT HCARE MANAGEMENT

doctors and other medical personnel. high, government’s focus onincreasing voluntary donations is important
Rural areas are the ones that spend on non-communicable diseases particularly for cancer victims and
bear the brunt, hence the policy will help to reach out to a larger scale other NCDs as it entails huge money.
aims at starting with medical of patients. After heart and lung disease, cancer
colleges in rural areas, mandatory We need to give a push to is the third largest cause of death
rural postings etc. A continuous effort innovative technology development, in the country. However the policy
will be made so that the public health clinical trials and medical care in India needs to have a separate section to
systems do not collapse and are able itself. This will not only ensure timely address the issues in cancer care. The
to retain the manpower. An outline care along with western countries but new policy needs to be executed so as
of positive aspects and issues of the also reduction in cost. to achieve a milestone especially
policy has been noted below. Along with all of this, we also need in India where deaths per day is in
Some Positive Aspects of the NHP to ensure that the cost of diagnostics thousands due to cancer and the
• The policy along private sector and medical equipment is controlled. majority of the population is under
partners looks at problems and solutions A widespread public awareness of the poverty line.
at a universal level
• From the point of view of the
less privileged population, the policy
proposes to provide free medical aid
right from free drugs to emergency Author BIO
healthcare services so forth and so on at
public hospitals
• Aims at providing 2 beds per 1,000
populations. This will enable victims to
get a bed within the first hour of injury,
because that is the time which is most
crucial for the victim and is most likely
to benefit from treatment
• The policy seeks to provide easily
accessible and affordable secondary and
tertiary care medical services.
Some Issues of the NHP
• To make National Health Policy
function flawlessly, the Centre has to
get robust and updated health data
• To reduce high out-of-pocket
spending, early deadlines should be
set for public institutions essential
medicines and diagnostic tests free to
everyone
• The policy mentions an increase in Suresh Ramu is also a Co-founder & Director of Cytespace Research and
health expenditure from 1.5 per cent Co-founder of Medwell Ventures. Prior to establishing Cytespace in 2011,
Mr Ramu spent 10+ years with Quintiles Transnational. As Vice President and
to 2.5 per cent by 2025, which entailsa Head – India, for Clinical Development Services, he managed all aspects of
span of another 8 long years. clinical trials conduct in the country. Holding diverse senior leadership positions,
As a cancer care hospital, the policies he was instrumental in creating two valuable assets for the organisation – the
world’s largest multi-shift data management operations to process clinical trial
introduced for Non-communicable data, and Asia’s largest cardiac safety lab. In his consulting role, Mr Ramu
Diseases (NCDs) are of prime advised on process improvement, cost management and customer relations at
importance to us. According to the PricewaterhouseCoopers. He was also an early team member at a telemedicine
start-up in India. Mr Ramu has a Bachelor’s degree in Engineering from the Indian
World Health Organization, an Indian Institute of Technology in Madras, and a Master’s in Business Administration
today has over twice the odds of dying of from the Indian Institute of Management – Calcutta. He is a member of
a NCDs than a communicable disease. the American Society of Clinical Oncology and has presented at various
professional conferences in India and abroad.
As the cost involved in care and medical
equipment of treating NCDs is extremely

www.asianhhm.com 15
HEALT HCARE MANAGEMENT
Cover Story

Healthcare
Business Models
in Southeast Asia
Evolution is vital
Healthcare facilities in Southeast Asia are facing a triple
threat of more insurance claims, a slowdown in medical
tourism and increased competition. A uniform slide in
third-quarter earnings of major facilities providers last
year was the clearest indicator yet, that they must initiate
business model transformation. YoshihiroSuwa, who leads
Roland Berger's healthcare consulting practice, explores
innovative business models that can be profitably adopted.
Yoshihiro Suwa, Partner, Roland Berger

D
espite an increasing demand
for higher quality healthcare,
fuelled by an expanding
middle class, the private healthcare
industry has lost some of its lustre.
Hospitals in general, are seeing a triple
threat of general decline of medical
tourism, reduced margins and an
increasingly competitive environment.
While external demand looks promising
in the long-term, recent financial results
of major private care and hospital
groups exhibit symptoms that show not
all is well.

16 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017


An analysis of the financial
statements of major private care and
hospital groups in Asia showed a
uniform slide in their third quarter
earnings of 2016. IHH Healthcare
did achieve 18 per cent year-on-year
increase in sales RM 2.4 billion in the
third quarter of 2016 and EBITDA
grew 15 per cent RM155 million
YoY. Even though sales and EBITDA
achieved double-digit growth, the
sales volume to EBITDA rate fell
slightly from 23.1 per cent to 22.4
per cent in the same period in
2015. The group’s biggest earner, its
Singapore market, grew less than
double digit for the first time, at
8 per cent increase in sales and a
15 per cent growth in EBITDA, when
compared to the same period in 2015.
A statement by the group's
spokesperson acknowledged that one
of the main reasons for slowed revenue
growth was fewer medical tourists,
who typically spend more than local
patients.
This is not the only difficulty on
record. Increasing use of healthcare
insurance as a payment scheme has also
dogged healthcare facilities providers.
KPJ Healthcare–a major healthcare
facilities provider in Malaysia–
contracted 1.86 million outpatients
(-0.9 per cent YoY) till the third quarter
in 2016, and 210,000 inpatients (+0.8
per cent YoY). While KPJ sees stable
visits from patients with insurance,
which pays 70 per cent of the hospital's
earnings, patients paying out of pocket
HEALT HCARE MANAGEMENT
have declined, putting a squeeze on
margins. According to the hospital,
the trend will remain until 2018.
Indonesia’s Siloam Hospitals
opened three new facilities in 2016:
Siloam Hospitals Labuan Bajo,
Siloam Hospitals Buton and Siloam
Hospitals Samarinda. Labuan Bajo is
located in the port city Flores Island
with a population of 100,000, Buton
is located in Southeast Sulawesi
with a population of 300,000 while
Samarinda is the capital city of East
Kalimantan with a population of
800,000. There are also plans to
open more hospitals in 2017 in major
cities and rural areas in Indonesia.
While it could target only major
cities to make the operations
commercially viable, competition
is stiff, not just from a marketing
perspective. Adding to the group's
headaches is that fact that it cannot
operate its rural hospitals the same
way it manages its urban locations.
This is because the population size
and economic scale in smaller cities are
a fraction of the capital city Jakarta.
To add to its difficulties, the cost
of personnel may be lower on average
in smaller cities, but that is not the
case for doctors. At the early stages of
the establishment of a hospital, it is
essential for a reputable skilful doctor–
who can be difficult to recruit–to
be at the forefront of the hospital’s
brand to attract more patients.
The Siloam group classifies its port-
folio of 23 hospitals into four catego-
www.asianhhm.com 17
HEALT HCARE MANAGEMENT

ries based on opening dates and loca-

tion: Mature, Developed, Distinct
and New. 40 per cent of patients
come from five of the oldest hospitals
classified as ‘Mature’, which saw a
6 per cent increase in the number of
outpatients and 3 per cent increase
in the number of inpatients in the
third quarter of 2016, the lowest
growth recorded. This, and other
factors mentioned above, underscores
our third point, that increased competi-
tion has reduced margins and volumes of
many private care groups in the region.
Despite these stumbles, it would
be wrong to conclude that invest-
ing in the private healthcare industry
could be unviable in the long-term.
The national medical expenses for the
six major Southeast Asian countries
(Indonesia, Malaysia, the Philippines,
Thailand, Singapore and Vietnam)
amounted to US$105 billion in 2014
and Roland Berger expects it to reach Expand Local Capacity and Quality in specific branches of medicine. This
US$240 billion by 2020. The aver- Some healthcare players have opted is strategically sound not only
age annual growth rate during this to expand locally and grow their from a services perspective
period is 14.7 per cent and the region is patient base to capture the growing to attract discerning medical tourists,
still an attractive market that will middle class locally. BDMS–Thailand's but also helps with margins. Since
continue to achieve double-digit largest healthcare player–has done better technologies will enable
growth. Historical trends indicate that exactly this. The group’s share of shorter patient stays by helping
governments will continue to shift the hospital beds in Thailand’s domestic them recover faster or recover
healthcare financing burden to the private hospital market has reached at home, more patients
private insurers or to individuals. 16 per cent in 2014. By region, can be accommodated or the
What is evident is that these factors BSMS’s presence has increased same number of beds.
show the industry may have reached across different regions in the country: To further diversify its business,
a critical turning point in 2016 and it 18 per cent in Bangkok, 17 per cent BDMS has begun transitioning
could be the start of a future that has in central Thailand, 24 per cent in its non-hospital services–originally
no more double digit growth. Some Southern Thailand, 12 per cent in intended as internally shared services
players may have even experienced Northeast Thailand and 5 per cent in amongst all business group –to generate
more than one factor, deepening the Northern Thailand. income. For instance, National Health
case for them to consider adopting While there were plans to establish Systems, the laboratory services arm
fresh business models that may presence in the Middle East, BDMS of BDMS, now offers its laboratory
augment future operations. ultimately decided that replicating services to customers outside the
the same service levels and quality BDMS group.
Evolution of Business Models would be commercially unviable, and The conversion of non-hospital
While new business models are opted to expand capacity locally and business to a revenue generating one
replacing existing ones, new players woo medical tourists from that region. also reduces BDMS' dependence on
are also injecting fresh thinking to gain To improve on quality and its general hospital business. Its decision
an edge. Our analysis identified three excellence, the group partnered with not to expand the general hospital
new business models that may help leading global medical institutions presence abroad means that it must
private healthcare players to operate on their area of specialisation, to reduce the dependence on general
in the future. gain insights on latest innovations hospital revenues, since it did not

18 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017


diversify the business geographically.
With the expansion of the network
into different types of medical
facilities, it can further farm revenues
from within the network.
Focus on Cost Management
Medical expenses will continue to rise
for the foreseeable future and is a
concern for many people and employ-
ers, where the latter often offers medical
insurance as part of local employment
packages to attract staff. To manage
these costs, some medical providers
are now offering Medical Billing
Management Services (MBMS) to
employers to lift some burdens off
employers' shoulders. Fullerton Health
–headquartered in Singapore– is doing
just that.
The group has operations in
four markets in Southeast Asia, and
Australia. It focuses on primary care
and has hospitals and clinics. The latter
provides checkups and outpatient
care for fees lower than general
hospitals.
MBMS provides claims
management for corporate clients. In
all the markets they operate, MBMS
provides cashless services at facilities;
medical examinations financed by
insurance claims and payments;
and consultation to control medical
expenses for its corporate clients
at all of its facilities. This not only
saves time and helps identify
where wastage occurs, but also
prevents medical claims fraud and
overcharging.
Patient Insurance that Supports
Preventative Care
Some private care groups are
expanding their business model
to integrate insurance, providing
a one-stop solution for customers.
One group in particular, Spain’s
Sanitas International, has created a
prepaid form of health insurance to
complement its vast network, which
comprises clinics, medical centres,
laboratories, ophthalmology and
dentistry facilities, and pharmacies.
The national medical
expenses for the six major
Southeast Asian countries
(Indonesia, Malaysia,
the Philippines, Thailand,
Singapore and Vietnam)
amounted to US$105 billion
in 2014 and Roland Berger
expects it to reach
US$240 billion by 2020.
The business model of Sanitas
is simple. After receiving a regular
fee from subscribers, the group will
manage their health and hopefully
profit. The healthier the subscribers,
the more profitable it is for Sanitas.
The emphasis is placed on health
management and disease prevention
of the subscribers. Subscribers can
view information ranging from
their medical information to the
management of medical fees online,
which encourages subscribers to
be highly aware about their health.
They are also encouraged to go for
regular checkups to prevent hereditary
diseases such as cancer from reaching
dangerous stages.
On the other hand, if the
subscribers are sick, they are able to
receive some discount on the medical
fees if they were to receive treatment
at the group’s clinics and testing
centres. This business model eliminates
the possible conflicts of interest
between hospitals and insurers by
Author BIO
Yoshihiro Suwa is Partner at the Jakarta office. He has worked
with Ronald Berger in the firm’s Japan office for most of his career,
joining the firm after graduation. Mr Suwa also spent time working
on new products in Novartis in Japan.
HEALT HCARE MANAGEMENT
matching the interests within the
network, so that subscribers can remain
satisfied and healthy while Sanitas
(and its network) profits. The result is
a highly efficient healthcare network
and community.
Survival of the Fittest
With economies in the region
maturing, business models for
private medical players must continue
to evolve to remain relevant, even if
the outlook is generally optimistic.
As our analysis of the private
healthcare providers in the second
half of 2016 showed, the industry is
not immune to shocks and must learn
the warning signs early and heed
their own advice, which is to take
preventative steps to maintain
and improve their own business
health.
While private care providers
primarily targeted high net worth
individuals in the past, many providers
are now seeking new addressable
growth areas and can apply new
business models that have emerged in
other regions.
Private healthcare providers must
be reminded that despite strong
demand for high quality healthcare
and rising incomes in the region, there
will always be a possibility of black swan
events. This may include overnight
introduction of a strict regulation,
or a blockbuster drug or technology
introduced which can cause an upset in
the market.
As the famous saying by Charles
Darwin goes, "It is not the strongest
or the most intelligent who will
survive, but those who can best manage
change."
www.asianhhm.com 19
HEALT HCARE MANAGEMENT

Becoming World Class,

with Class
C
Conventional wisdom and thousands of business books onventional wisdom
spend an endless amount of time talking about the keys and thousands of
business books spend
to outgrowing, out profiting and out maneuvering your
an endless amount of time
competition. Many will use this ‘wisdom’ to attempt to crush talking about the keys to
those in their path resulting in occasional , usually short term, out-growing, out-profiting,
success. But there is another way. There is another way to be and out-maneuvering your
successful not just for the short-term but for the long-term. Not competition. Many will use
this ‘wisdom’ to attempt to
just successful for you personally or even your organisation
crush those in their path,
but bring along your staff, your community and your region. resulting in occasional, usually
Organisations and leaders focused on values-based, not short-term, success. But there
ego-based leadership can attract rising stars, find amazing is another way. There is
partners and build momentum to last well into the future. another way to be successful—
not only for the short-term
Jeffrey E Thompson, Pediatric Intensivist and Neonatologist, Gundersen Health System but for the long-term. And

20 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017


not just for you personally, or even
just for your organisation—instead,
the kind of successful that brings
along your staff, your community,
and your region. Organisations and
leaders focused on values-based, not
ego-based, leadership can attract
rising stars, find amazing partners,
and build momentum to last well
into the future.
Our approach was developed in the
midst of enormous competition. The
Mayo Clinic, maybe the best known
healthcare brand in the world, was our
closest adversary. It is nearly 10 times
Figure 1
HEALT HCARE MANAGEMENT
our size and was originally just over
100 km away. We thought that was
a problem until they moved a major
branch less than 10 blocks away. In
addition, large insurance giants like
United Healthcare, a hundred times
our size, looked to expand in our
region and impart their version of
healthcare. In addition, if we were to
recruit the brightest and the best, we
had to recruit from across the country
to a small market area without the
glitter and excitement of a big city or
medical school. These were a pressing
collection of challenges.
www.asianhhm.com 21
HEALT HCARE MANAGEMENT
The key to succeeding for the long
term was not complicated, it was just
hard.
We made a decision to compete
not for size and profit but for the
long-term health and wellbeing of
the community. We believed we
could deliver ever-increasing quality
of care and have strong finances and
improve the health and wellbeing of
the community. The key word is ‘and’.
Not this goal or that goal, but all of
them. In addition, we were sure we
would find partners from across the
region that would help us deliver on
that promise.
To build an organisation that
serves the whole community, we had
to start with a strategic plan
that declared the purpose of the
organisation to be something more
than just taking care of sick people.
We decided that our purpose would
be to improve the health and
well-being of our patients and our
communities. We would focus all our
efforts on that solitary purpose. We
put the entire plan for this billion-
dollar organisation responsible for
hundreds of thousands of lives on
a single sheet of paper (Figure 1).
This outwardly focused purpose is
the first thing people read when they
are recruited into our organisation
and connects to how they will be
evaluated. It helps build a focus on
others. Our mission focuses
on distinguishing through
excellence. We are not going
to be satisfied with beating our
mediocre peers or our own mediocre
past. And we certainly are not going
to just be focused on crushing the
competition or just getting bigger;
rather, we are going to deliver on our
responsibilities to those who trust us.
Our vision proclaims the extent to
which we will go to deliver on our
promise to improve the health of our
communities. We aim to deliver on
our promise so well that we will be
nationally recognised. Finally, our
22 A si a n H o s p i t a l & H ea lt hcar e M an age me n t
Greatness is not a
function of circumstance.
Greatness, it turns out,
is largely a matter of
conscious choice and
discipline.
JIM COLLINS
commitment is to never rest on our
laurels, to always strive to be better
today than yesterday. Greatness is not
an accident, it is intentional. You have
to aim for it and drive for it.
It seems obvious, but
implementation of the values
statement is critical if you're going
to accomplish these lofty goals. Too
many organisations have clear values
on their Web site or on the wall of their
building, but do not have the courage
or discipline to live those values.
It is a package. The purpose tells
us why we exist, the mission tells us
where we are going, the vision convey
show far we will go, the commitment
asserts our relentless drive to do better,
and the values tell us how we will
behave on the journey.
Present this package to the brightest
and the best when they interview
with you, and you have a good start
at building an extraordinary team.
Use daily as the basis of your decision
making and priority setting, and
you have the start of a great
organisation. Living your values
becomes a strategic advantage. Then
reinforce the message at orientation,
during staff training, and at
performance evaluations. This plan
ISSUe - 37 2017
gives staff a clear path forward for
day-to-day work, as well as the
freedom to innovate.
The strategic plan applies to every
person, and everyone knows it applies
to every person. No exceptions. We all
have the same purpose, work toward
the same mission, intend to accomplish
the same vision, and are committed to
continuous improvement. And most
importantly we're going to do it with
the same values. We all know how we
will behave, how we will be treated, and
how we will prioritise our decisions.
We purposely built this type of
culture to be able to implement the
next part of the strategic plan. These
strategies needed an outwardly focused,
values-driven staff to compete. Our
focus on superior quality and safety
intentionally includes “through the
eyes of patients and caregivers”. Our
mission and vision require that we
achieve national-level excellence—
that we measure up to the best data
available. But that means nothing if
our patients and their families do not
believe that they receive the best possible
care. Likewise, our goal for patient
experience is to genuinely understand
what patients and their families need,
not just what we think they need.
Our third strategy is to make our
organisation a great place to work—
a great place, but not an easy place. We
expect very high performance in an
environment that has clear expectations
for behaviour—where all must embrace
a passion for caring and a spirit of
improvement. Many would consider
this a very hard place to work. It's
a hard place because the purpose is
outwardly focused, not on ourselves
or monetary goals. The mission is to
be excellent, not just to survive but to
be excellent in multiple categories—
to be so good that we can be nationally
competitive. Finally, we have adopted
a set of values that we will not
compromise. If you want to play outside
the values, it means that you will be
playing outside the organisation.

Figure 2
Our financial strategy is not to
make a set amount of money. Our
plan is to make care more affordable
for patients, employers, and our
communities. Again, this strategy
has a values-based, outward focus. We
look at finances and facilities as tools.
Important tools, valuable tools, but
just tools—never the prime goal. Our
staff is well compensated, and savings,
facilities and technology all are well
funded, but never to the detriment of
serving the broader mission.
The final major strategy is growth.
We included growth as a strategy
not to dominate the world or crush
the competition. Rather, growth is
beneficial when it supports our mission
and other strategies, never growth for
growth’s sake.
The plan is simple, but hard. The
culture is crucial. One of the key tools
to build a culture to serve this plan was
the medical staff compact (Figure 2). We
made it clear that the organisation would
meet its responsibilities, that it was
committed to providing an environment
that would achieve excellence through
recruiting great colleagues and by
providing clear communication, strong
HEALT HCARE MANAGEMENT
education programmes, competitive
compensation, and thoughtful change
management. Just as the organisation
has responsibilities, individuals have
responsibilities on their side of the
agreement. All medical staff are to
lead quality and service, demonstrate
integrity at the highest levels, treat all
people with respect, and understand
that things will steadily change in their
job. Part of the work is to help make
that change for you and your staff.
We started using the compact with
medical staff, but eventually the
approach included all leadership and all
staff positions.
This simple but consistent approach
was a critical part of moving our
strategic plan forward and developing
a culture that would serve a higher
purpose. Another important factor in
building a culture that can compete
at a high level is understanding the
big difference between a leaders’ lines
of responsibility on an organisational
chart and their actual breadth of
influence. Outstanding leadership and
strong, responsible behaviour can cast a
bright light across a broad swath of the
organisation—far beyond the leader’s
immediate peers or staff. Likewise, bad
behaviour can cast a shadow across an
equally broad swath and result in poor
outcomes, worse service, remarkably
less efficient work, and attrition of
valuable next-generation stars and
leaders.
The more influence your leaders
have, the more important it is for them
to be people builders, not just rules
police. They need to understand that
their job is to serve, not just manage.
They need to be shown how to get close
enough to the work so they understand
the complexity of the challenges that
staff face and the moral imperative of
strong outcomes being delivered in a
supportive culture. This is so important
that we expected leaders to set aside
time early in the day, every day (e.g.,
8-9am), to physically walk to their areas
of responsibility to talk with the staff, to
www.asianhhm.com 23
HEALT HCARE MANAGEMENT

the staff. Assuming that mid- or even

Potential
upper-level leaders are all on board is
a mistake. Make expectations, lines of
High Low communication, and performance as
transparent as possible. This will build
a culture and an ever-increasing level
High of performance from all staff.
Maureen Bisognano from IHI said
Performance

“You cannot give what you do not

DC
Low
Figure 3
make sure they have the right tools and
adequate staffing, and to get a better
understanding of the work.
As we evaluate our leaders, we must
understand the difference between
doing things and accomplishing
something of substance. If all we, as
leaders, do is hold our staff accountable,
to follow rules or checkboxes, the most
talented staff become disillusioned,
disengaged, and will not help you build
forward. Holding staff accountable
is always looking backward; being
responsible for the success of your
staff is looking forward. To deliver on
excellence, young leaders will need to
find a balance between the two. This
is consistent with our theme that
leadership is a responsibility to serve,
not a license to rule.
To build leaders, you need to be
intentional and disciplined. A key tool
we learned from General Electric was
they were responsible, to talk about
how they viewed them, and to discuss
their plans for development. It was also
an opportunity to get feedback from
other senior leaders about how they
saw the young leaders’ performance
and potential from a different point of
interaction. The nine-box sessions had
two important values. First, leaders
gained clearer and broader views of
their staff, and second, it set a tone
of everyone being responsible for the
growth and development of every
young leader in the organisation.
You have to be completely clear
about what you expect from leaders
and give them the tools to deliver it to
Jeffrey E Thompson, MD, is executive advisor and chief execu-
tive officer emeritus at Gundersen Health System. Dr. Thompson
Author BIO
have. If the staff do not feel cared for they
can't care, to embrace you have to been
embraced, to respect you have to been
respected. Do not be stunned by your staff’s
lack of care, connection or respect if they
have not through their eyes been cared for,
connected with and respected.”
I would argue that this applies not
only to the frontline staff but across
all levels in your organisation.
To compete against the best, you
have to aim to be the best. That starts
with developing the best environment
for your staff. To attract and retain
the best young leaders, you have to
know and be clear about why you're
here (the purpose) where you're
going (the mission, vision, and
commitment) and what values will
guide the culture in which they will
be immersed. It takes courage to set
bold goals and clear standards for all.
It takes discipline to follow through
on both systems and people building.
And it takes durability to stay with
your plan despite constant pressure
to compromise your values in the
interest of short-term gains.
The path is not complicated, it is
just very hard.

the nine-box matrix (Figure 3). is a trained pediatric intensivist and neonatologist, and served as
Our senior-most leadership group Gundersen’s chief executive officer from 2001 to 2015. After com-
pleting his professional training in 1984, Dr. Thompson came to
would gather, and each would score Gundersen with a desire to care for patients and to teach. He was
the performance and potential of asked to serve on Gundersen’s boards beginning in 1992 and was
all their managers, supervisors, and chairman of the board from 2001 to 2014.
Author “Lead True, Live your values, Build your people, Inspire your
directors. It was a chance for each to community”
present the young leaders for whom

24 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017

 1st edition

Conference & Exhibition

October 30-31, 2017

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HEALT HCARE MANAGEMENT

ACO meets Triple Aim

and save $millions
Accountable Care Organizations (ACOs) are the new
path for healthcare reform in the USA. Medicare’s Shared
Saving Program (MSSP) promotes it. The MSSP’s 33quality
performance measures and emphasis on care coordination
meet the Triple Aim goals. Medicare shares the savings with
the ACO if compliance with the quality measures is high.
Peter A Gross, Chair, Board of Managers, HackensackAlliance ACO

T
he Triple Aim as described
by Berwick states that the
health of populations should
be improved and at the same time the
costs of the healthcare system should be
reduced(1). What is new in the Triple
Aim is an emphasis on the experience
of the patient in the healthcare system.
These three aims can take place
without incurring additional costs.
In fact, the expectation is that these
improvement should occur with an
overall reduction in costs. The Triple
Aim was a stimulus for developing
the concept of the Accountable Care
Organization in the George W Bush
administration and adopted by the
Obama Administration.

Accountable Care Organization

The definition of an Accountable Care
Organization (ACO) is as follows:
“Accountable Care Organizations
are groups of doctors, hospitals,
and other healthcare providers, who
come together voluntarily to give

26 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017


coordinated high quality care
to their Medicare patients. The
goal of coordinated care is to
ensure that patients, especially
the chronically ill, get the right care
at the right time, while avoiding
unnecessary duplication of services
and preventing medical errors. When
an ACO succeeds both in delivering
high-quality care and spending
healthcare dollars more wisely,
it will share in the savings it achieves
for the Medicare program (2).”
Because of the sharing of savings, the
program is called the Medicare Shared
Savings Program (MSSP).
Quality Performance Measures
The issue that distinguishes the
ACO movement from most past
cost containment efforts is the
requirement to comply with a list of
33 quality performance measures.
Because of this new emphasis, I will
take up some space to show what this
noble effort consists of. The Centers
for Medicare and Medicaid Serv-
ices (CMS) put together the quality
measures. They are divided into four
domains
1.Patient /Care giver experience
domain
a. Get timely care
b. How well does your physician
communicate
c. Patient’s rating of doctor
d. Access to specialist
e. Health promotion and education
f. Shared decision making
g. Health status and functional status
2. Care Coordination / Patient Safety
Domain
a. All-conditions readmission risk
standardised
b. Ambulatory care sensitive
conditions
i. COPD or asthma admission in b. Hypertension
older adults
ii. Heart failure admissions
c. Percent of primary care physicians
who qualified for the electronic
health record incentive
• Improved the health of
populations
• Reduced costs of the
healthcare system
• An emphasis on the
experience of the
patient.
d. Medication reconciliation
performed
e. Screened for falls risk
3. Preventive Health Domain
a. Influenza immunisation
b. Pneumococcal immunisation
c. Adult weight screening and
follow-up
d. Assessment of tobacco use and
cessation information given
e. Screened for depression
f. Screened for colorectal cancer
g. Had mammography screening
h. Proportion of adults screened for
high blood pressure in the past
two years
4. At Risk Population Domain
a. Diabetes
i. Haemoglobin A1C <8 per cent
ii. LDL cholesterol <100 mg/dl
iii. Systolic blood pressure <14 mm
Hg
iv. Tobacco non-use
v. Aspirin use
vi. Percent of patients with diabetes
whose Haemoglobin A1C is poorly
controlled, that is, >9 per cent
i. Percent of patients with hypertension
whose blood pressure is <140/90
mm Hg
c. Ischemic vascular disease (IVD)
i. Percent of patients with IVD with a
HEALT HCARE MANAGEMENT
complete lipid profile and an LDL
cholesterol <100 mg/dl
ii. Percent of patients who use aspirin
or other anti-platelet medication
d. Heart failure
i. Receive beta-blocker therapy for
left ventricular systolic dysfunction
(LVSD)
e. Coronary artery disease (CAD)
i. Percent of patient with CAD who
meet all of the following criteria:
1. Medication for lowering
LDL-Cholesterol
2. ACE inhibitor or ARB
therapy for patients with CAD
and diabetes and/or LVSD
The scoring of the quality measures
is complicated. It can be found in the
first reference by Gross et al. (3). In
general, for most quality measures,
a high score is the goal. For some
measures such as Haemoglobin
A1C greater than 9 per cent, a low
score is preferable. CMS collects the
responses to the first domain on
Patient / Care Giver Experience and
also collects most of the results for
the second domain on Care
Coordination. The physician practice
has to provide the responses for the
later measures in the second domain
on Patient Safety and responses
for measures in the third and fourth
domains.
The connection between the Triple
Aimshown in round bullet points
below and relevant examples of the
33 quality measures shown in the
check symbol points below:
• Improve experience of care
• Getting timely care,
appointments, and
information
• Shared decision making
• Improve health of population
• Prevention with mammography
and colonoscopy
• Better care of diabetes, CHF,
CAD, BP, and IVD
• Reduce per capita costs of healthcare
• Reduce admissions,
readmissions
www.asianhhm.com 27
HEALT HCARE MANAGEMENT

Category
Component Expenditures/Patient
Short -term admissions
Emergency Room visits (#)
30 day All-Cause readmits/
1000 discharges (#)
Ambulance cost/patient
Amb. Care Sens. Cond. Discharge Rate/1000*
Chronic obstructive pulmonary
disease
Congestive heart failure
Bacterial pneumonia
Table 1
Decreasing Expenditures/Utilisation
Next we will address how savings
are achieved by first going after the
‘low-hanging fruit’ such as hospital
admissions, readmissions, and
emergency room visits.
The total amount spent on admis-
sions, readmissions, and emergency
room visitsare the largest expenses
and these were addressed first.
As shown above, these costs were
decreased each year as exempli-
fied for the year 2015 (sourced via
confidential data from the A1006
Hackensack Physician-Hospital Alli-
ance ACO, LLC, Consolidated
Aggregate Expendiure Utilization
Trend Report ACO A1006
Performance Year 2015, of the MSSP
[April 1, 2012, agreement start
date]). In addition, discharges of
Ambulatory Care Sensitive Condi-
tions (ACSC) were decreased
over time. The idea behind ACSC
is that these three diagnoses
very often can be managed as
outpatients and do not need to
be admitted to a hospital. Ambu-
1st Q. 2015 4th Q. 2015 Percent drop
$3,664 $3,148 14.08 per cent
612 556 9.15 per cent
202 167 17.33 per cent
$203 $92 54.58 per cent
10.27 8.82 14.12 per cent
13.68 9.95 27.27 per cent
8.40 6.82 18.81 per cent
*Ambulatory Care Sensitive Conditions
lance expenses, although not a large
part of our resource use, were very
high for our ACO. It turned out
that ambulance services were being
over used. Once we realised this
and CMS realised it, they enforced
the appropriate use of ambulances
and our costs per patient plummeted.
Patient-Centered Medical Home
Certification
Interestingly, these cost reductions
were achieved with an indirect
approach. Our emphasis at the
formation of our ACO was on
selecting the right physicians to belong
to the ACO. Our selection criteria
were that the physician’s office should
be certified as a Patient-Centered
Medical Homes by the National
Committee for Quality Assurance
(NCQA). A PCMH is defined
as a practice “that provides first
contact, continuous, comprehensive,
whole person care for patients
across the practice. PCMH has at
its foundation the Joint Principles
developed by the primary care
medical societies (American College
of Physicians, American Academy
of Family Physicians, American
Academy of Pediatrics, American
Osteopathic Association):
• Whole-person care;
• Personal clinician provides first
contact, continuous, comprehensive
care;
• Care is coordinated or integrated
across the healthcare system;
• Team-based care. (4)
If physicians wanted to join and
were not yet certified, we would pay for
training the physicians and their office
staff to become certified within one
year. In addition, the physicians had
to use an electronic medical records
system immediately or at least within
one year.Failure to do so meant that
the physicians could no longer remain
in our ACO. NCQA has published the
evidence that PCMHs are cost effec-
tive and improve quality (5). In March
2017, NCQA redesigned their criteria
for certification to account for recent
changes by Medicare and to simplify
the process. We will not review these
changes (i.e., the Medicare Access
and CHIP Reauthorization Act of
2015 [MACRA] and the Merit-Based
Incentive Payment System [MIPS]),
and Advanced Alternative Payment
Models) at this time.
The point of our heavy empha-
sis on PCMH certification is that
certified physicians understand the
future of healthcare and the inevita-
ble changes taking place. Given this
point of view, the physicians would
be more likely to comply with the
goals of the ACO by naturally provid-
ing more efficient care. Indeed, this is
what happened. So no instructions had
to be issued requesting that the physi-
cians decrease admissions and emer-
gency room visits. It just happened
from the inception of the ACO.
An important approach that
facilitated the decrease in resource
utilisation and costs was the fact that
the physicians saw the patients in

28 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017


their offices more frequently than in
most other ACOs. The more frequent
office visits permitted the physicians
to keep an eye on the patients with
chronic illnesses and manage the
changes as they occurred rather than
have toadmit the patient to a hospital
because these changes were neglected
in the outpatient setting. This point is
reflected in the 30-day post-discharge
provider visits per 1.000 discharges
where our office visits per patient
increased over the average for other
ACOs.
Care Coordination with ACO Nurses
Besides the PCMH certification policy,
the other important factor in our initial
creation of our ACO was the hiring of
nurse care coordinators. We started
with 3.5 for 11,000 patients and
eventually hired over 15 as the patient
population grew to over 30,000. The
purpose of the nurse coordinators
was to assist the practicing physicians
in managing their high-risk patients
and in complying with the quality
measures.
Nurses were carefully selected to be
out-of-the-box thinkers and ‘do-ers.’
They had to come with the right work
ethic and know how to deal with
people in a gentle manner. They were
not to perform clericalduties, were
not responsible for data analysis or
business development. They were to be
part of the group at practice meetings
even though the practice didn’t have
to support their salaries. They are
supposed to provide feedback to the
physicians on compliance with the
quality measures and are to take part
in value-based decisions. It took some
time to insinuate the ACO nurses
into the practice, but they eventually
became a key part of it. With the
physician leaders, the ACO nurses
wrote care coordination policies.
Achieving Cost Savings
For the first three years of the
program we were able to save
significant expenditures (3, 6).
In the first year that covered
April 2012 through December
2013, we saved US$10,747,669.
In the second year (January-December
2014), we saved US$6,464,895. In
the third year, the savings increased
dramatically to US$33,353,310.
Theoretically, we were entitled to
receive 50 per cent of the savings and
Medicare would keep the other 50
per cent. But remember that the
amount an ACO receives is dependent
on their quality score. In the first
year of the MSSP, every one received
100 per cent credit for reporting
activity with the quality measures,
so we received US$5.266.358. In
the second year, actual compliance
with the measures was required. Our
quality score was 89.43 per cent, as
a result we only received (89.43 per
cent times 50 per cent = 44.72 per
cent) or US$2.83.988. In the third
year our quality score rose to 95.70 per
cent, therefore, we received {95.70 per
cent x 50 per cent = 47.85 per cent)
or US$15,640,878. If you do the
math, the numbers are off a little
because CMS took out a sequestration
adjustment for when
US Government closed down for
a few months. The large increase in
the third year resulted from a large
increase in the number of physicians
in the MSSP that resulted in a
significant increase in the number of
patients in the program.
HEALT HCARE MANAGEMENT
Volume to Value Challenge
ACOs are expanding at a rapid rate
in the United States. Each year,
Medicare approves approximately
100 new ACOs. There are now over
700 ACOs in the United States.
Will thepredominant approach
remain unchanged so that volume
continues to be the ultimate goal
and keeping hospital full is still the
byword? Or will we switch to value as
the prime driver and keeping
patients out of the hospital unless
absolutely necessary is the new
byword? To improve quality and
decrease costs, ACOs appear to be a
reasonable approach to facilitate the
switch from volume to value.
References:
1. Berwick DM, Nolan TW, Whittington J. Health
Affairs 2008; 27:759-760.
2. Accountable Care Organizations (ACO)
– Centers for Medicare and Medicaid Services –
CMS.gov https://www.cms.gov/Medicare/Medicare-
Fee-for-Service-Payment/ACO/ Accessed July 18,
2017.
3. Gross PA, Easton M, Przezdecki E, et al.The
ingredients of success in a Medicare Accountable
Care Organization.Am J Account Care 2016;
4(2): 42-50.
4. PCMH Eligibility.http://www.ncqa.org/
programs/recognition/practices/patient-centered-
the medical-home-pcmh/before-learn-it-pcmh/pcmh-
eligibility.Accessed July 18, 2017.
5. PCMH Evidence.http://www.ncqa.org/programs/
recognition/practices/pcmh-evidence.Accessed July
18, 2017.
6. Gross PA, Menacker M, Easton M, et al.Case
study: how does an ACO generate savings
three years in a row?Am J Account Care2017;
6(17):27-31.
Author BIO
Peter A Gross is Professor of Preventive
Medicine and Community Health at Rutgers-
NJ Medical School. Past national leadership
positions include JCAHO, SHEA; and FDA.
He is a graduate of Amherst College and Yale
Medical School and published more than 250
articles.
www.asianhhm.com 29
medical sciences

The Global
Advancement of
Diabetes Management

I
Over the years there has been tremendous advancement t is hard to believe that 95 years
in pharmaceutical science, biomedical and technology ago diagnosis of diabetes meant
death. Since the discovery of insulin
to manage people with diabetes to lead a normal life.
in 1921, the mortality rate has
This article provides a brief overview of how diabetes decreased, but people with diabetes have
management has evolved over the years and how suffered from long-term complications
24/7 monitoring of diabetes helps in managing the leading to blindness, kidney failure,
condition better and increases life expectancy. amputation and heart attack. With
time, the focus on the management
Sanjiv Agarwal, MD & Founder, Diabetacare of diabetes has shifted from ‘keeping

30 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017


patients alive’ to ’keeping patients free
of complications’. Over the years there
has been tremendous advancement in
pharmaceutical science, biomedical
and technology to manage people with
diabetes to lead a normal life. This
article provides a brief overview of how
diabetes management has evolved over
the years.
The story of diabetes mellitus — its
discovery, description, and treatment—
is a remarkable chronicle covering
thousands of years of medical history.
3500 years ago the ‘experts’ of the
pharaoh of Egypt, preferred the option
of a mixture of ‘water from the bird
pond,’ elderberry, fibres from the asit
plant, milk, beer, cucumber flower,
and green dates to manage diabetes.
Diabetes has been described under the
heading ‘PRAMEHA’ in Ayurvedic
texts like Charaka Samhita and Sushruta
Samhita. In Charaka Samhita, it is
described that Prameha (Diabetes) is of
two types.
1) Sahaja: Due to genetic factors. This
can be compared to Type 1 and is
seen mostly in lean individuals.
2) Apathya Nimittaja: Due to
sedentary lifestyle and diet. This can
be compared to Type 2 and is seen
mostly in obese individuals.
It was Thomas Willis’ observations
in the year 1674 and Matthew Dobson’s
experiments in 1776 that established
the diagnosis of diabetes as the presence
of sugar in urine and blood. Before the
1920s, there were no effective treatment
for diabetes and it was a fatal disease.
Dr.Frederick Allen prescribed low
calorie diets that restricted patients to
450 calories per day. It prolonged the
lives of some people with diabetes by
a year or two. However, this changed
dramatically with Frederick Banting's
work, who discovered and isolated
insulin at the University of Toronto in
1921–22. This was one of the greatest
events in the history of medicine. The
innovation of insulin therapy has helped
prolong the life expectancy of people
with Type 1 diabetes.
Scientific evidence
demonstrates that most of
the diabetes complications
can be reduced by
managing blood sugar
level with diet, exercise,
and medication.
Gradually the knowledge on
diabetes improved and clinicians learnt
to distinguish between Type 1 diabetes,
where insulin was lacking and Type 2
diabetes where insulin was working
inefficiently. The mainstay of treatment
was still insulin. For many years, beef/
pork pancreas were the only source
of insulin. Human insulin became
available in the early 1980s and was the
first commercial product developed by
the recombinant DNA technology.
In the 1950s, oral medications
(sulfonylureas) were developed for
people with Type 2 diabetes. These
drugs stimulate the pancreas to produce
more insulin, helping people with
Type 2 diabetes keep complete control
over their blood sugar level. This has
been considered the beginning of the
history of Type 2 diabetes treatments.
Earlier, there was no treatment. Hence,
those diagnosed with Type 2 diabetes
had to take more insulin with a hope
that their cells would absorb enough to
manage their condition.
Metformin was introduced as
another tablet for diabetes in 1959 but
was not approved in the United States
until the 1990s. Today, metformin
is the most widely used treatment for
Type2 diabetes in the world. Its primary
medical sciences
mechanism of action is its ability
to reduce glucose production from
liver, but it also reduces glucose via a
mild increase in insulin-stimulation
mechanism.
In recent years, many other
treatments have been discovered and
have been put to use. These includes
α-Glucosidase Inhibitors (to prevent
absorption of glucose from intestine),
Thiazolidinediones (to reduce insulin
resistance), Meglitinides (to increase
insulin secretion), GLP 1 analogues (to
increase meal related insulin secretion),
DPP 4 inhibitors (to increase own GLP
1 levels) and SGLT 2 inhibitors (to
increase glucose excretion in urine).
Another major advancement has
been in the field of self-blood glucose
monitoring by patients. One drop of
blood is placed on a disposable test strip
which is connected to a digital meter.
The level of blood glucose will be shown
immediately and patients now can
alter their treatment. There have been
advances in alternate site testing such as
skin, tears etc. This technology will have
the potential to give continuous blood
glucose readings. Nowadays, there are
smart glucometers available with a SIM
card that can transmit data in real time
to the care givers, based on which they
can then provide guidance in managing
the patient’s diabetes.
In the late 1970s, the insulin pump
was designed to mimic the body’s normal
release of insulin. The pump dispenses
a continuous insulin dosage through
a cannula (plastic tube), using a small
needle that is inserted into the skin.
The new-age pumps are light, compact
and can easily be carried in a pocket or
clipped to a belt. Most of the recent
pumps are linked to continuous blood
glucose meter and can automatically
adjust the dose of insulin.
Yet another innovation in the
treatment of diabetes has been Islet
transplantation. Islet cells are present
in pancreas and are responsible for
secreting insulin. These cells are isolated
from a donor pancreas and purified.
www.asianhhm.com 31
medical sciences

real-time access to patient data to IoT device, doctor’s mobile app,

provide the best care options. Diabetes
management may be challenging and
patient’s caregivers may need special
guidance to take care of the patient.
Keeping this in mind, progressive
healthcare organisations have developed
360-degree comprehensive care for
diabetes with a 24x7 monitoring team
for the patient. Organisations have
introduced IoT-enabled personal devices
with in-built decision-making capacity
to enable the patient to self-manage his/
her diabetes. On one hand, this solution
supports patient profile management
based on electronic medical records and
on the other hand, it provides seamless
connectivity between the patient’s
nutritionists’ information system and
patient’s electronic medical records.
Scientific evidence demonstrates
that most of the diabetes complications
can be reduced by managing blood
sugar level with diet, exercise, and
medication. Blood pressure and blood
cholesterol control is also important to
prevent complications. Technological
advances and connected devices help
patients to improve their blood glucose
level. Unfortunately, there is still a
significant disparity between available
and ideal diabetes care. Health coaching
with self-monitoring of blood glucose
is still the cornerstone of care for all
people with diabetes.

Author BIO

This is then injected into the patient's

liver under ultrasound control without
any major surgery. Once transplanted,
these cells produce insulin and regulate
glucose levels in the blood. It is an
experimental treatment for Type 1
diabetes mellitus.
Another new development that has
evolved over many years is the HbA1c
test. This was devised in 1979 in order
to create a more precise blood sugar
measurement (The oxygen-carrying
pigment in red blood cells, is used to
track glucose changes over a period of
three months). The HbA1c became
a standard measurement for blood
sugar control in the comprehensive
ten-year study from 1983 to 1993-the
Diabetes Control and Complications
Trial (DCCT). With the conclusion
of the DCCT in 1993, studies showed
that people who were able to keep their
blood glucose levels as close to normal
as possible had less chance of developing Sanjiv Agarwal is the MD & Founder of Diabetacare. With over 20 years of entre-
complications, such as eye, kidney and preneurial experience in the field of healthcare in India and the UK, he has a brilliant
nerve disease. knack of understanding the healthcare needs of the consumer. The gaps and voids he
noticed in diabetes management programs in India led him to establish Diabetacare,
Diabetes is a multi-faceted a 24x7 diabetes care service that utilises mobile technology to manage and monitor
chronic illness requiring continuous diabetic patients’ health.
monitoring. Today, physicians require

32 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017

 11th Edition of International Conference on

Proteomics March 22-23 | London, UK

Theme: “Exploring Novel Drug in the Field of Proteomics”

Keynote Forum Oral Presentations Poster Presentations Young Researchers Forum

Welcome
Euroscicon Ltd likes to take this opportunity to welcome all of you to “11th Edition of International Conference on Proteomics”
which is to be held during March 22-23, 2018 at London, UK. Through our theme “Exploring Novel Drug in the Field of
Proteomics”, the conference will analyse the recent advancements and new modes that can be enforced to the research to take
Proteomics, one step further.
Proteomics Euroscicon 2018 will impact an attractive moment to meet people in the research field and therefore it takes a
delight in opening a gate to meet the ability in the field, young researchers and potential speakers.
The conference also includes essential topics on:
• Proteomics in Drug Discovery • Metabolomics
• Protein Expression and Analysis • Transcriptome Sequencing
• Chromatin Proteomics • Phylogentic Analysis of Protein
• Protein Microarrays • Genomic, Proteomic, and Metabolomic Data Integration
• The Cancer Proteome Strategies
• Proteomics for Bioinformatics • Molecular Docking and Structure-Based Drug Design
• Neuroproteomics Strategies
• Proteomics and cell Signalling

Contact: Venue & Accommodation :

Caroline Thomas London, UK
Program Manager
Direct: (+44) 020 3807 3712
E-mail: proteomics@eurosciconmeetings.com
proteomics@eurosciconconferences.com

Website:
http://proteomics.euroscicon.com/
medical sciences

Head and
Neck Cancer
Symptoms, early
detection and
prevention

Head and Neck Cancer is a major health problem globally.

Males are affected significantly more than females with a
ratio ranging from 2:1 to 4:1. The incidence rate in males
exceeds 20 per 100,000 in regions of France, Hong Kong, the
Indian subcontinent, Central and Eastern Europe, Spain, Italy,
Brazil, and among African Americans in the United States.
Vikram Kekatpure, Senior Consultant, Head & Neck Surgical Oncology, Cytecare Hospitals

H
ead and Neck Cancer refer that does not get healed, difficulty in Excessive consumption of alcohol is an
to tumours that develop in swallowing or change in the voice. There additive risk factor. The other primary
the region of mouth, throat, may also be neck swelling, unusual risk factors are Human Papilloma Virus
larynx, nose and sinuses. The symptoms bleeding, facial swelling or difficulty in (HPV) infection and Epstein-Barr Virus
of Head and Neck cancer may include a breathing. About 80 per cent of head (EBV) infection. Most of these cancers
lump or a sore throat or a mouth ulcer and neck cancer is due to tobacco use. usually start in the squamous cells that

34 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017


line the moist, mucosal surfaces in the
region. The disease can also begin in
the salivary glands which is relatively
uncommon.
Head and Neck Cancer is a major
health problem globally. In the United
States, this cancer grows by 3 per cent
per year, with approximately 63,000
Americans developing head and neck
cancer annually and 13,000 succumb-
ingto the disease. On the other hand,
in Europe, there were approximately
250,000 cases and 63,500 deaths in
2012; and according to recent reports,
the numbers are increasing. Males are
affected significantly more than females
with a ratio ranging from 2:1 to 4:1.
The incidence rate in males exceeds
20 per 100,000 in regions of France,
Hong Kong, the Indian subcontinent,
Central and Eastern Europe, Spain,
Italy, Brazil, and among African Ameri-
cans in the United States. Mouth and
tongue cancers are more common in the
Indian subcontinent, nasopharyngeal
cancer is more common in Hong Kong,
and pharyngeal and /or laryngeal cancers
are more common in other populations
and these factors contribute to the over-
all cancer burden in Asian countries. In
India, the burden of Head and Neck
cancer is massive. Head and Neck cancers
account for more than 550,000 of the
total cancer cases reported in India every
year. Since a large per centage of Indian
population uses some form of tobacco
and the fact that Indian population
has grown at nearly twice the rate of
the world in last 15 years, India is likely
to experience a significant increase in
burden of head and neck cancer.
Cancers of the head and neck are
categorised by the region of the head
or neck in which they begin. Some
common cancers of the head and neck
are:
Oral Cancer
Mouth cancer is the most common
type of head and neck cancer. It can
affect the lips, tongue, cheeks, roof
or floor of the mouth and the gums.
About 80 per cent of head
and neck cancer is due to
tobacco use. Excessive
consumption of alcohol is
an additive risk factor. The
other primary risk factors are
Human Papilloma Virus (HPV)
infection and Epstein-Barr
Virus (EBV) infection.
Symptoms of the disease can include
persistent mouth ulcers or a lump in
the mouth. This cancer may also affect
areas like the lips, the front two-thirds
of the tongue, the gums, the lining
inside the cheeks and lips, the bottom
of the mouth under the tongue, the
hard palate (bony top of the mouth),
and the small area of the gum behind
the wisdom tooth. Oral cancer or
mouth cancer comes under a wide
umbrella of Head and Neck cancer,
which is caused due to a destructive
tissue developed in the oral cavity. In
the Indian subcontinent oral cancer is
considered to be one of the major health
complications, as it ranks among the
top three types of cancer accounting to
over 30 per cent of all cancers. This type
of cancer is commonly caused due to
excessive smoking, chewing of tobacco
and drinking. Oral Cancer in India is
seen in both, men and women. This is
a common disease in both the genders
as now both, men as well as women
are induced to tobacco addiction. The
primary symptoms of oral cancer can
be identified when one notices red or
white patches or ulcers in the mouth
cavity, i.e., tongue, gums or at the
medical sciences
side of the mouth. Surgery to remove
the tumour in the mouth and affected
lymph nodes in neck is a common
treatment for oral cancer. The surgeons
will also perform reconstruction at
same time to minimise the functional
and cosmetic problems. Patients may
have surgery alone or may be combined
with radiotherapy for advanced stages.
Pharynx
The pharynx (throat) is a hollow tube
about 5 inches long that starts behind the
nose and leads to the oesophagus. The
throat has three parts: the nasopharynx,
the oropharynx and the hypopharynx.
Throat cancer can affect any part of the
throat. The most common symptoms
of this cancer in the throat include a
lump or a persistent sore throat. Ear
pain, neck pain, any foreign body
sensation, any itching sensation in the
throat or sudden weight loss are also a
few other symptoms of throat cancer.
It is also important to look out for
swelling of the neck. The treatment
is planned according to the stage and
options available for this cancer are
Surgery, Radiotherapy, targeted therapy
and Chemotherapy.
www.asianhhm.com 35
medical sciences

Head and Neck cancers
account for more than
550,000 of the total
cancer cases reported
in India every year.
Larynx
The larynx, also called the voice box,
is a short air passage bound by vocal
cords below and front of the pharynx
in the neck. Laryngeal Cancer affects
the various parts of the larynx, namely
epiglottis and vocal cords. Laryngeal
Cancer is also considered to be one of
the easiest cancers to detect as it starts
off with hoarseness of voice and then
advances to breathing problems in the
latter stages. If the hoarseness of voice
persists for more than 3 weeks, it is
advisable to get a laryngoscopy. Other
symptoms enclose a change in the voice,
difficulty in swallowing, shortness of
breath, noisy breathing and a persistent
cough. The treatment for laryngeal cancer
is radiation therapy or laser surgery for
early stage. However in advanced stage
voice box removal (laryngectomy) may
be required. Following laryngectomy
various techniques are available to voice
rehabilitation.
Paranasal Sinuses and Nasal Cavity
blocked nose, pain above or below the
eyes or blockage of one side of the nose.
The treatment for this kind of cancer is
surgery followed by radiation therapy.
Salivary Glands
The major salivary glands are in the
floor of the mouth and near the
jawbone. The symptoms of the cancer
affecting salivary glands are a lump or
swelling on or near the jaw or in the
neck or mouth, numbness in part of
the face, drooping on one side of the
face, difficulty in swallowing, trouble
opening the mouth widely or persistent
pain in the area of a salivary gland. The
treatments for this are surgery with or
without lymphadenectomy followed by
radiation therapy and chemotherapy.
The most effective form of detecting
head and neck cancer early can be
regular clinical examinations may
identify pre-cancerous lesions in the
head and neck region. When diagnosed
early, oral, head and neck cancers can
be treated more easily and the chances
of survival increase significantly. It is
expected that HPV vaccines may reduce
the risk of HPV-induced head and neck
cancer.
There are various types of treatments
for Head and Neck cancers. Surgery,
radiation therapy, chemotherapy and
targeted therapy are a few treatments
for the ailment.
Surgery
Surgery as a treatment is frequently
used in most types of head and neck
A renowned oncologist with over 14 years of experience in clinical
care, teaching and research, Kekatpure specialises in the man-
Author BIO
cancers. Usually the aim is to remove
the cancerous tissue completely along
with margins or surrounding normal
tissue. The lymph nodes in neck which
can harbor tumour are also removed
during surgery. Reconstructive surgery
is performed to achieve optimal
cosmetic and functional outcomes.
Radiation Therapy
Radiation therapy is also routinely used
for treatment of head and neck cancer.
Radiotherapy can be used as primary
modality or as adjuvant following
surgery depending on the stage of
disease. Various techniques such as
3D Conformal radiation, IMRT, IGRT,
etc., are used to reduce morbidity
associated with Radiation Therapy.
Chemotherapy
Chemotherapy for head and neck cancer
is used as part of curative or palliative
protocol. In curative protocol platinum
based chemotherapy is used as radiation
sensitiser. Palliative chemotherapy is
used to alleviate acute symptoms.
Targeted Therapy
Targeted therapy is a type of treatment
that uses agents such as monoclonal
antibodies or inhibitor to specifically
target a receptor of pathway in cancer
cells. Some targeted therapy used in
squamous cell cancers of the head and
neck include cetuximab, nimotuzumab,
bevacizumab and erlotinib. Recent
studies have shown promising results
for immune targeting PD1 inhibitors.

Nose and sinus cancer affects the nasal agement of head and neck cancers. Dr. Kekatpure is a member of
various medical and scientific societies at national and international
cavity — above the roof of the mouth levels, including the Foundation for Head and Neck Oncology
and the sinuses. The symptoms of the India (FHNO), Indian Association of Cancer Research, American
disease could be similar to the common Association of Cancer Research (AACR), AO foundation, and the
Head and Neck Cooperative Oncology Group. He is a recipient of
cold or sinusitis along with a decreased several awards and is credited with an award from the FHNO for his
sense of smell, pus or blood stained research paper and a Scholar-in-Training award from the AACR.
discharge from the nose, persistent

36 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017

medical sciences

Risk Factors for

Development of
Cardiovascular
Disease
The largest proportion of global mortality is attributed to
Cardiovascular Disease (CVD), withmore than three-fourths of
CVD relateddeaths occur in low-and-middle incomecountries.
The primaryrisk factors of CVD are strongly correlated with
health behaviours and overall physical condition. CVD
can be effectively prevented by controlling the associated
risk factors and proper medications management.

KATM Ehsanul Huq, Graduate School of Biomedical & Health Sciences, Hiroshima University
Michiko Moriyama, Graduate School of Biomedical & Health Sciences, Hiroshima University
Pradeep Kumar Ray, Engineering Research Center on Digital Medicine and Clinical Translation
(DMCT), Shanghai Jiao Tong University
Susumu Nakayama, Graduate School of Biomedical & Health Sciences, Hiroshima University
Md Moshiur Rahman, Graduate School of Biomedical & Health Sciences, Hiroshima University

C
ardiovascular Disease (CVD) Health in Mexico in June 2016, the CVD consists of heart and its
is the number one killer in World Heart Foundation declared circulation. It includes coronary heart
the world. Globally, about 25 per cent reduction of premature disease, angina, heart attack, heart
17.5 million people die every year due CVD related death by 2025. In failure, congenital heart disease (CHD),
to CVD. More than three-fourths of September 22, 2016, World Health valvular disease, cardiomyopathy,
the deaths occur in developing Organization (WHO), Centers for atrial fibrillation, arrhythmia, stroke,
countries. Sustainable Development Disease Control and Prevention (CDC), rheumatic heart disease, venous disease
Goals (SDGs) target 3 is to reduce World Heart Federation, World Stroke and peripheral arterial disease.
premature mortality through Organization, International Society of CVD occurs when arteries become
prevention and treatment of Hypertension, World Hypertension narrowed by a gradual build-up of fatty
non-communicable diseases by League and other partner organisations materials (atheroma) within the walls.
2030. In the World Congress of took the ‘Global Hearts Initiative’ to When atheroma breaks away from
Cardiology and Cardiovascular prevent and control the CVD. the arteries, after clotting it can block

38 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017


coronary and obstruct the oxygen-rich
blood supply to the heart muscles. Then
heart muscles become permanently
damaged and cause heart attack. When
the blood clot blocks the arteries of the
brain, then it causes stroke. Eighty per
cent of the CVD patients died due to
heart attack and strokes. Narrow arteries
can’t carry enough oxygen-rich blood
to the heart, that can cause pain and
discomfort in the chest called angina.
The risk factors for CVD include
unhealthy behaviours; e.g smoking,
Globally, about
17.5 million people die
every year due to CVD.
More than three-fourths
of the deaths occur in
developing countries.
less physical activities, salt containing
diet and overweight, and health factors
including cholesterol, Blood Pressure
(BP) and glucose. High BP is the
highest risk factor to develop CVD.
medical sciences
BP related with several genetic factors
and environment also influence to
contribute. Genetic factors influence
about 30-50 per cent and environmental
factors about 50 per cent for developing
BP. The factors including enzymes,
receptors and channels that regulate BP.
About 50 per cent of the hypertensive
patients develop stroke and ischemic
heart disease. Next is smoking, the
most important preventable cause
of death for CVD. It causes about
10 per cent of CVD. Globally, over
www.asianhhm.com 39
medical sciences
1.1 billion people smoke tobacco as
of 2015, and about 6 million people
die and it will increase to more than 8
million in 2030. It makes fatty substance
in the arteries and causes coronary
heart diseases that leads to heart attack.
Patients with diabetes are also at high
risk to develop cardiovascular disease.
CVD is the leading cause of diabetes
related morbidity and mortality. Obese
people are prone to diabetes due to less
physical activities that increase the risk
of CVD.
Congenital Heart Diseases (CHD)
are associated with genetic syndromes
and about 30 per cent of the congenital
heart diseases are related to genetic
illnesses. Environmental factors
including rubella infection, significant
alcohol intake, insulin-dependent
diabetes and obesity of the mother are
also contributing to develop CHD.
The genetic risk factor includes the
family history influences for CVD.
If both father and mother suffer from
heart disease before the age of 55, the
risk of getting heart disease rise to 50
per cent compared to other people.
There are also increased chances of a
stroke, if there is any family history.
Hypertension, high lipid profile and
40 A si a n H o s p i t a l & H ea lt hcar e M an age me n t
type 2 diabetes also have the genetic
component to develop CVD. It means,
if father or brother develops CVD under
the age of 55 and mother or sister under
the age of 65 diagnose with CVD, then
screening is recommended after the age
of 40 years for CVD.
CVD also varies in different ethnic
groups. CVD burden is the highest in
the South Asian population. It is the
most alarming that younger age groups
in South Asia develop CVD more
compared to other continents. With the
conventional risk factors, congenital,
adult metabolic, environmental pollu-
tions, social, and psychological factors
also act as risk factors for developing
CVD. In South Asian people, the risk
of getting coronary heart disease, stroke
and diabetes are higher compared to
other UK populations. Compared to
women, men are more prone to develop
CVD at an early age. With age, the
chances of getting CVD also increase.
Stress, alcohol consumption, and type
of work further influence the develop-
ment of CVD.
WHO has developed evidence-
based guidelines for the prevention of
CVD. People need primary prevention
who have the risk for developing CVD
ISSUe - 37 2017
and secondary prevention to avert recur-
rence of the CVD. The people who are
at risk need to maintain risk prediction
chart for specific preventive actions
and the degree of intensity they need.
However, CVD risk is higher in contrast
of the risk prediction chart for those who
are on antihypertensive therapy, obese,
have family history, maintain sedentary
lifestyle, elevated triglyceride, C-reactive
protein, fibrinogen, homocysteine, apol-
ipoprotein B or Lipoprotein(a), fasting
glycaemia, impaired glucose tolerance,
microalbuminuria, low HDL choles-
terol, increase pulse rate, socioeconomic
deprivation, and premature menopause
in case of female. For the secondary
prevention, intensive lifestyle interven-
tions and appropriate drug therapy are
empirical.
For prevention and early detection
of CVD, exploring the risk factors is
crucial. Unstructured clinical narrative
health records data can be extracted
and calculated to get the risk scores for
developing CVD. Data from electronic
health record (EHR) systems are a major
source for identification of risk factors
and assessment of the prognosis of
heart diseases. Information extraction
(IE) system has been used to take out
unstructured data from EHRs and risk
factors were successfully evaluated by
assigning indicators and time attributes.
Researchers and institutes have
developed different CVD risk assessment
calculator based on the scoring system.
These systems can help the patients to
predict the risk and control the risk
factors to prevent CVD. Framingham
CVD risk calculator includes age, sex,
present smoking status, total choles-
terol, high density lipoprotein choles-
terol (HDL-C), systolic blood pressure
and drug history for blood pressure
control. The estimation was calculated
for CVD within 10 years. The scoring
systems didn’t include the diet and level
of smoking as a risk factor. Reynolds
risk scoring system wasdeveloped for
men and women separately and includes
family history and C-reactive protein

with the Framingham’s variables.Some
other scoring systems included height,
weight, race, diabetes, history of heart
attack, family history, physical activities
and diet.
The American Heart Association
(AHA) developed a Health Campaign
especially for the young and adult
people to avoid smoking and smokeless
tobacco products, be active by engag-
ing daily physical activities, eat healthy
diets, maintain healthy weight and
control blood pressure, cholesterol and
glucose. A meta-analysis of prospec-
tive cohort studies found that ideal
cardiovascular health metrics signifi-
cantly reduced CVD, cardiovascu-
lar mortality and overall all cause of
death. Improved cardiovascular health
metrics can reduce death related to
coronary heart diseases between 2010
and 2020 by 30 per cent. Interventions
were recommended to complete cessa-
tion of smoking and stop environmen-
tal exposure. Asking patients to stop
smoking refers to smoking cessation
programme. Patients should control
blood pressure <140/90 mmHg and
seek counseling for lifestyle
modification. All patients should main-
tain lipid profile, use omega-3 fatty
acids, and perform physical activities.
Body weight should be maintained
and in conditions of obesity and
overweight, therapeutic lifestyle
intervention should be initiated.
Diabetic patients should check blood
glucose and maintain lifestyle modifi-
cations and treatment. Patients should
take antiplatelet and antihypertensive
therapy when necessary. CVD patients
should have influenza vaccine annu-
ally. Depressive illness patients should
be evaluated and treated, and cardiac
rehabilitation programme should be
implemented. Evidence approves that
inclusive risk factor management can
improve survival, reduce recurrence rate,
and improve quality of life. Healthcare
provider’s support to the patients, is
also essential for the wellbeing of the
patients.
medical sciences
CVD causes an enormous burden and treatment of the risk factor, (2)
in health and economy globally. Access encouraging healthcare providers and
to healthcare facilities and prevention patients to improve healthy behaviour,
of CVD intervention is inexpensive. and (3) targeting schools, worship
To implement the universal health places, workplaces, local communities
insurance system can reduce the risk of and, consequently the states and the
CVD; however, primary prevention is whole nation, is important. It needs
the key. In South Asia, one of the main innovative research, advanced tech-
risk factors is shifting in dietary behav- nologies and appropriate interventions
iour for CVD. Low cost, local tailored to save lives. Moreover, along with the
intervention practice for changing the health professionals, governments,
health risk behaviour can prevent CVD. businesses and public partners need to
To improve cardiovascular health, (1) be involved to achieve the goals.
changing the individual level lifestyle References available at www.asianhhm.com
Author BIO
KATM EhsanulHuq is a doctoral student of Hiroshima University.
He completed his masters from Uppsala University, Sweden, diplo-
ma from Swiss Tropical and Public Health Institute, Switzerland and
medical graduation from Bangladesh. He worked at International
Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in
different clinical researches specially vaccine trials, bioequivalence
studies and drug development.
Michiko Moriyama is a Professor of Division of Nursing Science
under the Institute of Biomedical& Health Sciences in Hiroshima
University, Japan. She has been involved in various types of re-
search activities such as Chronic Care and Disease Management,
Family Nursing, and Population Sciences. She has multidisciplinary
collaboration in different countries for sustainable development.
Pradeep Ray is the Founder and Director of the WHO Collaborating
Centre on eHealth at the University of New South Wales, Australia.
He led to completion several global initiatives, such as the WHO
Research on the Assessment of e-Health for Healthcare Delivery
(eHCD) involving a number of countries in the Asia-Pacific region.
Susumu Nakayama is a doctoral student at Hiroshima University,
Japan and completed masters graduation degree from Hiroshima
University. He has engaged in construction of community coop-
eration system for heart failure patients in Hiroshima prefecture of
Japan.
Moshiur Rahman is a Visiting Associate Professor at the Graduate
School of Biomedical &Health Sciences in Hiroshima University,
Japan. He has multidisciplinary experiences in clinical science,
public health, and molecular research. Expertize in planning, im-
plementing, monitoring and evaluation of public health programs &
research in developing countries.
www.asianhhm.com 41
technology, equipment & devices

Industry 4.0
Manufacturing and the
future of medical things

42 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017

 technology, equipment & devices

The I4.0 revolution is already re-defining how we

manufacture. It will help meet demand for increasingly
sophisticated, higher quality and rigorously regulated
medical devices. It delivers solutions in innovative new
areas such as patient-specific devices and ‘Lab on a Chip’
electronic diagnostics. What does the future look like for
manufacturing The Internet of Medical Things (IoMT)?
Francisco Almada Lobo, Chief Executive Officer and Co-Founder, Critical Manufacturing

T
he Industry 4.0 (I4.0)
revolution is already re-defining
how we manufacture ‘things’
today. It sets out the concepts for how
companies can achieve faster innovation
and increase efficiencies across the value
chain. But, in the world of medical device
manufacturing, which is burdened with
regulatory compliance and is still largely
dependent on paper-based processes,
what does Industry 4.0 really mean?
How will it help manufacturers meet
demand for increasingly sophisticated,
higher quality and rigorously regulated
medical devices, and beyond that
highly personalised custom devices?
New trends in how medical devices
are made and how they deliver value
is fundamentally changing, devices
are moving more and more into
the world of the Internet of Things,
utilising highly sophisticated chipsets,
processing capabilities and sensors.
They are mobile and connected like
never before, delivering solutions in
innovative new areas such as patient-
specific devices and ‘Lab on a Chip’
electronic diagnostic testing. What does
the future of manufacturing medical
devices, efficiently and profitably,
look like? Or, should we say
manufacturing the ‘Internet of Medical
Things’ (IoMT)?
Industry 4.0 embraces a number
of automation, data exchange and
manufacturing technologies that are
changing the landscape of how we
make products and expanding
the boundaries of innovative,
new manufacturing opportunities.
It is modelled on a Value Chain
Organisation that merges real and
virtual worlds usingthe Internet of
Things (IoT) and the Internet of
Services (IoS). It provides factories
with real-time intelligence allowing
them to efficiently produce products of
higher quality that can be completely
customised. Five years ago the medical
device connectivity market was largely
insignificant but it is now expected to
grow at a CAGR of 38 per cent over
the next five years by adopting the
capabilities of the IoT.
The IoT brings together physical
objects with embedded electronics,
software, sensors and network
connectivity that means they are able
to collect and exchange data with
each other. In the manufacturing
environment this becomes the
Industrial Internet of Things (IIoT)
with added machine learning,
machine-to-machine communication
and integration of existing automation
technologies. Smart machines are able

www.asianhhm.com 43
technology, equipment & devices
to accurately capture real-time data
and communicate with each other
and the products or materials they are
processing to make the best production
decisions. This not only increases
productivity but also identifies
any inefficiency, increases quality
consistency, and reduces waste both in
terms of better utilisation of machines
and reduced scrap. Alongside making
existing manufacturing processes more
efficient, I4.0 offers new opportunities
in terms of increasing competitiveness;
accelerating innovation; bringing new
products to market more quickly;
adding capability to easily customise
individual orders, and enabling faster
response to customer demands.
Medical device manufacturers are
experiencing increasing challenges in
terms of price and margin pressure,
speed to market, increased product
(and so manufacturing) complexity and
44 A si a n H o s p i t a l & H ea lt hcar e M an age me n t
more stringent regulatory compliance.
Pressure on the cost of medical devices
stems from excise taxes and increased
costs of meeting new regulatory
initiatives. Hospitals are also changing
the way in which they purchase
equipment, working to optimise their
costs in the ‘Value-Based Care’ model.
All of this is combined with increased
product complexity which can lead
to greater risks to quality and require
investment in better technology and
deeper analysis of production data to
improve processes.
Value-based care means a shift in
financial incentives for care providers
as they are compensated based on how
patients fare, rather than the number
of tests, visits or procedures performed.
Medical devices will almost certainly
become Cyber Physical Systems (CPS),
forming an Internet of Systems where
the value of information from sensors
ISSUe - 37 2017
within the devices is higher than the
value of the devices themselves. Patient
information gained from device sensors
or self-monitoring can reduce the over-
all care model costs with a stronger
focus on disease prevention and early
detection. For example, integrating
electrocardiogram capability or blood
pressure cuffs within a device increases
its value. However, this all requires a
single platform through which devices
can be connected across a care setting
or disease continuum. The Internet of
Medical Things (IoMT) brings together
technology, medical devices and appli-
cations that enable personalised patient-
specific devices and care programmes.
Mobile devices that can track
chronic and lifestyle associated diseases
such as diabetes is a fast growing market
area and one which responds to the
connectivity delivered by the IoT.
Device examples include contact lenses

that can detect glucose levels and devices
to monitor calorific intake. A new area
of bioelectronic medicine is also emerg-
ing, facilitated by the miniaturisation of
electronics. Here miniaturised devices
are implanted in the body may help
treat illnesses such as arthritis, diabe-
tes and asthma by influencing electric
signals in nerve pathways.
Other areas of innovation include
robotic-assisted surgery; next genera-
tion of smart inhalers that track inhaler
use, avoid triggers and warn of asthma
attacks, and biometric stamps that act
as a ‘lab on a chip’ (LOC) alternative
to reagents and chemicals. A LOC is
an automated, miniaturised labora-
tory system that can be used inside and
outside of a hospital for a wide range
of patient measurements such as blood
gases, glucose and cholesterol levels.
This technology enables fast diagnostics
with only small amounts of samples and
materials required. This biochip market
is estimated to be worth around USD17
billion by 2020.
In the future, innovation and agility
is clearly going to be vital for medical
devices manufacturers to respond to a
rapidly changing market place. The rate
at which manufacturers can get a new
product to market is being influenced by
the time to gain necessary FDA device
approvals. Regulatory approval requires
the collection of vast amounts of data
through the complete product lifecycle.
If design, process engineering, and
manufacturing systems are disjointed,
this further impacts the efficiency
of new product releases the whole
product development cycle can become
cumbersome and error prone. Strong
competitive forces in the market place
may mean that any delay in product
release results in missed opportunities
and loss of market position.
technology, equipment & devices
Although strict regulations mean
that changes may happen more slowly
in the medical markets compared with
some other industries, I4.0 offers medical
device manufacturers such incredible
benefits that it will happen. It provides
a pathway for efficient production of
increasingly complex products while
capturing and analysing data flows to
assist with regulatory compliance and
process improvement.
Regulatory compliance does not
guarantee high quality but the end to
end traceability and complete visibility
of production processes within the I4.0
model means compliance can be less
painful while product quality, and so
customer satisfaction, is increased.
To remain competitive, medical
device manufacturers need the ability
to innovate and respond quickly to the
changing ways in which patients can now
be treated. Customisation of patient-
www.asianhhm.com 45
technology, equipment & devices

specific devices will require high quality,
high mix production that particularly
lends itself to the greater automation and
higher levels of intelligence provided by
the I4.0 model. Physical objects passing
through production processes will
incorporate their own embedded
Software and Computing Power (CPS)
to interact with more intelligent
machines, Cyber-Physical Production
Systems (CPPS), on the plant floor.
The products (CPS) will be the service
consumers and the machines (CPPS) the
service providers. Intelligent exchanges
of information within this completely
networked environment will enable
production to be self-managing and
self-optimising.
This changes the plant floor from
a centralised control model to a
de-centralised one that requires little
or no operator intervention. Vertical
integration of the plant floor operations,
however, must not be forgotten as this
is vital for compliance with enforcement
of product quality at each production
stage. It is also needed to accommodate
other business processes such as logistics,
engineering, sales or operations — all of
which have components inside the plant
as well as others that reside beyond the
factory that are crucial to a business
process being executed effectively.
Without these, it’s almost impossible
to properly manage a production floor
of a certain complexity. A modern
Manufacturing Execution System
(MES) based on decentralised logic
offers a way to vertically integrate
systems so that corporate processes
cannot be avoided. For example, quality
processes may demand that a device
requires additional verification steps
before processing continues as part of
Industry 4.0 embraces a
number of automation,
data exchange and
manufacturing technologies
that are changing the
landscape of how we make
products and expanding the
boundaries of innovative,
new manufacturing
opportunities.
(SPC) can be triggered and checked
against limits within SPC rules.
The smart shop floor will use the
IoT as a communication pathway
supported by technologies such as
Cloud computing, which can provide
‘anytime, anywhere’ ability and storage
for the huge amounts of data generated.
The MES needs to be able to expand to
accommodate both the diversity and
volume of this ‘big data’. It needs to
aggregate it and put it into context to
turn it into valuable information that
may be used to improve processes,
identify any discrepancies and resolve
quality issues before they reach the
customer. Real-time analysis using
advanced techniques such as ‘in-memory’
Francisco Almada Lobo holds an MBA and an Electrical
Engineering Degreefrom University of Porto. He started his career
in a CIM R&D institute, and joined Siemens Semiconductor in 1997.
Author BIO
and complex event processes may also
be used to further drive efficiency in the
future.
Summary
The medical device industry is going
through an exciting time with many
new opportunities in innovative routes
to patient care. Those that ignore the
opportunities I4.0 offers will be in
serious danger of not being able to
compete in the near future as others
drive down manufacturing costs and
increase business agility in response to
developing technologies. One of the
main areas of benefit the decentralised,
smart manufacturing model offers is
the ability to efficiently individualise
products with high quality results —
something that will be critical to success
in the patient-specific devices market.
The implementation of I4.0 will
certainly be a transitional process for
the medical device industry because of
the importance in retaining compliance
and the need to prove quality systems.
Nevertheless, itcan and should be
planned into business strategies now
and benefits will be realised over
time. Modern MES platforms that
utilise decentralised logic provide
a realistic pathway to transitioning
from homegrown systems and paper-
based production models to the latest
technologies while ensuring control
of business process rules, managing
compliance and assuring quality control
and high product quality.

a higher level quality sampling strategy. Throughout Siemens, Infineon and Qimonda, hegained experience
in several manufacturing are as having, in 2004, led the first migra-
This requires communication to tion of an MES system in a running high-volume facility. Between
intersect the business rules so the quality 2005 and 2009, he managed the Porto Development Center for
procedures are not bypassed before Infineon and Qimonda, with implementation of automation projects
in the group plants worldwide.
the device continues through its Francisco acted as Chief Operating Officer of Critical Manufacturing
production processes. The MES also where, among other areas, he was responsible for the Product
provides a platform whereby collection business unit. Since 2010 he's the company's CEO.
of data for Statistical Process Control

46 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017

Day 1: 29 August 2017: Health Day
Mainstreaming Ayush: Staying Healthy
Yoga: Science of Infinite Possibilities
Diet, Therapy, Exercise for Fitness

Day 2: 30 August 2017: Bio Day

Medical Biotech: The Future of Healthcare
Agri Biotech: Produce More with Less
Animal Bio: Move the World for Animals
Bio Informatics: Introduction and Overview

Day 3: 31 August 2017: Organic Day

Organic Farming: Scripting a Success Story for India
Smart Foods for Wellness
Organic Medicines: Ancient Preparations for Modern Times
Organic Consumer Products: Together for a More Organic World
Information Technology
Dawn of the Future
IoT-driven medical devices
service enterprises
The ‘things’ in IoT can refer to a wide variety of devices
including implants, physiological monitors, wearables,
capital intensive diagnostic equipment, and so on. The
expanded sensing and communicational capabilities of
these ‘things’ herald the next big wave of the Internet.
Ram Meenakshisundaram, Senior Vice President and Global Delivery Head
Life Sciences, Cognizant
I
ndustries across segments are
moving from selling products to
selling services; even wind turbines,
locomotives and jet engines are now
sold as services. The emergence of
the Internet of Things (IoT) has now
enabled medical devices companies to
create a new business model premised
on services, personalization, and other
innovations.
IoT, where physical devices are
instrumented to capture and transmit
data covering everything from
environmental conditions to usage
patterns and user behaviours, is arguably
the next wave of information technology
advancement. The ‘things’ in IoT can
refer to a wide variety of devices including
implants, physiological monitors,
wearables, capital intensive diagnostic
equipment, and so on.
The expanded sensing and
communicational capabilities of these
‘things’ herald the next big wave of the
Internet. Estimates indicate that some
12 billion devices1 are already connected
to the Internet. This figure is expected
to grow to 50 billion devices by 2020.
1 http://www.cisco.com/c/dam/en_us/about/ac79/docs/in-
nov/IoT_IBSG_0411FINAL.pdf
48 A si a n H o s p i t a l & H ea lt hcar e M an age me n t
IoT’s power lies in connecting dots in an
innovative fashion. The transformative
possibility is evolving across a broad
spectrum: connected homes, connected
healthcare, connected factories, and
connected enterprises.
The healthcare industry is well on its
way to a smart, connected future enabled
by IoT, as market leaders recognise that
sensors connected through IoT can
transform business models and harbinger
new possibilities. Healthcare organisations
that integrate these ‘connected health’
trends into their practices, processes and
workflows can offer patients better care
and greater satisfaction while reducing
the cost of care. The global healthcare
IoT market is expected to grow from
USD 32.47 billion in 2015 to USD163.24
billion by 20202.
Game-Changing Possibilities
Physicians and patients increasingly
believe that ‘wearables’ could help them
better manage health and potentially
improve long-term care. Roughly 72
million wearable devices were shipped
2 http://www.marketsandmarkets.com/PressReleases/iot-
healthcare.asp
ISSUe - 37 2017
in 20153, a figure that will nearly double
to 156 million by 2019. These trends
indicate strong growth in the sector.
With IoT, the medical device
manufacturer can usher in true
customer-centricity. There are
three types of transformational
opportunities:
• Greater operational efficiency,
as a result of preventive maintenance
of devices and remote diagnostics and
software upgrades, improving customer
satisfaction
• Digital innovation around
the communication of vitals and
device information, and new services
that can help customers contextually
understand the insights
• Connected ecosystem, as a
result of the ability to link devices and
systems together, bringing superior
intelligence to the customer.
Let’s look at some opportunities
for digital disruptions. The number of
product recalls of medical devices has
increased nearly 100 per cent4 between
3 http://archive.eetasia.com/www.eetasia.com/
ART_8800713348_499488_NT_cf5904f0.HTM
4 https://www.fda.gov/downloads/AboutFDA/Center-
sOffices/OfficeofMedicalProductsandTobacco/CDRH/
CDRHTransparency/UCM388442.pdf

2003 and 2012. By investing in real-
time predictive analytics powered by
IoT, manufacturers can proactively
determine quality issues to reduce
the number of product recalls and
strengthen brand image.
According to the US Food & Drug
Administration (FDA), the number of
serious complications from medical
device use has outpaced industry growth
by 8 per cent each year since 20015. By
gathering information about the device
and its usage environment, medical
device manufacturers could reduce
these complications by informing
future product design and proactively
improving post-sales service support.
A leading medical device
manufacturer logs an average of
200,000 product-related customer
services complaints6 every year. The
ability to predict and proactively
address even a fraction of these
complaints would spell significant
competitive advantage for the
company. IoT powered devices have
brought such services within the realm
of possibilities.
Managed care at home can now be
a reality, providing relief to patients,
insurance companies, governments, and
hospitals. Devices can communicate
patient vitals in real time. Alerts can
be generated to flag patient need for
attention. This can be creatively used
in post-discharge care as well, such
as monitoring patients after a major
cardiac surgery.
Harnessing IoT Analytics to
Transform the Medical Device
Value Chain
Traditionally, manufacturers have
introduced new efficiencies to their
value chain by employing lean
manufacturing and Six-Sigma quality
techniques. While this can certainly
5 https://www.fda.gov/downloads/AboutFDA/CentersOf-
fices/CDRH/CDRHReports/UCM277323.pdf
6 https://www.cognizant.com/perspectives/how-iot-analyt-
ics-can-transform-the-medical-device-value-chain
The global healthcare
IoT market is expected
to grow from USD
32.47 billion in 2015
to USD 163.24 billion
by 2020
drive optimisation, manufacturers
can also accelerate transformation by
introducing new business decision
services powered by IoT and big data
analytics.
Success in developed markets varies
greatly from emerging economies,
which require a very specific
understanding of stakeholder needs. By
using data mining techniques, such as
Natural Language Processing (NLP),
medical device manufacturers can cost-
effectively obtain this information and
influence the product development
lifecycle for each market. When these
data sets are assessed in isolation, their
meaningful impact on the value chain
is limited. By identifying effective
ways to integrate these data sets and
apply analytics capabilities to them (for
example, predictive analytics and NLP),
organisations can more effectively
optimise the value chain. By analysing
IoT and an array of big data assets,
for example, an insulin pump maker
can enhance various components of its
value chain.
Author BIO
Ram Meenakshisundaram is the Senior Vice President and
Global Delivery Head for Life Sciences at Cognizant.
Information Technology
From a ‘process’ standpoint,
IT would need to engage with the
business much earlier in the lifecycle
to build a comprehensive data and
analytics strategy. From a ‘technology’
standpoint, companies would need
to invest in IoT capabilities, such as
changing device design (for example,
installing sensors to monitor real-time
device usage), and building or buying
predictive analytics systems and NLP
tools to analyse the information
gathered through these devices. From
a ‘people’ standpoint, investing in
knowledge management and learning
systems would go a long way in
improving the organisational adoption
of these new capabilities.
IoT should be viewed as a business
solution. The true value of IoT will be
realised when systems are designed to
provide impactful business outcomes.
For example, a medical device manufac-
turer can offer a service to labs around
the most profitable categorisation and
bundling of tests. Fertile ecosystems
that connect the dots must be visualised
where IoT can provide deeper insights
into a device’s operating environment
and its internal state.
There are some challenges that
we need to be wary of: the diversity
of data communication protocols,
energy needs, exposure to new security
vulnerabilities due to data exfiltration,
and privacy apprehensions. These
concerns are not intractable and will
abate in the coming times. The dawn
of services-based medical devices and
connected ecosystems for greater
customer centricity positions us on
the cusp of digital disruption and
presents a great opportunity to shape
the future.
www.asianhhm.com 49
Information Technology
Data Security
and Analytics
Shaping the future of healthcare
The article talks about digitisation of medical
records highlighting role of Predictive
Healthcare Analytics & Big Data in optimising
Indian and global healthcare industry. It
also brings out the need of IT security in
the healthcare domain for data protection
and compliance in the same segment.
Baskaran Gopalan, Senior Vice President, IT & Projects
Omega Healthcare Management Services Pvt. Ltd.
50 A si a n H o s p i t a l & H ea lt hcar e M an age me n t
T
he healthcare industry has been undergoing
tremendous change thanks to the ever
advancing innovation in computing
technologies. According to a recent report
released by Springboard Research, the growth in
healthcare IT market in India has been the highest
in Asia. A few studies also forecast Indian medical
technology market to grow from US$2.7 billion
in 2008 to US$14 billion in 2020.
The recent advent of analytics has impacted the
scenario of patient services in healthcare including
the management and delivery of healthcare,
governance and more. As the demand for improved
ISSUe - 37 2017

healthcare services rise, the need for
securing patient healthcare data and
easing access to it also grows manifold.
The need and demand for big data
analytics has grown tremendously
owing to the deep insights that can be
obtained to help resolve challenges and
improve services. Data analysis and
insights have been made a lot easier
with the use of big data platform that is
capable of processing terabytes and pet
bytes of data.
Big data analytics has now become
a necessity for all healthcare service
providers. Insightful information
regarding their management, planning,
and the relevant measurements can
help healthcare organisations to develop
their future vision, optimise time and
resources, and scale their financial
outcomes.
Data Analytics in Healthcare
Data Analytics can be utilised in the
healthcare industry for many purposes:
Public Health: Public health issues can
be addressed with a detailed analysis of
healthcare data covering disease patterns
and records of disease outbreaks.
Healthcare crises can be predicted
and prevented, thereby improving the
quality of care provided.
Electronic Medical Record (EMR): An
EMR is a consolidation of structured
and unstructured medical data for a
given individual. A digitised version of
the healthcare reports and prescriptions
will help in continual treatment giving
quick access to a patient’s healthcare
history.
Patient Profile Analytics: This
advanced analytics when applied to
patients’ profile can help identify any
impending health risks and facilitate
preventive care.
Fraud Analysis: Effective data analytics
can reduce fraud, waste and abuse by
thorough analysis of claim requests and
identifying claims with incorrect and
incomplete information well before
submission.
Safety Monitoring: Data analytics can
A few studies forecast
Indian medical
technology market to
grow from US$2.7 billion
in 2008 to US$14 billion
in 2020.
help in safety monitoring and negative
event prediction by real time analysis of
large volumes of data in hospitals.
Baby Steps of IT in Healthcare
While the World Wide Web came
about in the late 1900s, Gustav Wagner
had already foreseen the need for tech-
nology in healthcare and came up with
a professional organisation for health
informatics in Germany. The platform
Health Information Technology (HIT)
created by him is dedicated to proc-
ess information using hardware and
software. HIT is beneficial in storing
and using information on healthcare,
data and knowledge to communicate
and help make decisions. The platform
utilises communication and comput-
ers to build systems and share health
information.
In early 1990, the United States
healthcare industry started to be driven
by competition. Many households
and industries resorted to using ICT
as momentum in Internet usage grew.
This gave rise to the need of adopting
IT in healthcare. Even though it started
only with helping the service provider
with process-oriented systems, the focus
eventually shifted to being a patient-cen-
tered and outcome-oriented platform.
In the late 1990s, the need for more
integrated healthcare facilities, provid-
ers, and better managed care offerings
was felt in the healthcare BPO industry.
Information Technology
Year 2000 saw the use of technology
to increase productivity. Electronic
Medical Records (EMR) started being
adopted. The HIPPA Act which was
passed in late 1990s, brought in a
greater emphasis on EMRs and EHRs.
With continuous flow of information,
it created a platform for global digital
healthcare infrastructure. Cloud
computers along with cloud-based
big data analytics came together and
became the driving force for customer
requirements for value added services.
At the same time, Health Information
Exchanges (HIEs) earlier referred to as
RHIOs (Regional Health Information
Organisation) came about.
Need for IT in Healthcare
The Indian Brand Equity Foundation
(IBEF) states that India is considered to
be the largest Information Technology
(IT) sourcing destination in the world.
It accounts for approximately 67
per cent of the US$124-130 billion
market, with about 10 million workers.
India’s USP, according to the report, is
its cost competitiveness in providing IT
services. This accounts for services being
approximately four times cheaper when
compared to the United States. The
recent change observed is in the growth
of intellectual capital in the country
with a number of global IT firms setting
up their innovation centers in India.
The emergence of IT solutions
in healthcare is a consequence of the
need to improve outcomes and slash
costs. But, this process is heavily data-
intensive. The need to protect data
came along with the changing process.
IT started playing an important role in
the healthcare sector in late 1960s when
the techniques to utilise its advantages
recognised. This was when hospitals
and healthcare providers understood
the need to save data digitally.
The benefits of this are many: it
eases access to patients’ medical histories
during follow-up; with data being saved
in the cloud, it can be accessed from
anywhere. Likewise, IT has also made
www.asianhhm.com 51
Information Technology
medical billing easy and accurate. With
the help of medical coders, the hospitals
are able to utilise their resources
optimally and not engage them with
the process of manual billing.
Use of Electronic Health Records
(EHRs)
How many times have physicians
opened a file containing lab reports and
prescriptions without dropping any
of them? While handwritten prescrip-
tions have been a norm since ages, their
drawbacks are aplenty. Apart from the
trouble in analysing the content on the
prescription, papers are difficult to store
as they age with time. Sometimes, they
also get misplaced which leads to loss
of valuable data. They also cannot be
accessed with ease at any given point in
time. However, data that is stored digit-
ally can be accessed anywhere through
cloud. The format in which it is stored
is also understood by everyone. This
data will remain there till such time it
is manually deleted. And in case data
is lost, there are many ways to retrieve
the same.
The format maintained in an EHR
is better organised than paper charts
or prescriptions. EHR also gives a
consolidated list of complications such
as major illness, surgeries, allergies and
medications that should not be missed
during follow-up care or consultation
for any other ailment.
One study notes that 25 per cent of
paper charts are usually found missing.
Even in the presence of papers, specifics
were missing in 13.6 per cent of times.
President’s Information Technology
Advisory Committee reported that they
found 20 per cent of laboratory tests
being re-ordered as previous medical
records were not available.
This makes it important for hospi-
tals to maintain records digitally.
To find out how digitising patient’s
medical history has improved the effi-
ciency of hospitals, Harris Poll, on
behalf of Ricoh Americas Corpora-
tion, conducted a survey. His subjects
52 A si a n H o s p i t a l & H ea lt hcar e M an age me n t
included 2,053 adults in the United
States in 2015. He found that 74 per
cent hospitals that used digital plat-
forms such as tablets or some mobile
devices to store patient’s information
were more efficient. He also found
54 per cent patients to be less anxious
when they found healthcare providers
to be using digital platforms for data
collection.
Improving Revenue Cycle
Management
While there is a need for affordable
healthcare, the changing regulations
and the delayed cash flow directly
impact the revenue generated by
healthcare facilities. Data is much more
than the final outcome of analytics for
a healthcare provider. It involves a lot
of cost to a company where they would
have to employ resources to take care
of all the aspects from on-boarding a
patient to ensuring that all the data
about them is well-maintained.
Innovative use of analytics can
help these hospitals gain deeper
understanding of the techniques to
create quick, accurate, efficient and,
most important of all, predictive
revenues.
During the consultation process, a
lot of iterations take place in claims.
They are denied for a number of
reasons. Things that usually go wrong
ISSUe - 37 2017
include incorrect claims submitted to
payer; sometimes the information given
doesn’t turn out to be authentic, and
there would be additional negotiations
in the process. The increasing number
of iterations impacts the account
receivable cycle. This further impacts
profits.
With a sound RCM process
in place, top reasons for claim
denials such as incorrect patient
demographics, eligibility issues and
prior-authorisation numbers, can
be mapped and a pre-check can be
conducted to eliminate any possibility
of denial scenarios. Any information
found to be incomplete can be updated
immediately and resent so that there
is no time lag because of lack of
information.
The analysis of historic data to
understand the time and effort put
in to recover underpaid claims can
help understand the need for better
strategies. For example, if the spent
time does not justify the recovered
amount, a strategy to automate the
process can be devised thereby helping
in optimal use of available human
resources.
These insights will also help a
service provider set a threshold limit on
the revenue collection and determine
transactions for follow-ups beyond the
thresholds.
 Information Technology

The combination of data and its
analytics play a key role in revenue
cycle management process. They help
unearth hidden and previously unseen
insights to manage the revenue flow
more accurately and provide results
leading to profit generation for
healthcare providers.
Predictive Analytics (PA)
Here a combination of statistical methods
and technology are used to analyse large
amounts of information and predict
outcomes for individual patients. With
the help of predictive analytics, there is
a systematic process to monitor supply
chain efficiencies and improve patient
care, chronic disease management and
hospital administration. The use of this
analytical tool is fast gaining popularity
as healthcare systems explore how to
best use it to make improvements.
Predictive analytics is most useful
when both the predictor and the care
intervention are integrated with the
same systems. It is easier to identify
trends and obtain best results. Data
can be compared to analyse the
outcomes for all the diseases that a
healthcare provider could encounter.
Physicians and insurance companies
rely on predictive analytics for extensive
research and statistical analysis that can
range from improvement of patient’s
health, post medication, to their
readmission rates.
Health Information Privacy and
Security
Privacy is a fundamental governing
principle of the patient–physician
relationship for efficient delivery of
healthcare. Patients need to share
information with their doctors to
of time, a patient‘s medical record has a
collection of personal information that
includes identification, past medical
history, digital record of medical scans
etc. Safeguarding such data is a necessity
and companies do all that it takes to
protect the data.
Understanding the operational
effectiveness of data disclosure
technology from the field may help
hospital administrations refine
disclosure policies, as well as choose
appropriate data disclosure technology
solutions.
With the storage and access to
patient information becoming more
digital, and utilisation of Big Data
and Predictive Analytics, the security
and safety of such information in
compliance with various government
regulations becomes more critical.
Protecting the privacy of clients’
patient data is a core operating principle
at Omega Healthcare. The number one
objective of the company is to help
hospital and health systems improve
outcomes, and as a precursor to that
objective, priority is given to the security
of their data. Omega achieves this by
creating a culture with a deep focus on
HIPAA compliance through a security
awareness program. This programme
includes mandatory, rigorous HIPAA
training for new employees, regular
refresher trainings, monthly newsletters
with a focus on security, and on-going
dialogue about best practices.
We also instill an understanding
of exactly why we are working so
hard to protect data. HIPAA’s Privacy
Baskaran Gopalan comes with over seventeen years of experience
in the healthcare billing industry. He has managed operations for
hospitals and large physician groups in the past and possesses
Author BIO
and Security Rules are designed to
protect patients’ civil right to privacy.
Healthcare providers often feel a sense of
ownership over PHI because they work
so closely with it and are responsible
for its protection. This can happen
with vendors also. Our commitment to
protect and secure PHI stems not only
from our responsibility to our clients.
We also emphasise to employees that
PHI really belongs to patients, and it’s
our responsibility to protect patients’
privacy.
In addition to creating a culture that
focuses on the security and privacy of
PHI, our technology plays a significant
role in preventing data breaches.
Technology features such as tracking
and audit trails and features to protect
physical security of the data ensure that
patient information remains secure and
HIPAA-compliant.
The use of various business intelligence
tools makes data open to threats. At
Omega Healthcare, data is protected
from Internet threats using a firewall that
is configured in High Availability mode
and filters the data packets coming in
and going out of the company network
according to predefined access rules. The
firewall has three layers - the first layer is
Gateway Antivirus which checks for virus
and spam. After this the data is filtered
through Real Time Blacklist which is the
second layer and then filtered through
IDS/IPS which is the third layer for any
unknown signatures. Further, content
filter is used for securing HTTP and
HTTPS traffic. All the firewall logs are
reviewed and guarded.

facilitate the right diagnosis and

effective treatment, especially to avoid
selective drug allergy. However, patients
might not be comfortable in sharing
important information in cases of
health problems such as mental illness
and HIV as their disclosure may lead
to social discrimination. After a period
in-depth domain knowledge of the US healthcare industry, with a
special focus on Receivables Management.
Baskaran also has expertise in Quality Assurance processes and
client management having more than 8 years of experience at
other India-based Healthcare BPO/KPO organisations. Baskaran
joined Omega in its early months and has since then nurtured
India operations with some of the best industry practices as well as
fostered a culture of team loyalty.

www.asianhhm.com 53
Information Technology

HealthTech Innovation
Optimising telehealth services
Telehealth access to patient images, via technology that
supports secure, fast, diagnostic-quality image access
without moving image data, significantly improves patient
outcomes for both acute care and non-acute care.
Dave Waldrop, Co-CEO/CRO, Calgary Scientific

T
elehealth combines to-provider connections, telehealth value of telehealth for both non-acute
communications tools and improves outcomes, lowers costs and and acute care situations. In case of
health IT, thus enabling supports care coordination. the former, including patient images
healthcare delivery to bridge distance These benefits, which are spurring allows providers to share the full
and time and provide high quality adoption of telehealth across the globe, patient picture improving care. In
care irrespective of where the patient are magnified when images are added acute care situations, such as stroke,
is located. Through anytime, anywhere to telehealth encounters. This article images provide critical information
provider-to-patient and provider- looks at how imaging increases the that saves lives.

54 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017


Delivering Care Through Telehealth
is Reaching A Global Tipping Point
Worldwide adoption of telehealth as a
method of delivering care is growing.
While North America accounts for
about 41 per cent of the global telehealth
market, the market in Asia is expected to
grow at a CAGR of 12 per cent through
2020, according to a report from
US-based analyst firm Frost & Sullivan.
In Asia, telehealth modalities being
used include real-time telemedicine
encounters, remote patient monitoring
and mobile health. While adoption
is not moving as quickly as expected,
Asia-Pacific governments are building
the foundation to drive its adoption by
investing in infrastructure, such as nation-
wide 3G and 4G access, developing
telehealth and eHealth roadmaps, and
creating policies that directly or indirectly
attract investment in health technology,
reports Frost & Sullivan.
Like the North American market,
telehealth is an important tool for
delivering care to the increasing global
incidence of non-communicable diseases,
including cardiovascular and metabolic
disorders, cancer, diabetes, Alzheimer's
disease and other neurological disorders.
The appeal of telehealth to providers
is that it improves access to care
and supports communications and
collaboration without changing the actual
care. “We are not changing the clinical
service, but rather how, when and where
such service is conveyed,” explains Alexis
Slagle Gilroy, a partner at the law firm
Jones Day and American Telemedicine
Association board member.
As telehealth adoption grows, it is also
projected to save money. An analysis of
recently introduced telehealth legislation
targeted at expanding reimbursement
showed that some of its provisions
could save the U.S. government US$1.8
billion.
“Telehealth is the future of
healthcare. It expands access to care,
lowers costs, and helps more people
stay healthy,” U.S. Senator Brian Schatz
said in a statement in May 2017.
As a tool for bridging
both time and distance,
telehealth solutions need
to include access to
images from any place
on any device, whether
desktop, laptop or mobile.
Telehealth is Digital Health too
Like virtually every aspect of
modern healthcare, the foundation
of telehealth is digital. As a digital
tool, telehealth enables providers to
harness digital health data and share
itto overcome barriers and break down
communications silos. In fact, at large
hospital and health system campuses
telehealth is sometimes used to facilitate
cross departmental communications.
Whether telehealth transactions
span a hospital campus, city, state,
country, or globe, one key to their
optimisation is the integration of digital
patient images. Telehealth delivers
care through real-time (synchronous)
connections and through store-and-
forward (asynchronous) connections.
Integrating diagnostic quality image
sharing into both synchronous and
asynchronous connections optimises
the benefits of telehealth for both
non-acute and acute patient care.
In non-acute care situations,
enabling providers to share patient
images during telehealth transactions
improves coordination between
providers and significantly increases
patient access to care. For acute care
situations combining provider access
to images with telehealth saves lives.
In all cases, imaging rounds out the
picture of patient needs, providing
critical information for diagnosis and
treatment.
Information Technology
Telehealth and Image Sharing for
Nonacute Care: Lowering Costs and
Enabling Collaboration, and Care
Coordination
Imaging is expensive and made more so
by redundant, repeat imaging. Accord-
ing to a recent joint Healthcare Infor-
mation and Management Systems
Society (HIMSS) and Society for Imag-
ing Informatics (SIIM) white paper,
diagnostic imaging accounts for 10
per cent, or US$100 billion, of annual
healthcare spending in the US Almost
9 per cent of this imaging is repeat
imaging, which often happens when a
patient has been referred to a special-
ist who cannot access the images at the
referring provider’s location. As a result,
specialists often have to reorder image
studies creating an unnecessary cost.
In non-acute care situations,
telehealth solves this problem by
enabling referring providers to share
images with a specialist along with a
referral for a consult. This telehealth
method of connecting specialists
with providers, called e-consult, uses
web-based, electronic communications
to enable a primary care provider to
contact a specialist regarding a patient
issue. Related patient images are
forwarded with the communication,
enabling the specialist to determine if
an in-person visit is required and then
to have the images on hand for the
in-person consult if one is called for.
By providing both critical
information and a communications
link between primary care providers
and specialists, e-consult also solves the
problem of so-called “referral silence”
between primary care providers and
specialists. In a study published in
the Archives of Internal Medicine,
69 per cent of primary care physicians
said they send specialists notification
of a patient's history and the reason
for the consultation all or most of
the time and just 34.8 per cent of
specialists said they routinely receive
such information. E-consult, helps to
minimise this issue by enabling referring
www.asianhhm.com 55
Information Technology
providers to share as much information
as they can, including images, in the
communication.
Telehealth and imaging also
form a powerful tool for addressing
management of chronic disease. The
leading cause of blindness in the U.S.
is diabetic retinopathy. While early
detection of retinal complications can
decrease the risk of blindness by 95
per cent, long waits for access to
specialists has resulted in an high rate of
diabetic retinopathy among uninsured
patients, shows a study in JAMA
Network Internal Medicine.
To solve this problem among the
uninsured safety net population in Los
Angeles County, primary care providers
take images of patient retinas using
retinal cameras and then share those
images with optometrists via e-consult.
After reading the images, optometrists
would make recommendations for the
patient to see a specialist or not. This
process decreased the wait times for
screenings by 90 per cent, which before
the implementation of the telehealth
process was five months. The results of
the study show that this integration of
imaging with telehealth delivers patient-
centred, coordinated care.
Image Sharing Via Telehealth for
Acute Care: Saving Lives
Image sharing via telehealth in acute
care situations not only delivers the
same benefits provided in non-acute
settings, but also provides critical life-
saving benefits. When faced with urgent,
severe and complicated conditions such
as stroke or head trauma, emergency
care providers need real-time access
to neurologists and other specialists.
Telehealth provides the real-time access
for patients in remote or rural settings
and images provide the key patient data
that enable neurologists to make timely
diagnoses.
When a patient with head trauma
arrives in an emergency department the
first step is a CT scan. The next step is
to get those images to a neuroradiologist
56 A si a n H o s p i t a l & H ea lt hcar e M an age me n t
for reading and diagnosis. If the
patient is in a rural location or it’s
2 a.m. in an urban setting, access to
a neuroradiologist typically happens
via a telehealth connection. Once
the connection is made, the remote
neuroradiologist must access the
images to make a care decision, such as
whether or not to transfer the patient to
a trauma centre.
If specialists have access to patient
images during a real-time connection
with the emergency providers, they
can make decisions about transferring
the patient or not, saving the costs of
unnecessary transfers. In addition,
if a patient transfer is required real-
time image access allows the receiving
trauma team to view the images before
the patient arrives to prepare and saving
the costs and time required for repeat
imaging.
Revolutionising Stroke Care with
the Integrated Imaging and Real-
Time Communications of Telestroke
Stroke is the leading cause of death
and the third leading cause of disability
worldwide,making time critical to its
treatment. Telestroke, which combines
real-time access to images and video
communications, is a truly revolutionary
method of delivering care that impacts
global population health. For the
ISSUe - 37 2017
15 million people who suffer a stroke
annually in across the globe, today their
chances of surviving are significantly
improved thanks to the use of telestroke
and advanced medications.
As stated in a recent study on the
state of telestroke published in Journal
of NeuroInterventional Surgery, “The
mismatch between the distribution
and incidence of stroke presentations
and the availability of specialist care
significantly affects access to care.
Telestroke, the use of telemedicine for
stroke, aims to surmount this hurdle
by distributing stroke expertise more
effectively, through video consultation
with and examination of patients in
locations removed from specialist care.”
In the US, about 20 per cent of the
population live in rural areas without
access to either primary or specialist care.
When a patient with stroke symptoms
arrives in an emergency room or clinic
in one of these rural areas, there’s a good
chance the doctor who saves their life
will be located hundreds of miles away
and providing diagnosis and treatment
via telestroke.
The likelihood is strong that their
life will be saved and often they’ll walk
out of the hospital virtually intact
thanks to the enabling capabilities of
telestroke technology, which has at its
heart image sharing between emergency
room providers and remotely located
stroke neurologists. By sharing images
with remotely located stroke specialists,
emergency room providers are able
to get a diagnosis without having to
transfer a patient over long distances.
Stroke specialists will also give orders,
when appropriate, to administer tissue
plasminogen activator, or tPA, to break
up stroke-causing clots.
Patients must be given tPA within a
three-hour window of a stroke’s onset.
Patients that receive tPA often have
very limited physical impact from the
stroke, leading to both less time in the
hospital as well as much less time in
rehabilitation facilities, if they require
rehab at all.
 Information Technology

Follow up care is also made easier
when images can be shared with
primary care physicians, allowing
them to collaborate and communicate
clearly with the care providers after
a stroke. Telestroke has proven so
effective that during 2015 its use grew
38 per cent among hospitals in the
United States.
A 2016 study conducted by US
healthcare firm Kaiser Permanente
examined the outcomes for 2,500
patients diagnosed with acute ischemic
stroke. The results of the study showed
a 75 per cent increase in timely use of
the clot-dissolving drug tPA following
telestroke consultation. Patients
treated via telestroke also received their
diagnostic imaging test 12 minutes
sooner, and the drug was administered
11 minutes sooner, decreasing the
so-called door-to-needle time, or time
from arrival to administration of tPA,
to less than an hour.
“Particularly in hospitals with
limited local resources and/or limited
access to neurologic expertise, telestroke
is an important tool to aid in the
evaluation and treatment of potential
stroke,” reports the study. The study
also found that telestroke reduced
variability in stroke care, enabling
consistent outcomes.
For stroke neurologists, the imaging
is key to their ability to make the right
diagnosis for the patient. Working
without the images and the real-time
video links of telestroke is like “flying
in the dark,” says Andrew D. Barreto,
MD, associate professor of neurology of
UTHealth in Houston.
The Business Case for Telestroke
Models The Value of Patient Image
Sharing
Telestroke networks are structured
for both the hub and spoke locations.
As reported by HIMSS, timely
access to tPA enabled by telestroke
been shown to be economically benefi-
cial, saving millions of dollars each year.
Patients treated with tPA experience
lower healthcare costs, reduced disabil-
ity, and fewer long-term care needs.
With the direct costs of stroke reach-
ing US$30 billion a year, the improved
outcomes and long-term cost savings of
telestroke offset its upfront costs.
The other value telestroke brings
to hospital networks and healthcare
systems is that it can provide a model
for other applications of telehealth that
incorporate patient images. The close
collaboration between a spoke hospital
and the hub provider builds a partner-
ship and workflow that can be applied
to other types of care, such as head
trauma or cardiac care, which increas-
ingly uses cardiac CT for diagnosis.
Image Sharing Technology used
in Telehealth Requires Anytime,
Anywhere Access to Diagnostic
Quality Images Without Moving or
Copying Data
Image viewing technology used in
telehealth systems needs to support
several critical features. First, image
viewing tools must provide anytime
access from any device, including
desktop, laptops, tablets and
smartphones, so that no matter where
patients are located providers can use
the device at hand to view images.
In addition, the image viewer
must have appropriate accreditations
for diagnostic use. In acute patient
care settings, diagnostic clearance is
particularly critical because providers
have neither the time nor expertise to
Author BIO
interrupt their workflow to determine
whether the the tools they are using
are safe for diagnosis, notes Ryan
Minarovich, a lawyer and consultant
with the Tenzing Group which
specialises in regulatory compliance for
digital and mobile health products.
"Today's physicians have so many
tools and so much information at
their fingertips that it’s important
to guard both doctors and patients
from inappropriate use,” explains
Minarovich.
Most importantly, image viewing
technology must provide diagnostic
quality image access on any device
without requiring the transfer of image
data from one system to another.
Keeping image data on its originating
site is critical to modern healthcare for
several reasons. Modern patient images
are very large and providing access to
image data without moving it saves
time. In addition, this approach allows
maintains the protection and safety
of patient data by ensuring it stays on
the secured originating system and
isn’t transferred to less secure mobile
devices.
Conclusion: Integration of Patient
Images Increases Value of
Telehealth
Imaging is a critical component of
patient care. As a tool for bridging both
time and distance, telehealth solutions
need to include access to images from
any place on any device, whether
desktop, laptop or mobile. Without
image access, the ability of telehealth to
lower costs, improve care and save lives
is cut short. To provide quality care,
providers need access to a full patient
picture, images included.

around a hub and spoke system, with
urban or academic medical centres
providing the hub of expertise to spokes
of rural and remote care centres. While
telestroke systems can be expensive to
implement they deliver significant ROI
Dave leads global sales and marketing and is responsible for stra-
tegic corporate and operational decisions. Dave has been leading
global sales and marketing teams at the executive level for over 25
years, spending 18 years with Microsoft where he was a key driv-
er in building company wide initiatives in business development,
product marketing and sales roles.

www.asianhhm.com 57
Information Technology
E
lectronic Health Record (EHR)
is a life-long record of all the
clinical encounters, investigation
results and reports, etc., that a particular
person has throughout life. All of these
clinical documents need to be lined
up and merged together into a single
continuous document to help provide
that person’s health-related life journey.
Thus, there is a need to ensure that the
consolidation of the related clinical
documents of that person is made
possible in a seamless manner. This
requires that all electronic systems that
generate the various clinical documents
58 A si a n H o s p i t a l & H ea lt hcar e M an age me n t
of a uniquely identifiable person be
interoperable.
If merely displaying contents from
other systems was the requirement,
the need for extensive interoperability
would have been superfluous since
the external records could have been
made into something like a scanned
document in the form of JPEG image
or PDF file and having it displayed
would have been sufficient.
Such use, however, is severely limited
in scope and does not justify the use of
valuable computing resources as the
needs are much more. These include the
ISSUe - 37 2017
ability to analyse contents, help trigger
important actions that could potentially
be life-saving and automating routine
repetitive tasks are some of the more
meaningful use of electronic medical
records, all of which are possible only
through interoperability.
What is Interoperability?
Interoperability
Interoperability is defined as the
ability of two or more systems or
components to exchange information
and to subsequently use it. This is made
possible by taking advantage of both
 Information Technology

EHR Interoperability
Why, what and how
The ability to merge data from clinical documents like Electronic Medical
Records (EMR), investigation results and reports, medical reconciliation,
nursing records, operative notes, etc. authored by different persons at
various times at diverse locations using disparate electronic systems from
many manufacturers is critical to the creation and maintenance of lifelong
electronic health records of an individual. For this, both the structure and
contents need to be available in formats that can be properly processed
by electronic systems to ensure that the right contents are matched and
merged into a single life-long record. Interoperability is what makes this
possible. This article discusses the why, what and how it can be achieved.
SB Bhattacharyya, Head, Health Informatics
TCS Member, National EHR Standardisation Committee, MoH&FW, Govt. of India Member
IMA Standing Committee for IT, IMA Headquarters

the structuring of the data exchange
(syntactic interoperability) and the
codification of the exchanged data
itself including vocabulary (semantic
interoperability) so that the receiving
information technology systems are
able to properly interpret the data for
further action.
Syntactic Interoperability
Syntactic interoperability defines
the syntax of the data exchange and
ensures that such exchanges between
information technology systems can be
interpreted at the data item level and is
achieved through the use of a common
information exchange reference model.
Consequently, these standards specify
either the record structure or the data
exchange (messaging) formats.
Semantic Interoperability
Semantic interoperability is the ability to
automatically interpret the information
exchanged meaningfully and accurately
in order to produce useful results
as defined by the end-users of the
respective systems. This is achieved
using a clinical code system, whose
contents are unambiguously defined
and coded, to ensure that the meaning
of the information, as present in the
sending system, is identical to that
interpreted by the receiving system.
Why is Interoperability required for
EHR?
Persons have many encounters with
different care providers throughout his
life for the various illnesses they happen
to suffer from or for receiving help in
prevention and/or monitoring them.
Each encounter leads to the creation of a
single medical record. To help maintain
a life-long record of the progression of
one’s health, it is necessary to firstly
uniquely identify all records belonging

www.asianhhm.com 59
Information Technology
to the same person, then arranging
them from the very first to the very
latest, and thereafter understanding
their contents that have been created by
many authors using a wide-variety of
systems from different manufacturers
before consolidating them all together
into a single record.
Further complicating matters is
the fact that these records are usually
made by different persons who work in
various speciality areas like paediatrics,
medicine, ENT, ophthalmology, skin,
surgery, obstetrics and gynaecology,
etc. Due to the specific demands of the
various medical sub-domains, all of these
require different types of information to
be recorded in a particular way. Topping
all this is the inescapable reality that
each of the authors usually has a very
unique style of record writing as a result
of their medical training.
How can this be made possible?
Fundamentally, any type of record
consists of two parts: (1) the structure,
containing the individual data items
along with their corresponding data
types, data lengths and data formats,
60 A si a n H o s p i t a l & H ea lt hcar e M an age me n t
and (2) the content filled in by the
authors.
Since the record contents created
and maintained in one system needs
to be exchanged with and ‘interpreted’
by another system, a way needs to be
found whereby the other system is able
to correctly perform these tasks. This is
done by aligning the structure of the
records in the two systems and then
‘interpreting’ the exchanged contents.
There are two ways of aligning the
record structures. One would be to use
a common information framework for
exchanging data. The other would be
to use a common messaging framework
that can be mapped to by the systems
participating in the data exchange to
correctly identify the exchanged data
items.
Solving the structural issues is
simpler when compared to solving the
content issues. Not only do these need
to be accurately exchanged, but their
meaning too needs to be preserved and
subsequently ‘interpreted’ by the system
for further action. This translates into
the requirement that the content needs
to be in the form of some machine-
ISSUe - 37 2017
processable ‘code’. This ‘content coding’
is carried out through concept modelling
using principles of linguistics, computer
and information science.
These two types of models, namely
the information model and the concept
model, are based on the model of
meaning of the data item in context.
Both of them need to be considered
together for precisely deriving what the
author meant when making the record
entry.
Model of meaning
The ‘model of meaning’ is a human
conceptualisation of the world and
its contents. This is done using an
information model (model of the
information) and a concept model
(model of the concept) in order to
ensure that a data/record item, is clearly
understood by both humans and
machines alike, so that further action
may be undertaken as necessary by
either.
Information Model
An information model provides a
sharable, stable, and organised structure
of the information requirements or
knowledge for the domain context.
At a very basic level, it is a structure
that serves the syntactic aspects of
interoperability. This can be used for
designing records or data exchange
messages.
Concept Model
A concept model provides a way in
which information knowledge can be
represented and subsequently codified,
thereby serving the semantic aspects of
interoperability.
Example – Handing “Title” of a
Person’s Name
[NB, the following discussion related to
the data item ‘Title’ is purely imaginary
and has been provided here to help
illustrate modelling concepts.]
It is important to recognise that
when writing a record, one enters the
thought that one has about the item
in context. In the case of ‘Title’, this
would be ‘Mr’ if the person is a male,
‘Ms’ if the person is not a male,’Miss’

if the person is an unmarried female or
‘Mrs’ if the person is a married female.
This concept or thought or idea
(all synonyms), is modelled by making
a knowledge representation of the
human-readable term ‘Title’, which
is then transformed into machine-
processable code. This could result in
the following.
• Title is a part of Person Name
• Title is
a. Mr, when the person’s gender is
male
b. Ms, when the person’s gender is not
male
c. Mrs, when the person’s gender is
female and marital status is married
d. Miss, when the person’s gender is
Information Technology
female and marital status is unmar- user has chosen the title as ‘Mr’ in this
ried instance. [The structure is shown in
The above is what can be termed two different styles – JSON and XML,
as ontology. By applying Description currently the most commonly favoured
Logic to it machine-processable codes formats.]
can be generated, which the systems {
can use to interpret what the data item “Title”: “Title”,
actually means. “Type”: “String”,
The ‘title’ data item in a record “Value”: Mr
can be structured by using the or
followinginformation model. <title: string>
Mr
Title: string 0..1 </title>
This means that ‘Title’ is of the data type }
‘string’ and can be used either never (0) In the above, the section enclosed
or once (1), i.e., it is optional. by curly brackets ‘{}’ or tags “<></>” is
The above could be exchanged the structural (syntactic) part and the
as a message as structured below. The ‘Mr’ is the content (semantic) part.
www.asianhhm.com 61
Information Technology

If both the sending and receiving
systems use the same structure for
storing/exchanging data, there will be no
problem in achieving interoperability as
the data item will be correctly matched
up (both the data items are named
exactly the same, have the same data
type (text in this case) and convey the
meaning about the same thing (person’s
title in this case).
Using the above, a computer
system would be able to interpret the
term ‘Mr’. Supposing the system is
programmed to execute the rule that “if
the title is ‘Mr’ then automatically fill
in the person’s gender and ask the user
to enter the marital status else if the
title is ‘Mrs’ or if the title is ‘Miss’ then
automatically fill in the person’s gender
as well as the marital status” then the
system can accurately carry them out.
Although this example demonstrates
how a simple concept like the title
part of a person can be handled, by
adopting the same principle to handle
complex concepts like complaints of
productive cough-green sputum, on
examination-grossly enlarged liver,
diagnosis of recurrent appendicitis,
procedure of laparoscopic emergency
appendicectomy using flexible fiberoptic
laparoscope, assessment of eating and
drinking behaviour, family history
of chronic obstructive lung disease,
etc., presents immense possibilities for
very detailed rules to be put in place
to automate ordering, prompt for
additional information, etc.
Using well-proven and
widely available standards,
interoperability is no more
the maze that it was once
considered to be.
the provider observes like vital signs,
physical findings, etc.), Assessment
(things that the provider concludes like
clinical summary, diagnosis, etc.) and
Plan (things that the provider decides
will prove most effective in alleviating
the patient's condition like medications,
diet, etc.).
SNOMED CT is the most
comprehensive clinical code system
currently available that permits
unambiguously coding of all parts
of clinical documents. It ensures the
maintenance of semantic integrity
through its Machine Readable
Concept Model (MRCM), which is a
representation of the rules that comprise
the SNOMED CT Concept Model in a
machine-processable form.
The other clinical code systems
happen to be WHO Family of
International Classifications (ICD,
ICF, ICHI, ICD-O), LOINC, CPT,
CDT, DRG, NANDA, RxNorm,
ATC, etc. that address parts of clinical
document like diagnoses, investigation
observations (results), procedures,
diagnostic group, medication, etc.
Conclusions
A medical doctor is as effective as the
body of information about the patient's
health condition is available to him.
While neither everything is required
nor is necessary (mostly due to lack
of relevance of the information to the
patient's current clinical status), more
and detailed than less and sketchy is
always preferable in providing optimal
care – both from diagnostic and
prognostic points of view.
Interoperability is a serious issue and
is neither easy to understand nor easy
to implement. However, it cannot be
avoided either since without it no EHR
can be generated and/or maintained in
any shape, manner or form.
Using well-proven and widely-
available standards, interoperability
is no more the maze that it was once
considered to be. By following good
systems design practices and using
standards, truly interoperable EHR
systems can be made available to help
achieve universal health coverage.
References are available at www.asianhhm.com

How does SNOMED CT,ISO 13606,

Open EHR, HL7, etc. Help?
ISO 13606, open EHR or HL7 are Suman Bhusan Bhattacharyya is a practising family physician and
basically information models that can a business solution architect for medical devices and healthcare IT
applications with nearly twenty nine years of experience. He has
be used for designing clinical records (all worked for several IT MNCs in India and is currently Head of Health
Author BIO

three) and messages (HL7 only) there by Informatics in TCS based out of Delhi-NCR region.
facilitating syntactic interoperability. Currently, he is a member of EMR Standards Committee, Ministry
Handling the clinical record of Health and Family Welfare, Government of India and is also
member of Healthcare Informatics Standards Committee, Bureau
contents is a little trickier. Ideally, of Indian Standards. His main areas of interest include clinical data
an EMR has four broad sections analytics particularly treatment protocol planning using predictive
(SOAP)–Subjective (things that the analytics, EHR& EMR, mobility applications and application of ma-
chine learning techniques in healthcare.
patient states like chief complaints,
history, etc.), Objective (things that

62 A si a n H o s p i t a l & H ea lt hcar e M an age me n t ISSUe - 37 2017

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