Asian Hospital & Healthcare Managment - Issue 50

P R O U D L Y

I S S U E 50

2020

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Headway to Revamp Hospital Logistics Healthcare Accountability for Sustainable Care

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Foreword Yesterday, Today, and Tomorrow Our journey with healthcare A look at the global healthcare landscape indicates how the COVID-19 pandemic has exposed the weaknesses that exist in present-day health systems. It is clear that sustainable health remains a goal that is far from being achieved, what with quality of healthcare and equitable care being a common challenge for countries irrespective of their economic development.

The World Health Organization (WHO) had developed a framework in 2016 outlining key strategies that contribute to a fundamental transformation of healthcare and help countries in developing people-centric, sustainable health systems. These include engaging and empowering communities in building an integrated care system, strengthening governance and accountability, reorientation of care prioritising people’s needs, integrating inter-disciplinary medical care with social care, and most importantly creating an enabling environment that paves way for a transformational change. Interestingly, these guiding principles continue to be highly relevant in the aftermath of the pandemic-led crisis.

According to a WHO study, global healthcare spending is expected to be around US$8.7 trillion by end of 2020 with Asia-Pacific contributing to US$2 trillion indicating the highest annual growth rate from 2015. As high-quality universal health coverage gains paramount importance, it is critical to strengthen health systems by improving agility and building reserve capacity. The pandemic will further spur the growth of digitisation in healthcare, as we witnessed many countries willing to or making use of medical technology and digital platforms to deal with the health emergency. A study by Roland Berger suggests that digital products and services could contribute to 12 per cent of overall healthcare spending by 2025.

Experts from the Global Future Council on Health and Healthcare, an initiative of the World Economic Forum, have recently come up with a series of

stories that throw light on the importance of and the need to build sustainable, patient-centric health systems that are more resilient to improve the quality of global population health. In the post-pandemic era, we can expect to see healthcare organisations focus their efforts into improving efficiency through resource optimisation and reducing costs to develop sustainable health systems that provide high-quality care with better patient outcomes.

Our journey to the 50th issue In 2006, it all started with the idea of launching Asian Hospital & Healthcare Management (AHHM) a healthcare publication that offered reliable and accurate coverage of the sector by covering issues, trends, and technologies shaping the healthcare industry. We launched AHHM as a bi-annual print publication—meant for key decision makers and influencers—that carried out insightful analysis and topical articles from industry leaders, academicians and sector thought leaders. The magazine generated huge interest in readership and circulation pushing the need to making it a quarterly publication by 2008, with both physical and digital versions available for the readers then on.

It gives me immense pleasure to share with you the landmark 50th issue of this magazine. On behalf of the entire publication team, I take this opportunity to thank the authors, advisory board, clients and partners who have extended their unwavering support in our journey so far. We will continue to deliver the most insightful and relevant content to serve your information needs and help you stay ahead of competition.

Prasanthi Sadhu

Editor

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C O N T E N T S

COVERSTORY

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MEDICAL SCIENCES 36 Infectious Diseases, Chronic Disease and Prevention Gurrit K Sethi, Hospital COO, Care Hospitals

40 COVID-19 from Bench to Bedside Why deep understanding of human physiology may help doctors deter the virus?

CASESTUDY

Robert Skalik, Consultant Cardiologist, Exercise Physiologist, Senior Lecturer in Human Physiology, Wroclaw Medical University

46 Project Kavach A shield of protection in the battle against covid-19 Sangita Reddy, Jt. Managing Director, Apollo Hospitals

FACILITIES & OPERATIONS MANAGEMENT 48 Headway to Revamp Hospital Logistics R B Smarta, Chairman & Managing Director, Interlink Consultancy

INFORMATION TECHNOLOGY 52 The Overlooked Price of Healthcare Digitalisation Power management continuing to be a big challenge Mervyn Lim, Vice President, ResMed Asia

Rich Farrell, Director, Cloud & Data Centre Segment, Electrical Sector, APAC, Eaton

56 Telepathology for Remote Unreached Communities Feasibility during public health emergencies Md Jiaur Rahman, Md Moshiur Rahman, Masayuki Kakehashi

HEALTHCARE MANAGEMENT

Graduate School of Biomedical and Health Sciences, Hiroshima University

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06 Reconstructing Quality Management Implementation in Healthcare Organisations

50 ISSUES OUR JOURNEY

Uche Nwabueze, Professor, Maritime Administration,Texas A&M University

12 The Role of Nutrition in Healthy Ageing Readiness to change our approach to healthcare for the elderly David Heber, Chairman, Herbalife Nutrition Institute

22 Healthcare Accountability for Sustainable Care

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SPECIAL FEATURES 45 & 60 Books

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Home Sleep Testing The New Frontier in Obstructive Sleep Apnea Diagnosis With your practice having a fixed capacity and sleep clinics having 6-month long waiting lists,1 how do you clear backlogs instead of turning away patients.2 Home Sleep Testing (HST) is the answer. ResMed’s ApneaLink Air™ is a high-performance, reliable, and compact Type III HST device that can help grow your practice, increase workflow efficiencies, and improve patient care.

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* For Singapore, Malaysia, Indonesia, Thailand and the Philippines only. **The device is intended for home and hospital use under the direction of a HCP.- for apnea link device.

1. Sleepcentered. (2017). Sleep Test | Sleep Study | Singapore | www.sleepcentered.com.sg. [online] Available at: https://www.sleepcentered.com.sg/ [Accessed 11 Sep. 2020].

2. Nox Medical. (2020). Home Sleep Testing More Valuable Than Ever - The Nox T3. [online] Available at: https://noxmedical.com/about/news-press/article/home-sleep-testing-more-valuable-than-ever/ [Accessed 11 Sep. 2020].

The Thought Leadership Continues Online Join our webinar series where experts discuss the latest developments in sleep and respiratory care, and the best practices in providing connected care for patients. To register your interest, go to bit.ly/EA-Webinar-2

Scan the code and Breathe Easy with a specially-curated Spotify playlist.

Advisory Board

Beverly A Jensen President/CEO Women's Medicine Bowl, LLC

EDITOR Prasanthi Sadhu EDITORIAL TEAM Debi Jones Grace Jones

K Ganapathy Director Apollo Telemedicine Networking Foundation & Apollo Tele health Services

ART DIRECTOR M Abdul Hannan PRODUCT MANAGER Jeff Kenney SENIOR PRODUCT ASSOCIATES Peter Thomas David Nelson Susanne Vincent

Pradeep Kumar Ray Honorary Professor and Founder WHO Collaborating Centre on eHealth UNSW

PRODUCT ASSOCIATE John Milton Veronica Wilson

Nicola Pastorello Data Science lead BlueScope

CIRCULATION TEAM Naveen M Sam Smith SUBSCRIPTIONS IN-CHARGE Vijay Kumar Gaddam

Gurrit K Sethi Hospital COO Care Hospitals

HEAD-OPERATIONS S V Nageswara Rao

Pradeep Chowbey Chairman Minimal Access, Metabolic and Bariatric Surgery Centre Sir Ganga Ram Hospital

Associate Partner

In Association with

A member of Confederation of Indian Industry

David A Shore Adjunct Professor, Organisational Development Business School, University of Monterrey

Gabe Rijpma CEO Aceso

www.asianhhm.com | www.ochre-media.com

Peter Gross Chair, ACO Board of Managers HackensackAlliance ACO

Malcom J Underwood Chief, Division of Cardiothoracic Surgery Department of Surgery The Chinese University of Hong Kong Prince of Wales Hospital 4

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HEALTHCARE MANAGEMENT

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vidence from a structured interview of twenty healthcare quality managers suggests a lack of managerial understanding, but more importantly, the belief in the holistic nature of quality management and improvement programmes in achieving improved standards of patient care. There seems to be continued confusion as to what constitutes the implementation variables that would ensure success in driving the operations, people and strategic alliances required in a quality culture. For example, many hospitals focus on the quality assurance

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requirements of standard setting and monitoring and then think that by so doing they are implementing quality management. However, what these hospitals are actually doing is installing methods to inspect, correct and elevate medical performance rather than embarking upon an organisation-wide strategic initiative to improve quality of care and caring for patients.

The paper presents a model for the time constrained manager; a model that offers an understanding of the essential requirements for the success of quality management be it Six sigma or Total

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Quality Management in healthcare organisations.

Introduction

It is in pursuit of making quality management philosophy manifest, in making it operational and strategically useful in the modernisation of the delivery of care that practicing managers need a definitive model for guidance and for successful implementation.

To date, there are remarkably few, if any, empirical attempts made to offer an holistic implementation model of quality management and improvement

HEALTHCARE MANAGEMENT

Reconstructing Quality Management Implementation in Healthcare Organisations Quality management improvement programmes is being implemented in a vacuum, for example in a piecemeal fashion due to the fact that managerially and strategically many hospital systems lack the time required for detailed thinking, planning and execution, thus quality management programmes is seen as a political, reactive activity rather than an integrated approach to improving the quality of patient care and caring.

Uche Nwabueze, Professor, Maritime Administration Texas A&M University

in healthcare organisations; a model that would help improve the structure, systems and processes of the delivery of quality patient care, but more importantly, make the provision of healthcare affordable for the consumer.

The paucity of such models has meant that managers informed only by the generalised and limited prescriptions of the work of the gurus of the quality management: Deming, Juran, Crosby, and a few business consultants like John Oakland have adopted their own individual approaches to the implementation of quality improvement. Whilst such personalised models have the merit of affording recognition to those unique characteristics which all organisations possess, and which provide each with its own particular culture, they have the demerit of failing to ensure continuity of implementation with successive quality managers adding their own preferred definitions and approaches to what should be a comprehensive, coherent and sustained drive for enhanced quality throughout the organisation. The obvious consequence is a loss of direction and momentum and ultimately, the lack of constancy of purpose and focus.

In addition, the continued use of strategically challenged models based on subjective, and by definition, the idiosyncratic experiences of managers who have a poor understanding of the theoretical underpinnings or might one add, the tenets of operations redesign of work systems and employee engagement has invariably given rise to a fragmented internal work culture incapable of dealing with process and systems re-alignment with strategy and structure of the organisation.

Furthermore, claims are often made that if an organisation steadily improves quality, consumer satisfaction will increase and everything else will take care of itself. This assertion has given rise to the situation where organisations concentrate mainly on process improvement efforts that

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over treat symptoms and ignore root problems in inputs, throughput, and in the delivery of medical services (Eskildson, 1994). Despite the fact that the quality management literature emphasizes the need to improve patient valued outcomes, a large number of hospital systems focus instead on creating a quality management culture through organisation-wide training, self-managing teams, vision and value statements. The result is a state of confusion, long implementation time frames, frustration, resistance, and the abandonment of the program ultimately follows.

The findings of this paper are that the failure of quality in hospital systems is down to cultural, behavioural and strategic challenges because when change in how the organisation delivers care occurs, work relationships become strained and ambiguous. Furthermore, longstanding behavioural issues as it relates to poor employee attitudes and negative emotions impact job satisfaction, the ability of staff to engage with patients, and overall performance.

Strategically, due to the lack of a clan culture and employee buy-in that is required to achieve commitment and engagement of minds, hearts and souls to the visionary aspiration of ‘patientfocused’ service, quality management is cornered sadly to the mysterious graveyard of panacea that never quite delivered the goods.

Quality Gaps in Hospital Systems

Parasuraman et al (1985) and Speller (1993) identified seven gaps in their service quality model and suggested that if these gaps exist in the quality management implementation programme of an organisation that organisation is failing in the delivery of quality services to its customers. It is in this way that the paper utilised a structured questionnaire based on the Parasuraman etal (1985) model to identify service gaps in 20 hospital systems in Texas, USA. Twenty quality

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managers were asked to rate their organisation on each of the seven gaps by circling a code of 3, 2, or 1 in which 3 stands for high ranking (“we are good at this; I’m confident of our skills here”); 2 for medium score (“we are spotty here; we could use improvement or more experience’’); and 1 for low score (“we have problems with this; this is new to our organisation).

What the analysis of the twenty returned questionnaires revealed was that medical services provided at the hospitals fell short of patient expectations and they were stumbling in the dark with regard to the successful implementation of quality management.

This is not surprising given that the respondents noted that they need help with external communication with their patients and that internal communication within and between work teams, and between management and employees were a problem. Zemke and Schaaf (1989) note that “the success

The Proposed Quality Management Model for Healthcare Organisations Unlike most models that focus primarily on increasing customer satisfaction with the so called implicit assumption that it will improve organisational performance, a process focused model that is aligned with personnel agility would drive increased employee dedication and singular focus on the quality of care, quality of caring, and improved medical outcomes.

Quality should never be seen as a political game rather, it must be an integrated approach to improving the overall productivity of the organisation.

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of an organisation depends on how you treat, relate to, engage, motivate and reward your contact employees who deal directly with customers” (Zemke and Schaaf, 1989).

It was also ascertained through face-to-face interviews with the twenty quality managers other contributing factors to the difficulties encountered during implementation. The factors include: 1. Top management lacked understanding of patient’s expectation of service, which showed poor management perception (Gap 1) 2. Systemic failure in translating knowledge of patients’ expectations into service quality specifications, service standards and patient informed guidelines (Gap 2) 3. Structurally, the delivery of services failed to adhere to set quality guidelines (Gap 3) 4. Process alignment –failure to map the cycle of patients throughput (Gap 4) 5. Perception is the reality of most people and staff felt like pawns of faith (Gap 7) Evidence from the questionnaires and the structured interviews with the twenty quality managers suggest that these organisations are structurally complex, in which can be found different managerial patterns. The main patterns include: management by formality; a reliance on procedures and rules; management by committees; settlement and decisions by negotiation; and turf battles for resource deployment and allocation. As a consequence, it can be argued that what is required to successfully implement quality management in healthcare organisations is a comprehensive, industry specific model to avoid the fate of previous management systems that promised revolution and true reform and failed. A process led strategy will have the advantage of enabling hospitals to focus on its main purpose: arranging care, delivering care, and managing care.

However, the problem across many hospitals in the United States is that the

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The essential elements of the model include:

Top management must demonstrate its commitment and leadership to the strategic, operational and cultural effort by becoming process, employee and patient champions. This would require the development of a vision for the organisation, identification of organisational values and beliefs, and the development of a social learning culture. The signals senior management sends with its daily behaviour, actions and decisions will change and ultimately improve the attitude and behaviour of staff members. The implementation of quality management in a healthcare environment is not nembutsu –repeating prayers to obtain salvation.

In Japan, examples of successful implementation of quality improvement are led by top management who acknowledge the importance of quality control and then implement it by leading from the front lines. Management must show, engage, inspire and lead the way. Management must be seen by all employees to reach and scream from the mountain top about the virtues of quality and its focus on delighting the customer. It is

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The implementation of quality management in a healthcare environment is not nembutsu –repeating prayers to obtain salvation.

imperative to move from the ‘prescribed perspective of professional quality to the ‘felt perspective’ i.e., rendering services according to patients’ felt needs and expectations rather than to the professional’s ordainment. The key to effective patient care resides in: identifying the specific requirements, needs and expectations of patients’ and their families, continuous improvement, redesign and rightsizing of all organisational business and support processes; delighting the patient; and continuously managing and updating the patient/staff interface.

If quality management is introduced with a focus on process identification, process streamlining, process improvement, and process optimisation then it is reasonable to expect benefits to be delivered over a period of three years.

Therefore, organisations should tackle the obstacles to process discipline through training, education, communication, participation and facilitation. These must be supported by a slow, planned, purposeful approach that engages top management and capitalises upon bottom-up involvement.

AUTHOR BIO

delivery of medical care and nursing care processes are task-oriented, impersonal, out-dated, and unresponsive to the changing needs of today’s patient.

For example, one worker takes the patient’s registration information, another staff takes vital signs, and yet another staff moves the process forward. This represents the antithesis of efficiency and effectiveness of work performance. A process-led model will reorganise and reorient work activities so that when a staff member is arranging care for a patient, he or she follows the patient all the way through the provision of care, thus ensuring that there is no loss of communication, no missed opportunities and that the entire system works much more efficiently to the patient’s advantage.

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Based on what the author of the paper calls the ‘SMEP’, which means the Single Minute Exchange of Patients, a typical hospital must fast track patients through the system by reducing service lead times and also by employing the S:P ratio to better route patients to various medical cells. S –the total throughput time, the time it takes to arrange, deliver, and manage medical care. P –the clinically determined patient waiting time; the time between diagnosis and receiving treatment • If S>P=refer to medical cell • If S<P=refer to focused hospital • If S=P=use CA/PA Conclusion

Overall, the paper would surmise that quality management implementation in healthcare requires: No waste of movement –trading fat for muscle • Modifying and simplifying work processes • Process refinements –use of appropriate medical technology • Quality improvement –the utilisation of the right people However, the first reaction in a situation of disarray that is the fictional implementation of quality management in hospital systems is always to reach out for the short-term measure of ‘patching’ and ‘spot-welding’ here, there, and yonder. Achieving improved organisational performance is only possible when there is dramatic change in structure, organisation, and management; and succeeds when all employees fanatically participate.

References are available at www.asianhhm.com

Uche Nwabueze is a Professor of Maritime Administration at Texas A&M University, Galveston Campus, Texas, USA. Dr. Nwabueze’s research focuses on Healthcare process improvement strategies. Dr. Uche as he is fondly called by his students has served as faculty member across four continents.

The importance of Home Sleep Testing & earlier diagnosis Prof Susanna Ng Professor Susanna Ng of the Chinese University of Hong Kong, Department of Medicine & Therapeutics Faculty of Medicine discusses her commitment to the early detection and treatment of chronic respiratory illnesses such as Obstructive Sleep Apnea.

Home testing for patients is becoming a hot topic in many clinical discussions across Asia both for patient quality of life and safety of healthcare workers during the pandemic.

Tell us a bit about your practice in Hong Kong in sleep and respiratory disorders, specifically what trends are you seeing among your patients during this time?

“

Most of our colleagues are quite welcoming of home sleep testing, actually overjoyed.

Firstly, there is no more need to ask patients to wait. It’s very difficult to explain to a patient who is suffering the need to wait for 75 weeks.

”

Sponsored by

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I’ve been working in respiratory and sleep medicine for more than ten years.

Particularly for sleep apnea, it is quite a common disease in Hong Kong, but not many people are aware of it.

Doctors may suspect that patients are suffering from sleep apnea if they are obese. But we have seen from our own clinical practice that many of these patients are quite thin with BMIs less than 25. We also know that sleep apnea is related to vascular outcomes and also metabolic consequences, so I think early diagnosis is important but a constant hurdle.

A few years ago, we conducted a survey about the waiting time of polysomnography in our public hospitals.

The median waiting time in Hong Kong is 75 weeks. I think this is an unsatisfactory condition. It leads to poor insights on our patients.

Has this average 75-week timeline for patients to wait accelerated your thinking on Home Sleep Testing as a potential solution?

I think with the use of home sleep testing, patients can get an earlier diagnosis.

In that case they can enhance their compliance to our medical advice— whether that is weight loss, surgery, or use of a sleep app. Early diagnosis helps patients gain control of their disease management. It is a key reason for [the medical community] to do more research on home sleep testing.

Now with COVID-19, all in-patient sleep studies have been suspended for some time. Even though some services have restarted, patients are quite concerned about hygiene in a hospital setting. To get a diagnosis early and accurately for those IS S UE - 50, 2020

worried about infectious disease, I think home sleep testing is the way to go.

What typically brings a patient in to come and talk about their sleep problems?

One reason is that the patient is experiencing comorbidities—for example, young males with heart disease or hypertension.

How do your hospital and colleagues view home sleep testing as a whole?

Most of our colleagues are quite welcoming of home sleep testing, actually overjoyed. Firstly, there is no more need to ask patients to wait. It’s very difficult to explain to a patient who is suffering the need to wait for 75 weeks. Our colleagues receive referrals from endocrinologists, cardiologists for early sleep tests. For GPs, more seminars and educational opportunities to better understand early diagnosis and management of sleep apnea would be a good idea. Most patients GPs encounter have some sort of sleep problems.

You spoke about a few different devices you’ve used and validated. Are there current disposable diagnostic devices that you are interested to use and have sufficiently validated?

I think quite a few devices are wellvalidated. There are published data on the accuracy of home sleep testing.

But this is the way that we are going, to expect devices that have less contact to the patient’s body, yet with improved accuracy. We also expect a few more parameters to help us to predict which patients are improving with a particular treatment (for example CPAP) or who is going to get a worse prognosis from, say, a cardiovascular point of view.

We are expecting more interesting and useful devices in the near future.

HEALTHCARE MANAGEMENT

The article talks about how in the current scenario, it has become critical to lay enhanced emphasis on nutrition and health of the seniors. This applies to all possible set-ups where the elderly is living/being treated like, hospitals, old age homes as well as at home with families. Multiple researches have shown how with old age it becomes difficult to deliver optimal nutrition to body and suffer from malnutrition. There are steps that can be taken in right the direction to tend to the delicate nutrition balance required by our seniors.

David Heber, Chairman, Herbalife Nutrition Institute

The Role of Nutrition in Healthy Ageing Readiness to change our approach to healthcare for the elderly

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he best part of living a good life is acquiring quality health especially through the golden and productive age and, ensuring wellbeing and comfort through the less active years. WHO has done enormous research and work in advocating healthy lifestyles and diets and defines Healthy Ageing, “as the process of developing and maintaining the functional ability that enables wellbeing in older age.”

According to WHO, in order to lead

HEALTHCARE MANAGEMENT

a healthy and fulfilling life, a complete functional ability is needed so that individuals can meet their basic needs, are mobile, learn, maintain healthy relationships and contribute to society.

This ideal ability is attained through mental and physical capacities of an individual and Nutrition for Healthy Ageing is yet to receive the necessary focus, resources, and attention. Many healthcare professionals have expressed their need for more education on the nutritional status of the elderly.

Moreover, nutrition has come to be recognised by experts as one of the most critical contributors to healthy ageing. Optimum nutrition is imperative for health in persons over the age of 65 and malnutrition in the elderly is highly prevalent and often underdiagnosed.

An in-depth study revealed that, 35 per cent of community-dwelling elderly are nutritionally deficient in protein, calories, minerals and vitamins. Lack of proper amounts of protein and sedentary lifestyles can lead to loss of muscle and gain of fat. There are also hidden aspects of malnutrition with 20 - 65 per cent of hospitalised elderly suffering from nutritional deficiencies.

The prevalence of malnutrition in long-term care facilities is estimated to be between 30 - 60 per cent. The elderly population in Asia is becoming more conscious of their nutrition needs and are turning to functional foods that aim to promote better health and longevity by keeping chronic diseases at bay.

The challenge of healthy ageing and nutrition

Globally, the population of ‘older person’, aged 60 years or above showed an upsurge from 9.2 - 11.7 per cent during 1990 – 2013. By 2050, this number is estimated to be at 21.1 per cent and according to a United Nations Report on world population, ageing elderly population will be nearly 2.1 billion. If we observe this trend in Asia, by 2050, older persons are expected to account for 24 per cent of the population. In addition, developing nations in Asia are experiencing a much more rapid rate of population ageing compared with developed nations. We need environments and surroundings that are safer; to care and tend to the needs of these seniors who have helped us build the world that we live in today.

An online survey was conducted

by Herbalife Nutrition in May

2020 among 5,500 respondents in 11 countries i.e. Indonesia, Korea, Taiwan, Vietnam, Malaysia, Thailand, Philippines, Hong Kong, Singapore, Japan, Australia. This survey intended to better understand attitudes and understanding in Asia Pacific towards ageing. The insights from this survey revealed that people are concerned about ageing healthily, yet they are not confident they will be able to do so. The majority of respondents had a negative future outlook about their health and believed that they would likely suffer from chronic or acute illnesses or ailments. It’s also notable that the current set-ups are lacking and more concentrated to pharmaceuticals and housing and assisted devices.

The various surveys and research projects in this space indicate that concerns around ageing stem from the gaps in healthcare systems and lack of standard practices and guidelines in these program areas to take care of the elderly. Across Asia, efforts for integration between primary care and hospital care are underway to help relieve the health care burden, especially in the setting of increasing non-communicable diseases burden.

It is a big challenge, but a stepwise, practical solution towards better integrated care can start on a smaller scale: the patients, the healthcare providers, and the community. In particular, community-based and commercial programmes can address the underlying issues of sedentary lifestyle and poor nutrition.

Hospitals and elderly care centres are the places where senior patients can be screened for their body’s nutritional quotient using validated tools however, malnutrition management has not been considered as an integral part of patient care. According to a study by Regional Nutrition Working Group to understand the gaps and standard practices in patient population and healthcare settings within the region, it was observed that the international

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guidelines for the management of malnutrition are available, but they may not be easily applicable to programs in Southeast Asia. It was also concluded that collaboration between clinical community, professional societies and policy makers is needed to facilitate a positive change in the overall nutrition practice.

How ageing happens

There are multiple theories around ageing however, there isn’t one reason for why our cells change and grow old and the researchers are juggling between multiple possible explanations.

There is an internal process in cells that is genetically based with some individuals ageing faster than others called ‘Intrinsic Ageing’. At the same time, there are factors that affect ageing in a process called ‘Extrinsic Ageing’.

Ultraviolet light, environmental pollutants, and cigarette smoke interact with the genetic factors controlling the ageing process. Ageing is a complex process and it varies in the ways it affects individuals and body functions from person to person. Heredity, external environment, lifestyle, diet, exercise and leisure, past illnesses, existing conditions, both genetic and acquired and many other factors determine individual rates of ageing.

Significant changes happen in the ageing body and a few of them may be a direct result of poor absorption and utilisation of nutrients leading to a lack of physiological balance of essential macro and micro-nutrients.

As we age, the body may need more protein, vitamins, and minerals as the body absorbs a few nutrients with greater difficulty. Take vitamin B-12, for example. The body's ability to absorb the vitamin, after the age of 50 often fades because the gut produces lesser stomach acid required to break B-12 down from food sources. Skin ageing also leads to a lowered ability to convert sunlight to vitamin D and impacts absorption of calcium.

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An in-depth study revealed that, 35 per cent of community-dwelling elderly are nutritionally deficient in protein, calories, minerals and vitamins.

According to WHO, degenerative diseases such as cardiovascular and cerebrovascular disease, diabetes, osteoporosis and cancer, which are among the most common diseases affecting older persons, are all dietaffected. Dietary fat has been found to have some correlation with cancer of the colon, pancreas and prostate. Increased blood pressure, blood lipids and glucose intolerance are all significantly affected by dietary factors too. Bones also tend to shrink in size and density due to sedentary lifestyles and reduced protein, vitamin, and mineral intakes, especially calcium. A few elderly also look shorter and their muscles lose strength, endurance and flexibility. Structural changes in the large intestine result in more constipation in older adults and a lack of physical movement, fluids and fibre in diet enhances and worsens the condition.

The way an ageing body burns calories also slows down with age and metabolism and energy requirements for the elderly lower by about 100 kcal/ day per decade. Micronutrients play a significant role in promoting health and preventing non-communicable diseases and these deficiencies are often common in elderly people due to several factors such as their reduced food intake and a lack of variety in the foods they eat. On the contrary, an elderly person who is less active than usual and continues to consume the same number of calories will surely gain weight.

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Women comprise the majority of the older population in virtually all countries, largely because globally women live longer than men. By 2025, both the proportion and number of older women are expected to soar from 107 to 373 million in Asia.

This pattern involves its own special nutritional needs, emphases and patterns of malnutrition, including for example the incidence of osteoporosis in older women.

Osteoporosis and associated fractures are a major cause of illness, disability and death, and are a huge medical expense. It is estimated that the annual number of hip fractures worldwide will rise from 1.7 million in 1990 to around 6.3 million by 2050. Women suffer 80 per cent of hip fractures; their lifetime risk for osteoporotic fractures is at least 30 per cent, and probably closer to 40 per cent. In contrast, the risk is only 13 per cent for men. Women are at greater risk because their bone loss accelerates after menopause.

A lack of exercise, malnutrition during ageing years and ageing as a process has led to the emergence of a previously silent phenomenon known as Sarcopenic Obesity (SO). SO is described as a syndrome characterised by the rise of body fat mass in parallel with excessive low muscle mass, with underlying elements such as endocrine, inflammatory, and lifestyle disruptions.

SO is highly correlated with metabolism-related disease, chronic disease and functional disabilities, and has been described as ‘‘thin outside, fat inside” or ‘‘TOFI”. In a meta-analysis involving 12 prospective cohort studies, over 35,000 participants and >14,000 deaths, it was also concluded that SO is associated with an increased risk of death.

Diet, in addition to physical activity, play key roles in the prevention and management of multiple ageing conditions and disorders, SO being just one of them. In many countries

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around the world, diets have become energy rich, yet nutrient poor, and populations are overfed, yet undernourished. In other words, diets are high in energy density and low in nutrient density, contributing to an increase in the intake of ‘empty’ calories. To combat this trend, experts and nutrition policy makers have emphasised the importance of consuming high nutrient density diets.

Nutrition for an ageing body can be a complex and, delicate processes are required to ensure the right amount of nutrition is available through this phase of life.

Steps in the right direction

Healthy ageing requires a sustained commitment and focussed action from country leaders to formulate systematic enhancements and interventions; healthcare workforce training and education that can strengthen and support an active ageing population.

Governments also need to consider public-private partnerships to improve quality of care, promote healthy ageing, and impact outcomes for non-communicable diseases.

According to Ageing International, a 10-step framework to implement integrated care for older persons can be

hugely beneficial for countries. Based on this framework, the first and the most critical step and role is of the governance in establishing requisite structures followed by an in-depth evaluation of the demographics, current as well as future.

The healthcare systems including local care resources and care pathways specific to older age group (also including their nutritional evaluation and care) form the backbone of this integrated framework.

It is also critical to start the health and nutrition journey earlier. Beyond 50s, it is important to consciously make effort to keep both the body and mind active through community and social

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engagements. The contribution of healthcare professionals in this regard can be immense in helping individuals work towards their older age, early.

We have come across innumerable reasons that may lead to malnourishment in the elderly and a few practical tips and checklists for hospitals, care givers and therapy centres, on elderly care and nutrition can be very helpful in dealing with this issue.

Stay calorie-wise and nutritiondense: Most seniors have a small appetite and therefore their meal plans should be full of nutrition-rich foods that do not add volume to the diet. A simple example of this would be to add wheat germ into their cereals and baked goods, such as breads and muffins.

Mix-it-up: The sense of taste and flavour diminishes in most old age individuals and therefore, feel free to spice up and herbify the meals.

Turmeric, cumin, basil, coriander and lemongrass are not just adding to flavour but have health benefits associated too.

Many meals in a plan: Meal plans for the elderly should be small, frequent and lack non-nutritious fill-up food options completely. Water should be ample, fresh juices in moderation and coffee, tea, carbonated drinks should be avoided.

It’s not just a meal: In older age, eating is not just about consumption of a meal served. The inability to execute as many social interactions and physical activities in old age, can lead to monotony and boredom. Food can be a way to break this monotony. For hospital and elderly care set ups, special initiatives

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should be taken to break the routine like adding more colour to the food, organising brunch and lunches in open spaces and socialising opportunities for the elderly during their meals.

Supplement the missing nutrients: Vitamins, calcium, omega-3 fatty acids, iron supplements are imperative for the elderly as their bodies gradually loose the potential to absorb nutrients from food. In order to keep the essential macro and micro-nutrients levels in the body, supplementation should be included whenever needed.

Train for fitness: Physical activity is as essential as a nutritious meal for the elderly and hospitals and elderly care centres should invest in spaces and trainers for exercises and physical activities and recreation. Fitness plans and schedules should be created for the elderly and adhered too as well.

I engage with the elderly through communities that focus on healthy ageing and would like to share an experience of a fellow community member who once said that, his most grilling and torturous experience at the hospital was during the discharge process. Any complex procedure, lacking proper communication and elderly friendly practices can lead to a dissatisfaction and impact on patient’s state of health.

Nutrition, surroundings, processes, communication practices and facilities at the elderly care centres, all need a fresh scrutiny and perspective and we clearly have a long way to go. A systematic approach towards the cause of elderly care with equal participation from public and private entities will help achieve a standard that these seniors, in their golden age, deserve.

AU TH O R BI O

David Heber is the Chairman of the Herbalife Nutrition Institute (HNI), which promotes excellence in nutrition education for the public and scientific community and sponsors scientific symposia.

He is also the Founding Director of the Center for Human Nutrition at the University of California, Los Angeles, where he has been on the faculty of the UCLA School of Medicine since 1978. He is currently Professor Emeritus of Medicine and Public Health and Founding Chief of the Division of Clinical Nutrition in the Department of Medicine of the David Geffen School of Medicine at UCLA. His main research interests are obesity treatment and nutrition for cancer prevention and treatment.

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PROUDLY PRESENTING OUR 50TH ISSUE

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A New World for Hospital Infection Control ResMed talks respiratory care Mervyn Lim, Vice President, ResMed Asia

COVID-19 has put a significant strain on healthcare systems in Asia and around the world. With the outbreak of the pandemic and the surge in the number of patients requiring beds for COVID-19 response, many hospitals in the region have had to shift resources away from any non-intensive ICU treatments.1 This has led to the temporary closure of many so-called ‘elective’ treatments, including testing for chronic obstructive pulmonary disease (COPD) as well as services for patients with sleep disorders.

As the word ‘elective’ implies optional, this has created a complex situation for respiratory specialists responsible for the management of the

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Even though some services have restarted, patients are quite concerned about hygiene in a hospital setting.

PROF. SUSANNA NG

COPD patient population during this pandemic. According to a recent article in the European Respiratory Journal, we have not yet quantified how many

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COPD patients may have chosen, or were unable to, visit hospitals during this pandemic.2 Although researchers hypothesise—drawing on learnings

from the previous SARS epidemic, where chronic disease patients not affected by SARS ‘presented with worsened disease/symptom control’ largely attributed to ‘a widespread avoidance of the health care system’—that a similar situation is likely occurring in the COVID-19 pandemic.3 According to the Global Burden of Diseases (GBD) Study 2017, there were 3.2 million deaths due to Chronic Obstructive Pulmonary Disease (COPD) and 495 thousand deaths due to asthma.4 In Asia, the estimated prevalence of COPD in the region is rising according to Asia Pacific Family Medicine. However, the disease has historically been under-diagnosed and under-reported even before the outbreak of COVID-19.5 This situation will likely be exacerbated as health systems move towards recovery due to overburdened hospitals with backlogged cases and where spirometry cannot be performed.

The first reality that hospital leaders now face is the huge backlog of respiratory service cases caused by the closure of all non-critical services during the peak of the pandemic. However, even now despite this backlog and services reopening, volumes remain low. For example, South Korea and Thailand hospitals were conducting as low as 40 percent volume of elective/semi-elective procedures as of last month.6 A primary reason for this low volume could be patients’ concern over safe care environment and risk of infection when seeking so-called ‘elective’ services. Given the devastating impact that COVID-19 can have on the lung, it is natural for patients with

underlying COPD to avoid hospitals during this time.7 “Even though some services have restarted, patients are quite concerned about hygiene in a hospital setting,” said Prof. Susanna Ng of the Department of Medicine & Therapeutics Faculty of Medicine, The Chinese University of Hong Kong in a recent interview with ResMed. Such fears can lead to further delays in administering proper care, which can culminate in lasting impact on health.

Hospital administrators are striving to ensure patients of hygiene so that they are more likely to access necessary treatments, while also taking measures to protect the long-term wellness and safety of their staff. Minimising potential exposure to infection and creating a safe environment during the pandemic is top of mind. This has caused many administrators to re-examine some standard practices as they begin their post-pandemic planning.

Operational planning for post-pandemic resilience requires a balance of the following pillars:

Quality of Patient Care

Environment Safety

Staff Safety

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Harvard Business Review

treatments are delayed.8

balance of both reusables

to implore administrators to

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to ‘make staff safety a

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fundamental value that you

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won’t compromise for other

these gaps early.

organisational priorities.’11

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For example, many hospitals in Asia that perform in-patient testing for respiratory patients, still rely on reusable masks for cost efficiencies.

A recent paper12 lead by Dr. Ken Junyang Goh, Department of Respiratory and Critical Care Medicine, Singapore General Hospital, and Dr. Jolin Wong, Division of Anaesthesiology, Singapore General Hospital, discusses practical considerations in hospital planning during and after COVID-19. The authors advise that whenever staff are utilising reusable items it is of utmost importance to ‘ensure adequate capacity for prompt disinfection and sterilisation’ and that in some cases of infection control where facilities and manpower are strained ‘single use items may be preferable.’

Proper disinfection and sterilisation processes of CPAP and NIV masks used in clinic settings require staff follow specific disinfection protocols or specially approved sterilisation machines.

The need to minimise healthcare workers’ exposure to potential infections has driven several hospitals to consider stocking on disposable masks, in addition to reusable supply as a precautionary measure.

While both reusable and disposable variants have their roles respectively, the rising attention to minimise staff exposure to infection and patient preference are driving facilities to equip themselves with adequate supplies of both. In addition to ensuring availability of disposable masks in clinic, administrators are also considering supplying disposable accessories to accompany ventilation systems, such as disposable anti-bacterial filters, to mitigate exposure to both staff and patients.

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AcuCare is one type of disposable mask, designed to achieve fast patient acceptance of noninvasive ventilation (NIV). By helping patients accept NIV quickly and successfully, healthcare providers can reduce the need for intubation, decrease the risk of infection, and reduce the cost and length of patients’ hospital stay.13 In addition to making preparations to minimise infection risk in a hospital setting, there are also new considerations for respiratory patients who are able to avoid hospital visits entirely, but still need support in managing their conditions during this pandemic. Administrators are

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paying attention to the shift in adopting technologies to empower patients to take charge of their own health. Such innovations may also help in reducing the burden on hospital facilities and healthcare workers as well as for carers at home.

“Through the pandemic, many rules around telehealth have been relaxed but this is not a problem. You can certainly avoid infection risk with virtual care, it’s much easier to reach out to a patient without travel issues,” said Dr. Patrick Strollo, Professor of Medicine and Clinical & Translational Science in the University of Pittsburgh’s division of Pulmonary, Allergy and Critical Care in an interview with ResMed. There are several technologies that hospitals are considering for non-dependent patients with obstructive or restrictive respiratory conditions. For example, certain noninvasive ventilator systems such as Lumis 150 VPAP ST are designed to continuously monitor and support both the upper airway and alveolar ventilation from the comfort and safety of a patient’s home. Healthcare providers serving respiratory patients with reservations about visiting clinics may find such technology to be a viable alternative to ensure continued care while minimising infection risks.

Knowing the options available and empowering patients through technology can support continuity of care in out of hospital settings during this period.

The burden caused by COVID-19 to hospital systems in Asia is beginning to cause small but significant shifts in our care delivery. In light of this changing landscape, healthcare leaders

need to understand the technology and tools available to help the ecosystem stay on top in infection control, and continue to deliver quality care for respiratory patients.

Through the pandemic, many rules around telehealth have been relaxed but this is not a problem. You can certainly avoid infection risk with virtual care, it’s much easier to reach out to a patient without travel issues.

DR. PATRICK STROLLO To hear from experts and download valuable resources, visit ResMed at bit.ly/ea-hcp In line with the World COPD Day, ResMed Emerging Asia will be hosting a webinar on Telemonitoring of Home NIV patients – which will include an expert panel discussion

Saturday, 28th November 2020 3.00 pm - 4.30 pm (Singapore time) Scan to register today.

About the Author Mervyn Lim is Vice President at ResMed Asia. He is driven by a passion to improve patients’ quality of life by integrating technology and innovation into care models.

With a superior track record in industry digital transformation, he is leading the way in digital health solutions for sleep apnea, COPD and other chronic diseases.

Mervyn is an alumni of NUS Business School and University of Hull. He has extensive experience across Asia Pacific and in leading teams to re-imagine the delivery of healthcare.

1. Oliver Wyman. COVID-19: Responses & Implications to Healthcare in Asia. https://www.oliverwyman. com/content/dam/oliver-wyman/v2/publications/2020/apr/covid-asia-implications/COVID-19-Responses-andImplications-To-Healthcare-In-Asia.pdf 2. To, Teresa. Viegi, Giovanna. Cruz, Alvaro, et al. A Global Respiratory Perspective on the COVID-19 Pandemic: Commentary and Action Proposals. European Respiratory Journal 2020. https://erj.ersjournals.com/content/ early/2020/06/08/13993003.01704-2020 3. Ibid 4. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392: 1789–1858. doi:10.1016/S0140-6736(18)32279-7 5. Lim, S., Lam, D.C., Muttalif, A.R. et al. Impact of chronic obstructive pulmonary disease (COPD) in the AsiaPacific region: the EPIC Asia population-based survey. Asia Pac Fam Med 14, 4 (2015). https://doi.org/10.1186/ s12930-015-0020-9

6. https://www.healthcareitnews.com/news/asia-pacific/impact-COVID-19-apac-hospitals 7. To, Teresa. Viegi, Giovanna. Cruz, Alvaro, et al. A Global Respiratory Perspective on the COVID-19 Pandemic: Commentary and Action Proposals. European Respiratory Journal 2020.

8. https://hbr.org/2020/08/covid-19-created-an-elective-surgery-backlog-how-can-hospitals-get-back-on-track 9. https://www.eco-business.com/opinion/innovating-for-impact-dealing-with-a-mountain-of-medical-waste/ 10. https://hbr.org/2020/06/health-care-workers-protect-us-its-time-to-protect-them 11. Ibid 12. https://link.springer.com/content/pdf/10.1186/s13054-020-02916-4.pdf 13. Lindenauer PK et al. Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease. JAMA Intern Med. 2014 Dec 1;174(12):1982–93

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Healthcare Accountability for Sustainable Care As healthcare organisations focus their efforts to improving quality care and operational efficiency, accountability becomes a core component of their strategy for providing better clinical outcomes.

C

OVID-19 has pushed organisations across the globe into distress and healthcare organisations are no exception, due to increased demand for services amid mounting financial pressures.

The pandemic has acted as a warning signal stressing on the importance of improving health surveillance systems and infrastructure, public health interventions. Emphasis lies on the need to develop preventive measures, improve technology integration, and increase remote care.

Virus outbreaks and COVID-19 pandemic have exposed the limitations, weaknesses and the lack of preparedness by governments and the life sciences and the healthcare industry. Hospitals and health systems have been unable to handle pressures resulting from

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the unprecedented increase in patient numbers. Despite public and private health systems focused on contingency plans, they found it tough to cope with rising demand. While critical to operate according to the need of the hour, it is important for hospitals—crippled with finances owing to halted out-patient consultations and limitation to perform critical surgeries—to maintain transparency in patient management.

This will help build trust between patients and providers.

Accountability at the center of everything

Implementing policies that lay emphasis on quality care through good governance and effective resource planning and management has become the key in the current scenario. Any

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discussion related to improving quality of care while reducing costs will tie back to accountability as the focus lies on maximising care, minimising medical errors, improving efficiency for better outcomes.

Accountability is in a way comparable to healthcare stewardship in the sense that focus lies on showcasing responsibility towards patients. Importantly, accountability in a healthcare set up results in providing effective care through efficient use of available resources that include human, technological, physical and financial.

So what encompasses the culture of accountability in a healthcare setting and why is it important to create a culture? It is essentially a set of policies and guidelines indicating evidence-based decision making and caregiving. Creating

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COMPETENCE

GRATIFICATION

ACCOUNTABILITY

INFORMATION ACCESSIBILITY

AWARENESS Source: A new paradigm on health care accountability to improve the quality of the system, Journal of global health, June 2017

Transparency and accountability

a culture of accountability is done by making learning and development a continuous process, increasing collaboration and coordination across all the organisational divisions, and leveraging performance management for outcome assessment and improvement guidance. Healthcare organisations can partner with the public administration to develop programs aimed at providing public health education to communities while also striving to understand factors affecting community health.

A major challenge with accountability of healthcare systems lies in lack of clear mandate on adherence to standard operating procedures. Another challenge facing hospitals and healthcare organisations is fraud. When left unaddressed, these can result in failure of quality care.

In the wake of pandemic, accountability and transparency have become critical aspects owing to the risks of fraud.

Fighting pandemics and global health emergencies may require regionalisation of capacities to improve community health. ‘Transparency’ contributes to making organisations accountable and these two are interlinked. Healthcare organisations are prone to fraud and corruption, specifically in the areas of contracting, facilities management, pharmaceuticals etc. Complying with standard operating procedures and guidelines, along with increasing transparency across all the activities enables mitigate the risk of fraud and corruption, thus facilitating provision of effective care. International organisations (IO) such as the World Health Organization (WHO), United Nations (UN) etc. have advocated the use of good governance as a key mechanism to reduce fraud and corruption in health systems. Establishing appropriate governance and accountability enables organisations to hold leaders and staff

equally accountable for streamlined operations and effective care delivery.

Pandemics have occurred and may continue to occur, but our ability to overcome the challenges depends heavily on improving public health education, enhancing health systems’ capabilities to be effective and efficient in absorbing and serving sudden and heavy patient inflows. In today’s digital world, healthcare organisations can no longer cling onto legacy systems. It is important to deliver value to patients by integrating technology with clinician’s approach that translates into improved patient experience.

Healthcare organisations ought to implement mechanisms that focus on innovative application of technology coupled with clinician engagement for continuous improvement of care delivery.

Another challenge facing healthcare organisations is the growing demand for quality care while reducing any untoward incidents and being transparent. This situation is not limited to a country or a region, but goes beyond political and geographic

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boundaries. When health emergencies and pandemics occur, we get to witness the deficiencies or irregularities in disease prevention and care giving to the global population at large.

Creating a culture of change

When you create a culture of accountability, it facilitates growth and advancement of the organisation leading to sustenance in the long-run.

It is important that there exists a sense of mutual responsibility that leads to increase in employee engagement, performance improvement and ultimately greater employee satisfaction. A key step towards making accountability an organisational culture requires leadership to act in a way to making it an integral part of the work. Leading with accountability is all about demonstrating that behaviour and thus helping professionals assume responsibility for their acts. This way, they lead by example communicating the need to be responsible for their acts and the entire organisation follows suit.

Another dimension is the use of performance management systems and quality initiatives to enhance quality and efficiency for better health outcomes. Has the approach helped healthcare organisations achieve desired results, as is witnessed in other industries? It can’t be a resounding yes because of the lack of holistic approach to changing the organisational culture that complements quality or process improvement efforts.

In order to bring about a cultural change, it is important to lay focus on breaking down silos, creating synergies and ensuring each and every member of the organisation is made responsible for his/her actions, while helping them with continuous improvement. By fostering the right skill development and empowering professionals, organisations promote high performance and create a culture of change. Shared governance coupled

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A culture of accountability makes a good organisation great, and a great organisation unstoppable.

- Henry Evans

with accountability will lead to improvement at all levels beginning with individual departments, divisions and to the entire organisation.

A paradigm shift

Healthcare responsibility has predominantly revolved around the practice and approach to providing medical support and delivering care.

This asserts the point that medico-legal issues cannot just focus on determining and evaluation of physicians’ negligence or malpractice. Historically accountability in healthcare was primarily assigned to doctors and slowly shifting to being shared by caregiver groups. Since healthcare teams deliver care, it is important to stop considering accountability from an individual perspective and making it a collective responsibility.

In a collective accountability setting, individual health professionals have specific responsibilities in the broader framework of care delivery.

Each physician or doctor is expected to be transparent, play a key role in organisational initiatives aimed at evaluating medical errors and strategise plans for preventing those. Comparing different healthcare professionals’ approach in providing reliable support towards clinical risk

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management may offer some insight into addressing the issue from a treatment perspective. Accountability cannot just be limited to the impact of damage caused to a patient’s health.

It should rather be made an integral part of the overall care giving from patient admission to discharge. What is required is a shift to improving professional accountability that can be based on four key parameters: competence, information accessibility, awareness and gratification.

Developing competence and accessibility to relevant information equips healthcare leaders and staff in appropriate decision making.

Omar Ishrak, former CEO of Medtronic, had in the past spoken about how value-based care would be the future of healthcare and expressed concern that lack of accountability in healthcare could make it unaffordable to the population. Global healthcare community can take a cue from organisations that rely on value-based care in a bid to reduce costs without compromising on service quality.

From a global healthcare landscape, effective health management can be achieved when health systems are committed to improving clinical effectiveness, lowering costs, sharing accountability, enhancing safety and, most importantly, making the population healthier. But striving to achieve these goals is a tough task in a complex and financially constrained environment that health systems operate today. Healthcare organisations will be able to build and sustain high performance healthcare culture by making accountability an integral part of care delivery.

Ramakrishna Sadhu Independent Analyst

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Issue 11

World-class via Accreditations Driven by the rise in medical tourism, Asian healthcare organisations are fast embracing international accreditations and the awareness level is on the rise. Joint Commission International (JCI), the leading international accreditation body, has emerged as the gold standard in this area. It has already accredited 30 hospitals in the Asian region.

JCI has also set up its first international office in Singapore recently Anne Rooney, Executive Director, International Services, JCI

Issue 49

Issue 47

Food Safety and Regulations

Drones in Healthcare Drones present a tremendous opportunity to address supply chain shortcomings in the healthcare sector, reducing stockouts and wastage. Deaths due to diseases such as dengue, conditions like postpartum haemorrhage, loss of blood due to accidents and even time critical organ grafting can be addressed through faster responses, higherquality products and better availability. Health system shortcomings, especially those felt in rural communities suffering from a lack of infrastructure and forecasted growth that outpaces investment, can be addressed and lives saved by adopting advanced logistics systems in the sky.

We should, however, always remember that technology is not an end in itself but only a means to achieve an end. All disruptive technology also have limitations and disadvantages. These need to be factored in also K Ganapathy, Director, Apollo Telemedicine Networking Foundation, Apollo Tele Health Services

Emerging role of technology While drug regulation would be a topic of frequent updates and discussions on this platform, food safety and regulations has come to the fore because of COVID-19.The new normal will be introducing a lot of changes in the way people eat out and the food vendors prepare food. All practicing physicians and specialists who are running their own facilities should be updated about these regulations. More so because their customers and patients may not be well versed and may require that information from a credible source. This topic is now getting attention from regulators in various countries. It's noteworthy that while every country will have its own outlook and standards towards food safety and is at a different stage in terms of health-technology, the pandemic situation might bring them all at the same level.

Kent L Bradley, Chief Health and Nutrition Officer, Herbalife Nutrition

Issue 46

Blockchain in Healthcare Keeping patient data safe and secure Data privacy and transaction efficiency are major issues in today's health system. But worryingly, these may result not only in personal data breaches, but also create events that may lead to a poor health practice. Blockchain technology allows for patients to fully own their data, and the tractability features make it transparent for fault proof transactions and auditing.

Alessio Bonti, Lecturer and Innovation lead, Deakin University

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50 ISSUES OUR JOURNEY

Issue 45

The Science of Healthcare Delivery The Symphony Communication and Information (C&I) forms the base of care delivery, and, many times the outcomes of situations. This is true for any healthcare service organisation. The patient communicates problems and medical history to the doctor, the doctor communicates the condition and treatment plan to the patient and communicates orders to the nurses / RMOs, the orders for medication / investigation are communicated further, the results and effects are communicated back to the doctor, and to complete the loop, the patient condition is tracked. This loop continues till the patient is well again. What if this loop breaks or becomes a Chinese Whisper…?

We are impressed by the quality and content of your magazine.

Caroline Watkins University of Central Lancashire, UK Professor, Stroke and Older People's Care Department of Nursing

Gurrit K Sethi, Hospital COO, Care Hospitals

Issue 40

Primary Care The challenges of a changing world Substantial progress has been created in the accomplishment of a number of the elements of primary healthcare. Globally as a whole, ageing population, increasing urbanisation, and the emergence of diseases and technologies are creating new demand on the healthcare system.

The growing economies are impacting the rising cost of healthcare expenditure, which ultimately increases the concern of national economic competitiveness. Strong political commitment, community-participation, skilled providers, evidence-based medicine, and sound research are needed to tackle these challenges of the changing world through accessible, affordable, comprehensive and quality primary healthcare.

It is high time to get prepared for systematic and scientific addressing of the upcoming primary healthcare challenges.

Issue 24

Quantifying Value The new economics of healthcare Healthcare organisations are redefining value and have been forced to think in new ways about the process of care delivery.

Yosef D Dlugacz, Senior Vice President and Chief, Clinical Quality Education and Research Krasnoff, Quality Management Institute

Issue 38

Managing and Delivering Healthcare Looking forward to challenges

Md Moshiur Rahman, Associate Professor, Graduate School of Biomedical Health Sciences, Hiroshima University

The growing demand for the quality healthcare and the absence of delivery mechanisms pose a great challenge, the key growth inhibitor includes fastest growing population and informal costs. Healthcare industry should be able to carry out planning, monitoring and controlling the delivery system in affordable cost. In response new service models, delivery plans, accountability between provider and citizens is essential for effective delivery system.

Sajeda Chowdhury, Graduate, School of Biomedical Health Sciences, Hiroshima University

R B Smarta, Managing Director, Interlink Marketing Consultancy Pvt. Ltd.

Disclaimer: Authors’ profiles are in line with respective issues and may / may not reflect their current profiles.

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Issue 13

Consumerism in Healthcare Impact on business models and processes

Issue 38

Recruiting Medical Staff It is the culture not the money It is the Culture not the Money. The competition to recruit, and the great advantage to permanently retain the best medical staff is not accomplished by money or flashy perks. It takes clarity of purpose, lived values, and real communication. The payoff is efficiency, quality and growth.

Jeff Thompson, CEO Emeritus Pediatrician, Gundersen Health System

Harald Pitz, Vice President, Industry Business Unit Healthcare Higher Education Research, SAP AG

Issue 18

Healthcare IT in Asia Ready for Transformation

Issue 32

Asia is ready for rapid technological changes happening in healthcare globally.

Evidence-based Medicine and Outcomes Analysis

Pradeep Chowbey, Chairman, Max Institute of Minimal Access, Metabolic Bariatric Surgery, Max Superspeciality Hospital

An evaluation

Issue 13

Evidence-based medicine is fast overtaking experience-based medicine in the field of healthcare delivery. Outcomes analysis allows the assessment of the quality of care delivered and matches them against the resource costs. It is becoming increasingly imperative for the various stakeholders involved in the entire healthcare delivery process, that is, the care deliverers and clinical managers, are not only knowledgeable but also practice it on a regular and rigorous basis.

S B Bhattacharyya, Member, National EHR Standardisation Committee, MoHFW, GoI, India Member, Health Informatics Sectional Committee, MHD , BIS

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Consumerism has driven transformation and innovation in industries. Healthcare—despite significant improvement in the healthcare product—has seen limited transformation in the way it is approached and delivered.

However, major challenges put the affordability and sustainability at risk. Collaboration and patient-centricity will make information more easily available and understandable, change the patients’ behaviour and give patients wider choice. The passive patient will be transformed to an informed consumer who is able to select wellness maintenance and treatment from a collaborative global healthcare community that provides personalised, evidence-based care.

A SI A N H O S P I T A L & H EA LT HCAR E M A N AGE M E N T

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Healthcare Insurance in Asia Strengthening the insurerhealthcare provider relationship As Asia’s MSPs evolve, so too will Asia’s health insurance sector—and the symbiotic relationship that binds the two together. Indeed, it is not inconceivable that Asia’s large hospital chains may one day seek to enter the health insurance industry themselves.

Jean-Michel Chatagny, Managing Director, Strategic Corporate Development Asia, Swiss Re

50 ISSUES OUR JOURNEY

Issue 15

Six Sigma in Healthcare Effective use of the Tool Box The integration and coordination of the healthcare system's process improvement tools, utilising Six Sigma concepts, Lean, Management Engineers and Information Services are the key to ensure that processes are first assessed and simplified before introducing anything new.

Adrienne Elberfeld, Six Sigma Champion, Virtua Health Maria H Foschi, Assistant Vice President, Virtua Health

Just got the magazine and pouring over it. I have not seen any magazine like this in terms of content and direction.

Pradeep Chowbe Sir Ganga Ram Hospital, Chairman Minimal Access Metabolic and Bariatric Surgery Centre

Issue 14

Transparency in Healthcare Seeing is believing The growing demand for transparency in healthcare is lifting the veil on this notoriously murky industry, but achieving transparency is a problematic journey that requires unprecedented collaboration across sectors within the health industries and adherence to world-class standards.

Issue 13

Personalised Medicine Future architecture The standard ‘one size fits all’ approach of treating many individuals may soon become obsolete. More targeted approaches promise to improve outcomes while reducing toxicity and medical costs.

Timothy Yeatman, Executive Vice President, Translational Research, H. Lee Moffitt Cancer Center Research Institute, University of South Florida and President, CSO MGen

Issue 15

Telemonitoring in Cardiac Device Therapy Enabling optimal management of patients The vastly increased complexity of cardiac rhythm therapy over the past several years, demands commensurate improvements in overall device monitoring and telecommunication technology.

Auricchio Angelo, Professor Division of Cardiology, University Hospital

Sandy Lutz, Director, PricewaterhouseCoopers Health Research Institute

Issue 19

The Electronic Health Record Delivering healthcare for the 21st century An enhanced Appreciation of the connection between quality and coast has made the question of mass-market penetration of the EHR an issue of broad importance.

Louise Liang, Senior Consultant, Kaiser Permanente

Disclaimer: Authors’ profiles are in line with respective issues and may / may not reflect their current profiles.

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Issue 28

Breast Cancer

It covers a broad range of issues, which does make it interesting to read.

Past, Present and Future While a cure has not yet been found, public perception surrounding breast cancer has changed dramatically. Once a disease that women felt ashamed to discuss, breast cancer now has lost much of its stigma, providing the opportunity for politicians and healthcare officials to acknowledge that economic and political considerations bear on the success of breast cancer treatment as much as advances in medical science.

Mohammed Jaloudi, Department of Oncology, Tawam Hospital Jihad Kanbar, Department of Oncology, Tawam Hospital

Issue 18

Importance of Traditional Medicine In the age of technology Monitoring with implantable devices Most nations, except the US, have natural medicine traditions known and widely practised by the populace. With the increasing availability of Western techno-centred medicine, there’s a seduction in favour of ‘modern’ medicine over traditional treatments. Health outcomes in the US indicate the risks on this path and the importance of staying patient-centred.

Beverly A Jensen, Associate Professor, Communications UAE University

Issue 12

Diego Delgado University Health Network, Canada, Professor Division of Cardiology and Transplantation

Advances in Cardiac Surgery The combination of new intra-cardiac imaging technology and tool-tracking systems with the dexterity and stability of robotic instruments will enable safe and reliable off-pump intra-cardiac repair, including Atrial Septal Defect (ASD) closure and the repair of mitral valve insufficiency.

Yoshihiro Suematsu, Assistant Professor, Division of Cardiothoracic Surgery, University of Tokyo

Issue 41

Deep Learning in Medical Imaging New Artificial Intelligence (AI) and deep learning techniques can help medical imaging technicians spot anomalies and diagnose conditions in a fraction of the time previously needed (and generally with more accurate results). AI increasingly enables human capabilities like understanding, planning, and perception to be undertaken by software efficiently and at lower cost. Here, we present the most recent results in the field and discuss how it will change the role of medical imaging professionals.

Nicola Pastorello, Data Analytics Manager, Daisee Kim Berry, Principal Writer, Daisee

I am very pleased with the presentation and the quality of the journal.

Issue 24

Planning Secrets for Enhanced CT/ MRI Throughput This article will explore ways to maximize MR and CT patient throughput through the use of improved facility layouts, including optimizing the location, number and size of support spaces.

Amir Hannan Glossop Primary Care Trust, Primary Care, Lead North West Strategic Health Authority, UK, Lead, Information, Management & Technology

Scott Branton, Senior Associate, RADPlanning Robert Junk, President, Scott Branton, Senior Associate RADPlanning

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50 ISSUES OUR JOURNEY

Issue 11

Lean in Healthcare The team needs to involve the clinicians, nursing staff and the management. Having done that, they need to pick key processes that are in trouble and begin to analyse them and engage the people involved. The key here is to build some kind of internal knowledge.

Therefore, though the implementation of lean begins at the top level of the hierarchy it needs to be quickly passed down to the bottom. It's top down in the sense that the initiative must be supported by the top management but the actual implementation has to involve the people right at the frontline since they are the people who know exactly what’s wrong with the current processes.

Daniel T Jones, Founding Chairman, Lean Enterprise Academy

Issue 37

Industry 4.0 Manufacturing and the future of medical things 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)?.

Issue 15

Devices Containing Membranes Better membrane, improved outcomes Devices containing artificial membranes for the treatment of kidney disease lack the ability to replace or augment metabolic and endocrine functions, which are non-selective and biologically reactive.

Nicholas Hoenich, Clinical Scientist, Medical School Newcastle University

Issue 28

Data Standards for Medical Devices Why you should care Standard identifiers are an important component to achieving better visibility into the role of products in delivering better value in healthcare.

Karen Conway, Executive Director, GHX

Francisco Almada Lobo, Chief Executive Officer and CoFounder Critical Manufacturing

Issue 12

CyberKnife Radiosurgery An emerging surgical revolution The constellation of technologies that make up a modern CyberKnife system enable radiosurgery to be delivered with submillimetre accuracy to static lesions and better than 2 mm accuracy to targets that move with respiration.

John R Adler, Professor of Neurosurgery and Director Radiosurgery and Stereotactic Surgery, Stanford University School of Medicine

Disclaimer: Authors’ profiles are in line with respective issues and may / may not reflect their current profiles.

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Issue 15

Listen to the Patient Assuring quality care In striving for excellence in patient care via scientific means, clinicians may be omitting a potent source of relevant information-the patients themselves.

MJ Underwood, Professor, Department of Surgery, The Chinese University of Hong Kong CA Van Hasselt, Professor, The Chinese University of Hong Kong

Issue 46

CSK Cheung, Research Associate, The Chinese University of Hong Kong

Green Hospitals

WF Bower, Assistant Professor, The Chinese University of Hong Kong

Towards sustainability

Issue 39

Hospitals, being resource-intensive establishments, consume vast amounts of natural resources including electricity, water, food and construction materials to provide high-quality healthcare while ensuring hygiene. However, by deploying simple, smart and sustainable measures hospital can greatly reduce their carbon footprint. We call this concept Green Hospitals. The article talks about the various measures, challenges, and solutions to make greener and sustainable hospitals for the betterment of humanity.

Hina Gupta, Operations Department, MG Cooling Solutions

Issue 40

High Reliability In Healthcare

From ICU to I See You Small things make a big difference in healthcare Small Changes to Make a Big Difference in Patient Care - Once an ICU patient for three months (two of which were in a coma), Nancy recognises the incredibly challenging job of medical professionals committed to delivering the highest quality healthcare to the most ill patients. Through her unique perspective Nancy identifies communication strategies and multiple low-cost, high-impact techniques to achieve higher patient satisfaction.

Nancy Michaels, President, NancyMichaels.com

Creating the culture and mindset for patient safety High reliable organisations system ensures and manages resilience by focusing on safety of customers over other performances. Their intention is to provide trust worthy services and create environment where by potential problems are foreseen, recognised priory, and basically is always respondent to prevent tragic. Staff should be aware of the culture to be followed with patients and organisation should orient their mindset with help of quality culture programmes and put down model and strategies accordingly in benefit of patient.

Often patients are unaware of their rights and care provided, thus empowering them is essential.

R B Smarta, Managing Director, Interlink Marketing Consultancy Pvt. Ltd.

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I'm very much appreciated and enjoyed being a part of this issue. I was very happy with the content and presentation of the material on value-based healthcare.

Steve Garrington Group Commercial Director InterSystems

50 ISSUES OUR JOURNEY

Issue 30

Designing Navigation Friendly Hospitals While navigating complex healthcare facilities has been acknowledged as a critical issue by healthcare administrators for decades, the main focus has been on sign and map systems. This article discusses the findings of a study that examined physical design attributes manipulated by architects and interior designers, and their role in aiding navigation for facility users.

Sipra Pati, Research Coordinator, HKS, Inc. Debajyoti Pati, Rockwell, Professor Department of Design, Texas Tech University

Issue 16

Quality and Safety Creating a supportive culture A process-oriented approach, which sees care as both social and technical, naturally supports a positive quality improvement strategy and aligns the major subcultures.

Philip Hoyle, Director Clinical Governance, Northern Sydney Central Coast Area Health Service

Issue 19

Reducing ICU Mortality Strategies for the 21st century Over the years, Intensive Care Units have become the hot corner of hospitals. In the near future, new automated systems will ease ICU patient monitoring and secure delivery of sophisticated treatments.

Djillali Annane, Director General, ICU Raymond Poincar Hospital University of Versailles France

Issue 15

Art for Health's Sake An evidence-based approach The human mind and body are so intrinsically linked that "feeling" better is a huge step towards "being" better. This makes the role of art very critical in today's healthcare.

Upali Nanda, Vice President, Director of Research, American Art Resources

Issue 18

In and Out of the Emergency Room Streamlined design of patient flow Many factors influence the patient throughput in and out of the Emergency Department. Clarity in layout and simplicity in operations are keys to streamlined flow.

James W Harrell, Design Leader, GBN Architects

Issue 46

mHealth Technology Privacy & Control The health sector is one of the most vulnerable sectors when it comes to data privacy. Blockchain technology, which is currently emerging as one of the most promising technology for healthcare systems is evaluated here from a privacy standpoint to ascertain if it will alleviate the concerns around data privacy especially in light of the GDPR. Karpurika Raychaudhuri, University of New South Wales UNSW Pradeep Kumar Ray, University of New South Wales UNSW

Disclaimer: Authors’ profiles are in line with respective issues and may / may not reflect their current profiles.

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Issue 18

Issue 39

Healthcare IT in Asia Start with the Basics

Use of Telehealth Technology to Increase

Virtually all areas of Healthcare IT need further development. In fact, they will be in a state of evolution for a long time.

ED Capacity during Times of Surge

Peter Gross, Chair, Board of Managers, Hackensack Alliance ACO

Issue 41

Deep Learning in Medical Imaging New Artificial Intelligence (AI) and deep learning techniques can help medical imaging technicians spot anomalies and diagnose conditions in a fraction of the time previously needed (and generally with more accurate results). AI increasingly enables human capabilities like understanding, planning, and perception to be undertaken by software efficiently and at lower cost. Here, we present the most recent results in the field and discuss how it will change the role of medical imaging professionals.

Nicola Pastorello, Data Analytics Manager, Daisee Kim Berry, Principal Writer, Daisee

Emergency Departments (ED) usually function with limited staff trained for its proper functioning. During times of surge, the situation gets complicated due to non-availability of sufficient resources. Telehealth technology, through its ability to bridge the physical divide between casualties and their care providers, is could to be very successful in helping to deliver higher levels of care. This article discusses how this is made possible.

S B Bhattacharyya, Member, National EHR Standardisation Committee, MoHFW, GoI, India Member, Health Informatics Sectional Committee, MHD

Issue 37

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

Issue 17

Telehealth in Asia Healthcare for the communities The Internet and next generation communication technologies are revolutionising the delivery of care and are increasingly utilised to deliver better and more comprehensive care to communities that need it most. Telecare or the delivery of care virtually supported by Internet and communication tools is breaking new ground.

Gabe Rijpma, Health and Social Services Industry Director Public Sector Group, Microsoft Asia Pacific

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50 ISSUES OUR JOURNEY

Issue 13

Cardiovascular Medicine Integrating IT for better care New interventions are urgently needed to update cardiovascular practice to the level of fast pace in the other areas. The rapid and efficient cardiovascular services provided by these new paradigms will improve standard of care and cut cost by eliminating communication gaps, treatment errors and redundant diagnostic testing.

Hanumanth K Reddy, Adjunct Clinical Professor Medicine Cardiology, University of Arkansas for Medical Sciences and Clinical Professor Medicine, St. Louis University Medical School Ravi Komatireddy, Professor, Resident in Internal Medicine Dartmouth Hitchcock Medical School

KEY CLIENTS A S S O C I AT E D WITH US IN OUR JOURNEY

Issue 33

Managing Change An essential element of healthcare success No surgeon would ever enter the operating room without a refined understanding of the relevant anatomy and physiology. Yet, one of the most compelling reasons for the chronically high failure rates of change initiatives is a limited appreciation for the fact that the focus and skills necessary to operate an organisation are very different than the focus and skills needed to change an organisation.

This article spotlights the change resister: those saboteurs who are harmful to the health of next innovation.

David A Shore, Professor, Harvard University, University of Monterrey Business School

Issue 13

Connected Healthcare What next?

Healthcare in the 21st century will require a much higher degree of connectedness and mobility of information, knowledge, processes, devices and people.

John Grant, Managing Director, Connected Health Cisco Internet Business Solutions Group, IBSG Asia, Cisco Systems Inc. Kevin Dean, Managing Director, Connected Health Internet Business Solutions, Group IBSG Europe, Cisco Systems Inc.

Disclaimer: Authors’ profiles are in line with respective issues and may / may not reflect their current profiles.

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MEDICAL SCIENCES

C

OVID-19 has exposed the health quotient of countries and geographies, the basic civic sense of the populace, the healthcare infrastructure, the political saga and our susceptibility to economic distress. It has also exposed the pollution levels caused by urbanisation thus exposing effects on health. Each of these impacts our health – mental, emotional and physical. It is time to pick up the pieces and mend....

Like a serious joke, the pandemic has revealed much more about the status of our health than information about the disease itself. The speed of spread of the disease globally has showcased our susceptibility to infections, to environment, and, to social nuances.

It has laid bare the ability to deal with such problems and the catalysing possibilities of more such spreads.

COVID-19 struck at a time when we were still comprehending the effects and work around strategies for chronic diseases, having just transcended the curve for better management of infectious diseases and trying to negotiate the steep rising trend in chronic and lifestyle disease. We were caught unaware by this pandemic, despite the World Health Organization (WHO) warnings. This in the 21st century showcases the fragility and vulnerability of humans this age because of the economic development and ease of geographic transcendence.

Infectious Diseases, Chronic Disease and Prevention Most infectious and chronic diseases have a common ground – our basic environment and life force. A lot of infections start off as one but steadily lead to chronic conditions in absence of basic amenities, proper healthcare facilities and treatment protocols. As 2020 has gaped open many wounds, it seems like prevention and wellness has to be the new normal in healthcare.

Gurrit K Sethi, Hospital COO, Care Hospitals

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HEALTHCARE MANAGEMENT

Post the COVID-19 infections, it is yet to be ascertained what the aftermath would be – both in terms of chronic extensions of the disease as well as the preventive aspects especially given the virility of the disease.

Whatever the situation be, it is now imperative for us to look at the preventive measures. And these preventive measures cry for care for

the environment, for habit, which ultimately forms the base for health, and taking this further from preventive measures to wellness. Not just from the COVID-19 perspective but the overall scenarios in other infectious as well as chronic diseases.

Various surveys across the globe saw people suffering from chronic diseases shy away from hospitals for their regular visits. The numbers we see in our hospitals also tell the same story.

However, the turn up in the emergency rooms for critical care by those suffering from chronic conditions has also shown a very steep rise. This indicates that people are ignoring symptoms that can be, and, should be treated early on, preventing the aggression of the disease, choosing instead to stay at home and

then turning up when the condition worsens to a level requiring critical care attention.

Another grave and glaring aspect to look at is the effect on the healthcare workers. By mid of September, over 7,000 healthcare workers are estimated to have lost their lives in the pandemic while providing care to those ill and suffering from COVID-19. This pushes us to look at not only infection control preparedness, adherence to processes as well as availability of the required protective gear, but also to have a close look at the health quotient of the healthcare workers themselves.

Healthcare workers have a right to safety.

Alongside this right, there is a huge responsibility as well – a right to healthy living. But is that possible? Casting an eye to the stressful and long working hours for most healthcare workers, the reason for chronic conditions are fairly apparent. This change needs to start at home.

We need to keep a close eye on these statistics as we re-read and re-comprehend the pre pandemic

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MEDICAL SCIENCES

volumes of infectious and chronic diseases. The numbers resulting from the pandemic are yet to be accounted for. And given the compounding rate at which these could add up along with the aftermath of the pandemic, it is imperative that we create strategies to prevent infectious and chronic diseases from occurring as well as converting to each other. In fact, the larger objective around this should not just be prevention but also to better the health quotient of the general population.

According to the WHO and some publications, it is estimated that about 60 per cent of deaths happen because of chronic diseases and about 32 per cent because of infectious diseases.

Again, the pandemic will surely change these numbers. Two decades ago, approximately 46 per cent people suffered from non-communicable diseases, which is expected to have increased to an alarming high of 57 per cent. A lot of data is available to this effect and I do not intend to repeat that here. Reason to stress on this is because it is important to understand that most infectious diseases, if not treated or treated improperly, will lead to chronic diseases. A huge percentage of these are very preventable if we look after our lifestyle and environment – our life forces.

Let us understand some closely knitted basics that are today crying for attention: air, water, food, ecosystem and stressful environment. I would call these our ‘Life Forces’ today. If we take care of these basics, a lot will be taken care of for us in garnering support to reduce the daily concerns of these diseases. Each of these, in deterioration, has cast the net of illness – chronic as well as infectious. The table below attempts to draw out the correlation between the Life Forces and various highly prevalent infectious and chronic diseases. (Table 1)] In an attempt to prevent further deterioration of the health quotient of the populace, it is imperative to balance

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Life Forces Air, Food, Water, Ecosystem, Urban Living Infectious Diseases

Chronic Diseases

Chest infections - Influenza, TB, Common Cold

Asthma, COPD

Occupational Lung disorder (asbestosis)

Chronic bronchitis, CA Lungs

General climatic conditions

Pneumonia

Allergic reactions

Contaminated Food

Stomach infections (bitulism, listerosis, typhoid)

Contaminated Air

Diahrohea

Ulcers

Allergic reactions Unhealthy Eating

Overeating, Under eating (Kwashiorkar, Anaemia, Marasmes

Diabetes, Hypertension, Hormonal imbalances (PCOD / Thyroid / Pituitary)

Contaminated Water

Typhoid, Malaria, Diahorrea, Trachoma

Mineral and metal poisoning

Stress

Weight gain / obesity

Hormonal imbalances

Sleep disorder

Heart diseases

Table 1

Low immunity

out the betterment of the healthcare services with other aspects of basic clean and healthy living viz civic amenities, maintaining the ecosystem and a huge focus on a healthy emotional and mental environment aka stress-free living. The basic civic amenities should provide every citizen potable drinking water, good clean air, and clean (read chemical free) food. While we proudly boast of being born in the 21st century, a proud new generation with many new inventions under our belt, the deadliest

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of diseases have also been part of that set of inventions. And that is also something that threatens what we so carefully crafted out.

While the same is true in different measures across the world for these factors, a lot needs to be driven on the policy front in India. We have to push this through, and start taking cognisance of the geographicenvironment related health data. We must relate geographic spurts of various infectious as well as chronic diseases

MEDICAL SCIENCES

Prevention Availability of well distributed healthcare services

Civic Amenities

Skill Technology Infrastructure

Clean Water Clean Air, Clean Food Treatment possibilities

Ecosystem

Early detection Right diagnosis Right medication

Maintain natural flora & fauna

Healthy Emotional & Mental Enviroment

Prevention Vaccines Regular checkups Safe medication protocols

Reduced stress Table 2

This strengthening needs multifarious things to be done, including improved education, use of digital aid to overcome skilled manpower availability, a proper digital infra, ensuring each medical pass-out has a compulsory posting in the rural areas, amongst other things.

Quality control needs to focus on treatment protocol monitoring closely through digital aids. We also need to ensure that norms for accreditations are the same for both government as well as private hospitals, ensuring that the course offerings and curriculum in medical and nursing education colleges

adhere to these norms. Because of these dichotomies, a lot is left wanting. But the good part is that there is something that can be strengthened further.

In a nutshell, we are living in a time where we no longer have a choice to procrastinate about our health.

Health can also play a major role in making and breaking economies as the pandemic has shown. Time for us to retrospect, re-invent and work towards a healthier self – individually, statewide, nationwide, and worldwide.

Gurrit K Sethi, Hospital Chief Operating Officer, Care Hospitals; Strategic Advisor for Global Health Services, Global Strategic Analysis, contributes to healthcare by helping providers build and better business efficiencies and concept development, also strives to contribute socially through the Swiss Foundation, Global Challenges Forum as Strategic Advisor, through conception of sustainable health initiatives. She started her career from the shop floor working her way up to lead and set up different healthcare businesses. In her words, her significant achievements have been in bringing to life different SMEs and SBUs signifying a change in the Indian healthcare scenarios, as the opportunity paved the way along the healthcare growth curve in the country. With over 18 years in healthcare under her belt, across different healthcare verticals, she has carried transformational changes in the projects she has led, four of those being early stage start-ups. Gurrit is an avid traveller and voracious reader of varied genres, attributes which she says, provide her with incisive insights about people and systems and what drives them.

AUTHOR BIO

to usage of fertilisers and chemicals in farming, for example. Tracing the effects of genetic engineering of food varieties on long-term health effects needs to be checked out. Contaminated water has created havoc in the past and continues to. While we focus diligently on COVID-19, let’s also make a renewed effort to account for the continued number of mortality and cost spend on health issues pertaining to air / water / ecosystem contamination due to unhygienic living, industrial ravages of incorrect waste disposal, even domestic and farming waste disposal. These small measures will go a very long way in bettering the overall health of the nation, safeguarding from the future ravages of disease, enabling better life quality, better economic capability and also a lower health spend. In fact savings from these can actually be ploughed back to create and better the country’s public healthcare system.

Table 2 on prevention also attempts to specify all that needs to be done on the healthcare side towards treatment as well as prevention of both infectious and chronic diseases. The most important factor being that if services are readily available, those who need those services will definitely reach out there. However, in the rural areas, while the PHCs exist, no doctors or trained staff do, which beats the purpose of the whole situation. The plight of the Anganwadi and Asha workers was laid bare during the pandemic. Clearly the system needs to be strengthened.

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COVID-19 from Bench to Bedside Why deep understanding of human physiology may help doctors deter the virus?

The novel coronavirus (COVID-19) causing Acute Respiratory Distress Syndrome was considered responsible for the huge number of respiratory tract infections leading to severe respiratory failure in many cases. The COVID-19–induced failure of central mechanisms controlling breathing and circulation may explain the mismatch between the clinical symptoms and the objective physiologic life parameters in many patients.

A better understanding of the complex physiologic and pathophysiologic mechanisms implicated in the detrimental COVID-19 impact on the various human body systems should facilitate decision-makers to work out brand-new therapies. Moreover, a profound investigation of the human immune system and coronavirus interactions may help scientists build an effective and safe vaccine that seems to be one of the few reasonable options to prevent future coronavirus pandemics.

Robert Skalik, Consultant Cardiologist, Exercise Physiologist

Senior Lecturer in Human Physiology, Wroclaw Medical University

T

he novel coronavirus (COVID19) causing Severe Acute Respiratory Syndrome (SARSCoV-2) was considered responsible for the huge number of respiratory tract infections leading to severe respiratory and systemic complications in many cases all over the world. Much to the surprise of many physicians, the effectiveness of conventional intensive care therapies (e.g. mechanical ventilation) is below expectation in the respectable number of COVID-19

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patients suffering from acute respiratory failure. Doctors and decision-makers have realised that Extracorporeal Membrane Oxygenation (ECMO), emergency lung transplantation or other non-conventional therapies might be the last resort for some critically ill patients. The basic science, laboratory and experimental studies on the interactions between the virus and human systems supported by new IT technologies may contribute to the containment of the disease and

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its detrimental clinical consequences like never before. The implementation of human physiology knowledge and its rules may help doctors and scientists find more efficient diagnostic and treatment tools in COVID-19 patients.

To date, it is known that the COVID-19 infection may range from asymptomatic or poorly symptomatic course to an almost bizarre deterioration of life parameters (asymptomatic hypoxemia) through

MEDICAL SCIENCES

to severely ill patients with multiple organ failure including lungs, heart, kidneys, nervous system, and other organs. The virus binds and enters through Angiotensin-Converting Enzyme 2 receptor (ACE2) widely expressed in numerous human organs including heart, lungs, vessels, and the brain, which can result in the systemic inflammation, multi-organ dysfunction and cardiovascular complications (myocarditis, acute myocardial infarction, heart failure, brain stroke and venous thromboembolic events).

The pathophysiology of COVID-19related failure of various human organs and systems, and the proclivity of the virus to attack more ferociously some populations in the world or regions

in the particular countries (evidently higher mortality and number of infected people in USA, France, Great Britain, and Spain as compared with Middle Eastern or South Eastern European countries such as Poland, Czech Republic, Hungary, Greece) are obviously a complex and multifactorial issue. This is a result of some ethnic or territorial variations in the immune response, the virus potential to mutate, the responsiveness of physiologic regulatory mechanisms, the prevalence of particular co-morbidities (e.g. chronic heart failure, COPD and other

chronic lung diseases, immune system defects, diabetes, nicotine addiction, obesity), age of affected population, population-based genetic conditions and the effectiveness of quarantine and sanitary measures.

The latest analyses presented in September 2020 by British Medical Journal show that the efficacy of the majority of applied pharmacological therapies against COVID-19 might be limited. Antiviral drugs, including Remdesivir) or hydroxychloroquine, may not reduce the risk of death. The problem with the clinical effectiveness of many applied therapeutic tools in severe COVID-19 patients may result from pathophysiology and timing of the coronavirus attack

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MEDICAL SCIENCES

and its dynamics. According to the latest scientific reports, the time between the contact of the virus with the upper respiratory tract cells (pre-symptomatic/asymptomatic phase) and the virus entry into the epithelial lung cells (symptomatic) is only 24 hours and it takes the virus 7 to 10 days to develop the full-fledged severe clinical condition (hospital admission time). It can be assumed on this ground that it is too late for many symptomatic or severe patients to obtain the appropriate therapy before the virus enters the cells and continues its cell disruptive attack potentiated by the subsequent huge host immune response. However, there is a still good space for immunological treatments (plasmapheresis, monoclonal antibodies, immunosuppressive drugs) that may

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deter self-destructive response to the virus from the human immune system.

The creation of effective therapeutic models against the present coronavirus outbreak and the containment of future pandemics should be based on the following investigational routes: 1.

A profound understanding of the complexity of physiologic or pathophysiologic mechanisms of bizarre or unusual symptoms of the disease observed in many patients and their relevance for the selection of the therapeutic strategy and prognostication 2.

Artificial intelligence (AI)-based designing of symptoms and laboratory immune tests results configuration models (e.g. blood concentration of pro- and antiinflammatory interleukins such

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as IL-6, TNF, IL-4 and others) predicting the course of the disease and the effectiveness of various therapies in particular patients or groups of patients (“immunological response profiling”) 3. The new application of commonly used drugs (repurposed therapies) in combination with modern immunological treatments and sophisticated intensive care tools (ECMO) 4.

Development of brand-new therapeutic technologies and options based on the IT-assisted analysis of immunology, physiology and pathophysiology mechanisms involved in COVID-19 infection, i.e. the in-depth analysis of the virus-immune system interactions with special focus on the detailed investigation of mechanisms of the coronavirus entry into the cells 5. Preparation of ‘intelligent’ or ‘smart’ vaccine.

There are more and more physiologic and pathophysiologic evidences that some of the strange symptoms (smell and taste sensations or lack of dyspnoea in patients with relevant hypoxemia) in some COVID19 positive patients might be caused by damage to the Central Nervous System (CNS). The coronavirus causes smell and taste dysfunction that probably stems from some local injury in the brain and peripheral nervous system receptors. In addition, the virus may damage ‘breathlessness sensations’ centre in the brain insular cortex, central and peripheral chemoreceptors as it does taste and smell receptors.

The lung ventilation is controlled by the brain, peripheral arterial vessels’ chemoreceptors and the lung stretch receptors. The coronavirus may disturb the flow of the electrical signals between the lungs, chemoreceptors, autonomic controls of breathing and circulation and other brain centres. For this reason, the severely ill COVID-19 patients may not feel dyspnoea. Some

MEDICAL SCIENCES

coronaviruses have been reported to spread to the breath and circulation controlling centre in the brain stem from the stretch receptors and chemoreceptors in the lungs.

As recently reported by the prestigious New England Journal of Medicine COVID-19 may attack brain causing clinical symptoms. Moreover, the brain structures can be affected in few asymptomatic COVID–19 patients. Around 40-60 per cent of hospitalised COVID-19 patients experience neurological complications including nerve damage and stroke in USA. For this reason, CT scanning (or/ and functional MRI) of brain should become an adjunct tool to forecast the risk of clinical status deterioration, plan further treatment procedures or prognosticate death, mental or physical disability in symptomatic COVID-19 positive patients admitted to hospitals (especially those presenting symptoms that originate from the nervous system).

The acute respiratory failure in COVID-19 patients can be a result of damage to the lung gas exchange membrane and the concomitant impairment of central cardiorespiratory controls in the brain. Severely ill COVID -19 patients may suffer from respiratory failure that is augmented or coincided by acute heart failure.

The severe lung damage, cardiac failure and focal brain damage in the COVID-19 patients can be related to the direct viral intrusion into the cells, an excessive immediate host immune response to the virus (cytokine storm), arterial blood hypoxemia and acidosis in the wake of the alveolar-capillary membrane damage, the impairment of brain cardiorespiratory controls and the lung-heart interaction during the acute inflammation.

The enormous host immune response to COVID-19 attack called cytokine storm decreases the interferon response that may contribute to the mismatch between the onset of

viral intrusion and the severe clinical manifestation. It can be hypothesised that the early blood sample evaluation for the pro-inflammatory cytokine profile (high TNF and interleukin 6 with lowered interferon) might facilitate emergency physicians to predict the sudden deterioration of clinical status in the in-hospital symptomatic COVID-19 positive patients. The scientists and doctors from the renowned National Research Institute in Paris INSERM have just demonstrated that the severe clinical course in COVID-19 patients is most probably related to the poor interferon response and high load of pro-inflammatory cytokines. This immunological configuration, i.e. ‘unique phenotype’ (low Interferon, high interleukin 6 and TNF), is to be a hallmark of critically ill COVID-19 patients. The reduction of interferon level in blood, i.e. a relevant component of signalling system between the pathogen and host immune system, may be the way the coronavirus utilises to ‘lead astray’ our immunological system and take more severe course.

These observations may indicate that the mitigation of pro-inflammatory cytokine storm (e.g. application of antiinterleukin monoclonal antibodies, plasmapheresis, immunosuppressive drugs) plus interferon supplementation in the very early phase of the disease

The implementation of human physiology knowledge and its rules may help doctors and scientists find more efficient diagnostic and treatment tools in COVID-19 patients.

might be one of ways to save lives of at least some COVID-19 patients in ICU. FDA has approved the emergency use of plasmapheresis for the severe COVID-19 patients to reduce pro-inflammatory cytokine burden. The mitigation of excessive host immune response as mediated by interleukin 6 and other pro-inflammatory cytokines and the application of ECMO might deter or reduce the risk of enormous and irreversible damage to the alveolarcapillary membrane in the lungs and respiratory failure-related deaths in COVID-19 patients. According to the previous reports, plasmapheresis has turned out to be an effective treatment method in diseases with the hyperactive response of the immunological system, i.e autoimmune diseases, myasthenia gravis or multiple sclerosis. There are also reports on the application of plasmapheresis in Ebola viral infection.

The combination of plasmapheresis with ECMO may reduce the pro-inflammatory load on the gas exchange alveolar-capillary membrane and facilitate the lung recovery that is not guaranteed with use of ventilators in many cases.

It has been recently reported that dexamethasone (a commonly used steroid drug) can cause breakthrough in the treatment of the most severe COVID-19 patients demanding mechanical ventilation. Scientists from Wroclaw Medical University in Poland previously demonstrated that dexamethasone can protect cardiac muscle from acute ischaemia–induced damage. The acute inflammatory process causes release of natural steroids from adrenal glands in the early stage of inflammation, which is supposed to weaken the adverse effects of pro-inflammatory cytokines on various human systems in the experimental conditions. Dexamethasone as a strong immunosupressive drug can be most beneficial for COVID-19 severe patients with cytokine storm.

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strategies utilising inactivated SARSCoV may reinforce interleukin 4 production upon restimulation (COVID-19 attack).

Further research on the safe and efficacious vaccine (‘smart’ vaccine) should be focused not only on boosting humoral and cellular immune response, but also the profound investigation of the immune mechanisms that might block the virus entry into the cells and ways to enhance the virus entry blocking capabilities of human body.

Hence, the application of experimental models assisted with IT technologies such as AI and complicated computer algorithms, nanotechnology may help pharmaceutical companies predict the pro- and anti-inflammatory interleukins’ response to the various attenuated coronavirus antigens, the potential deleterious interactions between the host immune system and the virus antigens used for vaccine formulation and build an intelligent and safe for patients vaccine.

To conclude, the future research models on the effective treatment of patients with the severe course of COVID-19 infection should include all stages of the viral infestation,

AUTHOR BIO

Subsequently, this medicine has potential to reduce pulmonary and cardiovascular complications in some hospitalised COVID-19 patients.

Glucocorticoids probably reduce mortality, mechanical ventilation and duration of hospitalisation (the RECOVERY trial ).

One of the hypothetical ways to stop the COVID-19 pandemic is to apply drugs and therapeutic methods that have potential to prevent the intrusion of the coronavirus into the cells of various human systems and tissues. Protein kinase 2 inhibitors (Imatinib and Saracatinib) were proposed by scientists from Iran, Italy, United Kingdom, Romania, and Poland as a new treatment tool.

These inhibitors have power to block the effective binding of the virus to its ACE2 receptor and further penetration into the human cells.

The anti-inflammatory cytokineinterleukin 4 and its role to mitigate viral attack might be also an interesting target for investigation in the context of COVID-19 hostimmune system interaction. In the brand-new article by Yang et al., the array of immune mechanisms of the coronavirus infestation has been profoundly presented. COVID19 causes the enormous increase in the pro-inflammatory interleukins levels. Of note, the increase in the anti-inflammatory interleukin 4 is not so remarkable as compared with pro-inflammatory interleukins.

As demonstrated by de Lang et al., interleukin 4 can block SARS-CoV intrusion into the cells through modulation of ACE2 cell receptor. The interleukin 4-virus interaction takes place in the early stage of infection, therefore experimental efforts to treat SARS-CoV with this cytokine after infection failed. However, after pre-treatment of the cells with interleukin 4 and subsequent infection, excretion of SARS-CoV from the treated cells decreased. Vaccination

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pathophysiologic pathways through which the coronavirus interacts with the human body (virus entry into the cells, interferon-mediated signalling between the virus and host immune response, cellular and humoral response to the coronavirus – ‘cytokine storm’), human genetics, the ethnic specificity- related modulation of the host immune response to the viral infection, the analysis of various pharmacological treatment models using multiple combinations and configurations of the accessible drugs with convetional therapies (mechanical ventilation or ECMO) and formulation of the appropriate immunological diagnostic kits based on the blood measurements of the pre-selected set of interleukins (e.g.IL6,TNF,IL-4) for prognostication or tailoring the suitable treatment for the individual patients’ needs or modification of the applied therapies.

In fact, no matter how hard intensivists and other clinicians try to contain the pandemic, the ultimate victory over the virus will be probably made or marred by basic science.

References are available at www.asianhhm.com

Robert Skalik is a consultant cardiologist and exercise physiologist, a senior lecturer in human physiology in Wroclaw Medical University, Poland, consultant cardiologist in Specialist Hospital „Ventriculus”, Leszno, Poland.From 1998 to 2007, he worked as a physician and consultant cardiologist in Department of Cardiac Surgery and Cardiology, Wroclaw Medical University. He is an Elected Fellow of Royal Society of Medicine in London, Great Britain and Invited Member of VBHC- Centre Europe, the Netherlands.

He is an author and co-author of numerous scientific reports on cardiology and human physiology and one monograph on exercise physiology. He has special interest in general cardiology, cardiovascular imaging, exercise and cardiovascular physiology, cardiac rehabilitation and sports cardiology.

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BOOKS

COVID-19: The Pandemic that Never Should Have Happened, and How to Stop

Leaders in Lockdown: Inside stories of Covid19 and the new world of business

Author: Debora MacKenzie

Author: Atholl Duncan

No of Pages: 304

No of Pages: 240

Year of Publishing: 14 July, 2020

Year of Publishing: March 30, 2021

Author: Shailendra K Saxena

Description: An accessible, authoritative book about the coronavirus pandemic by a leading journalist on the subject.

Description: Leaders in Lockdown is a unique insight from the women and men who were on the frontline of leading the business world’s fight against Covid-19. From New York to Singapore to Hong Kong to the City of London it captures a remarkable moment in time – when the global economy was brought to a shuddering halt in the struggle to contain a deadly pandemic. These first-hand accounts of 100 days of lockdown tell stories of leadership in a crisis. They also share the wisdom of some of the world’s most thoughtful business leaders as they predict how the world will change because of Covid-19.

No of Pages: 233

In COVID-19: The Pandemic that Never Should Have Happened and How to Stop the Next One, one of the first books to look specifically at this pandemic, reporter Debora MacKenzie examines how governments fumbled the early stages of the coronavirus.

She illustrates how, if we had acted prudently years ago, we could have predicted and stopped this disaster.

Ultimately MacKenzie lays out how we might finally learn from our mistakes thanks to Covid-19, making this virus a turning point in how the world collectively acts to prevent outbreaks.

Coronavirus Disease 2019 (COVID-19):

Epidemiology, Pathogenesis, Diagnosis, and Therapeutics (Medical Virology: From Pathogenesis to Disease Control)

Year of Publishing: April 30, 2020 Description: This book provides a comprehensive overview of recent novel coronavirus (SARS-CoV-2) infection, their biology and associated challenges for their treatment and prevention of novel Coronavirus Disease 2019 (COVID19). Discussing various aspects of COVID-19 infection, including global epidemiology, genome organization, immunopathogenesis, transmission cycle, diagnosis, treatment, prevention, and control strategies, it highlights hostpathogen interactions, host immune response, and pathogen immune invasion strategies toward developing an immune intervention or preventive vaccine for COVID-19.

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PROJECT KAVACH

A shield of protection in the battle against COVID-19 Sangita Reddy, Jt. Managing Director, Apollo Hospitals

A

s we begin Unlock 5.0 in India, realisation strikes that we are three-quarters into the year. A year that has been unlike any other in most of our lifetimes with the COVID-19 pandemic bringing the world to a halt. The SARS-CoV-2 virus has changed our lives enforcing a ‘new normal’ as we return to our daily lives.

While we are slowly but surely gaining an upper hand on the novel coronavirus, we cannot afford to let our guard down.

It was towards the end of February this year as the number of COVID-19 cases were increasing globally and taking its first steps into the country that we realised that fighting the pandemic would require a comprehensive strategic approach.

Challenge

The first step to breaking the chain was implemented by the Government through the lockdowns. The second step required private healthcare to step up to the challenge and work side by side with the government in the battle against the novel coronavirus. At Apollo Hospitals, we began work on a plan that would encompass all aspects from information, screening and assessment, testing, to readying the infrastructure for quarantine for the asymptomatic positive cases and treatment facilities for the mild, moderate and severe cases. A month of intensive preparation, bringing together the best of resources of the Apollo Hospitals group led to the launch of ‘Project Kavach’ in March. ‘Kavach’ meaning shield brought together various elements to form a complete response plan to face the COVID-19 threat at the frontlines.

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Solution

With COVID-19 having an exponential spread, the number of patients were snowballing into the thousands and lakhs. Project Kavach was designed to break the chain through interventions at every stage - detection, testing, isolation, and treatment. Project Kavach included many components coming together to form a multi-pronged beachhead against COVID-19.

Information was the first step with a focused communication strategy to all connected nursing homes and all referral doctors with credible information regarding COVID-19. For the general public, screening and assessment through a specially designed AI-based Coronavirus Risk Assessment scan on the Apollo 24/7 app and website allowed screening and initial assessment about the potential risk of having the virus through simple interactive questions.

Based on the risk level, people were guided to contact the help center set up

by Apollo Hospitals. Patients at risk and falling under the ICMR approved testing parameters were guided to the authorised testing centres for the COVID-19 test.

The online Coronavirus Risk Assessment scan was a major success with over 14

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million people taking the assessment till date.

Testing was the second critical part of breaking the chain, Apollo laboratories approved for COVID-19 testing provided home collection of samples as well as drive-through testing using ICMR approved testing methodologies.

Then came quarantine and isolation – another important aspect covered under Project Kavach. This initiative branded ‘Stay I’ provided medical rooms in hotels with light medical supervision for quarantine and isolation in a clean and comfortable environment. This ensured that people who are asymptomatic or have only mild symptoms and don’t need hospital beds were not using scarce resources, thus reducing the burden on hospitals providing acute care for the seriously ill. Since its launch in March this year, Stay I has successfully touched lives of 2 million individuals and serviced over 65,000 bed days, out of which around 20% have been free of cost with the support of financial partners, HUL, SBI and Deutsche Bank. The project currently operates 23 facilities across the country in 13 cities such as New Delhi, Mumbai, Bengaluru, Chennai,

CaseStudy

Outcomes

The most important element of Project Kavach was of course treatment.

Necessary protocols were in place to manage patients who test positive for COVID-19 at all stages. A dedicated healthcare team trained in various aspects of the diseases including selfprotection, identification of symptoms and information flow in case of suspected cases was in place. Till date number of COVID tests conducted across the Apollo group are 239,371.

For COVID treatment, 2578 dedicated beds were made available across the group; while over 800 ventilators were installed. The largest number of isolation and ICU facilities in the private sector enabled advanced care to be given to over 2000 serious patients a month. As of date, the total number of patients treated for COVID are 75,154.

Continuity of care for existing patients was the final component of Project Kavach. The existing vulnerable patient pool who were already under

Apollo’s care were provided access to healthcare remotely using digital technology. The Apollo 24/7 app enabled telemedicine, doctor connect, home sample collection and home delivery of medicines to these patients so that their treatment for existing health conditions could continue without a break. Since the app went live, a total of 4 million people registered on the Apollo 24/7 app; whereas 1,500,000 individuals took the online Covid Scan on the app.

In addition to the scans, Apollo 24/7 app witnessed over 250,000 online consultations and delivered medicines to 300,000+ people.

For others, 3800 Apollo pharmacies across 18 states were kept open to serve people with all required medication, consumables and supplements with capacity ramped up from the 500,000 AUTHOR BIO

Hyderabad, Kolkata, Ahmedabad, Guwahati, Nashik, Pune, Vizag, Indore, and Mysore.

people served on a daily basis to 1 million if required.

Since its launch, Project Kavach has achieved its aims through a robust roll-out and has impacted millions of lives. However, the mission is not yet complete. We are also preparing for the future when a vaccine is made available and we would be required to administer it to a large population within a short time. For the present, while the number of new cases are showing a decline, there is always a risk of a second wave as we unlock. We need to be on our guard and not rest till COVID-19 is conquered! we should start gearing up to administer vaccines to our entire population. We will re-train our entire teams and create the infrastructure and capability to ensure that we can administer 1 million vaccines a day.

Sangita Reddy is the Joint Managing Director of the pioneering Apollo Hospitals Group, a proponent of integrated healthcare delivery. In addition to her operational responsibilities, Sangita led the group’s retail and primary healthcare endeavours.

An ardent champion advocating the benefits of a global delivery model through rural hospitals, outreach camps and telemedicine, Sangita is continuously engaged with the governments to deliver innovative health services harnessing digital platforms.

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FACILITIES & OPERATIONS MANAGEMENT

Headway to Revamp Hospital Logistics

The primary objective of healthcare management is to build consumer focused integrated primary health system improving quality, safety, access, performance and reducing inequity. In the healthcare system, logistics is governed by internal and external supply chains. In the case of internal supply chains, healthcare providers and patients require services with short lead time. Whereas, the external chain including manufacturers and distributors of healthcare products mainly focuses on cost reduction. Well, the entire healthcare system's focus is to provide service to patients, which is often limited due to time constraints.

R B Smarta, Chairman & Managing Director, Interlink Consultancy

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H

ealthcare is a crucial system governed by humanistic approaches that emphasise the personal value of an individual.

Human emotions and values form the core of the system which is efficiently supported by the creativity and proactive nature of healthcare staff. The approach has to be buoyant and focus should be on developing the noble human capacity to tackle the patient’s hardship, pain and despair. Basically, there are 3 pillars of healthcare system, can be called the 3 Ps: the providers of healthcare, the payers for healthcare, and the producers of healthcare products. These 3 Ps together form the value chain of the healthcare system.

(Figure 1)

FACILITIES & OPERATIONS MANAGEMENT

Advanced technologies and increasing healthcare awareness has increased the patients’ knowledge.

Moreover, technology coupled with feedback forms and review forms further increases the competitiveness in the healthcare market. In fact, technology is reshaping the healthcare industry in an irreversible way.

Previously, the only factor that was considered by patients while choosing the hospital or clinic is the quality of treatment provided. But today, the concept of quality, the technology adopted plus the effect of treatment with respect to time all is studied through internet reviews to find the best fit. Knowing all this, the healthcare management has to consider how business practices are affecting patient care. This might include internal and external stakeholders empowering the total healthcare system.

Managing logistics inside hospital

A supply chain management includes physical as well as informational resources to deliver a good or a service to the final consumer. In the broadest sense, a supply chain includes all activities related to production, processing, warehousing, and transportation. Hence, large multispecialty hospitals require specialised skills, digitalised IT systems, and team of people to ensure timely delivery of goods and services. Items involved internally in healthcare systems include drugs, medical equipment, catering, laundry, home-care products, waste management, information technology (IT), vehicle fleet management and general supplies.

Supply should be directly proportional to demand for smooth operations but that doesn't happen unless demand for available treatments

Pillars of healthcare value-chain system

and its financial perspectives are as per market opportunity. Simply put, a ‘centralised core approach’ to control the entire system might not be that useful, but a ‘centralised decision model’ can be used for coordination and is governed by a single decision-making system. Designing such a centralised system for hassle-free operations, effective communication and smooth coordination is necessary for better healthcare delivery.

COVID-19 has made us aware of acute shortages of materials like masks, PPE Kits, ventilators, intensive care unit (ICU) capacity, specific drugs, and, most importantly, the staff. The needs of healthcare resources were at peak and supply chain management has shown up their real time issues. I think, it is better to accept the reality and deal with it. Improving supply chain management is critical to ensure that healthcare providers have enough resources to do their duty. The internal supply chain should ensure delivery of each item at the appropriate time to ensure optimal treatment and patient safety.

Managing supply using advanced technologies:

Healthcare Provider

Healthcare Payers

Healthcare Product Producers

Figure 1

Source: Interlink knowledge cell

In hospital operations, the supply chain is regarding patient, information, and material flows. Flow of medical devices, laboratory samples, sterilised instruments, pharmaceutical products, prosthetic, and everyday commodities such as meals and beverages all has to be managed simultaneously.

The material flows either towards or away from the hospital and within the hospital. So, hospital logistics is subjected to procurement, in-house storage, transportation to various wards, and waste management. Trolleys and other manual carriers are already used in various hospitals, while some premium hospitals use ATS systems for material flow. ATS is an automated material transport system that is expanding towards ‘Hospitals 4.0’. (Figure 2)

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Step wise approach in logistical transformation Foundation Focus: Operations Goal:

To procure products Lowest price paid Reduced stock outs Limited focus on efficiency

Optimisation Focus:

Cost and Efficiency

Goal:

Spend analysis Standardisation

Optimisation: In-hospital operating costs Inventory carrying costs Lead times & stock outs

Transformation Focus: Goal:

Figure 2

Source: Oracle Whitepaper: The clinically integrated supply chain

Few technologies that are included in an ATS system are as follows: 1. Automated Guided Vehicles (AGV): These are trolleys controlled by a computer and have limited load carrying capacity depending on its features. They are designed to travel along the floor of a facility without an onboard operator. They work on directions given by software and sensor-based guidance systems. There are various AGV types, depending on the requirements. Some typically used AGVs include Automated Guided Carts (AGC), Towing AGVs, Automated Forklifts that include Pallet Jack, Counterbalance, Outrigger, Very

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Cost, Efficiency, Quality Patient-centric, Value-based purchase Lean material management Reduced SCM cost across the network Improve clinical outcomes Collaborative planning & Forecasting

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Narrow Aisle (VNA) AGV, Reach Trucks, Unit Load AGVs and other AGV designs for special applications.

The models that are used in hospital are mainly Automated Guided Carts (Hospital AGC) or Autonomous Mobile Robot (AMR). They are AGV on which a lifting platform is incorporated to carry a heavy load and transport of carts used in the distribution of goods.

Example: The New Royal Adelaide Hospital in Australia has installed around 25-strong fleet of RA-GV‘s (Robotic Automation’s Guided Vehicles). These are used to deliver drugs, laundry, sterilised items, food items, beverages (cold and hot), and

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are applied for waste management. The entire material flow between the patient wards, and the pharmacy, kitchens, and the other functional areas are managed by these AGVs. 2. Automated Mobile Robots (AMR): These are robots whose working is based on an array of onboard sensors, controlled by computers by encrypted mapping system. They can thus understand and move around surrounding area without an actual operator. This technology is widely applicable in warehouse area when coupled with Warehouse Execution Software (WES). This leads to better flexibility and efficiency in huge warehouse setups, whereby they can identify and avoid obstacles and reach to their locations even by rerouting if required.

Depending on the requirement they can be applied for: • Transportation of products and freight within a facility • Assisting in the picking process • Facilitating sorting • Increasing inventory visibility Example: Smart applications like HelpMate and TUG enable autonomous mobile robots to transport materials and clinical supplies within the hospitals, and the laboratories. The robot operates in multiple ways, as it can be commanded to unload the cart at one or multiple destinations. TUG robots are guided by a laser scanner and thus can follow obstacle free path.

3. Electrified monorail system (EMS): As the name suggests, a monorail system managed electrically, is actually a conveyor system which travels across a low profile track. Guided by the cameras for a better security, it is equipped for commercial and healthcare applications. The following are the features of EMS; • They can transport horizontal to vertical direction smoothly • They are designed for buffering to compensate for fluctuations in production

FACILITIES & OPERATIONS MANAGEMENT

RFID in logistics

The above mentioned technology can be applied in various departments depending upon the requirement. In case of routine operations, like sending or receiving materials or specimen such as blood samples or other pathological samples, can be configured with barcode or Radio frequency identification (RFID) chips. RFID chips are designed to capture electromagnetic field mentioned on tag which is labeled to the objects.

The tags transmit digital data, usually an identifying inventory number, and thus help in tracking and monitoring the supply chain of an object.

For example, in case of managing the logistics in the sterile department, these chips can be labeled to each of the equipments used thereby. This enables hospitals to track the tagged equipment, instrument, at any given time within the hospital. Same can be done with food items or even drugs. Once a product is labeled, the same can be shared with the receiver, who can scan and track the item ensuring product’s authenticity.

Way forward

To have an optimised and appropriate supply chain management across

hospital activities, a complete overview of location, quantity, and availability of all items is crucial. The complex structure of management can be eased using digital tools such RFID chips. In today’s digitised world, use of software integrated services and robotics like technology is common. Though the tools are designed for specific activities, all such activities are linked to a common interface which is handled by a team of people having decision-making capability. This forms a central decisionmaking team for all logistical processes and ensures efficient material flow in real-time. Such an approach allows hospital staff to simply follow the steps as indicated by the software.

In hospitals, a concept called “the iron triangle” relates to cost, quality, and access. These three main criteria form the pillars of healthcare services.

In India, patients suffer due to out-of-

pocket expenses and that impact life adversely. Cost of healthcare increases as it moves from the public to the private sector as more technology starts coming in. Thus, use of economical technologies such as RFID at grass root level starting from primary healthcare services will provide efficient and reliable care to maximum number of patients. The Indian government has already started to integrate digital apps to automate data processes and procedural steps. Thus, a digitally managed logistic system will be soon replacing manual processes.

References: https://www.oracle.com/a/ocom/docs/ cisc-whitepaper.pdf https://www.quirepace.co.uk/products/ electric-track-vehicles/products/unicar/ https://www.agvnetwork.com/types-ofautomated-guided-vehicles

R B Smarta has designed management agendas for profitable growth, relevant expansion, launching new concepts, ideas and projects for National and Global clients in Pharmaceuticals, Nutraceuticals and Wellness.

Being in the industry for more than 4 decades &amp; in consulting as a pioneer for 3 decades, he has a perfect blend of industry and consulting best practices.

He has added value and impact on performance of wide variety of clients, inclusive of start-ups to national and multinational corporate. His firm Interlink has created valuable insights and depth of knowledge in its knowledge bank, along with its consultants and associates.

AUTHOR BIO

• Horizontal and vertical storage to save space • Various loading and unloading stations • Supported by the switches for the distribution of materials in multiple directions • Bidirectional transport can be achieved with regulated speeds Example: EMS technology is used at the NHS Hospital at South Mead, Bristol, in the laboratory section. It is applied as a laboratory automation system whereby samples are transported through a monorail, and has reduced manual workload, and integrated the monorail system with analysers and other robotic equipment to have a fully automated laboratory starting from patient to analyser to report generation.

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The Overlooked Price of Healthcare Digitalisation

Power management continuing to be a big challenge

Technologies such as analytics and advanced diagnostic machines have accelerated advances in care and treatment while emphasising the central role of power management and quality. Now with the need to be able to scale operations in a matter of days, there is increased pressure on connected, always-on hospitals and clinics to get this right and avoid catastrophic downtimes.

Rich Farrell, Director, Cloud & Data Centre Segment, Electrical Sector, APAC, Eaton

T

he hospital environment today has changed significantly in the last two decades with research and technological innovations advancing patient care and treatment. However, the perennial expectation of doing more with less remains, exacerbated by a myriad of challenges faced by today’s healthcare systems. Even before the emergence of COVID-19, the rapidly ageing populations1 in many developed economies and a crippling healthcare worker shortage2 were already creating big challenges for hospitals worldwide.

To address these difficulties, hospitals have turned to digitalisation to identify a range of feasible solutions with technology and data being applied across an array of functions to support hospital operations and cope with 1 https://www.who.int/news-room/fact-sheets/detail/ageingand-health 2 https://www.who.int/health-topics/healthworkforce#tab=tab_1

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today’s challenges. For example, the use of analytics in diagnostics and wearables for remote patient monitoring helps augment healthcare workers’ capabilities and reduce hospitals’ reliance on manpower to complete manual tasks.

However, this growing adoption and reliance on data, connectivity and critical machines comes at an oftenoverlooked cost-an increasing energy demand.

The modern hospital is already notorious for consuming significantly higher amounts of energy compared to other building types due to their diverse needs. On top of the lighting, cooling, ventilation and heating needed to support hospital operations, the constant movement of thousands of staff, patients and visitors, and the need to remain open 24X7, all make it challenging to keep energy consumption levels low. What will a comprehensive power management approach look like for tomorrow’s hospitals?

INFORMATION TECHNOLOGY

What are some of the new factors influencing energy demand, and what will their impact be on an already crowded power grid?

More critical technologies mean more critical power is needed

Hospitals are a key component in the fabric of every community and are typically regarded as places of safety, especially in times of disaster or emergency. It is thus unthinkable to imagine a hospital without power, especially one that relies on a multitude of machines, sensors and systems to meet patient needs. Yet, it is the constant addition of such equipment and services to accommodate new patient needs and increasing dependence on modern technology that adds complexity, difficulty and cost to building a stable, reliable power system.

No matter the duration, it will be devastating if ventilators, surgery room equipment and intelligent monitoring equipment were to experience a power outage. To support critical life safety equipment, healthcare facilities need to be prepared with solutions that can navigate unavoidable outages, both temporary and extended. Not doing so would force them to make painful decisions about which systems to keep online and which to let go in times of power outages. Even extremely short power outages of a few seconds can compromise the health of individual patients and damage sensitive medical equipment and IT systems. For example, expensive hardware such as Magnetic Resonance Imaging (MRI) and Computer Tomography (CT) scanning equipment, are particularly sensitive to small disruptions in power quality which can trigger malfunctions that might even pose a danger to both staff and patients. With this heightened sensitivity to electrical disruptions, hospitals need to take extra precautions to protect modern IT equipment to avoid unnecessary safety risks.

At the same time, critical IT systems responsible for access and sharing of data also require critical power to keep running. Should the system fail, the inability to access test results or digitalised patient records can lead to an incomplete diagnosis or gaps in treatment. On the administrative end of hospital operations, limited connectivity to cloud-based platforms such as insurance policy databases or billing systems can slow down processes significantly.

These increasingly complex power demands, together with the volatility of power grids and the growing frequency of weather-related power blackouts3 are emphasising the importance of investing in the right infrastructure to keep many of these mission-critical systems up and running.

Hospitals and the Internet of Everything

While critical power may be key to keeping important machines and systems up and running, their heavy reliance on connectivity and networking adds another layer to the complicated power puzzle. Smart hospitals4 today run on the free-flow of data and interconnectivity of networks and devices, which help enhance patient care and streamline operations. For instance, Thailand’s Ministry of Digital Economy and Society is trailing 5G technology at Bangkok’s Siriraj Public Hospital to relieve network congestion5 and deploy unmanned vehicles6 for the contactless distribution of medical supplies within the hospital. Meanwhile, machine 3 https://www.climatecentral.org/news/weather-relatedblackouts-doubled-since-2003-report-17281 4 https://www.enisa.europa.eu/publications/cyber-securityand-resilience-for-smart-hospitals/at_download/fullReport# :~:text=%25E2%2580%259CA%2520smart%2520hosp ital%2520is%2520a,procedures%2520and%2520introd uce%2520new%2520capabilities%25E2%2580%259D

learning algorithms around the world are helping doctors analyse thousands of medical images7 to identify patterns and abnormalities faster and more accurately than ever.

The adoption of such technologies helps address many hospitals’ overarching challenge of maximising available resources while simultaneously reducing the workload on an already overstretched workforce. Yet many of these capabilities will no longer be available without a resilient power infrastructure to keep networking and communications equipment, and data centres up and running. The growing dependence on power to ensure constant interconnectivity reflects the growing prominence of the data centre as the hospital’s ‘traffic control’ centre.

Even the slightest outage can cause the complex, highly-integrated machine that is the modern digital hospital to fall into disarray.

Scalability in the new VUCA normal

One of the many major lessons learnt from COVID-19 is the need for hospitals to be able to scale up and down quickly to meet the demands posed by such health crises, especially as hospitals around the world brace for the multiple waves of infections in the coming weeks. With Volatility, Uncertainty, Complexity and Ambiguity (VUCA) becoming the new, everyday state of play and pandemics such as COVID-19 likely to happen more frequently8, hospitals will need to have the right infrastructure in place to be able to respond swiftly and effectively.

The challenge is a complex one, requiring many moving parts and supply chains to be carefully coordinated, and any delays could result in serious consequences.

From a power management perspective, hospitals will need to cater to a sudden increase in power load

5 https://www.khaosodenglish.com/news/2020/04/16/ siriraj-hospital-teams-up-with-huawei-adopts-5g-tech-tofight-covid-19/

7 https://www.zdnet.com/article/fujitsu-and-tokyo-shinagawa-hospital-to-develop-ai-for-covid-19-pneumoniadiagnosis/

6 https://www.bangkokpost.com/thailand/pr/1941024/ nbtc-joins-forces-with-siriraj-hospital-and-huawei

8 https://www.bbc.com/news/science-environment-52775386

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INFORMATION TECHNOLOGY

Getting the strategy right

While there is no panacea for hospitals’ power management woes, many of these challenges can be managed effectively with the right technology, maintenance strategy and a good understanding of local regulations.

Start by assessing your current power management infrastructure and back-up power resources to determine if sufficient resources are in place to support your existing IT load. If blackouts or disruptions are unavoidable, check your current Uninterruptible Power Supply 9 https://www.theguardian.com/world/2020/feb/04/ new-1000-bed-wuhan-hospital-takes-its-first-coronaviruspatients

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(UPS) solution to determine if it meets your back-up power requirements. A UPS is essential to keep data centres up and running, by adding a layer of protection to shield critical loads from power supply issues. Consider looking into newer battery technologies for your UPS, such as lithium-ion systems, which not only offer longer life cycles and better reliability but are also smaller and lighter. Having a robust back-up power strategy in place will protect highly sensitive medical equipment and critical networks, giving you sufficient time to quickly address any issues or power downtime safely. Other longer-term solutions such as microgrids can play an even bigger role in keeping hospitals functioning in the event of severe natural disasters while also helping to manage fluctuations that come with adopting renewables. Even then, IT teams should always have data backed up in an off-site location to ensure critical information is never lost as an added level of insurance.

Once the right technology is in place, maintenance has to take on a more preventative and collaborative approach as well. Working closely with trusted suppliers and communicating openly about requirements is critical as no two set-ups are identical. As a start, hospitals should set up a regular service arrangement that focuses on keeping power management equipment running at its best, and not simply as needed.

Testing, while sometimes a hassle, should also be done regularly to ensure systems work as they should when activated. If available, leverage predictive analytics solutions to identify issues before they become problems to help save additional maintenance costs and enable you to optimise your set-up.

AUTHOR BIO

for additional monitoring devices, diagnostic machines, connectivity, and other equipment that is needed to manage a sudden influx of patients.

In our recent experience with setting up field hospitals in Wuhan earlier this year, establishing a fast and stable connection to utility power is the key to getting things up and running in a matter of days. With more than 20,000 infections in Wuhan9, hospitals had to scramble to set up makeshift facilities to treat patients. Just as in regular hospitals, field operations also need to rely on the same critical equipment and reliable networking communications to coordinate information sharing and respond effectively. CT scanners and other diagnostic imaging equipment still require the same circuit protection and downtime needs to be avoided at all cost.

With COVID-19 and other potential pandemics being increasingly difficult to predict and manage, this ability to deliver the same standard of comprehensive care regardless of location will be important in slowing down the spread of diseases and delivering effective treatment. Moving forward, power management and infrastructure will be a critical component of every hospital’s emergency and pandemic preparedness plans.

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Finally, hospitals should always ensure that local regulations are adhered to when it comes to configuring your power management infrastructure. Such requirements are not just for ticking boxes off a compliance checklist but are also in place to ensure the safety of staff and patients. Doing so not just requires procuring the right technologies, but also making sure that the technical teams within the hospital receive the right training and can deal with issues promptly when they arise. Guidelines and regulations for power management sometimes also set benchmarks for sustainability, which can be useful references for hospitals looking to achieve emissions or renewables targets.

Looking ahead

Hospitals need to recognise that power management is an ongoing journey and one which constantly requires regular reassessment and adjustments.

To tap on the full potential of emerging technologies, networking and data, a comprehensive foundation in power management must first be laid to avoid any dangerous missteps. If these technologies and systems are not integrated or supported well, they may start to compete for bandwidth and increase the volatility of the grid.

Intermittent power disruptions may then become a regular challenge, hindering day-to-day operations and possibly impacting patient care. Thus, the value of investing in reliable power protection to support healthcare digitalisation cannot be understated. Hospitals, now more than ever, will have to take stock of their power management tools and be mindful of these additional factors in the rush to embrace digitalisation.

Rich is a technology evangelist, strategist & consultant with over 20 years of experience in the IT, Data Centre, and Hyperscale Cloud space. In his current role at Eaton, he collaborates with customers across the Asia-Pacific region to shape their cloud strategy and advises on data centre build best practice and industry innovations.

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Telepathology for Remote Unreached Communities Feasibility during public health emergencies

Diagnosis is often difficult in the remote unreached communities with no access to professional pathologists although it is fundamental to provide appropriate treatment.

During the Coronavirus (COVID-19) pandemic, it has become more important to accommodate innovative technologies of digital imaging and telecommunications for remote primary diagnosis, specialist referrals, research, and educational purposes. In this paper, we present recent progress in the research of telepathology in Bangladesh.

Md Jiaur Rahman, Md Moshiur Rahman, Masayuki Kakehashi, Graduate School of Biomedical and Health Sciences, Hiroshima University

T

elepathology can be explained as the electronic transmission of digital images of pathology for education, research, diagnosis, or consultation. The term ‘telepathology’ was invented in a scientific article by a pathologist Dr Ronald S Weinstein in 1986, who is also recognised as the ‘father of telepathology’. Using the internet and advanced telecommunication to provide remote diagnosis service is known as telepathology. The research of telepathology raised up and involving different field of research, education and using artificial in tendency. Currently, many countries have endeavoured to the analysis of research in telepathology for different poorhouses and beginning from the materials supplied by bibliometrics.

In the early 1950s, telepathology was developed from video microscopy (i.e., Television Microscopy) research to video microscopy used in basic research in the biological sciences. In 2011, during a multinational telepathology conference in Venice, Italy, the 25th anniversary of the publication of the first telepathology article (an editorial) in 1986 was marked and noted by Vincente Della Mea. A wide variety

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of digital slide imaging devices was demonstrated by twenty imaging companies. However, none of them were interoperable. The standards of telepathology were either nonexistent or at an early stage of evolution at the time of this multinational conference.

Afterwards, although, more than 400 laboratories in 32 countries have published telepathology articles, proportionately few of them use telepathology in their practices apart from transformation of irregular

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intraoperative frozen section diagnosis or second opinions on problematic surgical pathology. For the surgical pathology cases, by using the realtime video imaging or stored imaging, telepathology system supports the diagnosis. One of the examples of telepathology innovation and collaboration is to support to patients' benefits for the distance diagnostic service by this change and adaptation.

Numerous commercial and academic telecommunications networks have been

INFORMATION TECHNOLOGY

developed over the years. Telepathology is of great benefit to underserved and rural areas where there is a significant shortage of pathologists. In these areas, not only is there a high demand for diagnostic consultation, but also a need for continuing education and guidance on patient management.

In the recent decades, the implications of digital information technologies to pathology procedure have been spreading out, and the process of conventional pathological diagnostic service is moving with improved accuracy and convenience.

Developed countries like Europe, America, Canada, and Japan started using artificial intelligence (AI) in pathology. Meanwhile, developing countries like Bangladesh are using just a digital camera to capture microscopic images and sharing it through online systems. This way they are using telepathology for remote diagnosis to serve their unreached communities.

Advantage of telepathology in developing counties

In developing countries, disease burden is the highest with very limited resources for healthcare; a shortage of pathologists led to delays in diagnosis, sometimes misdiagnoses, and postmortem examinations. The lack of qualified health professionals and adequate facilities are the highest obstacles to overcome in the healthcare delivery throughout Southeast Asia, South Asia, and Africa.

There is a worldwide acknowledged shortage of trained pathologists greater than the primary care physicians with an estimation of more than 500,000 people per pathologist in the African continent.

Technological innovation and various efforts to fill the human-resource gap in pathology have led to the evolution and expansion of diverse telepathology solutions across the continent. Many platforms have accommodated the options for telepathology in developing and underdeveloped countries in sub-Saharan Africa. A lot of progress

The trend of using telepathology, wholeslide imaging, and digital pathology systems have been gathering momentum for several years.

has been made to help pathologists collaborate and bridge the gap of pathology service through the pairing of remote facilities with experienced ones. Diagnostics application is the most common use of telepathology in low resource settings along with teaching, education, and quality assurance. Apart from the diagnostic use, the adoption of telepathology in many underdeveloped countries may be a form of two-way communication, locally approachable services with user acceptance, low operational cost, and low risk during disease pandemic.

However, telepathology deals with numerous limitations in scaling up and widespread adoption. Two major factors as power supply and highspeed internet, which are extremely lacking in underdeveloped countries for telepathology. The legal barrier of health professionals in delivering care across borders and security concerns related to the confidentiality of medical information on the internet is still unclear. Multiple approaches including operational feasibility are essential to solve these problems.

Recent development in Bangladesh

Bangladesh is one of the developing counties with a critical shortage of health care facilities as well as care professionals.

Grameen Communications of Bangladesh has developed a telepathology system as an Information and Communication Technology (ICT) based healthcare service system.

Grameen Communications started this telepathology project in 2016 in four

different rural and sub-urban hospitals for unreached communities of Bangladesh.

In this project, haematological (complete blood count), stool (routine microscopy), and urine (routine microscopy) tests are being provided as some of the telepathological services.

Before starting the telepathology service, they ensured basic requirements were met for the successful implementation of the service, such as: 1) Skilled and trained human resource (e.g., pathologists and medical technologists), 2) Telepathology service platform, 3) Internet access, 4) Microscope, and 5) High-resolution camera/smart phone with a structured camera/phone holding frame.

A service team was built comprising of one online pathologist in the city and one laboratory technologist in each remote site. First, the laboratory technologist collects patient’s basic information like name, age sex, address and cell phone number for online registration. Then she/he collects blood sample, prepares slide, takes 6-10 microscopic images of a slide from different significant locations using conventional microscope and digital camera, and uploads the images to the online server of the telepathology system. Finally, the remote pathologist prepares the pathological digital report using telepathology system by image analysis and shares with the laboratory technologist through the online system.

By using telepathology system, Grameen communications served 3,000 remote patients.

In the pandemic of COVID-19

The COVID-19 pandemic is leading to unprecedented burdens on regional and institutional resources in healthcare facilities globally. The medical systems worldwide are facing unexpected operational challenges and stress to their social infrastructure and healthcare systems. The pathologic diagnoses and integration of histopathological and molecular data are crucial for timely induction of right treatment regimens for even non-COVID-19 patients with

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INFORMATION TECHNOLOGY

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this was actualised only because of the advancement of information technology, specially, the internet. To, mitigate the long-lasting sufferings of developing countries, this ICT-based telepathology system can provide satisfactory diagnosis for the most remote places using internet facilities. Therefore, where pathology services are unavailable and inadequate, a positive attitude in local government, and national and international organisations, especially the scientific bodies, is required.

Implementation challenges of this system include a change in the traditional mindset of patients and physicians. It is not possible to perform all tests by this telepathology system like biochemistry, serology and immunology. The gap of distance pathology service can be reduced using the telepathology system by an online professional pathologist.

If the telepathology approach can be scaled up throughout the world, it might contribute to improve healthcare services through proper diagnosis.

Technological innovation is great for many developing countries in critical sectors like health. Telepathology services are minimising the human recourse AUTHOR BIO

serious medical conditions. During public health emergencies like this COVID19 pandemic, when the infection risk becomes higher, the remote use of digital pathology enables healthcare systems to keep pathology operations going. The pathologists, their colleagues, and family members are at risk of contamination by a deadly virus. This disruption is causing revolutionary downstream effects to the healthcare delivery system, including essential anatomic pathology services. Workplace transmission events may lead to reductions of laboratory or health personnel due to exposure and/or sickness. If pathologists are unable to be present at their working facilities due to illness, quarantine, or travel restrictions, healthcare system will lose continuous patient care and cause uncertainty of pathological reporting. Several published studies have reported that when the patient care and protecting healthcare personal safety is crucial, the pandemic has found benefit in digital pathology for reviewing and reporting of pathology specimens for ensuring uninterrupted and expert pathology practice.

Pathologists have been instructed to work from home during the COVID-19 pandemic like many other professionals.

In this current pandemic situation, the remote telepathology allows healthcare systems to maintain pathology operations during public health emergencies. This situation makes eHealth necessary as it can overcome geographical barriers, increases the number of people served, and provides online diagnosis support for patients.

The COVID-19 outbreak is just the latest factor in support of enabling remote review of anatomic pathology images and cases. The trend of using telepathology, whole-slide imaging, and digital pathology systems have been gathering momentum for several years.

Powerful economic forces support this trend.

Telepathology systems have appeared as an amazing gift for ensuring effective healthcare service at low costs. And

gap and lead to the development and dissemination of various pathology solutions across the world. A pathologist selects the images to be analysed and study the slides remotely in realtime and deliver immediate analysis.

Integration of machine learning and AI is supporting pathologists to make an informed decision. These days, the use of telemedicine has been increasing regularly due to the rapid advancements in ICT. Innovative technologies for digital imaging and telecommunications are changing the way of traditional service delivery process. Infrastructure and experienced skilled staff are the prerequisites for its successful implementation.

In the developing world, telepathology is very essential because of the significant socio-economic differences resulting in urban areas getting better healthcare services while rural and remote areas remain disadvantaged. The telepathology system is an effective and feasible way to provide better treatment during the COVID-19 pandemic.

References are available at www.asianhhm.com

Md Jiaur Rahman is a graduate course student of Biomedical and Health Sciences at Hiroshima University, Japan. He completed bachelor degree from Bangladesh. He has been involved in various eHealth research activities such as Telemedicine, Telepathology and Virtual Blood Bank in the Grameen Communications, Bangladesh.

Md Moshiur Rahman is Associate Professor of International Health and Medical Care, Hiroshima University, Japan. He has outstanding academic credentials combined with experiences in global health, population and health science, research, administration, and leadership. He has more than 20-year experiences in health-related programs and researches in Bangladesh, Africa, and Japan.

Masayuki Kakehashi is a professor of Health Informatics, Graduate School of Biomedical and Health Sciences at Hiroshima University, Japan. He has been involved various research activities such as health informatics, mathematical model, cancer screening, and healthcare system. His research mission is to explore and establish useful information on health-related factors.

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BOOKS

AI in Health: A Leader’s Guide to Winning in the New Age of Intelligent Health Systems

VRx: How Virtual Therapeutics Will Revolutionize Medicine Author: Brennan Spiegel

Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again

Author: Tom Lawry

No of Pages: 2304

Author: Eric Topol MD

No of Pages: 222

Year of Publishing: October 6, 2020

No of Pages: 400

Year of Publishing: 12 February 2020

Description: Virtual medicine works by convincing your body that it's somewhere, or something, it isn't. It's affordable, widely available, and has already proved effective against everything from burn injuries to stroke to PTSD. Spiegel shows how a simple VR headset lets a patient with schizophrenia confront the demon in his head, how dementia patients regain function in a life-size virtual town, and how vivid simulations of patients' experiences are making doctors more empathic.

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Description: Product Description: This book defines key technical, process, people, and ethical issues that need to be understood and addressed in successfully planning and executing an enterprisewide AI plan. It provides clinical and business leaders with a framework for moving organizations from the aspiration to execution of intelligent systems to improve clinical, operational, and financial performance.

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Description: In Deep Medicine, leading physician Eric Topol reveals how artificial intelligence can help. AI has the potential to transform everything doctors do, from notetaking and medical scans to diagnosis and treatment, greatly cutting down the cost of medicine and reducing human mortality. By freeing physicians from the tasks that interfere with human connection, AI will create space for the real healing that takes place between a doctor who can listen and a patient who needs to be heard.

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Machine Learning and AI for Healthcare: Big Data for Improved Health Outcomes Author: Arjun Panesar

The Healthcare Gamechangers: 12 innovators around the world reimagining healthcare

No of Pages: 394

Author: Ashwin Naik

Year of Publishing: February 5, 2019

No of Pages: 212

Description: Machine Learning and AI for Healthcare provides techniques on how to apply machine learning within your organization and evaluate the efficacy, suitability, and efficiency of AI applications. These are illustrated through leading case studies, including how chronic disease is being redefined through patient-led data learning and the Internet of Things.

Year of Publishing: 23 April 2019 Description: Dr Naik shares his perspective of what we can do differently to address the gaps in today's healthcare system. He argues that to re-imagine healthcare, we have to start by 'thinking outside the hospitals'. Through an in-depth study of healthcare entrepreneurs from around the world, he gleans some key principles for the future of healthcare.

In these pages you'll discover: - What does the world of healthcare look like when we 'think outside the hospitals'?Who are the innovators around the world who are reimagining healthcare and how are they doing it?- What can we learn from each of the innovators and how is it relevant to our own life and health?Whether you are a healthcare professional or a healthcare consumer, you are becoming increasingly a decision maker of how to get better care.

Closing Death's Door: Legal Innovations to End the Epidemic of Healthcare Harm Author(s): Michael J Saks and Stephan Landsman No of Pages: 336 Year of Publishing: 4 January 2021 Description: Closing Death's Door brings the psychology of decision making together with the law to explore ways to improve patient safety and reduce iatrogenic injury, when neither the healthcare industry itself nor the legal system has made a substantial dent in the problem.

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BOOKS

Innovative Smart Healthcare and Bio-Medical Systems: AI, Intelligent Computing and Connected Technologies Author: Abdel-Badeeh Salem No of Pages: 248 Year of Publishing: 15 December 2020 Description: This book presents models for the deployment of intelligent computing, information, and networking technologies to aid in preventing disease, improving the quality of care and lowering overall cost. It also discusses the potential role of the AI paradigms, computational intelligence and machine learning techniques which are used in developing the SHS. It will provide examples of potential usage of such technology in smart healthcare and and bio-medical systems

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Statistics and Machine Learning Methods for EHR Data: From Data Extraction to Data Analytics

Something Awesome: A Life in Neurosurgery

Author(s): Hulin Wu, Jose Miguel Yamal, Ashraf Yaseen and Vahed Maroufy

Description: In this medical memoir, Dr. Friedman recounts the humorous, tragic, and always intense relationships of neurosurgeons to their colleagues and patients. He details what it takes to become a leading neurosurgeon and deal with deadly brain diseases and their devastating complications.

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No of Pages: 2000 Year of Publishing: 10 December 2020 Description: This book covers many important topics related to using EHR/EMR data for research including data extraction, cleaning, processing, analysis, inference, and predictions based on many years of practical experience of the authors. The book carefully evaluates and compares the standard statistical models and approaches with those of machine learning and deep learning methods and reports the unbiased comparison results for these methods in predicting clinical outcomes based on the EHR data.

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Author: William A Friedman No of Pages: 208 Year of Publishing: 16 February 2021

3D Printing in Medicine and Surgery: Applications in Healthcare Author(s): Daniel J Thomas & Deepti Singh No of Pages: 304 Year of Publishing:15 August 2020 Description: This comprehensive resource features practical experiments and processes for preparing 3D printable materials. Early chapters cover foundational knowledge and background reading, while later chapters discuss and review the current technologies used to engineer specific tissue types, experiments and methods, medical approaches and the challenges that lie ahead for future research. The book is an indispensable reference guide to the various methods used by current medical practitioners working at the forefront of 3D printing applications in medicine.

Industry 4.0 – Shaping The Future of The Digital World: Proceedings of the 2nd International Conference on Sustainable Smart Manufacturing

Sustainable Hospitality Management: Designing Meaningful Encounters with Talent and Technology

Author(s): Paulo Jorge da Silva Bartolo, Fernando Moreira da Silva, Shaden Jaradat and Helena Bartolo0

No of Pages:

No of Pages: 372

Description: Sustainable Hospitality Management: Designing Meaningful Encounters with Talent and Technology will generate international debate in the research and practice of hospitality management.

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Volume 24 of Advanced Series in Management explores topics at the very heart of hospitality, by looking at meaningful encounters: positive, welcoming, genuinely service-oriented interactions between humans, and the role of technology in creating or improving these encounters.

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