Asian Hospital & Healthcare Management - Issue 56

I S S U E 56

2022

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FOSTERING HEALTHCARE PERSPECTIVES An Executives Special Issue

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ESSENTIALLY BETTER

E va r i o o n e The economical hospital bed The Evario one from Stiegelmeyer is highly cost-effective and also appreciably alleviates the workload of staff. Intuitive operation, good manoeuvrability and reliable hygiene are decisive strengths in the everyday routine. Discover the advantages of this bed that’s at home in any hospital unit: • Choice of two safety sides to protect and mobilise • Tailor-made control concepts to suit the particular use • Hygienic design with few niches • Bed surrounds and optional holders offer space all round for equipment and accessories

stiegelmeyer.com

Foreword

EXECUTIVES SPECIAL ISSUE

Fostering Healthcare Perspectives An Executives Special Issue Digitisation

has

radically

altered

the

publishing

trends, technical developments, scientific information

industry over the years. Irrespective of technological

and managerial strategies. Here, I take a privilege to

developments, print medium has its own place in the

acknowledge our contributors, who are dedicating their

industry. Taking pride of launching 56th issue of our

efforts and valuable time by sharing their knowledge to

Asian Hospital & Healthcare Management magazine

our readers.

in both print and digital formats: this is an Executives

This Executives Special Issue covers a mix of articles

special issue, aimed at facilitating subject matter experts

on different topics like Healthcare ecosystem, Telehealth,

comprising the magazine’s advisory board and author

AI, Block chain, Digital health and many more by our

community share perspectives and insights on the

esteemed authors. As the journey continues, I would

latest trends, key issues impacting and influencing the

like to take things forward with the same energy for our

healthcare industry.

future issues and deliver rich content for our readers. We

Started our first step in 2005 and successfully running

will continue to strive to disseminate healthcare insights

towards the launch of issue 56 with a issue every quarter.

producing most relevant content and sincerely believe

In this journey, we came across many changes and tried

that this collaboration with the contributors will make our

our best to serve our audience and clients creating the

journey more successful in the future.

best possible platform increasing their visibility and

Please

use

the

opportunity

of

reading

our

facilitating outreach to their target audience. From a bi-

knowledge-driven articles and post your comments to

annual publication to a quarterly edition, supplemented

prasanthi@ochre-media.com.

by the newsletter, we have come a long way with the core objective of delivering most insightful content covering the latest in healthcare.

With cutting-edge content that revolves around the latest trends and subject areas critical to the industry, the magazine covers all the areas of the healthcare industry. The perfect combination of articles on industry

Prasanthi Sadhu Editor

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CONTENTS HEALTHCARE MANAGEMENT 06 Helping Consumers be their Own Health Advocates Kristy Appelhans, Vice President, Global Consumer Safety, Herbalife Nutrition

FOSTERING HEALTHCARE PERSPECTIVES An Executives Special Issue

15 Technology Entrepreneurship in Healthcare A practicum education perspective

COVER STORY

Pradeep Ray and Kwee-Yan Teh, University of Michigan-Shanghai Jiao Tong University Joint Institute

20 Behavioural Health and its Effects on Profits Gurrit K Sethi, Founder, Miindmymiind

24 Axios International's 25th Anniversary Joseph Saba, CEO, Axios International

31 Building a New Healthcare Ecosystem What the pandemic means for healthcare’s digital transformation Chris Khang, President & CEO

INFORMATION TECHNOLOGY 54 Telemedicine An exclusive interview Krishnan Ganapathy, Director Apollo Telemedicine Networking Foundation &, Apollo Tele Health Services; Hon. Distinguished Professor, The Tamil Nadu Dr. MGR Medical University; Emeritus Professor, National Academy of Medical Sciences, WHO Digital Health Expert

57 Integrated Healthcare The Singapore story Felix Lena Stephanie, Nanyang Technological University (NTU)

60 Overcoming the Barriers to Data-driven Healthcare Stella Ramette, Director, Customer Relations & Sales, Southeast Asia, InterSystems

DIAGNOSTICS 35 Artificial Intelligence May Help Radiologists Detect Fractures in Daily Practice Ali Guermazi, Professor of Radiology and Medicine, Boston University Nor-Eddine Regnard, Radiologist

64 The Role of Digital Health in Changing COVID-19 Landscape Anwar Rafique, CEO & Co-Founder, MyCLNQ Health Singapore

68 Accelerating Digital Transformation in Healthcare Kenneth Tan, President, Varian, a Siemens Healthineers

72 The Business of Telehealth

MEDICAL SCIENCES

Krishnan Ganapathy, Director Apollo Telemedicine Networking Foundation &, Apollo Tele Health Services; Hon. Distinguished Professor, The Tamil Nadu Dr. MGR Medical University; Emeritus Professor, National Academy of Medical Sciences, WHO Digital Health Expert

39 Cancer Care Roadblocks How do we overcome them and what does the future look like?

76 Application of Blockchain Technology in Hospital Information System

Mark Middleton, CEO, Icon Group

46 The Future of Integrated Eye Care is Digital Vaibhav Saran, Area Vice President for Vision Care, Asia Pacific Johnson & Johnson Vision

50 Role of Catheter Ablation in the Comprehensive Management of Atrial Fibrillation Rami Riziq Yousef Abumuaileq, Consultant Cardiologist, Palestinian Medical Services, Gaza, Palestine

Long Chiau Ming, PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam Khang Wen Goh, Faculty of Data Science and Information Technology INTI International University

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Advisory Board

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

EDITOR Prasanthi Sadhu EDITORIAL TEAM Debi Jones Grace Jones Harry Callum Rohith Nuguri Swetha M

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

ART DIRECTOR M Abdul Hannan PRODUCT MANAGER Jeff Kenney

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

SENIOR PRODUCT ASSOCIATES Ben Johnson David Nelson Peter Thomas Susanne Vincent

Nicola Pastorello Data Analytics Manager Daisee

PRODUCT ASSOCIATE John Milton CIRCULATION TEAM Sam Smith

Gurrit K Sethi Founder, Miindmymiind

SUBSCRIPTIONS IN-CHARGE Vijay Kumar Gaddam HEAD-OPERATIONS S V Nageswara Rao

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

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

Gabe Rijpma Sr. Director Health & Social Services for Asia Microsoft

Peter Gross Chair, 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

Associate Partner

Ochre Media Private Limited Media Resource Centre, #9-1-129/1,201, 2nd Floor, Oxford Plaza, S.D Road, Secunderabad - 500003, Telangana, INDIA, Phone: +91 40 4961 4567, Fax: +91 40 4961 4555 Email: info@ochre-media.com www.asianhhm.com | www.ochre-media.com

© Ochre Media Private Limited. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, photocopying or otherwise, without prior permission of the publisher and copyright owner. Whilst every effort has been made to ensure the accuracy of the information in this publication, the publisher accepts no responsibility for errors or omissions.

The products and services advertised are not endorsed by or connected with the publisher or its associates. The editorial opinions expressed in this publication are those of individual authors and not necessarily those of the publisher or of its associates.

Copies of Asian Hospital & Healthcare Management can be purchased at the indicated cover prices. For bulk order reprints minimum order required is 500 copies, POA.

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HELPING CONSUMERS BE THEIR OWN HEALTH ADVOCATES What comprises good health? With so many products on the market, there is often confusing information concerning its safety and efficacy. Amid a barrage of product claims, contradicting news and erroneous product claims, how should consumers decide? Reputation, conducting preliminary research, tech assistants and investing in mental health are some aspects both consumers and healthcare professionals can look more into, in the drive towards individual health advocacy.

Kristy Appelhans, Vice President, Global Consumer Safety, Herbalife Nutrition

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hat comprises good health? For some, having a good immune system and proper food consumption may suffice.

For others, it is increasingly about taking vitamins, minerals and other dietary supplements that offer functional benefits that we may not obtain from our everyday diets. Unfortunately, with so much information sources and the wide array of nutritional supplements in the market, it can get confusing for consumers to assess their needs, and the safety and efficacy of the options available.

A report by Ernst & Young (EY)1 revealed that the pandemic has underlined the importance of health, fitness and wellness in Asia-Pacific consumers, and they are concerned with protecting their health and 1 https://www.ey.com/en_sg/consumer-products-retail/how-to-win-asia-pacific-consumers-in-the-new-era

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that of their family. There is also strong consumer interest 2 in using nutritional supplements as one way to boost their immune health. In parallel, a Herbalife Nutrition Myths survey 3 revealed that 60 per cent of consumer respondents in Asia-Pacific were confused about nutrition facts, while less than a quarter answered half or more questions of a general knowledge nutrition quiz accurately. Against this backdrop, it is essential that consumers who are receptive to and geared for a healthy lifestyle, have adequate access to the right information.

Consumers see healthcare professionals (HCPs) as a trusted source of nutritional information. As such, HCPs are well positioned to educate consumers on good nutrition and the supportive role of supplements, so that consumers can eventually become their own health advocate. Here are a few thoughts that can help HCPs guide people to achieving their personal wellness goals in a consistent and sustainable way.

it is unsurprising that many individuals do not meet the recommended intakes for many essential micronutrients, to the detriment of their overall wellbeing.

This is where HCPs can step in to reinforce the importance of micronutrients to their patients and illustrate the various ways a healthy diet and supplementation can boost general immunity, health and physical fitness; as well as educate the consumers about thoughtful consumption. On the other hand, nutritional needs vary from person to person; they are influenced by factors like age, gender, life stage, dietary restrictions and wellness goals. It helps to consider a multi-faceted approach to wellness – targeted nutrition to support the organs, sleep, and mood – all contributing to an individual’s overall well-being.

For these reasons, consumers may find it difficult to get the right amount of nutrients solely through diet or require guidance to identify supplements that may be best suited for their personal dietary considerations. In these cases,

The importance of micronutrients

Vitamins and minerals are essential nutrients that our bodies need in small amounts to function properly. However, more than 2 billion 4 people, or one in every three individuals, suffer from what is known as hidden hunger, or micronutrient deficiencies globally.

In addition, a Herbalife Nutrition survey 5 revealed that only 33 per cent Asia-Pacific consumers are very knowledgeable about the health benefits of vitamins and supplements and four in five said they would like to know more about the benefits of different vitamins and supplements. Therefore, 2 https://www.fortunebusinessinsights.com/vitamins-andsupplements-market-104051 3 https://www.herbalife.com.sg/apacnews/press-release/ nutrition-myth-top8/ 4 https://www.globalhungerindex.org/issues-in-focus/2014. html 5 https://www.herbalife.com.sg/apacnews/press-release/ survey--changing-health-priorities-in-asia-pacific/

It helps to consider a multi-faceted approach to wellness–targeted nutrition to support the organs, sleep, and mood–all contributing to an individual’s overall well-being.

consumers can also consult with their HCPs to properly incorporate supplementation in their daily nutritional regimen. This kind of patient-doctor transparency and partnership is critical in helping to support favorable clinical outcomes.

Reputation matters

The marketplace is filled with new nutrition products that claim compelling results. Consequently, consumers can often be overwhelmed by the wide selection of product options and have trouble telling facts from myths due to lack of research or understanding.

Beyond just looking at the lowest cost, there are other factors to consider because the quality of the ingredients and manufacturing practices can vary.

To begin with, getting solid information around the company’s governance, management team and group of advisors in public domains can establish an initial level of credibility. The next step is to understand the company’s dedication to science, quality, and safety.

Does the company source their raw ingredients with the utmost care? Look for the company’s Good Manufacturing Practices (GMP), product guarantee, third-party verifications and certificates (such as ISO 17025 or NSF) and level of scientific and medical experts employed.

Another way that consumers can keep track of updates regarding food and nutritional quality information is with their local government agencies and nutrition organisations. Most often than not, these agencies and organisations work in parallel with industry players to establish and improve food and nutritional standards. By keeping abreast with news from these agencies and organisations, consumers can make more informed decisions about their product selections. Some examples of credible information sources in the region include those from GERMAS in Indonesia, Korean Nutrition Society, Nutrition Society of Malaysia (NSM), International Life Sciences Institute

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Taiwan and National Institute of Nutrition (NIN) in Vietnam.

Supplement formats

Thanks to innovation and technology, consumers today have access to a wide range of supplement formats. With so many options, it may be difficult to choose the best one, but ultimately, it boils down to needs and preferences.

Some of the most common forms include: • Tablets: These pills are made by crushing active ingredients. Since tablets do not have coatings, they can sometimes have an aftertaste to them • Capsules: With capsules, ingredients are enclosed in an outer shell. They

may be in the form of pills that are coated with an easy-to-digest casing to prevent an aftertaste, or ingredients may be enclosed in a two-part capsule • Chews: Some consumers may prefer the experience of chewing supplements, so this alternative format can be more desirable • Gummies: Once just for children, gummies are now widely available for adults. The appeal is the easy-tochew and tasty format, and some may feature unique flavours • Powders: Many consumers prefer powders because they are easy to swallow and can be mixed with beverages or other liquids for simple consumption.

• Functional beverages and liquid supplements: For consumers on the go, these liquid products contain supplemental nutrients and provide a convenient alternative to other formats. However, they commonly have a shorter shelf life once opened.

Mental health is wealth

These days, health also includes mental wellness and state of mind. It’s estimated6 that mobility restrictions and daily Covid-19 rates led to an additional 76.2 million cases of anxiety disorders globally in 2020 alone.

Now more than ever, there has been an urgent call to strengthen mental health systems, as well as for individuals to take steps towards promoting selfmental wellbeing. In this light, both HCPs and consumers should place greater emphasis on the importance of countering mental stress and other psychological illnesses. HCPs can make a conscious effort to engage with their patients and evaluate their mental wellbeing during consultations.

In the meantime, people should be encouraged to reach out for help when they feel their mental health is being compromised. Community support also makes a big difference. Joining a support group with those of similar

As the head of Global Consumer Safety at Herbalife Nutrition, Kristy Appelhans oversees a comprehensive global post-market safety surveillance program and nutrition safety education. She is also frequently involved in various industry-related harmonisation and regulatory projects, including her advisory contributions in 2012 in collaboration with other organisations in the completion of IADSA’s (International Alliance of Dietary Supplement Associations) Global Guide to the Handling of Adverse Event Complaints. Amongst her numerous publications related to global food and dietary supplement safety and surveillance, Dr. Appelhans co-authored a chapter on post-market safety surveillance in the book titled New Product Development in Nutraceutical and Functional Foods: from concept to market.

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AUTHOR BIO

6 https://www.sciencedirect.com/science/article/pii/ S0140673621021437

EXECUTIVES SPECIAL ISSUE

health and wellness goals or life stage can help individuals feel encouraged and motivated in their personal journey.

Staying fit with technological assistants

Technology and social media also play important roles in healthy active living.

Wearables and online platforms have enabled home-based consumers, whose mobility has been constricted due to lockdowns, to get fit from the comforts of their home. In a Herbalife Nutrition Health Inertia survey7 among 5,500 consumers, one in two respondents use technology tools such as fitness classes and videos, fitness trackers, fitness and workout apps and nutrition apps to support their healthy living regimens.

Some also found that social media had 7 https://www.herbalife.com.sg/apacnews/press-release/ health-inertia---infographics/

a positive influence on their mental health, and cited factors such as reading motivational and light-hearted content as well as inspirational posts from social media influencers as having a positive effect on their psyche.

Technology has also enabled HCPs and even health entrepreneurs to reach their audiences more easily. We have witnessed more and more HCPs opting for digital channels and tools such as podcasts, webinars and Facebook Live sessions to stay connected with their communities. This has not just helped in building their own brand online but helped many consumers to be educated and get access to useful health related information.

Driving self-advocacy

Like anything – whether it is diet or exercise – consistency is key. Supplements are not a one-and-done deal; it needs to

be incorporated into daily routines and a lifelong wellness plan. Recent studies suggest that taking certain targeted nutrition supplements like selenium and CoQ10, lutein 8 and calcium9 may have long-term benefits if taken consistently.

Encouraging self-health advocacy is crucial, especially with the pandemic’s need for HCPs to limit face-to-face interactions and reach out to consumers through other means. Helping consumers gain the ability to make more educated decisions about their nutritional needs in relation to their desired health outcomes is a step in the right direction. As we move to a postpandemic reality, self-care attitudes are essential in the longer term, with the deft guiding hand of HCPs along the way.

8 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5894963/ 9 https://pubmed.ncbi.nlm.nih.gov/28351509/

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Evario one – the international bed with attention to detail New hospital bed provides relief on international wards Healthcare systems worldwide are under pressure like never before. High time, therefore, for a hospital bed that can be used economically, noticeably relieves nursing staff and promotes patient recovery. Stiegelmeyer is pleased to introduce the new Evario one. Technical product manager Lars Schröder speaks about the new bed’s advantages.

Mr Schröder, what do you particularly like about the Evario one?

I am proud that this bed meets many requirements better than comparable models on the world market at a very good price-performance ratio.

Can you give a few examples?

Let's take the height adjustment of the mattress base.

The Evario one has a range of 38 to 82 cm. That is significantly more than many hospital beds, especially in the upper range. Nurses of all body heights can work with the Evario one in an upright posture and relieve the strain on their backs. One of the biggest causes of health problems is thus defused. And that's not all: thanks to its modern motorisation, the bed travels through this large adjustment range in only 23 seconds, which is 5 seconds faster than most comparable models. Added up to a working day, this saves a lot of time, and especially in an emergency, every second counts.

LARS SCHRÖDER started working at Stiegelmeyer 18 years ago. He has since been involved in the development of several of Stiegelmeyer’s best-selling hospital beds such as Seta, Puro, Evario and, of course, the newest model Evario one.

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And this speed is not at the expense of load-bearing capacity?

No, the Evario one has a high safe working load of 250 kg, which it can handle in mains operation alone without battery support. We have tested the load capacity of all components far beyond the normative regulations. In our test bay, the bed was even able to bear a weight of 1,150 kg without damage when at standstill.

Of course, no one should imitate this in everyday life, but it gives an idea of how durable the Evario one is.

Buyers are investing here at a very good price in quality that will pay off for many years. Especially since Stiegelmeyer is always available as a strong partner with its proverbial service and 15-year promise to supply spare parts.

Keyword maintenance: How does the bed support the technical staff in everyday life?

A great advantage is the placement of the battery and the control unit under the backrest. There they are easily accessible at all times and can be removed and replaced without loosening screws. If the bed has split ¾-side safety sides with integrated control panels, technicians will also find helpful options there for maintaining the bed.

This brings us to the topic of operation.

What options does the Evario one offer?

There are several customised control concepts, all of which can be used without training. Generally, a handset with colour-highlighted buttons is available.

Thanks to easy-to-understand symbols, even cognitively impaired patients can manage well. With the help of an unlocking magnet, the nurse can also activate the CPR function and the Trendelenburg position directly on the handset and thus react quickly in an emergency and selectively lock individual functions.

What's the deal with the control panels you just mentioned?

Since the introduction of our Evario hospital bed, we have offered integrated control panels for the split plastic safety sides. With the Evario one, we have now reduced the functions to the essentials with the " control panel light". The panels are integrated on both sides of the head side safety side elements. Facing inside they offer comfortable adjustment options for the patient, facing outside they also contain helpful functions for nursing staff and technicians. When the backrest is adjusted, the safety sides and the panels move with it so that they always remain within reach of the patient.

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In addition to the handset and the panels, we offer nurse controls at the foot end, which allow the nurses to effortlessly lock individual adjustments. The smaller operating module S again combines the essential options in a very concentrated way, the larger nurse control M provides a lot of comfort.

What choices do our customers have for the safety sides?

There are two versions to choose from, both of which cover three quarters of the mattress base and thus offer standard-compliant safety. If a patient needs protection over the entire length of the bed, filler pieces can be easily inserted.

The split ¾-safety side consists of two plastic elements per bed side. In order for the patient to stand up, it is sufficient to lower the larger foot-side element. This can be done in seconds with one hand.

The second alternative is the continuous ¾-side safety side with slender bars. Here, the patient enjoys an unobstructed view into the room or out of the window at all times. The continuous ¾-safety side swings down parallel to the mattress base and therefore does not require any additional space next to the bed – an advantage in small multi-bed rooms, for example.

That sounds really promising. In conclusion, can you think of any other benefits of the bed?

But of course. The great thing about the Evario one is the attention to detail, which is reflected in numerous small strengths and innovations. Suppose the patient has moved the bed to the comfortable sitting position to enjoy his meal. When returning to the lying position, the mattress base automatically stops in the horizontal

position – this is an advantage that by no means all hospital beds offer.

Or the protection when moving and manoeuvring: On the one hand, the bed can be steered very well anyway, especially with a fifth castor as a directional castor. On the other hand, it is optimally protected against collision damage when manoeuvring and during height adjustment by wall deflection rollers and cones. Of course, the Evario one also offers many attachment options for accessories all around.

The wishes of our customers and the requirements of the international markets have shaped the design of the bed. Now I am looking forward to seeing the Evario one in use.

All in all, the Quado, with its excellent price-performance ratio, is an asset for any facility. It saves space, costs, physical effort during transport and cleaning, and even saves on paperwork. At the same time, the Quado is an attractive piece of furniture that gives the rooms a modern look.

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TECHNOLOGY ENTREPRENEURSHIP IN HEALTHCARE A practicum education perspective Technology entrepreneurship plays a major role in the healthcare today as seen from the massive increase in new healthcare technology ventures. This article discusses the experience of developing and implementing practicum courses in technology entrepreneurship, integrating the approaches of three related disciplines of education; highlevel approach of business, hands-on practical approach of medicine and technology-driven approach of engineering.

Pradeep Ray and Kwee-Yan Teh, University of Michigan-Shanghai Jiao Tong University Joint Institute

T

he world has seen a massive growth in the development and deployment of new technologies (e.g. mobile phones, drones, Virtual Reality devices, Artificial Intelligence

and Machine Learning) in healthcare, resulting to cost effective, higher quality, virtual (important during the Covid 19 pandemic) services. This is caused by a huge proliferation of

technology entrepreneurship. However, entrepreneurship is risky (and prone to failures). Hence researchers are working on evolving techniques, such as Business Model Canvas (BMC) to validate new business ideas and reduce failures in startups1.

Many academic institutions all over the world are now developing entrepreneurship curricula to teach young students in different fields (business, engineering, healthcare etc.) to exploit technological developments and develop new products/services in different business sectors including healthcare. For example, The University of Michigan-Shanghai Jiao Tong University Joint Institute (JI) launched the Minor in Entrepreneurship program for engineering students in 2017 by leveraging the world leading entrepreneurship program of the University of Michigan (USA) and pioneering Chinese technology entrepreneurship curricula in Shanghai Jiao Tong University Entrepreneurial education is focused on equipping students with the ability to understand the business issues in taking a technology to the market in the form a product and service.

In addition to the technical skills, 1 1-Caiwei Chen, Yongqi Zheng, Pradeep Ray. “Healthcare Technology Entrepreneurship in China.” Asian Hospital & Healthcare Management (AHHM), Issue 55, 2022. https://www.asianhhm.com/magazine. Accessed March 2022

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they need to understand the business issues from the perspective of start-up (entrepreneur) and also from the cultural perspectives of an established business (intrapreneur). Hence JI established the Centre For Entrepreneurship (CFE) to teach this minor in entrepreneurship through a practical program involving a combination of classroom courses, practicum courses (in collaboration with the industry) and extra-curricular activities, such as talks by leading experts in the field and competitions among student groups.

This paper discusses the experience of the University of Michigan-Shanghai Jiao Tong University Joint Institute in the development and operation of the Minor In Entrepreneurship, focusing on the key practicum courses that distinguishes an entrepreneurship curriculum from business, medicine and engineering curricula. The paper starts with a brief description of the JI Minor In Entrepreneurship curriculum, followed by practicum courses VX423, VX425 and BUS2551J, each with student learning in the context of healthcare industry.

JI Minor in Entrepreneurship

This minor curriculum has three components: Two core courses (5 credits) on business and entrepreneurship, namely VX402-Managing a Business (introducing business functions, such as marketing, operations, finance/ accounting and human resources and strategy) and VX420-Entrepreneurship Basics (covering the Business Model Canvas and its application in student group ideas) Two practicum courses (7 credits) that apply the knowledge of core courses in projects with industry partners, namely VM/VE450-Capstone Design Project (where a group of 5 students develop and present a solution to a problem given by an industry partner) and Vx423-Intrapreneurship (where each student works as an intern with an

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industry partner for the semester, attends classes on Saturdays, and finally presents a report on possible innovations for the company) or, VX425-Technology Entrepreneurship (where a group of 2 or 3 students develop and pitch a practical business plan for a technology commercialization) or, BUS2551JDesign for Sustainable Development (where a group of 3 or 4 students work on a practical, social entrepreneurship project towards a sustainable development goal) Elective courses (at least 3 credits) chosen from many courses in JI, such as Brand Management (VX251/VX351), Social Entrepreneurship (VX440), E-Business Management (VX422), Supply Chain Management (VG441), Creativity (PSY3110J) and related business courses in other institutions, subject to the approval of the Director of JI CFE. To further immerse students with extra-curricular entrepreneurship activities, the UM-SJTU JI Center for Entrepreneurship holds other entrepreneurship events that aim at stimulating interest for entrepreneurship among students and connecting students with successful real world entrepreneurs, including talk series, entrepreneurship competition, and entrepreneurship week. ‘Meet the Entrepreneurs’ talks (every six months) presented by a successful entrepreneur or intrapreneur to share his/her perspective on realworld entrepreneurship opportunities.

Students are encouraged to participate in activities, such as competitions (organised

by JI CFE and partners) and conferences organised by global organisations, such as IEEE with 400,000 members in more than 100 countries.

Since such a practical curriculum requires special expertise across industry and academia, JI established the Centre For Entrepreneurship (CFE) under the leadership of a distinguished professor (Pradeep Ray) with multi-disciplinary expertise (across business, engineering and medicine) in both academia and

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industry. This minor also helped deepen JI collaboration with local industry in China and also with collaborators all over the world that produced nearly 40 publications including three books .

Fifty JI students have completed this minor (since its inception in 2017) that enabled most of them to earn admission in top business schools in North America and Europe. This article focuses on the three practicum courses VX-423 (Intrapreneurship), VX-425 (Technology Entrepreneurship) and BUS2551J (Design for Sustainable Development, focusing on Healthy Ageing).

VX423-Intrapreneurship

Intrapreneurship means entrepreneurship from within an organisation. Many companies in the world now want their employees to come up with new entrepreneurial ideas and convert them into viable businesses. This course gives students the critical thinking armed with pivotal concepts to understand how entrepreneurial innovation works within an organisation. The course focuses on the understanding how intrapreneurship works, given the complexities in the culture, business policies and procedures and inter personal relationships that are critical for the success of an intrapreneurship project. A student actually works as an intern in a company while doing this course.

VX423 is by no means a traditional course where students complete the entire semester sitting in a classroom. Instead, VX423 involves paid internship by students in selected companies for about three months and hence they must have been accepted by a partner company. All students joining this course need to have completed the prerequisite core course VX420-Entrepreneurship Basics that has discussed the Business Model Canvas (BMC) technique for the assessment of entrepreneurship ideas. This is a small class consisting of less than 15 students so that the Instructor and the Teaching Assistant can visit each company

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(where an enrolled student is an intern) in the beginning of semester (to introduce the course and assessments to company supervisors) and at the end of the semester during the final presentation of the student about the internship (and mark the student performance from the company perspective). A student works closely under the supervision of a company executive and the instructor of the course.

During the internship, not only do students fulfil their job responsibilities, but they are also required by the course instructor to submit a report on existing company environment for intrapreneurship. In order to achieve this, students apply the concepts of intrapreneurship learned from lecture sections (concentrated on Saturdays) of VX423 and actively gain information about the company culture, business processes and procedures at their internship companies either by direct observation or talking to other people within the company. Since this is a practicum course, students are required to present and discuss the application of above knowledge in Fortune 1000 companies and also their company of internship.

Several students completed this course while doing internships in healthcare companies. As an example, one of our students participated in VX423 when he was a sophomore (2nd year) student, and served as a software engineer intern at MediTool, a medical technology company in Shanghai. He developed an automatic lung segmentation algorithm that could speed up surgical planning and provide reference images to surgeons during the actual surgeries. The way his internship experience differed from an ordinary internship was that he should bear in mind what benefits and profits he could create for MediTool. Per request

by VX423 course instructor, he needed to analyse the business environment for MediTool and came up with a potential intrapreneurship plan on how his engineering efforts at the company could

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Many companies in the world now want their employees to come up with new entrepreneurial ideas and convert them into viable businesses.

be turned into a profitable sub-business for the company. According to his report, his automatic lung segmentation could be sold either as a standalone product or as an add-on for MediTool’s existing medical image processing software. He further gave an estimate of the annual profit from his software based on statistics about lung surgeries in China.

As a consequence, his understanding of the concept of intrapreneurship as well as the medical technology industry was greatly deepened thanks to VX423.

Although this course has consistently obtained very high student satisfaction (due to solid practical learning opportunity), the course faced challenges and here are the lessons learned: Interested students need to be interviewed by several companies before any of them gets the paid internship.

Hence the process of selection needs to start at least six months (unlike all other courses in JI) before the course enrolment, particularly in large multinational companies Since the process had to start so early and students had other options (e.g. international exchange visits) at the same time, many selected students dropped out. Consequently, we had to start with 20 internship positions but less than 15 actually started the internship. This led to a disappointment of some industry partners While JI CFE had to work closely with industry partners on the course

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learning outcomes, it had to stay out of the internship contracts between a student and the company because different companies had different terms (payment etc.).

VX425-Technology entrepreneurship

High technology, such as Artificial Intelligence, biomedical and space technologies improve the quality of life in the society and their growing acceptance offer tremendous opportunities for engineers and technologists to become entrepreneurs.

For example, mobile devices (e.g., smart phones, drones and robots) provide one of the most prolific and popular ways to implement entrepreneurship ideas in the service industry today. Since UM-SJTU JI is primarily an engineering education provider, students here can learn and exploit opportunities in technology entrepreneurship in a big way.

This course builds upon the entrepreneurship knowledge gained in the prerequisite core course VX420-Entrepreneurship Basics on fundamentals of entrepreneurship (including Business Model Canvas) to take a business idea to the next stage of entrepreneurship/intrapreneurship, using an attractive business plan to communicate with various stakeholders, such as funding agencies, corporate establishments, governments etc.

The course discusses best practices in entrepreneurship (and case studies) in the context of technology entrepreneurship.

Students learn to apply entrepreneurship concepts in a technology they are familiar with. They start with a technology they have used in their first engineering project in UM-SJTU JI (e.g., VG100 course) or in their past internship experience and then apply various commercialization techniques including customer development, design thinking and practical entrepreneurial development environment (patents, regulations, incubators, accelerators etc.) and discussions with mentors

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from the instructor and industry mentors Healthcare technology is quite popular among students and nearly 50 per cent projects are from this industry, as published in AHHM in 20212.

BUS2551J-Design for sustainable development, focusing on healthy ageing

This began as an action-based learning course in which students worked in teams of three or four and applied engineering design practices and entrepreneurial concepts to address sustainable development needs of entrepreneurial and community partner organisations. The global sustainable development agenda aims at balancing social wellbeing and environmental protection with economic progress. This agenda crosscuts with the accelerating challenges of population ageing worldwide, especially in China.

The rapidly ageing population of China brings strong and still growing demands for elderly care services. Several industry partners of the UM-SJTU JI 2 Pradeep Ray, Steven Wijaya and Junxiang Zhang, mHealth in China: A Growing Market, Asian Hospital and Healthcare Management (2021) Issue 51, https:// www.asianhhm.com/magazine accessed Feb 2021.

AUTHOR BIO

(from industry) to commercialize the technology of their choice.

This is a practicum course and hence students learn technology entrepreneurship by applying the concepts of entrepreneurship taught in this course and other previous entrepreneurship courses (e.g., VX420/ VX402). They may also use any Minimal Viable Product (MVP) they may have experienced as part of an entrepreneurship competition or in an internship job. Students develop (in small groups of 2-3) a business plan iteratively (with industry mentor support) based on a technology they select in consultation with the instructor.

Student groups also carry out detailed market analysis including customer development (including interviews).

This necessitates students to understand thoroughly all aspects of the proposed technology entrepreneurship project, such as the value proposition of the product, customer /market segments, channels for the product to reach the targeted customer segments, resource mobilisation (intellectual property, finance, people and infrastructure), partners and alliances, legal issues, role of supporting ecosystems (e.g., incubators), all costs etc. Hence this course involves several guest lecturers from industry and government to give students a hands-on, practical perspective.

This course had nearly 12 students each year since its inception in 2019.

Students seem satisfied with the current contents that evolved over these years.

Here are the lessons learned: It is important o present all content in the context of a real entrepreneurship project, otherwise students get lost in abstract details.

It is important to help create (assess) the business plan step-by-step, iteratively based on textbook, lectures and guest lectures, otherwise students tend to ignore many of them The iteratively process requires students to make a series of presentations to the class and documented feedback

Center for Entrepreneurship are market leaders in meeting these demands. We have leveraged the JI CFE tie with Haiyang Group, the largest integrated eldercare service provider in China, to structure the BU2551J course around the theme of Healthy Ageing. Multiple field trips to Haiyang residential care homes and other eldercare service providers are organised, during which students apply tools of human-centred design (immersion, interviewing, prototyping, etc.) to gain deeper empathy for the stakeholders, and thereby better understand the context in which design and entrepreneurial opportunities may be present in the Healthy Ageing space.

Conclusion

This article has presented the development of a practicum courses on technology entrepreneurship in the University of Michigan-Shanghai Jiao Tong University, China for both domestic and international students. Since such courses require the collaboration with various stake holders (e.g., industry partners.), they are different from usual university courses and hence the articles has discussed some lessons learned.

Pradeep Kumar Ray is the Founder Director of the Centre For Entrepreneurship (CFE) at the University of Michigan-Shanghai Jiao Tong University Joint Institute and is currently leading an international research initiative called Technology Entrepreneurship for Sustainable Development (TESD) involving more than twenty partners from all over the world. He is the founder of the WHO Collaborating Centre on eHealth in the University of New South Wales (UNSW)-Australia (2013).

Kwee-Yan Teh is Associate Teaching Professor at UM-SJTU Joint Institute, Assistant Director of its Center for Entrepreneurship, and lead instructor of Design for Sustainable Development and its predecessor practicum course, in which students designed an underground water salinity monitoring system to help elucidate the nexus between sea level rise, drinking water salinity, and public health in coastal Bangladesh.

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BEHAVIOURAL HEALTH AND ITS EFFECTS ON PROFITS While the VUCA (Volatile, Uncertain, Complex, Ambiguous) environment is changing the consumers’ buying behaviours, it is time to recognise the employees’ behavioural patterns for delivery to the consumers as well. The effects of mental health and changing behavioral patterns in the pandemic affected times impacts the businesses not just from the outside but the inside as much.

Gurrit K Sethi, Founder, Miindmymiind

I

t is about time for us all to wake up. Wake up to the problems that our mental states present. Given the statistics of the number of people suffering from depression, this is bound to have an impact on the businesses that we run, given the productivity levels of the employees.

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As per a recent study by GOQii, 43 per cent Indians suffer from depression because of the changing scenarios owing to the COVID-19 pandemic. What’s more alarming for the businesses is that 59 per cent of the under-study population said they had no pleasure in doing things these days, and, 12 per cent

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felt this way every day. Furthermore, 57 per cent complained of tiredness or low energy regularly. Another study done in 2020 using the DASS (Depression, Anxiety, Stress Scale), published in the NIH, showed similar results. 25 per cent, 28 per cent and 11.6 per cent of the participants were moderate to extremely severely depressed, anxious and stressed respectively. 36 per cent of workers in India concurred that their mental health worsened with work from home – a critical outcome of the pandemic. On a more severe note, on December 7 2021, the Indian government said in Rajya Sabha that 10.6 per cent of adults in India face some kind of mental disorder.

This sure is a tall acceptance.

In October 2021 the UNICEF, as per a survey done across 21 countries, reiterated about India that only 41 per cent of young people in India said that it is good to seek support for mental health problems, compared to an average of 83 per cent for the other 21 countries. This points to the suppressive nature of the society. A question to all of us is, does the corporate world reflect a similar trajectory?

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directly linked to the employee wellness factor. This needs organisations to be proactive about wellness—and this means not just physical wellness but also mental well-being of the workforce. They need to knead in the socio emotional factors as well because these are critical factors to the employees’ overall well-being. Thus, the importance of the Culture at the work place as this defines the environment for the workforce, which impacts their emotional selves and subsequently the psychological expressions. There are various studies today that also point to the link between a person’s psychological well-being and the physical health. A conducive and supportive environment can help better the productivity of the employees which impacts the financial health of the company in multifarious ways.

The Human Resource department’s responsibility does not simply end at hiring, record keeping, complying with labour laws of the land and getting the right insurances. Rather it only begins from there. Creating a conducive environment and then maintaining it is not just a string of activities any more, rather this needs to be a well thought through strategy in sync with the overall direction of the business and the annual goals to be achieved.

Today, it is critical to choose which OB model an organization needs to adopt and why. This may change along the trajectory of growth. And when the

AUTHOR BIO

A study by Assocham showed that nearly 42.5 per cent of employees in the private sector in India suffer from mental health issues at work. A study by Oracle in 2020 stated that 84 per cent employees reported increased stress and or anxiety at work than any other year.

These are alarming numbers. Data from the various studies above point to a simple fact – these trends are bound to impact our output. The loss of productivity at the individual level is bound to add up to the business level and finally aggregate to economic losses.

On a different note, another study reflected that out of the country’s approximately 1.1 million active registered companies, barely a 1000 are estimated to have a structured employee assistance programme (EAP) for mental health. A Deloitte 2020 survey also reported that while 80 per cent organisations recognised the importance of employee well-being, only 12 per cent were ready to address the issue.

According to the World Health Organization (WHO), the economic losses due to mental health conditions between 2012-2030 is estimated to be US$1.03 trillion in India. WHO also points out that for every US$1 invested in treating common mental disorders, there is a return of US$4 in improved health and productivity.

The 7th Fold survey also concluded that for every rupee spent on employee wellness, employers get a saving of Rs.132.33 as savings on absenteeism costs, and Rs.6.62 back as reduced healthcare costs. Approximately US$20 Billion is the estimated loss to Indian companies due to the lack of employee wellness programmes.

Despite all these surveys, mental health remains the most underplayed and underestimated problem in the country today. We either refuse to recognise it or refuse to accept it. A redressal can come only after admittance.

From the perspective of Organisationnel Behaviour (OB), productivity of the organisation is

change needs to happen, a professional and well thought through intervention is required.

The changing scenarios and dynamism in the business world needs to be matched with a similar dynamism and adoption in the OB (organisational behaviours) strategy to ensure that the organization remains relevant and in the game. This is defined not just by the revenue numbers and the marketing strategy. We need to understand that the OB will finally define the employee behaviours that will drive these numbers. Organisations that have focused on ‘internal branding’ and taken care of what the employees think of their employer and have invested in people’s development and growth have shown a good growth trajectory.

Of course, this needs to be in sync and alongside the product innovation and development, the sales and marketing strategies and other important elements of business.

So, it’s time to invest in Organisational Behaviour – this is a slightly long and tedious process – to understand the challenges through the right kind of diagnostics, which can help in the choice of models to be adopted and then structure a series of change actionables.

However, an immediate call to action can be to start to invest in the physical and mental well-being of employees.

A happy and healthy employee is a productive employee, it’s that simple.

Gurrit K Sethi, Founder, MIINDMYMIIND, contributes to healthcare by bringing to life new concepts which enhance accessibility, helps providers re-engineer businesses, works with Global Challenges Forum (a Swiss Foundation) on sustainable health initiatives. An avid traveller and voracious reader, these attributes provide her with incisive insights about people and systems and what drives them.

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MEDICAL FAIR ASIA Gears up for ‘Business as usual’ but Better with a Phygital Edition In-person trade fair and extended online engagement The 14th edition of MEDICAL FAIR ASIA will see its return to Marina Bay Sands, Singapore, from 31 August – 2 September 2022, with a 3-day physical trade fair, followed by a week-long digital extension.

After the successful full-digital edition in 2020 which saw participation from 345 companies and over 8,500 online visitors, this year will see MEDICAL FAIR ASIA presenting a hybrid model - a winning approach that brings the best of the in-person experience and

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essential digital tools so participants can continue to connect and engage. The digital extension will offer value-added opportunities for networking, smart business matching, and access to on-demand content from anywhere in the world.

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“Adding the hybrid component to the in-person trade fair expands MEDICAL FAIR ASIA’s reach to a wider international audience, both because of potential capacity limits on-site and travel limitations.

The digital extension also offers additional benefits for exhibitors in terms of branding exposure and a more seamless approach to follow up on sales leads, and more importantly for both exhibitors and visitors – a robust environment in which to continue connecting and to do business effectively,” said Ms Daphne Yeo, Senior Project Manager, MEDICAL FAIR ASIA, Messe Düsseldorf Asia.

Reflecting the well-established credentials of the region’s hallmark medical and healthcare event, MEDICAL FAIR ASIA 2022 Phygital Edition draws reference from the many lessons learnt over the last edition and will present special highlights such as Pandemic Management Solutions, as well as a focus on Mental Health – together with the Community Care Pavilion and Start-Up Park; two regular features over the last three editions which have seen growing relevance and interest from trade visitors.

With 650 exhibitors and key national and country pavilions expected to participate in 2022 representing a diverse range of medical and healthcare products, solutions, equipment and new technology, the internationality of the trade fair is also expected to be well-reflected in visitor participation. As a must-visit sourcing platform, MEDICAL FAIR ASIA is anticipated to draw 10,000 in-person and online visitors with 40 percent coming from overseas.

Mr Gernot Ringling, Managing Director, Messe Düsseldorf Asia, said, “We are very much looking forward to reconnecting in-person with our exhibitors, visitors, and industry partners, which is essential to developing and maintaining relationships. A trade fair is a full sensory experience and is about both planned and spontaneous encounters on the show floor. With the challenges brought on by the pandemic, it has presented opportunities for us to re-think how we deliver our events; so reconnecting, rebuilding and recovering will be a main focus for us – thus, with MEDICAL FAIR ASIA 2022 we will provide the best offerings of a physical trade fair enhanced with the power of digital so the medical and healthcare industry can continue to do business, share best practices, innovate, and learn.”

Beyond a networking, sourcing and procurement platform, MEDICAL FAIR ASIA Phygital Edition will also feature a comprehensive line-up of concurrent events, including: 2nd edition of Paradigm Shifts in Healthcare Symposium - Prehabilitation and Pandemic Management in Community Health • Medicine+Sports Conference Asia • Medical Festival Asia MEDICAL FAIR ASIA will once again co-locate with MEDICAL MANUFACTURING ASIA, a trade fair focusing on the medical technology and medical manufacturing sector, jointly organised by Messe Düsseldorf Asia and the Singapore Precision Engineering & Technology Association (SPETA). Together, the two trade fairs will present a synergistic one-stop event representing the medical and healthcare.

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Axios International's th 25 Anniversary Axios International completes 25 years of operation in 2022. What has been the key inspiration / vision that has helped the company grow?

The building of Axios International1 is very strongly connected with my experience of working with WHO, as part of the UNAIDS Drug Access Initiative. As a part of this initiative, I was in-charge of negotiating with pharmaceutical companies to launch one of the first antiretroviral (ARV) access programs in some of the emerging economies of the world which helped address the rising incidence of AIDS. Once these programs were successful, I realised that access would not be limited to just HIV treatment but in fact, should be used to address several unmet needs of people across different diseases. And with that vision, we founded Axios International in 1997. And ever since, our vision has remained the same – to enhance healthcare access for people across the world.

How has Axios International impacted the lives of patients over the last 25 years? What has been the company's global and, more specifically, Asian footprint till now?

At a global level, Axios International has reached more than 9 million patients over 100 countries in the last 25 years.

In the early days, we were only focused on supporting poor patients with access to healthcare, but we gradually realised that there is a large segment of middle-class people who are neither rich enough to buy medication nor poor enough to get donation. Over the years, we've tried to address the needs of this segment through innovative tools and personalised cost sharing programs. We strongly believe that simple price reduction or rebates are not the route to build healthcare access, and companies need to consider the entire treatment cycle, and constantly follow up with patients to ensure that they stay on treatment and benefit from optimum health outcomes.

1 https://axiosint.com/

In Asia, ageing populations and high healthcare needs demand that healthcare stakeholders work with each other so that their combined strengths can effectively address the diverse needs of people.

Axios has always believed in multi-sectoral collaborations, and we look forward to working with Asian governments and other stakeholders to support people in

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JOSEPH SABA CEO, Axios International

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the most effective manner possible. In fact, in Malaysia, we've a partnership with the National Cancer Society2 to ensure that cancer patients are comprehensively cared for , covering all aspects of treatment right from understanding of the disease, to access to healthcare and finally, to adherence for long term benefits. Apart from oncology, we also run a range of patient support programs in Asia that cover multiple therapeutic areas, including immunology, haematology, psychiatry, pulmonology and gastroenterology.

How do you define healthcare access and adherence and how do you ensure that your patient support programs can help achieve both?

Going back to my initial working days when I was a part of the UNAIDS program, I had a strong realisation that treatment plans only work if they are followed through by patients completely and are not left mid-way. This is the only way to maximise patient’s medical benefits. And so, this has been our guiding principle while working at Axios International throughout. We've always ensured that our patient support programs carried a critical component of patient follow-up. This component ensures that Axios is engaged with patients even after they leave the physical settings of a hospital or clinic 2 https://cancer.org.my/

leading to long durations of treatment cycles and hence, optimum health outcomes. In fact, some of our past studies have demonstrated that patients who are part of the Axios' programs have much longer treatment durations than even patients who are completely reimbursed, highlighting that a proper follow up with patients after they leave the hospital is key to delivering quality treatment.

What has also assisted treatment adherence is the development of scientific tools like Patient Needs Assessment Test (PNAT)3 by our team at Axios International. PNAT is an insightful tool that understands why certain patients drop out of treatment cycles, the various reasons beyond price affordability that can play an important role in impacting patient will to stay on treatment. This tool has further expanded the scope of our programs, ensuring that adherence is strongly ingrained in all our access solutions.

How big is the Axios family currently, and how do you ensure that all of them have a strong commitment towards building healthcare access?

Our Axios family has grown substantially over the years, and we have a strong team of over 200 employees today.

We’ve our international offices located in Africa, Asia, Middle East, and Europe that work with healthcare stakeholders across the globe to ensure that we can support populations in most of the developing countries and emerging economies of the world.

While our teams have different areas of expertise but the one thing, they've in common is the commitment to empower people with healthcare access.

We ensure that when we seek staff, we look out for this commitment in particular and as we work together, we further instil the spirit of this purpose through internal engagement. Patient-centricity 3 https://axiosint.com/adherence

or providing highest quality service to our patients has always been the motto at Axios International; our employees understand and practice it sincerely and all our patient support programs are designed accordingly.

Tell us about some of the key initiatives undertaken by Axios International that have helped the company improve patient experience while setting new benchmarks in the industry?

We’re proud that Axios International has always evolved over the years to build tools and systems that serve patients in the most effective manner, immaterial of where they are.

Our fundamental achievement is in the design and development of our patient support programs that are based on scientific analysis and are personalized for optimum outcomes. Unlike many players in the healthcare access space who seek to support patients through subsidies and short-term incentives, our programs take a comprehensive view of treatment plans and offer access solutions with the help of scientific and insightful tools like Patient Financial Eligibility Tool (PFET) and PNAT. PFET is a unique confidential assessment tool that helps determine the true financial capability of patients by considering three key parameters – income, assets and standard of living. PFET ensures that we can offer treatments to a large community of patients who are neither rich enough to buy medication nor poor enough to receive donations.

Based on this tool, we design our cost sharing programs where patients pay only a part of the treatment cost, and the rest is funded by other healthcare stakeholders in the ecosystem.

PNAT, on the other hand ensures that patients stay on treatment for longer durations, increasing their overall probability of improvement and full recovery.

PNAT aims to understand the unique requirements of each patient across 5 key dimensions - social and economic,

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4 https://axiosint.com/digitalsolutions

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What is the future of healthcare access in Asia and what role do you see Axios International playing in it?

Healthcare access will be strongly linked to reaching patients outside the hospital space going forward, and digtialisation will play a big role in achieving it. Also, access will not just be about making medication available, but it will focus on patients receiving their full course of treatment for optimum health benefits.

The healthcare sector will also need to prepare itself holistically to ensure that whenever next public health emergency strikes, we have all the resources to tackle it efficiently. We should be able to reach out to our most vulnerable patients and look after them in the most comprehensive manner.

The future of healthcare will also be about personalisation. We will see lots of personalised medicines being produced which will have to be matched with personalised treatment plans and follow ups.

Multi-sectoral collaboration is another area which will be important in the future of healthcare. No single stakeholder has the wherewithal to serve large communities of patients, partnerships between public and private sectors will gain more importance leading to the development of synergistic models which will strengthen healthcare access.

Finally, more relevant data will be needed to inform decision-making data from access programs will provide

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breakthrough insights on the disease evolution, treatment, patients’ perceptions, outcomes and cost. Healthcare actors and professionals will need to explore approaches to capture accessrelated real-world insights (RWI) to better understand the impact of access interventions so that more efficient ones can be designed in the future.

I believe that Axios International will continue to play a dynamic role in the future of healthcare access. Equipped with our comprehensive patient support programs, strong adherence initiatives, digital healthcare solutions, our inclination for partnerships in global/ regional healthcare ecosystem and our investments in capturing RWI, we will always ensure that we serve our patients in the best possible manner. Going forward, we intend to widen our reach across Asia by expanding our patient assistance programs and by covering new chronic diseases to serve a wider spectrum of patients. Building sustainable healthcare access is our vision for Asia, and we will keep working towards it.

B I O

COVID-19 has exposed several inefficiencies within the healthcare sector in Southeast Asia and beyond. How did Axios respond to the pandemic and how did you ensure that your patients were looked after throughout?

In the middle of 2016, when we were working on our access and adherence solutions, we realised that a gap existed once patients left the physical settings of a hospital. Since patients were not in touch with healthcare providers anymore, there was no certainty that they would follow their treatment schedules as planned which could lead to suboptimal health outcomes. And that is when, we started working on our digital healthcare solutions to ensure that the engagement between Axios International and patients is continuous and unhampered.

As a result, when the COVID-19 pandemic struck the world, I'm proud to share that our patient support programs remained untouched, we looked after our patients just the way we were caring

for them before, and there was no negative impact on their treatments. With the help of our digital solutions, our program managers ensured that we constantly communicated with our patients, that they received their treatments and there were regular follow-ups. In fact, COVID-19 illustrated the need to be in touch with patients in the space outside hospital settings and throughout their treatment journey, something that we at Axios International were anyhow doing through our programs.

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therapy related, patient related, healthcare team and system, and condition related aspects. It is used to understand and address the many barriers, patients and their families encounter daily as they strive to maintain optimal health.

Our other big initiative that has helped patients tremendously, especially during the ongoing pandemic, has been the offering of our digital healthcare solutions, Axios+4. We are in the digital age and we need to leverage this technology to better serve our patients. These tools have further helped us engage with patients after they leave the physical settings of a hospital and have allowed us to communicate and follow-up with them through their treatment cycle. It is after all, the follow-up with the patient which is of tremendous importance and plays a big role in them sticking to their overall treatment plan.

Joseph Saba is Co-Founder and Chief Executive Officer of Axios International, a global healthcare access company with approximately 25 years of specialised experience developing practical and sustainable solutions to patient access challenges in emerging markets. Under his leadership, the company has launched a number of successful drug access programs and developed innovative access strategies and new models for healthcare systems strengthening.

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Erbe Academy in Singapore

Learn, Experience, Share Education is one of the core pillars of the Erbe Group vision. The Erbe Academy program is one of the company's success stories. It provides a network for doctors, nurses and the company's global sales team to gain new knowledge and experience and share it with peers. In addition, the Erbe Academy qualifies employees to act as reliable partners for healthcare professionals and institutions worldwide. Erbe does not merely want to offer products, but also holistic solutions for their customers. Now they are taking the next step and starting to enhance the success story of the Erbe Academy.

As a family-owned and operated business, Erbe develops, manufactures and markets surgical systems for professional use in various medical disciplines all over the world. Erbe technology leads the market in many countries and is therefore an inherent part of the working processes in the OR. The portfolio comprises devices and instruments for electrosurgery, thermofusion, plasma surgery, cryosurgery and hydro surgery.

By combining these technologies, innovative applications become possible, particularly in General Surgery, Gastroenterology, Gynaecology, Pulmonology and Urology. Erbe employs more than 1300 people world-

wide, over 650 of them in Germany. Approx. 170 employees work in research and development. The intensive collaboration with renowned users from medical schools and hospitals is the key to success with which Erbe successfully furthers developments in medicine.

Christian O. Erbe has been running it in fifth generation since 1996. Following Reiner Thede's retirement, Christian O. Erbe restructures the management board in 2020 with Dr. Helmut Scherer, Daniel Zimmermann, Prof. Markus Enderle and Marcus Felstead.

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This new management structure strengthens the future viability of the company, enabling it to achieve the goals of the Group's strategy for sustained profitable growth. To continue this positive development, the Management is focusing on internationalization, digitization, and environmental sustainability and promoting a culture of responsibility in all departments and Areas.

Erbe is opening up new markets and thus expanding its competitive position to be able to offer superior customer benefits as a solution provider, both medically and economically.

Erbe Singapore Erbe Singapore was founded in 2013 with Fritz Maier as its appointed Managing Director. Erbe Singapore’s core activities are sales, marketing and education and technical services for our products in our region. Our region spans Australia, New Zealand, South East Asia, South Asia, and Korea including the Pacific Islands. In the recent years, Erbe Singapore has taken on global roles in the field of clinical studies, marketing communication and digital solutions.

Fritz Maier spoke to Asian Hospital and Healthcare Management Magazine, about their recent venture: The Erbe Academy in Singapore Why is education so important for Erbe Singapore?

We work with employees and distribution partners in the region to ensure that our customers receive the right products at the right time and know exactly how to use them. It is therefore important that they are consistently educated on the latest developments of our product portfolio. Our products are safety-related and, if wrongly used, can cause harm to the user and/ or the patient. Therefore, proper education is of utmost importance to us, and a mandatory requirement from the regulators. Furthermore, our products are an integral part during the education of the next generation of Surgeons and Gastroenterologists. We partner up with societies to train basic techniques and new and advanced procedures that incorporate the use of our products.

Tell us more about the Erbe Academy in Singapore.

What’s that and how did you establish it?

At the Erbe Academy, we offer many courses and trainings. We share our experience and our know-how and train the participants in using our technologies. We do this for our own employees in sales, technical service and marketing. And we do this for external parties like doctors, nurse technicians, and many more medical disciplines. In the meantime, more than 40,000 28

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persons have taken part in our trainings! At our headquarters in Tübingen, we have a physical academy, worldwide we have been training people “on the road”.

Erbe Academy in Singapore will be the first academy abroad. It is based in the German Centre in Singapore and it a makes use of a facility called the Life Science Incubator (LSI) which is a hands-on lab with a simulated operating theatre where people can experience our devices first hand. We can use the meeting and conference facilities for small and large groups. Our office is located there as well.

Which target groups/medical professionals do you address with your academy?

While we certainly address our own employees as well as our distribution partners with typical 1-week seminars, we are planning a large portfolio of customized trainings for nurses as well as doctors in different specialties and fields of expertise. We want our customers to be comfortable and at ease once we install our products, therefore we created this virtual training ground where they can familiarize themselves with our products before they use them in their hospitals.

Do the trainings take place at your premises, on-site at the hospital or digitally via Zoom?

During the pandemic, it got increasingly difficult for us to visit the hospitals themselves, hence we decided to create this space so that our customers can come and visit us with any group size that is allowed. At the same time, our space also has hybrid connectivity, which allows our customers to be trained remotely, not only because of Covid-19 but also the sheer size of APAC that we cover. If a doctor from French Polynesia or Tahiti would like to join us for a training, it would take him or her several days to reach Singapore, imagine that! Therefore, it is more convenient for them to join our trainings digitally.

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What is the initial feedback?

During the first Academy training, we conducted the first 5-day International Surgery and Resection seminar. We had 9 participants from four countries and they all enjoyed not only the location of the training but also the training content and the concept of theory and hands-on which gives them excellent theoretical as well as experiential learning experience.

What is the content of the training? What are the objectives of the training?

The content of the training can be a large range but will always include the actual use of our devices and instruments. It could be more focused on how to set them up and how to operate them correctly. Or it could be a training of a specific procedure for example endoscopic submucosal dissection (ESD) which is the resection of early cancer in the gastrointestinal tract.

This procedure can be conveniently trained on ex-vivo models and requires repetitive hand skill training that doctors can ideally perform in our new premises.

Training Programs at the Erbe Academy in Singapore – training our employees, distribution partners and healthcare professionals In a typical seminar for our employees and or distribution partners …we conduct both lectures and hands on sessions that educate them on the different topics/ disciplines, technologies and clinical applications. We mainly conduct two 5-day seminars, 1) Surgery and Resection Seminar and 2) Flexible Endoscopy Seminar. The Surgery and Resection Seminar focuses on General Surgery, Gynaecology, Urology and Hepatology in correlation with both open surgery and laparoscopy. During this seminar, we also focus on imaging technologies, that is used during laparoscopy. The Flexible Endoscopy Seminar focuses on Gastroenterology and Pulmonology. These trainings help our employees and distribution partners to better understand our products and technologies.

The trainings for healthcare professionals will be kicked off with customized trainings for Gastroenterology and Interventional Pulmonology as well as a course covering Basics of Electrosurgery & Safety in the OR. Before developing trainings for other specialties such as General Surgery, Urology, thyroid surgery, liver surgery, breast surgery (which could incorporate the use of ICG fluorescence imaging). These trainings

will be targeted at surgeons, endoscopists, nurses and biomedical engineers.

We plan to have these didactic sessions on a weekday afternoon, combined with lectures, cases discussions and practical session into a 2-4hrs package. Now, let’s have a look at how such a customized gastroenterology and pulmonology training is conducted.

Gastroenterology: The session starts off with lectures on the fundamentals of electrosurgery (power, modes, effects), before focusing on how electrosurgery can be utilized in gastroenterology applications. (including the introduction of some of our proprietary waveforms such as endoCUT, preciseSECT and softCOAG). The next focus will be on the basics and application of Argon Plasma Coagulation (for angioectasias, radiation proctitis, post polypectomy/EMR margin ablation, etc). Participants will then be given the opportunity to discuss challenging cases and share experiences and solutions. The session will conclude with a practical session in the Erbe Academy – LSI Lab, where participants will be able to apply what they have learned on porcine explants with the endoscope together with Erbe technology.

Interventional Pulmonology: With a similar training style, IP sessions start off with lectures, explaining ‘Fire & Ice’; electrosurgery, plasma surgery & cryosurgery. Before focusing on the various applicative regions of the lung; central airway obstruction, peripheral pulmonary lesions, interstitial lung disease, lymph nodes and nodule biopsies. After case

I was impressed with the focus on technology and clinical outcomes. I was fascinated by the dedication and passion displayed by the trainers and their profound ability to explain complex theories in a simpler manner.

JAMIE GRIMSHAW Managing Director Erbe UK

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discussions and sharing, participants will experience Erbe technology on porcine explants through a bronchoscope.

The Covid-19 pandemic has taught us the benefits of remote streaming and virtual capabilities. Such trainings could tap on the global reach of experts and connect them to our session. These experts could facilitate the session with live/recorded lectures, demonstrations, surgeries.

How big is your training team, who are the trainers?

The training team currently consists of 8 people and we have started with the first resource here in APAC and we will add more with the course of the growth of the Academy. We have full support from our headquarters in Tübingen, Germany. The trainers from the training team came down to Singapore and it was a great pleasure to collaborate closely with our training team.

Our clinical and hands-on trainings are developed and conducted in tandem with the Clinical Application Team, a global team of specialists who spends their time with physicians, figuring out their needs and the appropriate way to teach in simulated environments.

What do the participants particularly appreciate?

The participants enjoyed the hands-on sessions during the training. This allowed them to understand the technologies much better in terms of application to real-life settings. The technicalities behind electrosurgery helped our participants understand our products better.

Getting hands-on on the actual devices and performing minimally invasive surgery techniques on ex-vivo models is always exciting and allows even non-physicians to get a glimpse of how difficult it is for example to hold a flexible endoscope.

• Relevant and Relatable – solving real problems that the learner has • Blend and Bind – merging the real world with digital With these challenging requirements- fulfilling the needs of our employees and customers within a blended hybrid world of learning and having to stimulate the next generation - the Erbe Singapore team is looking forward to fulfilling programs of education in our new space.

The Erbe Academy in Singapore – the future is ours.

Fritz Maier is the Managing Director of Erbe Singapore Pte Ltd, a wholly-owned subsidiary of Erbe Elektromedizin GmbH Germany. The electrical engineering graduate joined a French automotive company in Paris from 2000-2004 upon completing his MSc (EE) in Germany.

After obtaining experience in the automotive industry, the German native joined Venture Corp, a Singapore-based OEM/ODMmanufacturer, and started their European marketing and design office in Frankfurt, Germany.

Despite his busy schedule travelling and managing the two subsidiaries, Mr. Maier completed a Global Executive MBA from INSEAD Business School in 2016

What are the challenges of training the next generation?

For our next generation, which is used to access their gadgets at any point of time, training has to follow new learning elements. We have particularly singled out 6 elements which are: • Brief and Beautiful – mirroring what they see on their mobile devices • Agile and Accessible – short intervals of digital bursts – just like TikTok • Instant and Intelligent – quick videos and how to articles • Collaborative and Communal – Creating digital communities Advertorial 30

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EXECUTIVES SPECIAL SPECIAL ISSUE ISSUE EXECUTIVES

BUILDING A NEW HEALTHCARE ECOSYSTEM What the pandemic means for healthcare’s digital transformation As healthcare organisations grapple with responding to the endemic and adapting their operations to fulfil other aspects of their care mission, they must also begin to define and prepare for the future of care amid economic, regulatory, and social uncertainties. What might the post-Covid-19 landscape look like? How can health systems address a range of possible challenges? What are the opportunities to revolutionise care? To succeed in the future, healthcare leaders need to rethink what this crisis revealed and continue to drive these new movements in how we deliver care.

Chris Khang, President & CEO

COVID-19 exposed vast weaknesses in health systems around the world and has exacerbated gaps in quality and service while highlighting the critical role of quality healthcare during an emergency. Though it has inflicted devastating health and economic costs, it has also created a once-in-a-generation chance for transformational health system changes.

Now, as healthcare organisations grapple with responding to the endemic and adapting their operations to fulfil other aspects of their care mission, they must begin to define and prepare for the future of care amid economic, regulatory, and social uncertainties.

What might the post-pandemic landscape look like? How can health systems address a range of possible challenges? What are the opportunities to revolutionise healthcare?

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To succeed in the future, healthcare leaders need to rethink what this crisis revealed and continue to drive these new movements in how we deliver care, to “build back better”.

Healthcare in ASEAN

The pandemic not only brought with it a new level of stress for providers, but also for patients, and technology was the solution that calmed fears, provided relief, and most importantly, allowed for communication between providers and patients who needed care.

It seemed that almost overnight, technology provided access where access was limited, and the flexibility of telehealth increased the workflow efficiency for providers.

More importantly, the world witnessed the “proof of concept” for how technology can positively impact the healthcare industry—at scale.

However, demographic, epidemiological, and socioeconomic trends show that even greater challenges lie ahead for health systems, especially in ASEAN. Populations are rising fast in some of the poorest countries and ageing rapidly in higher-income settings.

Many countries face a protracted epidemiological transition, where stunting coexists with obesity, and surging non-communicable disease burdens, such as cardiovascular disease and cancer, come atop persistent infectious threats.

Rising citizen expectations for healthcare have followed urbanisation and globalisation, even as climate change, economic crises, institutional fragility, and conflict threaten to overwhelm fragile health gains in many countries. It’s no surprise then that healthcare expenditure in the ASEAN region is on a pre-COVID path to grow by over 70 per cent between 2018 and 2025—with the fastest growth expected in emerging economies who can leapfrog into this new paradigm.

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In seeking a sustainable solution to healthcare, countries in ASEAN have had to narrow their focus towards ensuring access to its citizens, both from a cost perspective as well as a geographic standpoint, while shifting their focus from treatment of disease to prevention.

While the utilisation of technology in healthcare is not new, the importance of intelligent applications of technology to improve efficiencies is critical, deploying it to improve patient care and to improve the lives of healthcare providers as healthcare demand rises.

As the world slowly emerges from the COVID-19 crisis, health systems will enter a period of critical risk and opportunity. Bold choices now can transform health systems for the decades to come, bringing goals like precision health within reach.

Where most medical therapies are designed with the average patient in mind, precision health1 aims to deliver a highly personalised course of treatment

based on a patient’s genetic makeup, health history, family medical history and lifestyle choices .

By using healthcare artificial intelligence (AI) applications to better understand, monitor and predict a patient’s health journey, precision health can help with disease prevention and when diseases occur, enable clinicians to make more informed treatment decisions.

The key to the success of precision health is the use of healthcare AI technologies that can analyse massive sets of health data and distill actionable insight for the care of individual patients.

GE Healthcare has developed intelligence platforms to support organisations on the path to precision health by enabling more than 50 healthcare applications and medical AI algorithms.

With technological advances, clinicians will have the opportunity to increasingly harness precision health in 2022 to treat various diseases and disorders. The solutions currently in development are expected to radically change care delivery models and improve outcomes for generations to come.

1 https://www.gehealthcare.com/campaigns/healthcare-it/ precision-health

Towards building a more resilient healthcare ecosystem

Powering the future of healthcare through precision health

Remote monitoring solutions are fast emerging as a reliable and costeffective technology to connect ICUs using a hub and spoke model.

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So how do we get there? The hard-earned wisdom earned during the pandemic has led to visions of a new, more resilient healthcare ecosystem—one that is Intelligently Efficient, leverages technology to reduce burnout, expands access with virtual care and improves data management to strengthen clinical decision-making.

Apply the principles of intelligent efficiency Inefficiency in health systems is a global problem. The World Health Organization (WHO) estimates that 20-40 per cent of health systems’ resources are wasted, which undermines service delivery.

During the pandemic, healthcare institutions everywhere were forced to

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re-evaluate their operations. For some institutions, viewing efficiency as a process that improves every component of the care system and one that uplifts every individual who interacts with that system is already becoming a reality.

These institutions strive for a state in which quality care flows seamlessly and efficiently for providers and patients, guided by relevant insights. A concept GE Healthcare has termed Intelligent Efficiency.

Any new technology must help clinicians diagnose earlier, better, and faster so that healthcare providers can achieve a more precise diagnosis. After all, operational efficiency can only be improved with real-time visibility.

With more patients, fewer open beds, and workflow chokepoints, hospitals, and health systems in ASEAN for example are turning to single data infrastructure software known as “command centres,” featuring real-time decision support tools.

These hospitals would now be able to see unprecedented orchestration of patient care activity in real-time, using apps or “tiles” on a central dashboard.

Enabled by AI—including machine learning, natural language processing (NLP), computer vision, and other modes—tiles are built for specialised use cases related to patient flow, quality, risk management and system optimisation.

This can lead to substantial savings for hospitals as the result of operating at maximum capacity, improving metrics such as a decrease in the average length of stay, and reduced emergency room diversion.

Leverage technology to reduce burnout In the COVID-19 era, burnout has become an issue across healthcare professions, with GE Healthcare research revealing that nearly two-thirds of doctors surveyed still cite excessive bureaucratic demands as the primary cause for burnout, more than one-third pointed to long hours, and eight per

cent of doctors said the stress of treating Covid-19 patients was the primary cause of their burnout.

And although electronic health records – a frequently cited contributor to burnout in other studies – certainly made the list of culprits, clinicians also pointed to chaotic workplaces, after-hours workloads and too many bureaucratic tasks as major factors.

But when technology works for clinicians by surfacing actionable data on command, healthcare has a stronger chance to hold on to the people who keep the system running smoothly.

In using an ultrasound, for instance, examining the central nervous system of a foetus can require multiple keystrokes.

But a deep learning model built into the device can cut the number of keystrokes by 78 per cent, streamlining the process, reducing the opportunity for error, and limiting repetitive tasks.

Technology for MR and CT also leverages AI to make imaging faster for both technicians and patients. Intelligent MR slice prescription software uses deep

learning algorithms to automatically detect and prescribe slices for routine and challenging knee and brain exams, delivering consistent and quantifiable results. It automates the workflow and optimises technologist efficiency and reproducible planning to ensure exam consistency for the same patient follow-up.

All this helps to take time off clinicians’ plates and makes things more efficient, so they can focus on what truly matters: patient care.

Expand the care ecosystem with virtual care In Asia, where healthcare systems have long been familiar with SARS outbreaks, hospitals were the quickest to deploy telehealth and remotemonitoring technologies in the face of COVID-19.

The COVID-19 pandemic has now led to examining the necessary frameworks for supporting the wider adoption of telemedicine worldwide.

Under-utilised care paths like

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telemedicine have become popular, sparking new urgency around using digital technology to improve workflows and make systems more productive.

Remote monitoring solutions are fast emerging as a reliable and cost-effective technology to connect ICUs using a hub and spoke model. There are two types of remote monitoring, one connects remote hospitals to those in metropolitan city centres, and the other allows monitoring of ICU beds across the floors of a hospital building at a single location. It enables clinicians advanced consultation, care, and monitoring of their critically ill patients without having to physically transfer them to a super-specialty hospital. This reduces the risk of clinical deterioration.

A MOH Telemedicine Centre has been deployed extensively in Vietnam since the onset of the pandemic. Using the solution to enable remote monitoring and efficient care for critically ill patients remotely across the country, it extended the critical care expertise of clinicians in the capital city to patients in rural communities where specialists are not otherwise available.

AUTHOR BIO

Improve data management to strengthen clinical decisions Healthcare systems everywhere are overwhelmed by the amount of data they collect, where research shows that a typical hospital generates enough data per year to fill 20 million four-drawer filing cabinets where 97 per cent of that data never gets used

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The World Health Organization (WHO) estimates that 2040 per cent of health systems’ resources are wasted, which undermines service delivery.

And many don’t have the means to turn that information into the valuable insights they need for more efficient care.

The effective use of data requires changing the way it is stored and used today. Experts say healthcare leaders must revamp the protocols and technologies that silo data and prevent information from informing action. Data integration strengthens clinical decision-making and patient outcomes by providing easilyaccessible and expeditious insights to healthcare professionals when they need it.

Hospitals must craft plans to manage and capitalise on unstructured data, a challenge that existing technology can mitigate. They must look to invest in digital technologies that will help aggregate their data, applying AI and analytics.

These new intelligence platforms have been designed specifically to meet the need to take advantage of that data in new and significant ways. One solution is the implementation of cloud-based systems that can effectively and safely manage the exchange of relevant, real-time data to clinicians across the hospital enterprise, while anonymising patient data when required. Such systems are being deployed to streamline data gathering and boost patient privacy and data security.

With actionable data, the application of technologies like AI across the entire patient journey can help achieve precision healthcare that’s integrated, efficient, and highly personalised.

The COVID-19 pandemic brought many trials and tribulations to an already overburdened sphere. But having earned battlefield stripes on the front line during the Covid-19 surge also brought an opportunity for those leaders who were able to modernise and improve their healthcare ecosystems, accelerating transformations in the making and offering a glimpse into the future of healthcare.

The transition to a more holistic health ecosystem is about improving outcomes by finding new ways to reach and treat patients while creating capacity for providers and making precision health a reality. To achieve this, health systems must continue to prioritise digital innovation. It will be essential for responding to patients’ expectations for greater expediency, access, and convenience.

Chris Khang is President & CEO of GE Healthcare’s businesses in 13 markets across Southeast Asia, Korea, Australia and New Zealand (AKA), since January 2022. He is also President & CEO of GE Healthcare ASEAN, based in Singapore, leading 10 countries across the region since July 2021. Since joining GE as President & CEO, Korea in January 2012, Chris has been driving sustainable growth by promoting GE’s global excellence in technology and innovation, engaging the government and strategic private customers, and closely cooperating with GE business teams in Healthcare, Aviation, Renewables and Power. In 2019, Chris took on the direct responsibility for GE Healthcare Korea as President & CEO and has led strong, strategic business growth with a focus on operational rigour. Outside of work, Chris has a passion for developing and nurturing tomorrow’s leaders and is a regular guest speaker at universities.

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Artificial Intelligence May Help Radiologists Detect Fractures in Daily Practice In a recent paper published in Radiology, Guermazi et. al. used artificial intelligence (AI) algorithm for automatically detecting X-rays that are positive for fractures. They showed AI assistance helped reduce missed fractures by 29 per cent and increased readers’ sensitivity by 16 per cent, and by 30 per cent for exams with more than one fracture, while improving specificity by 5 per cent. They concluded that AI can be a powerful tool to help radiologists and other physicians to improve diagnostic performance and increase efficiency, while potentially improving patient experience at the time of hospital or clinic visit.

Ali Guermazi, Professor of Radiology and Medicine, Boston University Nor-Eddine Regnard, Radiologist

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issed fractures on standard radiographs are one of the most common causes of medical errors in the emergency department and can lead to potentially serious complications, delays in diagnostic and therapeutic management, and the risk of legal claims by patients.

In a study recently published in Radiology, Prof. Ali Guermazi et. al.

Showed an improvement in clinicians' diagnostic performance in detecting fractures in standard radiography using artificial intelligence software, BoneView

by Gleamer, compared to reading radiographs without assistance.

This was a retrospective study including 480 radiographic examinations of adults over 21 years of age, with indications of trauma and fracture prevalence of 50 per cent. Radiographs included were of the limbs, pelvis, dorsal spine, lumbar spine and rib cages.

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DIAGNOSTICS

Figure 1: This infographic summarizes the study design and the main results of the primary analysis

The radiographs were obtained from various US hospitals and clinics.

There were 350 fractures in 240 patients and 240 examinations without fractures.

The radiographs were analyzed twice (with and without assistance of Gleamer's Boneview automatic fracture detection software). Readers had 1-month washout period between the two analyses.

There were 24 US board certified readers from six different specialties (four radiologists, four orthopaedic surgeons, four rheumatologists, four emergency physicians, four family medicine physicians, and four emergency physician assistants) with different levels of seniority for radiologists and orthopaedic surgeons.

The gold standard was established based on the independent reading of radiographs by two musculoskeletal

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radiologists.

Discrepancies were adjudicated by an expert musculoskeletal radiologist, Prof. Guermazi. It was also determined whether the fractures were obvious or not.

The standalone performance of the software on this dataset was evaluated globally, as well as the improvements in the diagnostic performance of the readers in terms of sensitivity, specificity and time saving. An analysis was also made by type of reader and by anatomical location of the fractures.

The results of the study showed an absolute gain in sensitivity in the detection of fractures of 10.4 per cent with the assistance of the Boneview software of 75.2 per cent against 64.8 per cent without the assistance of the software (p<0.05).

There was also an absolute gain in specificity of 5 per cent in fracture detection with software assistance, with specificity increasing from 90.6 per cent without assistance to 95.6 per cent with software assistance (p<0.05).

A significant absolute gain in reading time of 6.3 seconds per radiograph

Figure 2: Anteroposterior elbow radiograph shows a radial head fracture which was missed by 4 readers without software assistance, and by no readers with software assistance

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(p=0.046) was found, with reading time decreasing from 55.5 seconds without assistance to 49.2 seconds with software assistance. These results from the primary analysis are summarised in Figure 1.

The absolute gains in sensitivity per patient were 7.6 per cent for radiologists, 9.1 per cent for orthopaedic surgeons, 9.9 per cent for emergency physicians, 9.4 per cent for emergency physician assistants, 17.2 per cent for rheumatologists and 9.3 per cent for family physicians.

The absolute gains in specificity were 2.8 per cent for radiologists, 2 per cent for orthopaedic surgeons, 3.4 per cent for emergency physicians, 2.5 per cent for emergency physician assistants, 14 per cent for rheumatologists and 5.2 per cent for family physicians.

Sensitivity gains were better for non-obvious fractures (+12.4 per cent) than for obvious fractures (+7.5 per cent) (p= 0.05).

Sensitivity gains were large (more than 10 per cent) and significant for most locations (foot-ankle, knee-leg, hip-pelvis, elbow-arm, ribs). Sensitivity

Figure 3: Oblique radiograph of the ribs shows 2 fractures of the 5th and 6th left ribs which were detected by the software. At least one of the fractures was missed by 9 readers without software assistance.

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Figure 4: Anteroposterior knee radiograph shows subchondral fracture of the lateral femoral condyle which was missed by 3 readers without software assistance, but picked by all readers with software assistance.

gains were not significant for the dorsolumbar spine and shoulder-clavicle.

Absolute gains in sensitivity per fracture were similar for single (+10.1 per cent) and multiple (+11.5 per cent) fractures (p=0.54).

The standalone performance of the software was good with an Area Under the ROC Curve of 0.97.

The sensitivities per patient averaged 88 per cent. The sensitivities and specificities were 93 per cent and 93 per cent for feet-ankle, 90 per cent and 93 per cent for knees-legs, 90 per cent and 87 per cent for hips-pelvis, 93 per cent and 100 per cent for handswrists, 100 per cent and 97 per cent for elbows-arms, 84 per cent and 83 per cent for shoulder-clavicle, 77 per cent and 69 per cent for rib cage, 77 per cent and 80 per cent for dorsolumbar spine respectively.

Figure 5: Anteroposterior shoulder radiograph in internal rotation shows a calcification around the glenoid which was mistaken for a fracture by 6 readers without software assistance. The software did not label this as a fracture. Only 2 readers still considered it to be a fracture with software assistance.

Figures 2, 3 and 4 illustrate fractures missed by some readers, which were recovered by using the software. Figure 5 shows an example of a false positive by some readers but not with the software.

The absolute gains in sensitivity per patient were 7.6 per cent for radiologists, 9.1 per cent for orthopaedic surgeons, 9.9 per cent for emergency physicians, 9.4 per cent for emergency physicians, and 8.5 per cent for physicians in the general population.

In conclusion, the results of this study recently published in Radiology showed an improvement in the diagnostic performance of readers from different medical specialties using Gleamer's BoneView automated fracture detection software in the detection of limb, pelvis, rib cage and dorsolumbar spine fractures in sensitivity and specificity as well as a

time saving in the reading of standard radiographs.

These results can have major impact on the management of patients by emergency physicians, radiologists, orthopedists, rheumatologists and family doctors. Indeed, the gain in diagnostic performance can have an impact on the immediate management of patients in the emergency room or in the general practice, by increasing the relevance of the diagnostic and therapeutic management. In particular, type of software can probably help to select the necessary complementary examinations (CT and/or MRI) for the right patients to confirm fracture diagnoses and assess their severity at an early stage and thus avoid complications such as fracture displacement, non-union, pseudoarthrosis, persistent pain and

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AUTHOR BIO

DIAGNOSTICS

Guermazi is a Professor of Radiology and Medicine and Assistant of Diversity at Boston University School of Medicine. He is the founder and Director of the Quantitative Imaging Center (QIC) within the Department of Radiology at Boston University School of Medicine, Boston, MA, a research group focusing on Musculoskeletal Radiology and especially MRI that provides radiological analysis services for industry, foundation or NIH-sponsored trials. Professor Guermazi was the Deputy Editor of the musculoskeletal imaging section for the RADIOLOGY journal from 20132019. He has authored or co-authored more than 600 peer-reviewed papers and made numerous scientific presentations at national and international osteoarthritis, rheumatology and radiology meetings.

Regnard is French board-certified musculoskeletal Radiologist and co-founder of GLEAMER. He has 12 years of clinical experience. His interest in artificial intelligence led to the conception of several algorithms that help radiologists world-wide in their routinely daily practice.

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even algodystrophy. This may allow patients to be treated early by immobilisation or surgery and for fractured patients to be referred to specific trauma departments.

This can probably increase patients’ recruitment to consultations and orthopaedic surgery.

The gain in specificity provided by the software may also result in a reduction in the overtreatment of patients who do not have fractures. The time saved in the analysis of radiographic readings could be used to treat more complex cases.

From an organisational point-of-view, having such a tool would allow radiologists to prioritise the reading of standard radiographs by probability of anomalies.

This would help them in choosing which radiographs to analyse first. This is relevant in the emergency context where the flow of additional radiographs can be significant and added to the usual workflow.

In addition, the use of such a tool can decrease the rate of discordance between the opinion of emergency physicians and radiologists, thus decreasing the rate of second visits to the emergency room for the patient and increasing patient satisfaction. Finally, missed fractures are one of the most frequent causes of complaints from patients visiting the emergency room. The use of this type of tool should help to reduce this legal risk.

All these aspects could be investigated in further studies of the medical, economic and legal impacts of the software.

The study had several limitations: the prevalence of fractures was significantly higher than in real life.

The readers had only the clinical indication of the traumatic context without the precise location of the painful symptoms. This is a usual situation for radiologists but is more unfavourable for clinicians who are used to analysing images after examining the patient. Another limitation is the choice of the gold standard on the basis of specialised musculoskeletal radiologists' advice only on standard radiographs. This type of gold standard is less precise than the result of a CT or MRI scan but remains relevant to the software's objective, which is to show fractures that are visible on standard radiographs and not occult. Finally, the readers were not analysing the images in their usual workflow and were therefore not limited in their analysis time as may be the case in real life.

All in all, this original study by Prof. Ali Guermazi is the first of such magnitude with so many US physician specialists, on so many anatomical locations to scientifically demonstrate the interest of using an artificial intelligence software for automatic fracture detection on standard radiographs.

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CANCER CARE ROADBLOCKS How do we overcome them and what does the future look like?

This article explores the importance of a multidisciplinary approach to cancer care and the current obstacles of accessing radiation oncology including: current consumer and clinician perceptions, infrastructure challenges constructing radiation oncology facilities across ASEAN, and regional shortages of specialised clinical expertise. It also discusses future trends – increase use of AI, and remote clinical and training capabilities.

Mark Middleton, CEO, Icon Group

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n 2020, there were an estimated 19.8 million new cancer cases and over 10 million reported cancer deaths. By 2040, the number of new cancer diagnoses is expected to rise by 29.5 million annually and will continue to be one of the leading causes of death worldwide. Long-term effects of COVID-19 will exacerbate the cancer burden and a widening global healthcare gap is creating unending

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MEDICAL SCIENCES

roadblocks to vital cancer treatment.

How can we overcome barriers to care and what investments need to be made to take us into a future less burdened?

The first phase in solving any problem is acknowledging it. In 2050, in Asia-Pacific alone a staggering 9.8 million new cancer cases are projected, a number that will place unsustainable

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pressure on public hospitals and all available local cancer treatment facilities. Lack of access to cancer care needs to be resolved and more importantly access to comprehensive cancer care is required. Radiation therapy is an effective and proven modality for treating a wide-range of cancers, with over 50 per cent of

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new cancer cases clinically indicating the patient should receive radiation therapy over the course of their treatment. Radiation therapy is also a well-tolerated and highly effective treatment in palliative cases and results in higher quality of life. However, across Asia and many developing countries radiation therapy is being

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under-utilised due to several industry, community, and economic factors.

Perceptions of radiation therapy

From conversations with our oncologists in Singapore it is clear there continues to be some misconceptions around the safety and efficacy of radiation therapy among general community, particularly

those in older generations. Similarly, a few years ago there was less knowledge of radiation oncology even within the clinical setting, where referral pathways would often bypass a Radiation Oncologist. While today, Singapore does enjoy exceptional healthcare and there is a greater emphasis on multidisciplinary meetings and a much higher uptake of radiation referrals and general community awareness, there is still room to grow in education and utilisation.

However, in surrounding countries like Vietnam, Indonesia, Laos, and regional areas of Malaysia misconceptions of radiation therapy prevail with fears of safety, myths around side effects, and a lack of radiation oncology referrals affecting the regions cancer mortality rates. Investing in education programmes and support and advocacy groups is an important step to eliminating these perceptions and empower patients and doctors to make informed decisions.

Infrastructure deficiency

Radiation oncology facilities require substantial financial investment and infrastructure. On average, low to middle income countries (LMICs) have access to only 0.71 radiation therapy machines per million population in comparison to 7.62 machines per million in high income countries. This gap will accelerate in correlation with expected increased cancer diagnoses, so what is the solution?

Successful healthcare ecosystems thrive on partnerships and collaborations.

The industry should be seeking greater investment in government and private sector partnerships in order to close the infrastructure gap, increase efficiencies and foster multidisciplinary advancements in cancer treatment. For LMICs in particular, it’s also important to establish national cancer control programmes and increase discussions with international bodies such as the World Health Organization (WHO) and the Union for International Cancer Control (UICC) to improve patient

access. This multi-sectoral approach will allow countries to close local knowledge gaps and build more facilities where they are needed. But establishing radiation oncology departments doesn’t just involve bricks and mortar, specialised technical support and clinical expertise is required.

Shortage of clinical expertise

In a survey by the Federation of Asian Organizations for Radiation Oncology, member countries saw only 54 per cent of the region's need for radiation oncologists being fulfilled, with most countries in the region producing less than 10 new radiation oncologists annually. This shortage runs across all radiation professionals, including medical physicists, radiation therapists and specialised oncology nurses. The lack of expertise and bottlenecks in training causes lower quality of care, an inability to introduce new treatment technologies, issues with machine maintenance, and ultimately poorer patient outcomes. So if we can’t access local expertise, how can we bring the best possible care to more people?

At Icon, we are proud to have longstanding relationships with shared care partners across the ASEAN region which enables us to deliver seamless care both travelling into Singapore for treatment and follow-up care within the patient’s own country. This shared-care model utilises Singapore’s well-experienced oncologists and clinical teams, alongside hospitals across ASEAN to help eliminate deficiencies of expertise.

During COVID-19, this model evolved with the increase use of telehealth and safe home delivery of medications to dissolve geographical barriers and continue access to treatment.

Similarly, whilst there has been an increase of medical physicists in the region, the majority of training practices have not changed over the last six to ten years. In that time the complexity of radiation technology has increased significantly causing a knowledge

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shortfall in local physicists. In 2019, Icon established a partnership with Vinmec Central Park International Hospital in Ho Chi Minh City, Vietnam to manage a new radiation oncology department onsite. This centre was only made possible with the support of Icon’s internationally recognised medical physics team who worked alongside local teams to commission the linear accelerator and provide ongoing training for machine maintenance and deployment of new techniques. However, to create sustainable healthcare, robust training programmes should be implemented.

Lack of training facilities and programmes

‘Give a man a fish he’ll eat for a day, teach a man to fish he’ll eat for a lifetime.’

Whilst there is no one true silver bullet to closing the radiation oncology care gap, investment in education is a sure fire way to improving outcomes and sustainable growth of radiation therapy.

Striving to improve health outcomes across ASEAN, Icon Group recently launched Icon ECHO clinics, utilising the Project ECHOTM (Extension for Community Healthcare Outcomes)

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The future does look bright but if we are to affect change, decrease cancer mortality and increase access to comprehensive care we need to invest in sustainable solutions.

clinics continue to evolve and can easily be adapted to various clinical streams and disciplines. It is proof that collaboration and knowledge is key to the creation of healthy communities.

Icon has partnered with Mt Alvernia Hospital in Singapore to establish a state-of-the-art cancer centre on the Mt Alvernia hospital campus which will bring all aspects of cancer care under the one roof. Not only will this centre contribute to the need for increased access to comprehensive care, it will also elevate the standard of clinical knowledge as the home to Varian’s regional training hub. The training facility will service radiation oncologists, medical physicists and radiation therapists across SouthEast Asia and foster a learning culture, providing clinical education and training to upskill medical professionals across ASEAN. This builds on Icon’s longstanding global partnership with Varian which allows for economies of scale, early adopters of new and emerging radiation technologies and products, and a collaborative workforce which allows Icon’s clinical experts to contribute to advancing Varian’s innovations through international consortiums, committees and large-scale research projects.

Increased utilisation of remote technologies also paints much of this training solution and form a large part of the future of radiation therapy.

A brighter future

model. Project ECHO uses technology to share knowledge across miles, leveraging free web-based platforms to connect clinicians with real-time collaborative, case-based learning. Icon ECHO clinics are based in Singapore and utilise the group’s international network of clinicians to support practitioners across the Asia Pacific empowering them to deliver better care to people within their communities. In its early stages, these clinics have seen positive outcomes and have nurtured existing shared care partnerships. The

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With defined cancer care roadblocks and the progression of solutions, we have the power to forge a better way forward. Research and trends in cancer care indicate the acceleration of radiation therapy techniques and investment in emerging technologies are and will lead to better patient outcomes.

COVID-19 expedited the need for healthcare to innovate. At Icon we quickly evolved our international remote capabilities, which are underpinned by a centralised team of expert dosimetrists and radiation therapists. Already operating a well-established remote

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radiation therapy planning function, which sees this central team plan personalised complex treatment plans for patients in China and the broader Icon network, we took this expertise a step further. Investing in assisted reality (AR) headsets, Icon has introduced a remote radiation therapy training program where our international teams remotely train new clinical teams in China, Australia and New Zealand, with AR headsets that allow both trainer and trainee to walk through and assess processes in real time. This has eliminated geographical barriers and is elevating the standard of local expertise, which can be seamlessly deployed anywhere in the world. It’s these technological innovations that are shaping the future of radiation therapy.

Patients diagnosed with multiple brain metastases are continuously seeing better quality of life through new evolutions in stereotactic radiosurgery.

This technology is eliminating the severe side effects and often poor outcomes of whole brain radiation, allowing clinicians

to precisely target multiple tumours in the brain. Today, with this cutting-edge technology radiation oncologists are targeting as many as 20 metastases in one treatment plan and are continuing to see an increase in the total volume of tumour which can be treated at any one time, giving new hope to thousands of palliative patients. Similarly there have been evolutions in Image Guided Radiation Therapy, Proton therapy and this concept of flash therapy, treating the entire dose of radiation at once in one large precise fraction, rather than over the traditional daily fractions. Most recently, the use of artificial intelligence (AI) is allowing oncologists to adapt, replan and optimise radiation delivery in real-time accounting for daily changes in tumour shape and normal organ movements.

This use of AI based algorithms is revolutionising precision radiation both during treatment and even during the planning stages.

The field of radiation oncology will continue to thrive in a tech-focused

future. The promising use of theranostics is seeing the implementation of radioactive drugs to identify tumours and deliver therapy directly in the tumour cells, limiting damage to surrounding healthy tissue and organs. The use of AI is in its infancy, but medical physicists and engineers are continuing to see benefits across industries and apply these within radiation technology. The machines are getting smarter, and clinicians are pushing the limits alongside these growing developments.

The future does look bright but if we are to affect change, decrease cancer mortality and increase access to comprehensive care we need to invest in sustainable solutions. The healthcare industry must consider the needs of specific countries, continue to crosscollaborate, place cancer on the agenda, educate and eliminate barrier through innovation. Only then can we have a future less burdened by cancer.

References are available at www.asianhhm.com

AUTHOR BIO Mark is the global Icon Group CEO with a clinical background as a radiation therapist. He has extensive management experience and has worked in cancer care in North America, Europe and Australia. He has published 25 peer reviewed papers and is a frequent invited international keynote speaker. He has a Master of Business Administration from Deakin University and is a Fellow of both the Australian Institute of Management and the Australian Institute of Radiography.

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EXECUTIVES SPECIAL ISSUE 4 8 AUGUST 2022

Special issue is designed to focus on a theme or a sector trend. This issue is aimed at facilitating the industry leaders share perspectives and insights with our readers on key issues impacting and influencing the industry. The issue would also cover a few articles on trending topics in the pharma industry.

If interested in contributing, please reach out to prasanthi@ochre-media.com or gracejones@ochre-media.com

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THE FUTURE OF INTEGRATED EYE CARE IS DIGITAL The merits of an eye health ecosystem is immense – it delivers a personalised, intuitive, and integrated patient experience, and eye care professionals can enhance productivity and engage with a broad set of caregivers, improving eye health outcomes and affordability. Over the next few years, Singapore will see the roll out of a brand new eye health ecosystem with a projected investment of over SGD10 million. As we work towards changing the trajectory of eye health, public-private partnerships will continue to be critical in ensuring the seamless delivery of care to meet patients’ eye health needs at every life stage.

Vaibhav Saran, Area Vice President for Vision Care, Asia Pacific, Johnson & Johnson Vision

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S

ight is the most precious of our five senses, and accounts for 80% of what we learn and remember 1. However, we are seeing the risk of losing the gift of sight rapidly increasing globally. While there has been tremendous progress in advancing the trajectory of eye health over the years, there is still a lot of work to be done.

Globally, at least 2.2 billion people have a near or distance vision impairment. In at least one billion – 1 Journal of Behavioral Optometry. Children’s Vision Care in the 21st Century & Its Impact on Education, Literacy, Social Issues & the Workplace: A Call to Action. Accessed August 10, 2018.

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quality of life, it also leads to reduced employment prospects and work productivity. According to a recent study by the Lancet Global Health Commission on Global Eye Health, vision impairment and blindness has been estimated to cost a total of US $408.5 billion of potential global productivity losses annually.4 Closer to home, Asia-Pacific as a region calls for greater attention. Home to a population of almost 4.7 billion and one of the most rapidly ageing regions, addressing eye care needs in this region would have a significantly positive impact on achieving universal eye health goals. However, the AsiaPacific is also facing the stressors of another health crisis. The vast majority of countries in the region have been focusing healthcare efforts and innovation towards mitigating rising COVID-19 cases throughout 2020 and 2021. While we continue to focus on fighting the pandemic, we should not forget that the myopia epidemic is still 4 The Lancet Global Health Commission on Global Eye Health (2021). Global economic productivity losses from vision impairment and blindness.

or almost half – of these cases, vision impairment could have been prevented or is yet to be addressed, with uncorrected refractive errors and cataracts being the leading causes of vision impairment and blindness.2 Moving forward, myopia alone will impact nearly half of the global population by 2050.3 Most notably, compromised eye health does not just impact lives, but also livelihoods. Beyond affecting 2 World Health Organisation. Blindness and vision impairment.

3 Holden BA et. al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology 2016;123:5:1036-42

As we work towards changing the trajectory of eye health, publicprivate partnerships will continue to be critical in ensuring the seamless delivery of care to meet patients’ eye health needs at every life stage.

lurking in the background, and our efforts to arrest it should not come to a standstill.

In fact, COVID-19 highlighted the gaps that urgently need addressing.

During the height of the COVID-19 pandemic, patients with eye health issues were either being turned away from hospitals, or they themselves opted to delay non-urgent procedures and consultations to avoid interactions that would risk contracting the COVID-19 virus. This delay in treatment has had an adverse impact on patient outcomes.

This demonstrated that there is a critical need to reimagine our existing eye health systems to ensure they remain resilient in the face of major disruptions such as future global health crises. The question is: how?

Integrated eye care is an urgent necessity

As a start, having integrated care is key.

Essentially, this entails establishing a network connecting key stakeholders at different stages of the patient journey, from patients, caregivers, healthcare professionals, government, to industry players. Through this loop, everyone can communicate and collaborate seamlessly throughout each and every touchpoint. For example, important healthcare information obtained consensually from patients can be exchanged more easily between primary care partners and specialists at outpatient clinics. From there, they can identify common care goals for patients and prioritise and streamline interventions, to ensure that the patient receives effective and efficient care.

Specifically for eye health, the merits of an integrated ecosystem are immense.

It delivers a personalised, intuitive, and integrated patient experience. Eye care professionals can also enhance productivity and engage with a broad set of caregivers, improving eye health outcomes and affordability.

It is also a tried and tested approach. In Singapore, the National

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Electronic Health Record (NEHR) was established in 2011 with the central ethos of “One Patient, One Health Record”. Patient health records are digitalised and consolidated on a secure, shared database, so that healthcare professionals can have a holistic and longitudinal view of their patients’ healthcare history. It achieved considerable success, with next steps looking at developing the next mega project, the Next Generation Electronic Medical Record (NGEMR) system.

Beyond Singapore, such healthcare ecosystems have been improving patient outcomes for more than a billion lives across Asia today. For example, in China, Ping An Good Doctor has been a game-changer as a one-stop Internet online medical portal, tapping into telehealth while offering options for in-person follow-ups and expedited appointments with a hospital. Similar players like Practo in India and Halodoc

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in Indonesia increase access for patients with hospital-based physicians and general practitioners, and even manage electronic health records for hospitals.

With the level of data collection and sharing taking place in an ecosystem approach, cybersecurity and respecting the privacy of patient data can be of concern. As eye health progressively becomes anchored on data and digitalisation, there is a need to protect users and inspire trust in a technological future, by investing in digital infrastructure to ensure that the foundations for secure data sharing are in place.

An eye health ecosystem focused on data and digitalisation

Today, establishing an eye health ecosystem is key to addressing eye health, but most importantly, data and digitalisation present enormous potential to amplify the ecosystem’s

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impact on patients. To bring this to life in the region, it was announced in August 2021 that a new integrated eye health ecosystem will be established right here in Singapore over the span of three years. Focused on data and digitalisation, the ecosystem aims to improve overall access, capacity, and hyper-personalisation of patient care.

Pioneered by Johnson & Johnson Vision, key initiatives to be piloted in the ecosystem include a community eye health e-referral network, peoplecentric eye care powered by Artificial Intelligence (AI), and telehealth.

For example, the two-way e-referral network aims to increase the efficiency and effectiveness of all stakeholders involved in the eye health journey by connecting patients, optometrists, and ophthalmologists seamlessly over a digital collaborative platform.

Through this network, optometrists and ophthalmologists will be able to send

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patient care capacity, access and quality.

Strong and effective collaboration between the public and private sectors is also critical in the talent engagement needed to successfully transform the eye health system into an integrated one. Integrated care calls for integrated information and technology, which requires experts from areas ranging from cybersecurity, user interface (UI) and user experience (UX) design, artificial intelligence (AI) development, and blockchain. This provides exciting job opportunities in the market for digital talent to enter and support the growing healthcare sector.

To achieve the desired outcomes and vision of this project, Singapore Economic Development Board is supporting Johnson & Johnson Vision in its efforts to develop talent,

AUTHOR BIO

information about the patient securely and also communicate about treatment options for the patient seamlessly. This includes identifying common care goals for patients, as well as prioritising and streamlining interventions to make the patient journey fuss-free.

With data use, privacy can be a huge issue and needs to be taken very seriously. The fundamental principle that Johnson & Johnson Vision operates on is that the user data ultimately belongs to the user. Johnson & Johnson Vision partners closely with the Singapore government and privacy laws such as the General Data Protection Regulation (GDPR) to ensure full security and safety for our consumers.

The overall aim of connecting patients and consumers seamlessly with eye care professionals is to ensure a more efficient process, and provide seamless and coordinated care. Through telehealth, patients can access care more easily, and will not be restricted from seeing their eye care professionals, as occurred during the COVID-19 pandemic. The timely management of cases in turn will have the potential to reduce patient waiting times and cost.

Creating valuable partnerships

Notably, this new ecosystem will see industry partners like Johnson & Johnson Vision working with the national eye health infrastructure to greatly improve the patient care experience. As we work towards changing the trajectory of eye health, public-private partnerships such as this will continue to be critical in ensuring the seamless delivery of care to meet patients’ eye health needs at every life stage.

Governments will be able to leverage private sector resources and expertise and these collaborations will provide the right conditions to test new innovation and models that have the potential to advance national and local public health goals, thereby improving

Vaibhav Saran is the Area Vice President for Vision Care, Asia Pacific, Johnson & Johnson Vision, a global leader in eye health delivering innovation that enables eye care professionals to create better outcomes for patients throughout their lives, through products and technologies that address unmet needs including refractive error, cataracts and dry eye

which includes working with local medtech firms and incubators to source technologies, and with healthcare providers to pilot novel multichannel strategies and platforms.

Collaboration has always played a role in Johnson & Johnson Vision’s efforts to advance the global eye health trajectory, and such ongoing partnerships is key to setting the foundations of the integrated eye health ecosystem. Notably, Johnson & Johnson Vision established an SGD 36 million collaboration with Singapore National Eye Centre (SNEC) and Singapore Eye Research Institute (SERI), with the aim of improving access to eye care specifically for myopia. The research on how myopia develops, how it progresses, and how it may be intercepted, will create a wealth of data that the ecosystem can tap into to identify key indicators and mitigate eye health issues at its early stages.

Similarly, with the objective of delivering hyper-personalised eye care, Johnson & Johnson Vision partnered with AI Singapore (AISG), under its flagship 100 Experiments Programme (100E), to investigate the use of AI to improve consumer experiences, and to leverage data for real-time insights to better support patient needs in eye health. The pilot provided useful learnings that will help shape hyperpersonalised patient care as part of the integrated ecosystem.

Despite the important role sight holds in our everyday lives, it remains severely underrepresented in the healthcare priorities of populations regionally and globally. How it impacts patients at every life stage – from young to old – further cements the needs for an integrated approach that utilises data and digitalisation to improve eye health outcomes and affordability. However, global health goals cannot be achieved in silos; strategic cooperation between public and private sectors will be the key to deliver high quality patient care for eye health.

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Role of Catheter Ablation in the Comprehensive Management of Atrial Fibrillation Atrial fibrillation (AF) is the most common arrhythmia that can lead to significant morbidity and mortality. Anti-arrhythmic drugs (AADs) are limited by a relatively low efficacy and substantial side effects. Interventional electrophysiology became an effective option in the management of selected patients with AF. Current guidelines recommend catheter ablation for patients with symptomatic paroxysmal or persistent AF for whom AADs have failed (class I). Patient with AF and multi-cardiovascular morbidities might have more recurrence rate of AF after ablation compared to those without significant morbidities. Advancement of technology would further improve the safety profile and clinical outcome of AF ablation. Future research would further refine our knowledge and might expand the groups of AF patients who would derive clinical benefit from AF ablation. Early referral of ideal candidate for AF ablation is much appreciated as it would be associated with better outcome at long term.

Rami Riziq Yousef Abumuaileq Consultant Cardiologist, Palestinian Medical Services, Gaza, Palestine

A

trial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide. The currently estimated prevalence of AF in adults is around 2 per cent. With ageing of the world population and intensifying search for undiagnosed AF, the prevalence of AF is expected to increase.

Increasing age is a prominent AF risk factor, but other comorbidities including hypertension, diabetes mellitus, heart failure, coronary artery disease, chronic kidney disease, obesity, and obstructive sleep apnoea are also important and relatively modifiable risk factors which are considered potent contributors to AF development and progression.

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Patients with AF usually have recurrent symptoms and significant impairment in their quality of life. AF could increase risk for major adverse cardiovascular outcomes mainly stroke, heart failure, and cardiac death.

rapid development of new ablation techniques over the last two decades, the results of CA procedures have been significantly improved at terms of efficacy and safety.

inside of the heart to help break up or insulate the electrical signals that cause/ trigger irregular heartbeats.

CA for AF

Cornerstones of AF management

It is well recognised that AF is caused by rapidly firing electrical foci that are often located in the pulmonary veins especially when fibrillation is paroxysmal.

Histological data show that myocardial tissue of the left atrial wall extends into the pulmonary venous walls. Clinical and animal studies reveal both double potentials and fractionated electrical activity in the pulmonary veins, which are related to the complex architecture of the myocardial sleeves in the veins.

Based on these data, circumferential pulmonary vein isolation (PVI) became the accepted interventional therapy to treat AF. Simply, CA for AF is a procedure to treat atrial fibrillation. It uses small burns (radiofrequency) or freezes (cryoballoon) to cause some therapeutic scarring on the

In general, CA is a recommended treatment option for AF when AADs therapy fails in controlling patient’s symptoms (class I).

Current European Society of Cardiology recommendations: 1. CA for AF with pulmonary vein isolation (PVI) should be considered as first-line rhythm control therapy to improve symptoms in patients with symptomatic paroxysmal AF episodes (class IIa).

2. CA for AF may be considered for persistent AF without major risk factors of AF recurrence as an alternative to AADs class I or III, after taking into account patient’s choice, risk, benefit, (class IIb).

3. Use of additional ablation lesions beyond PVI (i.e., atrial low voltage areas, lines, fragmented activity, ectopic foci,

When evaluating AF patients in the clinic, careful characterisation of AF is necessary for proper decision-making, and optimal management of AF patients.

This includes evaluation of AF-related symptoms (e.g., fatigue, tiredness, exertional dyspnoea, palpitations, and chest pain) and quantify the patient’s symptom status using the modified European Heart Rhythm Association (EHRA) symptom scale before and after initiation of treatment, determining the type of AF (paroxysmal, persistent, longterm persistent, and permanent atrial fibrillation), clinical assessment of stroke risk, burden of AF, etc.

Comprehensive management of AF consists of three main aims: 1- The alleviation of patient’s symptoms; 2Prevention of tachycardia-mediated cardiomyopathy at atrial and ventricular levels; 3- Minimising the risk of stroke.

The first two aims can be achieved with either a rate control or rhythm control (maintaining sinus rhythm) strategy. The third goal can be fulfilled by careful evaluation of AF patient’s risk of thromboembolic event according to CHA2DS2VASc score to determine the patient’s need for oral anticoagulation.

For patients in whom a rhythm control strategy is chosen, catheter ablation (CA) and antiarrhythmic drugs (AADs) therapy are the two therapeutic strategies to reduce the frequency or eliminate episodes of AF. AADs (class I and III) have been widely used for rhythm control in AF. Owing to the limited success and perceived side effects of AADs, CA has emerged as recognised option and early choice treatment strategy in certain groups of AF patients. With accumulating experience and the

Current recommendations and guidelines regarding CA for AF

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rotors, and others) may be considered (class IIb).

4. Repeated PVI procedures should be considered in patients with AF recurrence provided the patient’s symptoms were improved after the initial PVI (class Ia).

5. CA for AF is recommended to reverse left ventricle dysfunction in AF patients when tachycardia-induced cardiomyopathy is highly probable, independent of their symptom status (class I).

CA techniques, efficacy and safety

Two ablation techniques still dominate when performing PVI: 1. point-by-point radiofrequency (RF) ablation of the atrial tissue surrounding the pulmonary veins using a single-point catheter with the aid of a three-dimensional mapping system toward complete electrical isolation of pulmonary veins.

2. Single-shot ablation technique with the use of a cryoballoon (freezing approach). Each technique has its advantages and disadvantages, but with similar safety and efficacy in the treatment of paroxysmal AF. The recognised and appreciated advantage of the RF-based approach is that it can be

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used to ablate atrial tissue beyond PVI, which is usually needed for the treatment of long persistent AF or recurrent AF after a first PVI attempt particularly when encountering significant areas of electrical atrial tissue remodelling.

Evaluation of CA efficacy is mainly measured on the basis of: elimination

Histological data show that myocardial tissue of the left atrial wall extends into the pulmonary venous walls. Clinical and animal studies reveal both double potentials and fractionated electrical activity in the pulmonary veins, which are related to the complex architecture of the myocardial sleeves in the veins.

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of late AF recurrence and decrease of the AF burden. Late recurrences of AF is defined as the development of any type of atrial arrhythmia lasting more than 30 seconds (AF, atrial flutter, or atrial tachycardia) between 3-12 months after the CA procedure. AF burden is measured as the percentage of time in which the patient’s cardiac rhythm spent in AF during a certain monitoring period. Early recurrences of AF within the first 3 months of follow-up are of limited clinical significance since only half of those patients will finally develop later episodes of AF. Based on the above success measures several clinical trials have shown that a first AF ablation procedure can eliminate late recurrences in approximately 70 per cent of patients with paroxysmal AF and decrease the AF burden by 80 per cent in a follow-up ranging from 1 to 5 years. Success rates are typically lower in patients with persistent AF reaching 50 per cent after a single procedure. For those with late recurrence or remaining significant AF burden, the success of the second AF ablation (PV re-isolation) is >90 per cent.

CA for AF is a relatively safe procedure with overall complication rate varying between 2-3 per cent. The rate

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Defining the ideal or best AF candidate for CA

In seeking the AF patient who will gain the most benefit from a CA treatment strategy, several factors have to be taken into account. The expected low probability of late AF recurrence after CA, the improvement in the quality of life, and the decrease in the long-term morbidity and mortality should be combined with the lowest risk of periprocedural complications.

Advanced age, long AF duration (long persistent AF,>1 year after the initial diagnosis), severe left ventricular systolic dysfunction (EF<30 per cent), increased left atrial size (diameter >5 cm), and the presence of comorbidities (obesity, hypertension, untreated valvular disease, metabolic syndrome, obstructive sleep apnoea, kidney disease) are the main factors predicting a high recurrence rate of atrial arrhythmias post-ablation.

However, none of the above factors is an

absolute contraindication to CA. Only in the presence of left atrial thrombus is the procedure contraindicated.

Based on the above, the ideal candidate for CA would be the relatively young patient with several symptomatic episodes of paroxysmal AF of recent onset (<1 year) and without comorbidities or signs of structural remodelling of the heart (normal LVEF, no or minimal atrial enlargement).

Although the majority of AF patients undergoing ablation in everyday clinical practice do not fulfil all these criteria, most of them still experience a beneficial effect. New technologies are underway intending to improve the effectiveness and safety of CA and to increase the success rate even for AF patients who are currently considered poor candidates for this treatment strategy.

Early referral of ideal candidate for AF ablation is much appreciated as it would be associated with better outcome at long term. Transition from paroxysmal to non-paroxysmal AF (or from subclinical to clinical AF) is often characterised by advancing atrial structural/electrical remodelling or worsening of atrial cardiomyopathy which are associated with more late AF recurrence rate after PVI. At 10 years of follow up >50 per cent of paroxysmal AF might progress to persistent AF.

AUTHOR BIO

of complication might be affected by several factors like local centre’s expertise, learning curve, equipment available, local protocol, and patient selection approach, etc... Life-threatening complications, although very rare, can occur. In-hospital mortality following ablation varies between 0.6 and 2 per 1,000 patients.

Cardiac tamponade is the most serious complication but is relatively uncommon with an incident rate between 0.6 per cent and 1.3 per cent but decreases with experienced operators, while local vascular complications are the most common type of adverse effects related to the procedure. Other recorded very rare complications include early or late presentation of pulmonary vein stenosis, catheter entrapment, periprocedural embolic events, phrenic nerve injury 0.4 per cent, atrioesophageal fistula 0.1 per cent, vagal nerve injury and pericarditis.

Several patient’s related variables could increase complications rate like advanced age, obesity, multi-morbidity have all been associated with an adverse outcome after CA.

Risk factors for AF progression include age, heart failure, hypertension, chronic kidney impairment, chronic pulmonary diseases, diabetes mellitus, previous stroke, and left atrial remodelling.

Follow up after ablation:

1. After AF catheter ablation, it is recommended that: Systemic anticoagulation with warfarin or a non vit-K antagonist (NOAC) is continued for at least 2 months post ablation, and long-term continuation of systemic anticoagulation beyond 2 months should be re-evaluated based on the patient’s stroke risk profile (e.g., CHA2DS2VASc level) and close monitor.

2. Major cardiovascular risk factors have strongly been related to AF late recurrence after CA. Post CA, physician’s efforts should be directed toward better control of major cardiovascular risk factor and co-morbidities (e.g., hypertension, diabetes mellitus, valvular heart disease, pulmonary disease, kidney disease, systemic inflammatory disease etc…).

3. Careful evaluation of patient’s symptoms and close monitor of cardiac rhythm for AF late recurrence and/or AF burden are recommended in order to guide better management and decision after CA procedure.

Rami Riziq Yousef Abumuaileq is a Consultant Cardiologist (M.D., Ph.D.) at Palestinian Medical Services- GazaPalestine. He has an appreciated record as expert/referee of cardiovascular disease and research. Currently, he is Associate Editor at European Heart Journal, Editor at BioMed Central, a Journal Referee for American Journal of Cardiology and a Member of the Clinical Case Review Committee at the prestigious ESC Congress 2020, 2021 and 2022. He had completed his Medical Doctorate of Cardiology with advanced fellowship at Cardiology Department of the Tertiary University Hospital of Santiago de Compostela-Spain.

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TELEMEDICINE An exclusive interview with Krishnan Ganapathy 1. You are on the Board of ATNF & ATHS. How did you come to be involved with them?

It started on September 16 1996, I had just finished delivering an

institute lecture at the Indian Institute of Technology Kanpur, a globally recognised institution. Just after the Q & A ended at 09:00PM, Prof. Srivathsan, HOD of Electrical

Engineering Department insisted I have dinner with him. He introduced me to the word “Telemedicine”. We jointly prepared a project report from 11:00PM – 04:00AM. Then commenced a love affair, which over the next 26 years has taken its toll. My legally wedded wife is often relegated to No. 3.

Initially, I was wedded to Neurosurgery and now it is Telehealth. Having started the first Stereotactic Radiosurgery unit in South Asia and as Secretary of the then 2200 strong Neurological Society of India, conventional wisdom dictated that I should continue to focus my skills and energy completely, on what I was trained for, namely neurosurgery. However, deep down was a nagging feeling: “Was there not something else, which I could do, which could help more than a few thousand neurosurgical patients.” And then the story began. I took the road less travelled by and the rest, as they say, is History! In fact, I embarked on making Geography History, and distance meaningless!

KRISHNAN GANAPATHY is a Former Secretary and Past President Neurological Society of India, Telemedicine Society of India & Indian Society for Stereotactic & Functional Neurosurgery. Hon. Distinguished Professor, The TamilNadu Dr. MGR Medical University, Emeritus Professor National Academy of Medical Sciences Member Roster of Experts Digital Health WHO. Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services, India.

URL: www.kganapathy.in E Mail: drganapathy@apollohospitals.com

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Dr Prathap C Reddy Founder Chairman Apollo Hospital Group visionary Nostradamus that he is, gave me all the support and encouragement.

On March 24th 2000, Bill Clinton formally commissioned the world’s first Very Small Aperture Terminal (VSAT) enabled village hospital at Aragonda in Andhra Pradesh (birth place of Dr. Reddy). In 2001, Apollo Telemedicine Networking Foundation was formally established as a not for profit Section 25 company. Taking modern healthcare to remote areas using technology was the mission of ATNF. In between my neurosurgical commitments, I spent time and effort to help a skeleton staff of four full-time employees to achieve what in 2001 appeared preposterous: remote consultation. Every opportunity to put a then hardly existent Indian Telemedicine on the world map was utilised. In 2007 the commercial arm Apollo Telehealth Services was started.

Today the Apollo Telehealth division alone has about 1275 employees.

Almost 25,000 e-Health transactions are done every day. With a dynamic CEO and an outstanding support staff the initial passion displayed by the founders has become infectious and contagious. The organisation is on auto pilot mode. This would not have been possible but for the freedom and encouragement given by Dr Sangita Reddy Joint Managing director of the Apollo Hospitals Group who oversees the Telehealth Division.

2. Who benefits the most from integration of Telemedicine into Health Systems?

There is no one set of patients benefitting more from using Telemedicine. Incidentally I prefer the term Telehealth to Telemedicine The former is an all encompassing term covering every aspect of health including promoting wellness, while the latter implies only a one to one diagnosis and treatment. Providing dependable Knowledge on a smart

phone will lead to people empowerment and a reduction of preventable diseases. Promoting health literacy the e Way is critical. Under Ayushman Bharath, the world’s largest Universal Health Coverage for 500 million Indians, 150,000 Telehealth enabled Wellness Centers will be functional throughout India. Theoretically, every single individual, healthy or sick, rich or poor, urban or rural, educated or not, can benefit in different ways through “contactless” medicine. Distancing is a term that should not exist for those deploying Virtual Healthcare - we are always there 24/7 on a small or large screen.

3. What are the challenges facing Telehealth today?

In one way the challenges facing Telemedicine today are far less and can be addressed. When I first embarked on Telemedicine 24 years ago, the very word was unfamiliar to most. It took a decade of intensive persistent evangelisation to create the semblance of an awareness.

The second decade was spent in achieving a behavioural modification and technology acceptance among all stakeholders in the ecosystem. During the last four years, thanks primarily to Public Private Partnerships, revenue generating business models have started to become available. The single most important challenge facing Telemedicine is addressing the question WiiiFM (What is in it For Me). WiiiFM is different for each stakeholder. COVID 19 pandemic has made the entire globe realise that today distance is meaningless. Physical distancing could be the norm. Convincing the beneficiary that Telemedicine has advantages over in-person visits, will no longer be a major challenge, particularly with proactive steps taken by the government. The challenge is to customise and make available a cost-effective, need-based, userfriendly, efficient, secure Telehealth

system compliant and adherent to newly formed regulations. Telemedicine systems must be future-ready and culture-sensitive. Insurance companies in India have already started recognising Telemedicine for reimbursement. Revenue generation is critical for ensuring self sustenance.

4. You are reputed as having helped pioneer introduction of Telemedicine in India.

What advice do you have for someone wanting to establish a Telemedicine programme?

Be future-ready. Learn from the mistakes of your predecessors.

Remember that no Telehealth programme can be sustained unless it is revenue generating. Technology is a means to achieve an end not an end by itself. With more access to technology do not forget that you are a doctor first and last. TLC (tender, loving care) can be bestowed virtually. Empathise, sympathise with your patient on the screen (small or big). Wipe their tears.

Listen to them Find out what they want. Answer all queries. Technology is the least important. Context is critical. Stop a teleconsult if your gut feeling suggests necessity for a face to face interaction. Adhere and comply with all changing regulations.

We are in a stage of transition. All transitions offer great opportunities.

Telemedicine, like medicine itself, is not black or white. It is still various shades of grey. Look back to March 10, 1876 when Alexander Graham Bell made the world’s first telephone call, a request for medical help, “Watson come here I want you”, after having spilt battery acid on himself.

We now have a diamond spoon in our mouth. COVID-19 is providing us with tens of thousands of virtual non-Covid patients! You cannot ask for a more opportune time to initiate Telehealth. A strand of RNA 120 nms has become the most efficient CTO (Chief Transformation Officer)

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5. What impact has the COVID19 pandemic had in integrating Telemedicine in day-to-day clinical practice?

Following notification of COVID-19 as a pandemic, on March 25, 2020 the Ministry of Health, Govt of India notified Telemedicine Practice Guidelines for the country. This had been pending. Due to uncertainty of legality in deploying Telemedicine, many doctors were not using this. Today, thousands of doctors have attended orientation programmes conducted by the Telemedicine Society of India and other organisations. I have personally given 52 webinars in the last 22 months on various aspects of Telehealth. Over 35,000 doctors have attended. One webinar during the first wave was attended by 11,775 doctors.

Another webinar was for 8 countries and 808 attended. The interest then was unbelievable. Hundreds of hospitals in the public and private sector started offering free teleconsultations for screening of COVID 19 patients.

Contactless medicine is now being accepted. It appears that the work from home (WFH) culture will include doctors as well!! In every crisis there is an opportunity. Delivery of healthcare services is being re-looked at. Even when the pandemic becomes an epidemic, Telehealth is here to stay.

It will take centre stage after being in the periphery for 24 years.

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guidelines regarding Data Ownership of EMR have been notified. Protected Health Information, data ownership, data access and confidentiality, EMR preservation and patient identifying information have all been addressed in great detail under existing Indian laws including IT Act 2000 and their amendments. The stakeholders understand the importance of cybersecurity. However, sometimes I feel that we are getting paranoid about cybersecurity in healthcare. Yes it is important, but if we wait for a totally fool proof secure system, EMR’s and HIS would never see the light of day and the cost would be astronomical.

Even the White House can be hacked!!

It depends on how badly the hacker wants the information. I have always felt that there is a cultural difference between India and the west so far as hacking health records is concerned!!!

We are not primarily a society which will litigate at the drop of a pin. Trust still is part of our vocabulary.

6. There is debate over the robustness of cybersecurity measures for patient data in Telemedicine. What is your opinion on this?

7. What is the importance of Global Certification in Telehealth?

We concede that privacy and security of patient data is important. 200 million healthcare records have been reported to have been compromised in the USA alone. The later entry of India in using electronic medical record (EMR), has ensured that we don’t piggy back, we don't even leap frog (after all how far can a frog leap) we pole vault. Ethical, legal, social issues

Quality is never an accident. It is always the result of intense sincere effort, intelligent direction and skilful execution. The International Standards Organization (ISO) has developed a Technical Specification, ISO/TS 13131 Telehealth Services. This standard, supports healthcare planning, service and workforce planning, organisation responsibilities and financial and IT

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management. ISO develops standards recognised and respected globally. It brings experts together to improve quality and provide world-class healthcare services. To maintain global recognition, maintaining quality needs to become a habit, a unique opportunity to transform one’s DNA if necessary !! Success is the sum of small efforts, repeated day-in and day-out.

Standardising systems, processes, documentation and re documentation alone will ensure providing quality remote healthcare for anyone, anytime anywhere. On December 10th 2021 the ISO 13131 -2021, certification for Telehealth Services was obtained for the first time, anywhere, by Apollo Telehealth Services. This was a remarkable display of considerable team work led by passionate managers.

8. At 71 what do you now intend to do?

I am reasonably satisfied with my erstwhile professional career both as a neurosurgeon (helped start Stereotactic Radiosurgery in 1995 and Robotic Radiosurgery in 2008) and my contribution to the growth and development of Telehealth from 1998 onwards. I am delighted that the Next Generation is doing far better. I am optimistic that in my life time, I will see digital health and technology-enabled remote healthcare being universally incorporated into the healthcare delivery system. Twenty two years ago Dr. Prathap Reddy in his infinite wisdom told me “Ganapathy, your job is to make the pie bigger, your share of the pie will automatically become bigger”. I now wish to concentrate on knowledge transfer, sharing what I have learnt over the last half a century, by giving more talks and writing more.

My recent appointment as a National Emeritus Professor by the National Academy of Medical Sciences India offers an opportunity to spend some time in different medical institutions interacting with students and staff.

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INTEGRATED HEALTHCARE The Singapore story Digital health may seem to be the answer to achieving patient-centric health, but there’s more to it than that. For healthcare to be truly patient-centric, it must first and foremost be ‘integrated’–‘One Patient One Health Record’, as envisioned by Singapore. While it may be tempting to assume that such a vision is quickly and readily realisable in a city-state like Singapore, this can’t be farther from the truth.

Felix Lena Stephanie, Nanyang Technological University (NTU)

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igital health may seem to be the elixir to achieving patientcentric health, but there’s more to patient-centricity than that. For healthcare to be truly patient-centric, it must first and foremost be ‘integrated’ – ‘One Patient, One Health Record’- as envisioned by Singapore. While it may be tempting to assume that such a vision is quickly and readily realisable in a citystate like Singapore, this can’t be farther from the truth.

Singapore is a multi-ethnic city-state with a population of 5.9 million. The island nation enjoys the rare distinction of being among the top ten healthiest countries in the world and having a healthcare system well regarded as one of the world’s most efficient. It boasts a two-tier system where the public and private sectors play intersecting roles in the provisioning as well as the financing of healthcare services. While 80 per cent of the primary healthcare demand

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is met by private clinics run by general practitioners, public health facilities account for about 80 per cent of total acute hospital inpatient admissions and 40 per cent of total nursing home beds.

The remaining demand for beds in acute hospitals and nursing homes is met by a combination of private and not-forprofit health facilities.

The bedrock of Singapore’s healthcare financing system is what is known as the S+3Ms scheme —Subsidies plus Medisave, MediShield Life and Medifund—which is based on the philosophy of shared responsibility. This means the government would subsidise healthcare costs, but the people would still have to assume personal financial responsibility for their healthcare through co-payments and voluntary, supplemental private insurance coverage for higher benefits, in order to keep the healthcare system viable and sustainable.

It therefore comes as no surprise that Singapore’s total health expenditure expressed as a percentage of its GDP, remains at around 4 per cent.

Notwithstanding the accolades Singapore’s healthcare system has garnered, its risk-shifting policy has resulted in an out-of-pocket health expenditure for its population that stands at a whopping 30 per cent of its total health expenditure. To put this in perspective, this is more than double the 14 per cent average for both the ‘OECD’ and ‘high-income’ categories of countries. Such a situation does not bode well for Singapore’s ‘hyper-ageing’ population which is soon bound to confront the double whammy of a higher prevalence of noncommunicable diseases and a corresponding escalation in demand for healthcare services, further driving healthcare costs. It goes without saying that out-of-pocket health expenditure will also rise in tandem, potentially inflicting financial distress on the country’s population.

Recognising that the demands of such a rapidly ageing population could possibly render the predominantly

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hospital-centric healthcare model unsustainable in course of time, the Singapore government evolved what is called the ‘3 Beyonds’ strategy in 2016, to guide the long-term transformation of its healthcare system. The ‘3 Beyonds’ are namely, ‘beyond healthcare to health’ focusing on health promotion and disease prevention, ‘beyond hospital to community’ focusing on care in the community or at home in lieu of hospital admissions where appropriate, and ‘beyond quality to value’ focusing on researching treatments that provide the best value for money.

To support the ‘3 Beyonds’ strategy that reiterates personal responsibility for health and healthcare, a prerequisite is patient-centrism – genuinely putting patients at the centre of healthcare. This translates to taking cognisance of the barriers that stand in the way of delivering truly patient-centric care and eradicating those. The most fundamental of these barriers have to do with information, or rather, the lack of (or limited) access to it for patients.

According to a 2018 study, only an estimated 27 per cent of private licensees in ambulatory care comprising general practitioners, specialists and dentists, accessed and reviewed patient data on the NEHR.

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A patient-centric healthcare system is expected to reduce information asymmetry in the provider-patient relationship, benefitting patients and empowering them in their healthcare decisions and choices. However, such an outcome may not be desirable for healthcare providers, particularly those from the for-profit sector, who have been traditionally leveraging such information gaps to their advantage. Although there are some of these healthcare providers who may seemingly be willing to share health information with their patients, they may only want to do so within a private network – a mutually beneficial arrangement for the entities in the network. Any patient information is strictly shareable only within the network, resulting in information blocking. This restricts patients’ healthcare choices to the entities in the network or increases their healthcare costs (by way of duplicative consultations and tests) if they opt to move out of the network.

Singapore has no doubt made some headway with respect to addressing the aforementioned information barriers through their National Electronic Health Records (NEHR) initiative launched in 2011. However, 10 years later, it continues to remain a work in progress. The NEHR, conceptualised to

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the NEHR, the uptake has been slow.

According to a 2018 study, only an estimated 27 per cent of private licensees in ambulatory care comprising general practitioners, specialists and dentists, accessed and reviewed patient data on the NEHR. As for those contributing and uploading data to the NEHR, it was a dismal 3 per cent.

Just as Singapore was contemplating legislation of a Healthcare Services Bill requiring mandatory data contribution by all licensed healthcare providers and institutions, including clinical laboratories, a cyberattack on the IT systems of SingHealth—one of Singapore’s 3 healthcare clusters— in July 2018, forced a pause on the plan. Although the NEHR was not impacted, the cyberattack resulted in a data breach affecting nearly 1.5 million health records, which, understandably, sparked concerns and anguish among the already apprehensive medical fraternity. This unexpected turn of events led the Singapore government to postpone wider implementation of the NEHR. This meant the mandatory data contribution by all healthcare providers was postponed as well, until a rigorous, independent, third-party review to identify vulnerabilities was completed, and safeguards put in place. As at the time of writing this article, this remains an unresolved issue.

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realise a part of Singapore’s ‘One Patient, One Health Record’ vision, may be one of the fundamental steps towards achieving patient-centrism. However, it is nothing short of a giant leap considering the complexities involved.

To bring this strategic vision to fruition, first and foremost, an integration of the fragmented healthcare system encompassing the public, not-for-profit and private sectors, is a prerequisite.

An integrated health system will enable ‘continuum of care’, defined as a system’s capability to track patients over time across an array of healthcare services at all levels of care. Such a system which facilitates a longitudinal view of a patient’s health history, is also what is needed to help Singapore realise its ‘One Patient, One Health Record’ dream and pave the way for it to accomplish its ‘3 Beyonds’. Having ready and ubiquitous access to their lifelong story of treatments, tests and prescriptions not only empowers patients, but also supports their healthcare providers in terms of making the best possible decisions relating to their healthcare.

Such a system is also bound to generate a huge amount of health data which may be harnessed to drive productivity, innovation, competition, accountability, and new business models in healthcare.

Given Singapore’s openness to technological innovations that foster efficiency, its thrust on the digital literacy of its population, its proclivity to heavyhanded governance, and of course, its ‘smallness’, it may be easy to assume that achieving integrated healthcare may not be a herculean task, if not a trivial undertaking. This, however, is not as simple as it seems. While Singapore has been successful at integrating the public sector healthcare providers it finances and regulates, and having them onboard the NEHR, its efforts have not paid off with the private sector.

In spite of a SGD 20 million fund earmarked to assist private practices in updating their existing systems so that these become interoperable with

The lesson to be learnt from the Singapore story is that achieving ‘integrated healthcare’ in the true sense is an arduous endeavour even for a small nation. The challenges involved in integrating healthcare at a national level are often underestimated. These challenges are not just limited to technical issues, but in fact have more to do with political and economic issues. It is also evident from Singapore’s account that government intervention is crucial for initiating and developing an integrated healthcare system on a national scale. The lower-thanexpected uptake of the NEHR among private sector healthcare providers is attributable to the lack of a clear mandate and well-defined incentives from the Singapore government.

Without the entire spectrum of public, not-for-profit, and private healthcare providers participating in the NEHR system, Singapore’s dream of integrated healthcare via ‘One Patient, One Health Record’, will be jeopardised.

Nevertheless, as of date, Singapore remains one of those few countries that have made significant progress on this front. It remains to be seen if Singapore will gravitate towards the carrot and stick approach to get the private healthcare sector on board when the time is ripe. Given Singapore’s quest for excellence in providing public services, the country’s healthcare system holds out a promise to transform into a truly integrated, affordable, and sustainable system, an embodiment of its ‘3 Beyonds’ strategy.

Lena is a lecturer at Nanyang Technological University (NTU), Singapore.

She has a PhD in information studies from NTU as well. Her research interests lie primarily in the areas of e-health and digital ecosystems. Lena has several publications to her credit, her most recent work being a book titled “Capturing Value in Digital Health Eco-Systems: Validating Strategies for Stakeholders" published by the Taylor & Francis Group in 2021.

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OVERCOMING THE BARRIERS TO DATA-DRIVEN HEALTHCARE The pandemic has boosted datadriven healthcare. But healthcare providers will have to work hard to sustain this innovation and benefit from new approaches like valuebased care, predictive analytics and AI. Continued success also requires cultural change in data literacy and collaboration and the embrace of technologies like interoperability and data management.

Stella Ramette, Director, Customer Relations & Sales, Southeast Asia, InterSystems

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OVID-19 has boosted data-driven healthcare.

There has been a boom in telehealth and innovation in data technology supporting pandemic response initiatives, including genomic sequencing, testing and tracing, and the remote monitoring of COVID-19 patients.

Healthcare providers have also found new value in their electronic medical record (EMR) systems.

EMRs have supported telehealth, providing easy access to patient data in new settings to maintain quality of experience, and helped providers to pivot their operations, such as setting up remote clinics or new COVID wards.

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Data-driven healthcare approaches, like value-based care, predictive analytics, and AI, promise further benefits. But providers will have to work hard to sustain innovation. Continued success will require cultural change in data literacy and collaboration with suppliers, as well as technologies like interoperability and data management.

Trust in data needs to be a focus

We all know that there is value in data.

With analytics tools, healthcare providers can unlock that value by linking data across different systems and analysing it in new ways to inform decision-making or ‘operationalise’ the data.

But poor data quality is holding many organisations back. A recent study1

by Sage Growth Partners found that only 20 per cent of healthcare executives in the U.S. fully trusted the data they rely on to make decisions, with 64 per cent saying it was ‘somewhat credible.’ This is also a big problem for Asian healthcare organisations.

The study found that 53 per cent of healthcare executives say poor data quality reduces their decision-making ability. It also impacts their ability to identify gaps in care, meet quality metrics, and optimise the revenue cycle.

For a healthcare organisation with 2000 beds, Sage Growth Partners calculated the average cost of poor data quality to be US$12.9 million per year.

Factors leading to poor trust in data

Talking to healthcare executives in Asian hospitals, we have identified several factors contributing to poor trust in health data. One is the way information systems are used. If a system is not fully adopted by staff, or data entry is difficult and people take shortcuts, then the data is not trusted.

For example, when users of a clinical application or EMR module are under pressure, they may choose the first item on a drop-down list rather than taking

the time to select the correct item. When this data is analysed later, it will become evident that it is skewed or inaccurate, and clinicians will not trust it to make decisions.

Inconsistent data is also a widespread problem. Data may make sense within the system it was created, but not when compared with data from another system. For example, a radiology test and a lab test on the same patient may be correct when viewed in the proper context. But if the patient demographic data does not match, how can you be sure it’s the same patient?

Another common factor is around naming. Suppose the names of medications, consumables, or suppliers are not the same across different systems.

In that case, it is difficult to trust the data when it is aggregated for analysis unless further work is done to make the data consistent.

Build trust through data management

The challenge for most healthcare organisations is to move from somewhat trusting their data to fully trusting their data. That can be achieved

During the pandemic, breakthroughs in digital health have given providers a once-in-a-lifetime opportunity to innovate and improve how care is delivered. To take advantage of it, they need to sustain their efforts through cultural change and embrace enabling technologies like interoperability and data management.

by “harmonisation” or creating a single source of truth for data across the organisation and beyond.

Smart data fabric technology can greatly assist this process. It can unify, harmonise and analyse data across a healthcare enterprise with far less time and effort than manual processes. It can also support a wide range of analytic capabilities – including self-service business intelligence, natural language processing, and machine learning – to make it easier and faster for healthcare organisations to process and share larger volumes of data, and ensure it can be relied upon for analysis.

These data management capabilities are essential to encourage greater use of data and build trust in it. They can assist clinicians and other carers in leveraging healthcare data and understanding the best treatment for an individual patient. This could be achieved by applying AI algorithms trained using a complete and accurate patient data set.

For example, Mercy Radiology2 in New Zealand, working with Ferrum AI3, has deployed AI algorithms that use machine learning to improve over time with use. Operating in a second read capacity for radiologists, the use-cases are in lung nodules on CT scans and limb fractures on X-ray. The algorithms have improved the quality of reporting, and “there has been positive engagement from clinicians as well,” says Lloyd McCann, CEO of Mercy Radiology and Head of Digital Health for Healthcare Holdings Limited.

Provide value to engage clinicians

The positive engagement of clinicians is an important point. Improving the quality of healthcare data, and trust in it, requires the active engagement of clinicians. They need to see the link between the quality of data captured 2 https://www.radiology.co.nz/

1 https://www.intersystems.com/sage-data-report/

3 https://www.ferrumhealth.com/

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by clinical systems and the quality of outcomes achieved.

Clinician engagement cannot be taken for granted. Doctors and nurses are often very unselfish and generous.

However, they are also very busy people, and if you want to engage them in improving data quality, you must be able to answer the question, “What’s in it for me?”.

To do that, healthcare providers need to find ways to deliver data back to clinicians in ways that help them do their jobs. This could be as simple as using visualisation tools to allow clinicians to better understand diagnostic pathways or outcomes for a particular patient. Or it could be as complex as feeding their data into machine learning algorithms to create diagnostic support tools.

Marie Kondo your data!

Another strategy is to consider which applications provide the most value to clinicians and are most likely to

Smart data fabric technology can unify, harmonise and analyse data across a healthcare enterprise with far less time and effort than manual processes.

have good quality data. In January, I had the opportunity to speak with the digital health community at the Asia Healthcare Analytics Summit4. One tip I gave was to Marie Kondo your data!

If a system doesn’t bring you joy, then consolidate it or replace it with one that does.

4 https://hopin.com/events/asia-healthcare-analyticssummit-2022

Adopt a “growth mindset”

The global pandemic increased the willingness and the appetite to change and opened the way for innovation. The challenge for leaders of healthcare organisations is to sustain this enthusiasm and encourage a “growth mindset” where people are motivated to find and adopt new and better ways of doing things.

Reflecting on what his organisation learned from the remotelysupported deployment of a new EMR system, Lloyd McCann described the need to embed a change culture.

“Through COVID-19, we’ve come to learn that seeing change as a change management process is not enough. Through the virtual go-live experience, for example, we learned that the factors for success are mostly driven by human teams,” said McCann.

“We’ve got to build and embed a change culture across the health system and across the organisation.

Because only when people are comfortable that change is part of the new normal will we start to derive the true benefits and value of digital health approaches.”

A smaller set of systems suppliers with broader capabilities will simplify your operations and make it easier to harmonise your data. While a smart healthcare data fabric enables data harmonisation, automated processes will be easier to set up, and creating a complete dataset will be easier if all your systems are well adopted and trusted.

Finally, you should aim to minimise manual processes. Use automation to do the heavy lifting and employ your staff to identify new data insights and operationalise them to be used day in and day out with minimal effort.

Improve people’s data literacy

For organisations to change and grow to adopt data-driven healthcare, people need to understand the potential of technology.

Organisations can start by assessing their levels of data literacy. That will give you an understanding of people’s capacity to adopt new technology and participate in developing data-driven care initiatives.

Then, you can determine what levels of literacy are required to drive change and benefit from new technology investments. After setting those goals, you can put learning and mentoring programs in place to get there. Leaders should take a tailored approach. For example, some staff may need basic training in how to use digital devices.

But even very digitally literate people like systems developers may benefit from new skills. For example, InterSystems recently conducted a summer internship program for five information technology students from Charles Darwin University.

We taught the students about FHIR®5, HL7’s newest clinical data interoperability standard, and how to use it within the new TrakCare Interoperability Toolkit to submit to and retrieve and display information from the InterSystems TrakCare unified healthcare information system.

Using this toolkit, the students were able to quickly develop a prototype for a 5 https://www.hl7.org/fhir/

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mobile phone app to help hospital ward nurses to capture and monitor patients’ vital signs. The app uses FHIR to make it easy for nurses to capture patient data at the bedside and to integrate with data already entered in the TrakCare EMR system to quickly alert them about any deterioration in a patient’s condition.

“Disruptive” solutions for better care

Healthcare leaders should also look for innovative data-driven solutions from suppliers, including health tech companies and start-ups, medical technology and device companies, pharmaceutical companies, and others.

By working collaboratively with suppliers, healthcare providers can take advantage of global innovations and learn from their experience.

InterSystems is working with one company, RxMx®, that develops apps and portals around lab testing to ensure the safety of specialty medications. Built on the InterSystems IRIS for Health™6 data platform, RxMx’s Chameleon platform7 provides automated risk management to keep patients safe throughout complex specialty treatments while integrating with labs and other vendors in real time.

We will see many more ‘disruptive’ solutions that provide better care for patients and make lives easier for clinicians. Health providers will increasingly integrate their systems with those of medical device manufacturers and use big data and AI for improved diagnosis and predictive analysis. And we 6 https://www.intersystems.com/products/intersystems-irisfor-health/ 7 https://rxmxcorp.com/our-platform/

Stella Ramette is a creative data technology provider dedicated to helping customers solve the most critical scalability, interoperability and speed problems. Based in Singapore, Stella leads the company’s South East Asian healthcare operations, providing local resources to a growing customer base and ensuring that InterSystems is responsive to their needs.

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Stella has over 20 years of experience spanning healthcare IT, diagnostics, medical imaging and medical technology. She has held positions in management, sales, marketing and product management for established multinational corporations including Philips, Tieto, Atos Medical and Qualcomm.

will see more innovative care solutions from start-ups using healthcare data standards like FHIR that make them easier to integrate.

Build interoperability at the beginning

At the moment, healthcare providers can struggle to integrate innovative solutions into their workflows and systems.

For example, more and more medical devices are collecting data, whether in the hospital or the home. These are new sources of valuable data, but healthcare providers can find it challenging to use them for analytics and data-driven care.

Manufacturers and start-ups need to consider how devices can integrate with existing data infrastructure using standards-based interoperability support. For example, many remote monitoring devices currently require their own data infrastructure. Because of the cost involved, this is a considerable barrier to providers approving business cases.

If products include standards-based interoperability, they can leverage existing infrastructure to make them easier and more cost-effective to deploy.

A modern interoperability standard like HL7 FHIR, which works securely via the Internet, could make a real difference to a product’s viability.

InterSystems believes it is essential to prioritise interoperability and data cleansing so that data is usable in machine learning and other innovative, data-driven solutions. Our company’s cloud-first data platforms also solve the speed and scalability problems that healthcare must overcome to manage the exponential growth in data it produces.

During the pandemic, breakthroughs in digital health have given providers a once-in-a-lifetime opportunity to innovate and improve how care is delivered. To take advantage of it, they need to sustain their efforts through cultural change and embrace enabling technologies like interoperability and data management.

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THE ROLE OF DIGITAL HEALTH IN CHANGING COVID-19 LANDSCAPE Due to the ever-increasing demand in healthcare for COVID-19, digital healthcare is needed to meet the needs of patients.

Here is how it helps with the pandemic.

Anwar Rafique, CEO & Co-Founder, MyCLNQ Health Singapore

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hen COVID-19 first emerged, it changed the norms of citizens' daily lives worldwide within a matter of weeks. Implementation of government regulations, lockdowns, and other precautions to slow down the disease spread and keep society safe have entirely altered how various services are provided.

One of the core concerns worldwide is the challenge of maintaining the safety

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and well-being of staff and keeping up the quality of care due to pandemicrelated restrictions.

Other challenges faced include:

· Meeting the demand for services · Providing the services based on current workforce capacity · Adapting quickly to constant policy and regulatory changes.

In particular, there continue to be

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numerous healthcare-related challenges as the pandemic continues. Although the current delivery of medical-related services remains an obstacle, digital technologies and data solutions have addressed many of the top challenges across industries.

With that being said, the new normal digital health agenda will probably be narrowed down to three core areas: · Developing remote care · Coping with the pandemic's financial impact · Accepting the lessons, we can learn from crisis management.

Remote care

The volume of telehealth visits in Singapore had increased from 23 per cent to 30 per cent in 2020 when COVID-19 first emerged. This is because most Singapore residents are getting more concerned about visiting the clinics in person for fear of being exposed to the virus.

With new variations of COVID19 still emerging, there will likely be an increase in digital health usage.

Moreover, patients' expectations of the telehealth service are ever- increasing because a return to usual business is unlikely to happen anytime soon.

Hence, although providers may become comfortable delivering the care via technology, they may find themselves hard-pressed to sustain this level of use permanently. This is because the technology and operational workarounds used may not be robust enough to meet the demands.

Now that remote care is the new norm, health systems should build a steady, permanent bridge to address the organisational, financial, and clinical structures and processes.

The health system will have to implement digital health elements in medical aspects such as online health records, clinical protocols towards telehealth visits, getting reimbursed for

telehealth visits, and changing hospital and doctors' practice processes to support the digital health implementation.

For example, they would have to create a system on waiting rooms and convert them to virtual waiting rooms to accommodate telehealth visits. While doing so, they should also ensure that they provide care in the proper setting and create a fantastic experience via the "digital front door".

Delivering care in the proper setting

Quality is the most critical factor in healthcare. For this reason, health systems should ensure that the patients are cared for in the most suitable environment.

For example, healthcare providers should figure out the best way to turn care from emergency rooms that would usually belong in a doctor's office to remote care. They should also think about the feasibility of managing chronic care via home health services to reduce visits to the doctor's office.

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One instance would be the Home Recovery Programme1 should you be diagnosed with COVID-19. Instead of going to the hospital, patients with milder symptoms can now stay at home and use telehealth to access consultations without the need to travel to the clinic or hospital.

Creating an excellent patient experience

With the pandemic, consumers now heavily rely on digital technologies for many of their everyday activities. For example, working from home is the default. Meals are delivered through Grab Food or Food Panda, and items are now delivered through Qoo10 or Amazon.

Because of the efficiency of these services, there will be expectations that the digital health experiences will be equally effective, if not even more so.

To meet the criteria of a quality digital health service, health systems need to enable patients to handle routine interactions conveniently and efficiently, such as scheduling online medical consultations in Singapore, paying bills, finding doctors, refilling medications, and navigating the health application itself.

While most health systems offer these capabilities, there is always room for improvement in easy navigation and excellent performance in the app.

Financial health

The definition of "value-based care" has been challenging because the cost-benefit perspectives for each involved party are different. After all, the description is subject to individuals' preferences and objectives.

Nevertheless, "value-based care" to healthcare providers may stem from revenue improvements and reductions in operating costs. Many health systems will focus their resources on value1 https://ssivixlab.com/remote-care-101-home-recoveryprogramme-for-covid-19-patients/

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· ·

Digital health solutions and technology will continue to play a vital role in optimising processes and systems to improve efficiency and enhance outcomes with lower costs.

based care and provide health plans to emphasise them to address the revenue challenges.

For instance, health systems should increase investments in several digital health capabilities: · Analytics that examine factors such as disease, insurance coverage, and doctor to identify the quality of care and overall costs after reimbursement · Support for care managers who guided the patients' care processes across various providers and services · Patient registry with chronic disease to help the health system ensure the condition is being well-managed across the population · Remote patient monitoring and other technologies that will help with health monitoring Besides managing the revenue within the pandemic period, health systems should also reduce costs and limit budgets. To do so, health systems should seek opportunities to apply digital health tools that can ensure the smooth running of clinical and administrative operations.

Improvement of electronic health record usage should continue to ensure information can be entered correctly.

The digital health function may be pressured to operate with fewer resources to reduce expenses. Hence, the efforts made would be:

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·

·

Consolidating multiple technology applications to one Using cloud servers to host applications Optimise performance of existing applications through upgrades, reengineering clinical workflows, and conducting refresher training on application usage Leverage vendor capabilities to virtually support implementations

The permanence of aspects related to pandemic crisis management

When the pandemic was at its peak, health systems were forced to increase their decision-making speed drastically.

This is so they could combat challenges such as personal protective equipment shortage, high usage of ICU (Intensive Care Unit) beds, and protocols to protect staff.

At the same time, they would provide safe treatment for patients.

The crisis also resulted in rapid experimentation of new ways to manage clinical and operational processes.

During this time, digital health systems discovered new ways to do telework, implemented chatbots to respond to health-related questions and concerns, and collaborated to give treatment across the country.

The results from this pandemic should not be shelved once the pandemic subsides. Instead, health systems should solidify the results gained from their organisational capabilities.

The most prominent impact on the health systems' digital plan is acceleration. Before the pandemic, most health systems may already have the concepts to continue developing telehealth, implement apps that support quality care, improve the patients' healthcare experience via "digital front door", and lower care delivery costs.

However, it's likely put on the back mind until the pandemic hit.

Due to the pandemic, what may have taken a decade to accomplish would hypothetically be shortened to

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three years. Now that digital health is quickly developing and is on the front line, it has become a strategic partner to health systems worldwide.

Digital health solutions and technology will continue to play a vital role in optimising processes and systems to improve efficiency and enhance outcomes with lower costs.

While this pandemic has cost us lives, jobs, and a sense of normalcy, we still have the power to decide the future.

After all, it has pushed healthcare workers to take faster action, work smarter, and a higher-focused approach when making decisions.

Challenges that digital health providers may face

While digital health companies are rapidly expanding, providing plenty of job opportunities, they face many challenges.

These include consumers' hesitation to switching from face-to-face to digital healthcare, the effectiveness of online consultation compared to a physical consultation, the availability of high-speed internet and devices, the development of managing processes and spam calls, and patients' data privacy.

Moreover, digital health should accommodate the patients who could not access these services easily or those in dire need of a physical examination.

For instance, patients with acute illness or in need for lab tests would have to make a physical visit to the clinic. Moreover, healthcare providers should develop a secure verification system to ensure that the patients do not accidentally share confidential information with unverified individuals.

In Singapore, the digital health providers have also faced challenges to keep up with the demand surge for services during the pandemic. As a result, consumers have to wait longer to consult a doctor online in Singapore, leading to a reduction of the quality of healthcare.

Hence, policymakers will have to take a measured approach regarding

the sector development. Because the government has the right to steer this dominant sector and exercise a large control over it, this has to be considered while healthcare providers assess the potential of a digital health aspect, such as telemedicine.

Continuing to gear up for the future

The adoption of digital health in Singapore has mimicked the high transmission of COVID-19. After all, the usage of digital health-based services has considerably increased, with frontline workers such as healthcare employees banding together to use everything they've got to fight back against the crisis. Therefore, digital health is here to stay due to its far-reaching influence.

In time, digital health may make way for new models and "go-to" providers.

After all, the digital health acceleration resulting from the pandemic has shed light on the crucial unmet needs by the healthcare systems and where digital innovation can generate the most value.

The healthcare and technology sectors need to proactively stay ahead in this constantly evolving digitalised world. Pursuing new operating systems concepts can enable fundamental advantages, such as lower costs of services and better access to patients.

Conclusion

In this post-pandemic world, the consensus is that we should not revert to the previous healthcare delivery methods. On the contrary, we should continue supporting digital health tech innovators to create and develop creative solutions to tackle our country’s most prominent healthcare problems.

After all, new technologies would open the chance to provide better outcomes and reduce health inequalities. Perhaps they may even ensure that cardiac and stroke patients receive faster diagnosis and treatment.

It’s our hope and vision that healthcare providers will continue to adapt, embrace and experiment with new technology so that digital health will continue to bring in positive improvements in the years to come.

MyCLNQ Health has developed the MyCLNQ app, the leading app for telemedicine in Singapore, as part of embracing digital health ecosystem. With this, you can access private ambulance services in Singapore to receive the medical assistance you need without having to leave the comfort of your own home and virtual supervised ART testing.

AUTHOR BIO Anwar demonstrates an impressive background and domain expertise.

He has 2 decades of diversified experience within banking and financial services. Anwar believes in giving back to the community and is a grassroots leader engaged in volunteer services. He is fascinated with all new technology like AR/VR, AI & Machine Learning and how this can be used to make more efficient and affordable digital healthcare service to the community.

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Accelerating The Digital Transformation in Healthcare How do we ensure cancer patients have access to the best possible care, no matter where they live?

The availability, awareness, and affordability of new technologies and how to use them are fragmented.

This article explains how producers, providers, and governments can accelerate the digital transformation needed to expand access to cancer care.

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C

ancer patients should have access to the best possible care, no matter where they live. In Asia, the estimated number of cancer cases will grow from 9.3 million in 2020 to over 14 million by 2040.1 Almost half

1 International Agency for Research on Cancer: Estimated number of incident cases from 2018 to 2040, all cancers, both sexes, all ages

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Kenneth Tan is the President of Asia Pacific, Japan and India at Varian, a Siemens Healthineers company that specialises in radiation therapy and oncology informatics software.

Kenneth has 20 years of experience in healthcare, driving complex strategic shifts through organisations. He manages Varian’s strategic growth in Asia Pacific, including integrated innovations in remote diagnosis-planning, machine learning, artificial intelligence, and cloud-based delivery.

Transforming every stage in the cancer care journey

of these patients will have no access to appropriate treatment. For those who do have access, there can be considerable variability in the quality of care available.

Access to cancer care is a universal challenge. It impacts patients and providers in every country. However, in low to middle income countries (LMICs), it can be more pronounced.

Radiation therapy typically forms part

of best practice cancer care for around 50-60 per cent of patients, but less than 10 per cent have access in LMICs.2 This is primarily due to a shortage of equipment and trained oncology professionals.

Even in high-income countries, patients face a significant challenge accessing cancer care. Data from Australia shows that patients in rural areas are up to 35 per cent more likely to die within five years of a cancer diagnosis.3 These challenges require a renewed focus on digital transformation of the entire cancer care continuum, from diagnostics and imaging to interventional radiology and radiotherapy, through to follow-up care.

We can quickly make use of advances in cancer care by accelerating the adoption of new technologies, understanding and creating greater awareness of the cancer needs, and training digitally-enabled oncology professionals.

Here are five ways digital transformations can increase access to advanced cancer care.

2 Expanding global access to radiotherapy - The Lancet Oncology 3 Remoteness of residence and survival from cancer in New South Wales | The Medical Journal of Australia (mja. com.au)

Every cancer patient is different. There is a significant need for sustainable solutions that can be customised and used to address each patients’ unique needs. Today, care providers are asked to navigate an array of specialised resources, tools, and solutions that don’t always work efficiently together.

Cancer care must be redefined through a fully integrated care pathway.

One that addresses the entire patient journey—from early detection to diagnosis, therapy, and follow-up care.

Each stage can be made more efficient and integrated, creating an intelligent oncology operation that will give cancer teams the power to be more patient-focused.

Artificial intelligence (AI) and machine learning have been shown to improve the early detection of cancer by accurately identifying at-risk patients.

They also make diagnostic tests more precise.

Software systems help create robust, customised treatment plans for virtually every type of external beam radiotherapy.

Plans can be done quickly using models designed by academic institutions and remotely by multi-disciplinary teams.

Finally, treatment and follow-up care can be tailored to meet the patient’s ongoing needs as they progress. Cuttingedge digital solutions allow caregivers in clinics of all sizes to customise

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their approach to meet patient needs, without sacrificing cost-effectiveness or operational efficiency.

Driving a consistent approach between diagnosis and treatment

For cancer patients, time is critical to survivorship. Waiting is not an option when it comes to effective treatment.

However, patients are treated on different timelines, and the quality of their care depends on several factors outside of their control. This results in significant variability in the effectiveness of each patient’s care.

Connecting imaging and treatment through digital services reduces this variability. Greater connectivity helps improve workflows and shortens the time to treatment, thereby improving outcomes for patients.

New technologies also enable faster and more precise diagnoses, allowing healthcare providers to create an informed, personalised plan for treatment. They can leverage highly targeted treatment options that spare as much healthy tissue as possible by identifying the case earlier. This is where image-guided treatment options can lead to improved long-term quality of life.

Radiation therapy is often delivered over several weeks or longer. As patients undergo treatment, they may experience weight loss or other changes to their anatomy, requiring new treatment plans.

AI-driven adaptive therapy can predict these changes and rapidly personalise the patient’s treatment, reducing clinicians’ time planning. The treatment better targets the tumour, reduces dosage to healthy tissue and can be delivered in a shorter time slot.

Console imaging capabilities help create a simple experience for clinicians when treating moving tumours.

By seamlessly combining imaging, treatment, and digital solutions, connected technologies can help healthcare providers ensure patients get the treatments they need exactly where they need it.

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Making multi-disciplinary care a reality

Often, the patient’s care is determined by the first point of interaction with the health system. If patients first see a surgeon, they will receive surgery first; if they see a radiation oncologist, the chance is higher they will receive radiation therapy.

Cancer care is a multi-disciplinary and increasingly complex system, often requiring multi-modal treatment.

Shared research and insights are becoming more critical in highlighting opportunities along the patient journey to improve outcomes.

Data analytics, AI, and machine learning will enormously impact the cost effectiveness of treatment planning – and improve the quality and utility of data generated

However, care providers currently operate in silos, making it challenging to translate individual findings into broader solutions.

This lack of connectivity leads to breakdowns in treatment planning and implementation.

The accelerated adoption of software can help to move us away from fragmented care. It enables treatment centres, research institutions and practices to work together and provide more integrated, multi-disciplinary care, creating opportunities to share capacity. The patient can also be an active participant in sharing information and making treatment decisions.

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We can democratise access to cancer care by bringing oncology teams closer together to build multi-modal treatment plans more effectively. Specialists working together can use the latest clinical evidence to determine the best course of treatment for the patient.

With remote access, professionals who may be geographically disbursed can also input into the treatment roadmap.

Oncology teams can also access data on treatment outcomes from anywhere in the world, allowing them to tailor more effective treatments.

Creating a digitally enabled workforce

According to a 2018 study published by the Journal of Global Oncology, 4 out of 8 LMICs in Asia have a ratio of more than 800 new cancer patients for every clinical oncologist in the country. By contrast, each clinical oncologist in the US must care for just 137 cancer patients.4 Globally, an additional 150,000 skilled clinicians will be required to deliver the care needed worldwide. The gap between cancer care supply and demand increases by 14 per cent every year.5 Local communities require more highly trained technical personnel and specialised clinicians, particularly for radiation treatments. Continuous Medical Education Programmes must embed digital health as part of its curriculum to encourage the adoption of new digitally enabled techniques and technologies.

Training programs can be delivered via virtual live learning using technologies that replicate workplace/ in-person training, such as Augmented and Virtual Reality. Trainees can come together to discuss, practice, and collaborate in a virtual environment.

This makes training more economical and efficient for prospective trainees.

Virtual training reduces travel costs 4 Global Survey of Clinical Oncology Workforce 5 https://www.siemens-healthineers.com/insights/transforming-care-delivery/increase-workforce-productivity

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and has a flexible in-program design.

People have opportunities to interact and network with each other, while spending less time travelling.

Such value-based training reinforces the digital transformation of healthcare and empowers the workforce to stay updated with the most advanced technologies in radiation oncology.

Fostering an environment that favours efficiency and innovation

Despite considerable opportunities to help build access to cancer care, existing care models are not structured to help integrate new solutions and encourage a digital transformation in healthcare.

Challenges range from the lack of a regulatory framework tailored to digital health, complex and opaque reimbursement pathways, and a lack of awareness or familiarity with digital solutions.

Policies covering telemedicine and remote monitoring were developed quickly in response to the pandemic.

Reimbursement frameworks for AI, machine learning and software as a service (SaaS) require a similar urgency to address the gap in access to cancer care.

We have seen how digital technologies can support clinical decisions. Regulatory frameworks should encourage clinicians to adopt tools that augment their existing processes, allowing them to be more patient-focused and driving better outcomes.

Proving the cost-effective benefits and improvements in clinical outcomes will be critical to building the case for new care models. Suppliers and caregivers can work together to develop robust clinical evidence highlighting where digital technologies are superior to existing standards of care. Building awareness about the benefits to patients, such as digital therapeutics, will also be vital.

Cloud technologies allow patients to report information about their symptoms and quality of life in real-time.

Communicating with healthcare providers helps to keep them more engaged in their care.

In turn, the clinical care team can use the technology to provide recommendations to remediate distress and proactively manage the patient’s health before their condition becomes more severe.

More effective reimbursement and co-payment policies that incentivise the adoption of e-health will encourage the digital transformation to a more cost-effective and beneficial healthcare system—one that expands access to care for more patients.

Conclusion

Experts predict that cancer can become a manageable, chronic disease so that a cancer diagnosis will no longer hold the fear that it does today.6 But the gap in cancer care is growing faster than the infrastructure required to address the need.

Advancing digitisation in healthcare will help ensure that care pathways across Asia will be similar regardless of 6 See ‘Survival Data’ sources at https://www.varian.com/ why-varian/intelligent-cancer-care

where the patient lives. To do this, we must encourage digital transformation at every stage, building comprehensive support tools and ensuring caregivers are supported by data-driven insights to enable personalisation at every step – for patients, clinics and networks.

AI and machine learning can improve clinical processes and workflows. Clinicians can collaborate to drive clinical excellence, create personalised treatment plans and continually enhance patient outcomes.

Multi-disciplinary cancer boards and remote access can unlock capacity between organisations. Software and insights can be integrated into the cloud so that caregivers anywhere in the world can access the latest information and deliver more accurate treatments.

Data analytics, AI, and machine learning will enormously impact the cost effectiveness of treatment planning – and improve the quality and utility of data generated. Reimbursement policies should reflect this change.

These technologies should be easy to use by radiologists, medical oncologists, surgeons, and radiation oncologists alike. Together, we will enable a better coordinated, better informed, and better-managed journey for each cancer patient.

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THE BUSINESS OF TELEHEALTH Telehealth is slowly being integrated into the healthcare delivery system worldwide. Communications dealing with organisational challenges, human resources and deployment of Management science in initiating, sustaining and making viable telehealth activities are few. This article shares the author’s learnings over 22 years of association with a number of small and mega telehealth projects operational in India and overseas, virtually reaching the unreached.

Krishnan Ganapathy, Director Apollo Telemedicine Networking Foundation &, Apollo Tele Health Services Hon. Distinguished Professor, The Tamil Nadu Dr. MGR Medical University; Emeritus Professor, National Academy of Medical Sciences, WHO Digital Health Expert

Introduction

A detailed need assessment study is the first step in this direction. Risks in programme implementation, challenges in providing tele consultants, necessity for training, retraining, learning, relearning and unlearning has to be considered. Identifying champions in the team and community and making

the project self-sustaining is critical.

Future-ready access to cost-effective, need-based, appropriate technology including a robust telecommunication network is vital. Patient perspectives of telemedicine quality need to be considered. Measurable, reproducible, objective parameters quantifying success need to be defined. Legal, regulatory and

Robust Hands-on Training @ Chennai Apollo, Feb 7, 2015 - March 24, 2015

security issues have to be complied with.

Cultural transformation is necessary for acceptance of technology enabled remote virtual healthcare. Urban teleconsultants deploying cutting edge technology need to be sensitised for community interaction. Implementing pandemic associated specific strategies and providing equitable, quality, accessible, affordable healthcare, in a milieu of infrastructure and personnel shortage, is always a challenge.

Planning a telehealth project – Initial steps

Fig 1: Hands on Training of Telemedicine Coordinators

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The need assessment team interacted with all stakeholders including administrators, doctors, district health officials, patients and the community. Clinical problems were identified. Beneficiaries, at the "bottom of the pyramid" had to interact with urban super specialists. Challenges included (a) convincing the community that an urban healthcare provider could appear on a screen, make a diagnosis and advise treatment empathising with them (b) convincing doctors at the remote centre, that the new service would not undermine their importance (c) convincing government that a radical exponential cultural transformation could be implemented and the

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Apollo Coordinators reaching the community to explain services programme would be cost effective using appropriate need based technology and (d) Programme Managers would be transparent, accountable, responsible and open to external third party audit.

Managerial decisions were reviewed in real time and corrective measures instituted.

Acceptable, clear, unambiguous, reproducible, measurable parameters to decide on what constituted success were defined. Quality of service was measured through feedback. Key Performance Indicators were defined. Channels of communication and grievance redressal mechanisms were instituted. Escalation and evaluation matrices were customised.

Internalisation of processes and protocols enabling smooth functioning was ensured with constant training. Training, capacity building, CME programmes, weekly and monthly project reporting, efficient community engagement and optimised capacity utilisation were implemented. Monitoring and evaluation included impact assessment study of measurable milestones and monthly reports. Program management included budgeting and defining Service Level Agreements (SLA) for all activities.

This included data bandwidth SLA for Service Providers and penalties for Service Commitment outage.

Training

Training was carried out for staff and government employees in (a) Clinical areas, (b) Information Technology (IT) (c) Attitudinal Change (d) Community Linkage and (e) creating beneficiary delight. Change management and workflow process re-engineering were new areas. A new workflow process was integrated into the existing government healthcare system. An intensive threemonth training was given [Figure 1], for Telehealth Coordinators / Facilitators.

Training covered basics of telemedicine, telemedicine equipment, IT for teleemergencies, trouble shooting, petty cash accounting, Management Information Systems and reporting and community

Fig 2: Telemedicine staff @ Remote Centres in the Himalayas

linkage programmes. Staff were taught to present clinical problems in an emergency setting. A well-integrated teleconsultation unit with remote diagnostic devices (digital 12 lead ECG, Spirometer, Stethoscope, Point of Care Diagnostics) and seamless Internet connectivity, enabled implementation.

Telehealth services commencement

Community contact was initiated with resource persons distributing simple, illustrated information booklets in local language. Change management issues were faced with local staff, who initially perceived telehealth as a threat.

Technology provided virtual specialists on a screen, but providing drugs and tests was difficult. “Just enough” bandwidth always available, was better than unreliable ideal bandwidth. Redundancy was provided with additional backup.

power. Subsequently, solar panels were introduced. Specialists in quaternary care hospitals, had to provide teleconsults for a token compensation. Younger consultants were more enthusiastic.

Cost-effectiveness

Evidence of cost-effectiveness is necessary for widespread telemedicine adoption. Ensuring funding and sustainability is necessary. Donors, governments, cross-subsidy, for-profit companies, and rarely venture capitalists have been sources of funding. Successful telehealth applications are generally run by local telemedicine champions with ad hoc funding. Few have succeeded in reaching large-scale, enterprise-wide adoption. Personal user advantage and incentivisation is as important as advocating general societal advantages.

Risks in implementing programmes

Measuring performance of a telemedicine network

Technology acceptance was a concern.

A resource in each centre was dedicated for community outreach. A detailed Standard Operating Procedure was made. Constant skilling and upskilling ensured use of hardware and software.

English speaking translators were made available. Dedicated generators, with adequate diesel ensured constant

A telemedicine network is usually a sub-system within an organisation.

Telemedicine systems should compute setup and running costs to ensure sustainability Measuring performance is essential, selecting characteristics to be measured, choosing a method to measure, analysing collected data and implementing decisions based on

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Fig 3: Teleradiology technicians being trained

these results. “Performance” criteria would differ for each stakeholder eg. patient, telehealth coordinator, teleconsultant and financial officer.

Societal perspectives could be different.

Measuring impact should be contextual with appropriate indicators and metrics.

Indicators ‘indicate’ impact but do not quantify, whereas metrics are ‘numerical indicators’ quantifying impact.

Combination of indicators and metrics is needed. Indicators could include (a) Utilisation (How busy is the network? (b) Quality (how good are responses? (c) Usability (how easy is the system to use? trouble shooting technical problems?) and (d) patient outcomes.

Social factors influencing growth and development of telehealth

Local champions promote participation, exploiting technological and financial options. Sustainability depends on existing structures and processes in the local healthcare delivery system, policy frameworks, communication and technology costs and physician and patient acceptance. Telehealth service is sustainable when it is part of a healthcare delivery system. Collaboration within the institution, developing community alliances, external partnership, shared vision, exploiting funding opportunities and technological options, identifying critical services, engaging external specialists and improving administrative processes are important. Telehealth iementation requires rethinking and redesigning of functions, structure and culture to achieve improvements in cost, quality, service and speed.

Main objectives are developing new business processes supporting and improving service delivery, continually evaluating enterprises structure and

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operations to achieve more responsive systems. Interpersonal trust, faith in reliable appropriate technology and teleconsultation process is necessary.

Use or non-use is determined by social context in which technology is implemented.

Collaboration between entrepreneurs, managers, bureaucrats, healthcare professionals and patients is critical. Analysis of beliefs, perceptions and attitudes about telemedicine is important. Solutions should be technologically appropriate and culturally sensitive. Appropriate technology is the simplest solution achieving the desired purpose in existing social, cultural, economic and environmental conditions, promoting self-sufficiency. Such a technology with fewer resources is sustainable. Change management is addressing the human factor, defined as “resistance to change”.

Change is the process of switching from “old” to a “new” situation. Individuals are aware of reasons for change, changes that are necessary, details of new technologies, its implementation and new skills required. Most telehealth evaluation studies are technologycentred and focused on utilisation rates.

Patient opinions shape marketplace and need to be studied. Healthcare is a competitive industry. Low utilisation rates could be due to poor telemedicine encounter experience.

Quality measurements influencing growth and development of telehealth

Telehealth is a major innovation at the technological, social and cultural levels. Telehealth projects are complex, innovative and continually evolving.

Some effects cannot be anticipated.

Telehealth has a poor record of

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implementation and adoption.

Incentives to health professionals have been suggested to increase telemedicine adoption. Self-sustaining telemedicine applications improve access to healthcare and savings. Rate of adoption is the speed with which a technology is adopted.

Importance of introducing evaluation and monitoring, needs to be recognised.

Quality Assurance (reviewing reports, monitoring cases/users and checking data) in telemedicine programmes has been stressed.

Barriers to adoption of telemedicine

These include technology integration, interoperability, standardisation, security, time constraints and financing.

Technology can be provided, but health professionals need to use it. Their perceptions, legal issues, technical difficulties, time, convenience and cost are critical. Hurdles relate to reimbursement, policies governing telecommunication and information technologies, development and licensure.

Difficulties in introducing telemedicine and eHealth have been pointed out.

Internal resistance to changes in work processes and organisational transformations are barriers.

Success of telemedicine

Acceptance by clinicians and beneficiaries, demonstrable savings, improved access to healthcare and reduced effort and travel time, adoption into everyday practice are reasons for successful telemedicine applications.

Active deployment of Management Science in disruptive innovations like telehealth is limited. Adoption of telemedicine, patient satisfaction and doctor-patient interactions depend considerably on utilisation of Human Management principles. The latter is intuitive The diffusion of innovation (DOI) theory is useful in assessing perceptions about a new technology such as telemedicine. Telehealth adoption is a complex behaviour determined by a large set of psychosocial factors.

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If patients perceive that telemedicine will save time/money and increase comfort, they may adopt telemedicine.

Pre experience perceptions shape decision to (a) sample telemedicine services and (b) use services regularly.

Greater the perceived advantage and perceived compatibility, greater the intent. User advantage determines speed of adoption. Rate of adoption is speed with which technology is adopted. Increased access results in increased utilisation. To ensure effective operation, skilful planning and implementation are as essential, as system design, software functionality and technical prowess. Optimisation of work processes is important. Operations need to be reinvented to use newly available information. Identifying significant pain points results in new innovative solutions. Innovative uses of telemedicine have been reported The changing healthcare scenario

AUTHOR BIO

The new normal will be predominantly remote healthcare. Physical visits will be for procedures in single speciality hospitals. Personal health records will be updated in real time and stored in the cloud. Individuals will manage their own health with assistance from a nurse practitioner. Smart robots with artificial intelligence (AI) will help conduct or interpret lab tests and other tasks performed at home with networked diagnostic devices. Internet, mobile computing and inexpensive sensors will offer opportunity to democratise healthcare, making the system resilient.

Technology enabled care will increase

Fig 4: Illustrations of Real time Dashboards of various Telehealth projects

productivity and savings, improving health outcomes. Continuum of healthcare will provide individualised care maximising resources.

A peep into the future

Instead of patients moving from remote areas to hospitals, information will move from a centralised area to the patient Digital efficiency should not be at the cost of TLC (Tender, Loving Care). Telemedicine should be a tool to achieve an end, requiring skills in medicine, digital tools, information and communication technology and administration. Telehealth will make healthcare accessible, accountable, equitable and affordable maintaining patient trust. Humankind is witnessing an unprecedented growth in Healthcare Information Technology. Machines will be interacting directly through the World Wide Web (Machine to Machine

KRISHNAN GANAPATHY is a Former Secretary and Past President Neurological Society of India, Telemedicine Society of India & Indian Society for Stereotactic & Functional Neurosurgery. Hon. Distinguished Professor, The TamilNadu Dr. MGR Medical University, Emeritus Professor National Academy of Medical Sciences Member Roster of Experts Digital Health WHO. Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services, India.

UR L

: w ww. k gan ap at h y.i n

E M ail : d r gan ap at h y @ ap o l l o h o sp i ta l s. c o m

– or the Internet of Medical Things).

Present human to machine interaction will reduce. With three billion using social networks, distance will become meaningless and Geography History!

Remote Healthcare is here to stay. The WFH (Work from Home) culture will be adopted by the healthcare provider and the beneficiary. The future of healthcare, lies in building hundreds of stand-alone, small, satellite clinicians offices and diagnostic centers. Existing hospital-centric focus will shift to patient-centric focus Acknowledgments:

Scores of individuals have managed various telehealth projects. Dr Prathap C. Reddy Founder Chairman Apollo Hospital Group had realised in 1998 that telehealth would be the future.

Dr.Preetha Reddy Vice Chairperson and Dr. Sangita Reddy Joint Managing Director, gave carte blanche to the operational team. Vikram Thaploo CEO is managing an outstanding team of dedicated professionals. S Premanand Chief Business Officer and Dr Ayesha Nazneen Chief Operations Officer among others have overseen dozens of section managers and their assistants who are all part of this extraordinary team facilitating 25,000 e Transactions every day.

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Application of Blockchain Technology in Hospital Information System

B

lockchain is a distributed database of cryptographically chained blocks that aggregates value exchange transactions in a chronological order. Each block in the blockchain is immutably recorded across a peer-to-peer (P2P) network, and each one is cryptographically linked to the previous block.

Meanwhile, the hospital information system (HIS) is a comprehensive, standardised information system designed to organise the hospital's financial, administrative, and clinical functions. The goal of launching HIS was to increase the quality of public healthcare services, notably in terms of patient satisfaction and record management.

HIS

Blockchain technology was found to be useful in the real healthcare environment, mainly on the management of electronic medical records, biomedical research and education, remote patient monitoring, pharmaceutical supply chain, health insurance claims, health data analytics, and some other potential areas. The main reasons for the implementation of blockchain technology in the healthcare sector are data integrity, access control, data logging, data versioning, and non-repudiation.

Long Chiau Ming, PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam Khang Wen Goh, Faculty of Data Science and Information Technology, INTI International University

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The current HIS, which is mainly cloudbased, has several issues that influence its efficiency and effectiveness. HIS incorporates the system of computer and improves the service efficiency, which concentrates on patient, ancillary, admission, financial, and clinical applications.

HIS consists of at least two of the following components: 1. Clinical Information System (CIS), 2. Financial Information System (FIS), 3. Laboratory Information System (LIS), 4. Nursing Information System (NIS), 5. Pharmacy Information System (PIS), 6. Picture Archiving Communication System (PACS), 7. Radiology Information System (RIS).

EXECUTIVES SPECIAL ISSUE

The HIS was implemented in order to create a non-segregated healthcare delivery system. It's a good automated file system that can exchange information for more storage in a public hospital and can be used for medical statistics and research. HIS gives the necessary data to management at the appropriate time, in the correct format, and at the appropriate location, allowing for effective and efficient decisionmaking, especially in crucial situations where limited margins of error are allowed. HIS improves patient care by accurately evaluating data, generating management recommendations, and allowing a hospital to transition from a retrospective to a contemporaneous view, all of which have an impact on the quality and care of a patient's life.

HIS is critical for developing, starting, organising, and maintaining the hospital's subsystem processes, as well as ensuring a synergistic operation.

The HIS also improves health status by promoting well-being and empowering individuals and communities to take charge of their own health. The benefits of implementing HIS at the hospital include reduced transcribing mistakes and duplication of information input. Improved drug usage tracking is also a result of HIS adoption.

In healthcare organisations, the HIS has been shown to improve the efficacy and productivity of patient services.

Patients and healthcare practitioners have a better understanding, trust, and satisfaction as a result of the HIS adoption. This relationship will improve effective communication, resulting in more efficient chronic illness care and improved physical health and quality of life.

Types of blockchain technology

There are three different types of blockchain, which depend on the availability and management of data, and the action taken by the user. These are public permissionless, consortium (public permissioned), and private.

Entities can act as a reader or writer in a blockchain. A reader will read or inspect the content of record or verify the blockchain passively. In contrast, writers involve in the consensus protocol, who have the capability to expand the blockchain. In a public permissionless (public) blockchain, the data are accessible and visible to the public. Some parts of the blockchain might be encrypted in order to safeguard a participant's anonymity. Without any clearance, anyone can join blockchain and function as a node or a mere minor.

Entities are free to participate in the consensus process and write or read on a public blockchain. Only a select group of nodes is allowed to participate in the distributed consensus process, which results in the consortium blockchain.

A public permissioned blockchain can be utilised inside a single industry, such as the banking sector, where public use is restricted and centralised. Many industries, including financial and political entities, as well as insurance companies, can adopt consortium blockchain, which is open for public use but still remains moderately centralised trust. A private blockchain is one in

Electronic medical records, biomedical research and education, remote patient monitoring, drug or pharmaceutical supply chain, health insurance claims, health data analytics, and other area are the commonly used cases of blockchain technology in healthcare.

which only a small number of nodes are allowed to join the network. Private blockchain is a permissioned, distributed network that processes transactions by controlling nodes and is mostly used for private purposes.

Need for and advantages of blockchain technology in patient data management

Healthcare data is one of the most valuable sources of medical intelligence. In the healthcare sector, blockchain technology enables patients to have personal control over their data, resulting in more effective patient data management. Blockchain technology eases the stress on physicians by giving a higher level of intelligibility and amenability organisation, which functions as digital time-saving and enticing tools for patients to manage their own care.

Due to the decentralised features of blockchain technology in the healthcare industry, which produce immutable and objective data resources, individuals may access up-to-date information, statistics, and evaluations about healthcare service providers. With the support of patient-centred care and a secure P2P network, patients can freely exchange their private health records with medical providers without worrying about their information being stolen. Data sharing is essential for improving the quality of healthcare services and creating a smarter healthcare system. The Health Information and Management Systems Society (HIMSS) defines interoperability as "the capacity of multiple software applications and information technology systems to communicate, exchange data, and use that data".

Interoperability is responsible for the speed with which medical researchers may get important information from various data sources and for improving data quality and quantity. Blockchain technology in the healthcare sector is critical for storing and maintaining a patient's medical history. Because of the patient's disconnected hospital

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visits, which result in discontinuity and unavailability of the prior record, the patient's medical history record may not be available or adequately preserved.

As a result, blockchain is employed to preserve a chronological record of a patient's history during each visit to any hospital. Due to the inaccessibility of disconnected data, blockchain eliminates the need for a patient to repeat a laboratory test, potentially lowering the expense and risk of repeating a highradiation test.

medical practitioner credentials, and justifying insurance claims. To track medicine delivery, a startup called iSolve implemented an end-to-end blockchain technology solution. Tracing prescription medicine fraud is one of the applications of blockchain technology in medical and device traceability in healthcare. The reproduction of a prescription, doctor-shopping, and changing the number to change the prescription itself are all examples of false medication prescriptions. Doctor-

Advantages of blockchain in payments and reimbursement

AUTHOR BIO

Fraudulent billing and claims are one component of healthcare that need to be removed and avoided. In essence, health insurance is used to protect an individual's assets against the potentially crippling costs of medical treatment.

The patient may pay a set amount during treatment, but the remaining charges are presented as claims to the healthcare firms. The providers are compensated through the claim adjudication process, whilst the insurer determines the financial responsibility for the payments and pays the amount due to the provider.

The insurer has the option of paying, denying, or reducing the amount paid to the provider. A smart contract is used in blockchain technology to avoid fraud in payments and reimbursements.

Smart contracts are a key component of blockchain technology in healthcare.

The advantages of smart contracts in the use of blockchain technology in healthcare are that they are immutable and trustworthy, and they can be controlled with trusted information that is shared equitably between the parties.

Long Chiau Ming completed Bachelor of Pharmacy (Hons) and Master of Clinical Pharmacy at UniversitI Sains Malaysia. He obtained PhD (Pharmacy) at the Department of Pharmacy and Pharmacology, University of Bath, England. To date, he has 14 years of academic, research and industrial experiences. He has supervised more than 50 research projects and 15 postgraduate research students and published prolifically in SCOPUS/ISI indexed research papers in the field of clinical studies and pharmacokinetics. Dr Long is also the Associate Editor of BMC Health Services Research and Managing Editor of Malaysian Journal of Pharmacy.

Khang Wen Goh is an Associate Professor at INTI International University, Malaysia. He is currently heading the Faculty of Data Science and Information Technology at INTI International University. He obtained his Ph.D. in Swarm Intelligence from University Technical Malaysia Melaka in 2019. He is a dedicated academician with more than 12 years of teaching experience in higher education and possesses more than 15 years of research experience. He is actively involved in various research areas such as Swarm Intelligence, Mathematical Modelling, Fintech, Pharmaceutical Information Technology, Healthcare Data Analysis, and Precision Farming Optimisation. He obtained 2 FRGS grants as principal investigator in 2016 and 2019 which focused on Computational Analysis on Protein Structure Prediction and Islamic Finance Portfolio Optimisation respectively.

Advantages of blockchain in drug and medical device traceability

Each phase of the transactional information process acts as a trusted tracking in transparent and immutable ways, such as tracking and reconciling inaccuracies in patient data, inspecting

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shopping is when a fraudster visits several doctors in order to obtain a large number of original prescriptions.

Experts use blockchain technology to address this issue, with a monitoring programme deployed to improve access and response time; to avoid any suspect buying patterns, prescription data is examined, alerting physicians and pharmacists.

The term "open-ended loop" refers to a situation in which the feedback between the physician (prescription

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EXECUTIVES SPECIAL ISSUE

writer) and pharmacists (prescription fillers) is lacking. Blockchain can break this open-ended loop. The first step in the blockchain technology solution for prescription drug fraud is a machinereadable code that works as a unique identification and is connected to the prescription written by the doctor. The name, quantity of the drug, anonymised identity of the patient, and a timestamp are all included in a block in the blockchain, which acts as a unique identification. The symbol was scanned once the pharmacists had completed the prescription. The prescription fulfilment is tracked and compared to the blockchain. The pharmacists will be notified if the prescription is suitable for filling, and the data will be provided to demonstrate the prescription's accuracy.

The Counterfeit Medicine Projects, which were started by Hyperledger, a research network across industries, are addressing the counterfeit drug problem by incorporating blockchain technology. Each medicine is time-

stamped, making it easy to determine when and where it was created. The blockchain data was utilised to track the production of bogus drugs. The use of blockchain technology ensures a higher level of drug safety as well as a lower cost of health-related follow-up.

A pharmaceutical supply chain management system keeps track of the information gathered for manufacturing, the manufacturing process, and the distribution of the finished goods. The patient suffers significant side-effects when a false drug is administered. Product recognition, tracking, validation, discovery and response to nonstandard drugs, alerting upon nonstandard drugs, and the ability to store pertinent information, including affirmation and product information, are all key requirements for supply chain management technologies, and blockchain technology is compatible and relevant with each of them.

By storing unique device identifiers for each medical device, keeping track,

and delivering firmware upgrades via smart contracts, blockchain technology in healthcare improved the safety and security of medical devices and supplies.

Device monitoring may improve the safety and efficacy of medical devices by providing numerous responsive device recalls and alerts. Immutability is implemented through blockchainbased medical device tracking to prevent device loss, theft, or hostile intervention.

Conclusion

Blockchain technology is still a fairly new technology that has not been widely implemented in the healthcare sector.

Electronic medical records, biomedical research and education, remote patient monitoring, drug or pharmaceutical supply chain, health insurance claims, health data analytics, and other area are the commonly used cases of blockchain technology in healthcare.

References are available at www.asianhhm.com

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